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Background. Globally, more than 830 maternal deaths happen daily, and nearly, all of these occur in developing countries. Similarly, in Ethiopia, maternal mortality is still very high. Studies done in pastoralist women are almost few. Therefore, the objective of this study was to assess the determinant factors of maternal death in the pastoralist area of Borena zone, Oromia region, Ethiopia. Methods. Community-based unmatched case-control study was conducted on 236 mothers (59 maternal deaths (cases) and 177 controls). The sample included pregnant women aged 15-49 years from September 2014 to March 2017. Data were collected using a structured questionnaire adapted from Maternal Death Surveillance and Response Technical Guideline, entered into the EpiData, exported into SPSS for analyses. Odds ratios (ORs) and 95% confidence interval (CI) were computed to determine contributing factors of maternal death and control potential confounding variables. Results. About 51 (86%) of all maternal deaths were due to direct obstetric causes. Of this, hemorrhage (45%), hypertensive disorders of pregnancy (23%), and obstructed labor (18%) were the leading direct causes of maternal deaths. Husbands who had no formal education were 5 times higher compared with their counterparts (AOR = 5.1, 95% CI: 1.6-16). Mothers who were not attending ANC were 5 times more at risk for death than those who attend (AOR 5.3, 95% CI 2.3-12.1). Mothers who gave birth at home/on transit were twice to die compared to health facility delivery (AOR 2.6, 95% CI 2.4-6) that were contributing factors of maternal deaths. Conclusions. Husband’s level of education, lack of antenatal care, and home delivery were the factors contributing to maternal deaths in the zone. Frequent and tailored antenatal care, skilled delivery, and access to education also need due attention.
The study was conducted in the pastoralist area of the Borena zone, one of the 18 zonal administrative divisions of the Oromia region, Ethiopia. The zonal capital, Yabelo town, is located 575 km from Addis Ababa in the south direction. The zone has 13 districts (10 pastoralists and 3 agrarian), 2 town administrations, and 248 rural and 15 urban kebeles (the smallest administrative unit). Based on the 2007 GC Ethiopian Central Statistical Agency (CSA) report, the 2017 projected that total population of the zone is 1,365,753 with an estimation of 302,240 women of childbearing age (15–49 years), of which 47,391 of them (3.47% of total population) are expected to be pregnant [6]. Population density of the zone is assumed to be 23 people per km2, and 91% of them live in rural areas with arid and semiarid climate condition. Most of the rural kebeles and villages are very remote in terms of health access and facilities. The zone has 3 hospitals (1 zonal and 2 district), 66 health centers, 217 health posts, and 92 private clinics. Only 35 (53%) of 66 health centers and 3 hospitals are providing basic emergency obstetrics care and two hospitals providing comprehensive emergency obstetrics care services. A community-based unmatched case-control study was conducted among pregnant women who delivered between September 2014 and March 2017. Cases were all women of the reproductive age group who died during pregnancy, delivery, and within 42 days after delivery between September 2014 and March 2017 while controls were all women in the reproductive age group who delivered including stillbirth and abortion, those alive within 42 days after delivery between September 2014 and March 2017. Cases who fulfilled the standard case definitions of maternal death given by international classification of disease-10 (ICD-10) and controls who have a willingness to participate in the study were included. Of deaths, not related to pregnancy and/or beyond 42 days of termination of pregnancy were excluded from the study. The sample size was determined by the two population proportion formula using Epi Info version 7 considering the following assumptions: 95% CI, 80% power, 1 case to 3 control ratios (1 : 3), percent of controls represented as 45.42%, and adjusted odds ratio of 2.594 (odds of rural to urban resident) from a case-control study done at the Jimma Referral Hospital, southwest Ethiopia [5]. So, a total of 216 (54 cases and 162 controls) sample size was determined. By adding 10% for the nonresponse rate (5 cases, 15 controls), 236 (59 cases and 177 controls) samples were included in the study. Individual cases and controls fulfilling the inclusion criteria were selected retrospectively from the most recent death (for cases) and delivery including termination of pregnancy and still births (for control) until the determined sample size was achieved. All maternal deaths reported from September 2014 to March 2017 through Maternal Death Surveillance and Response (MDSR) was retrieved from verbal autopsy summary and facility-based abstraction form. Then, the sampling frame was prepared. For each selected case, three delivered mothers were interviewed as controls. But if more than three control mothers were eligible, simple random samplings were used. Data were collected by four senior midwifery nurses and two health officers with the help of health extension workers (HEWs) as a local guide, using a structured questionnaire that adapted from the Federal Democratic Republic of Ethiopia, Ministry of Health MDSR Technical Guideline [7]. The questionnaire was translated into the local language, Afan Oromo. Maternal death information was collected from maternal death reporting format (VA summary form) and facility-based abstraction form. Controls’ information was collected from women in the reproductive age group who gave birth or terminated the pregnancy in the study period. Data collectors were trained by the principal investigators for one day on the details of data collection instrument, interviewing techniques, and the importance of data quality and research ethics. For study variables, see Table 1. List of the study variables. Questionnaires filled every day were reviewed and checked for completeness and consistence by the principal investigator for keeping quality. After data collection was completed, each filled questionnaire was coded by the principal investigators. The data were entered into EpiData version 3.1 and exported into SPSS version 20 computer software programs for cleaning and analyses. For each variable under the study, simple frequency was run and used to check for entry errors, missing values, and outliers. Any identified error was cross checked with the previously coded original questionnaires using the code number and then corrected accordingly. Following the data checking for any discrepancies, descriptive analysis was performed. Bivariate logistic regression analysis was done to decide whether there is an association between maternal death and different factors to select candidate variables for multivariate logistic regression. Variables with a p value less than or equal to 0.25 or crude odds ratios show that significant association were entered into multivariate binary logistic regression to identify predictors of maternal deaths. P values of <0.05 and/or AORs with 95% CI interval not containing number 1 were taken as statistically significant. ORs, 95% CI, and p values were reported for all independent variables. Graphs and figures such as bar/pie charts and tables were used to present findings of the study. Delays and categories of delays were summarized from maternal death reporting format (VA summary) and facility-based abstraction form, which are developed based on the WHO delay modalities. Maternal death is the death of a woman while pregnant or within 42 days of the termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. Direct obstetric death is maternal deaths resulting from obstetric complications of pregnancy, labor, and puerperium period, whereas indirect obstetric death is a maternal death resulting from any previously existing disease aggravated by pregnancy or disease that developed during current pregnancy. Ethical clearance was obtained from the Institutional Review Board (IRB) at College of Medicine and Health Science of Hawassa University. Permission was also gained from the Borena zone health department and respective district heath offices of the study area. Informed verbal consent was obtained from individual study participants after briefing the risks and benefits of the study. Name of the study participants was not written on the questionnaire.
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