Background: Several studies concluded that there is a reduction of maternal deaths with improved access to caesarean section, while other studies showed the existence of a direct association between the two variables. In Ethiopia, literature about the association between maternal mortality and caesarean section is scarce. This study was aimed to assess the association between maternal mortality ratios and caesarean section rates in hospitals in Ethiopia. Methods: Analysis was done of a national maternal health dataset of 293 hospitals that accessed from the Ethiopian Public Health Institute. Hospital specific characteristics, maternal mortality ratios and caesarean section rates were described. Pearson’s correlation coefficient was used to determine the direction of association between maternal mortality ratios and caesarean section rate, taking regions into consideration. Presence of a linear association between these variables was declared statistically significant at p-value < 0.05. Results: The overall maternal mortality ratio in Ethiopian hospitals was 149 (95% CI: 136-162) per 100,000 livebirths. There was significant regional variation in maternal mortality ratios, ranging from 74 (95% CI: 51-104) per 100,000 livebirths in Tigray region to 548 (95% CI: 251-1,037) in Afar region. The average annual caesarean section rate in hospitals was 20.3% (95% CI: 20.2-20.5). The highest caesarean section rate of 38.5% (95% CI: 38.1-38.9) was observed in Addis Ababa, while the lowest rate of 5.7% (95% CI: 5.2-6.2) occurred in Somali region. At national level, a statistically non-significant inverse association was observed between maternal mortality ratios and caesarean section rates. Similarly, unlike in other regions, there were inverse associations between maternal mortality ratios and caesarean section rates in Addis Ababa, Afar Oromia and Somali, although associations were not statistically significant. Conclusions: At national level, a statistically non-significant inverse association was observed between maternal mortality ratios and caesarean section rates in hospitals, although there were regional variations. Additional studies with a stronger design should be conducted to assess the association between population-based maternal mortality ratios and caesarean section rates.
This study was designed to analyse secondary data of the Ethiopian EmONC assessment survey of 2016. Data about all maternal and neonatal health services in hospitals from 1st January 2015 to 31st December 2015 were retrospectively collected from May to December 2016. The Ethiopian Public Health Institute (EPHI) conducted this survey to assess the status of maternal and neonatal health indicators in Ethiopia [20]. Ethiopia is a multicultural country located in the horn of Africa. The country is a Federal Democratic Republic of nine regional states, namely, Tigray, Afar, Amhara, Oromia, Somali, Benishangul-Gumuz, Southern Nations Nationalities and People Region (SNNPR), Gambella, and Harari and two city administrations (Addis Ababa city administration and Dire Dawa city council). With a population of 109,302,118, Ethiopia is the second most populous country in Africa after Nigeria. The Ethiopian health system is structured into a three-tier healthcare system, which includes primary, secondary and tertiary level health care. These levels work together through a referral network. Primary level health care comprise of primary health care units (PHCU) that are networked with district hospitals. A PHCU consists of one health center (HC) and five satellite health posts (HPs). A HC, serving approximately 25,000 people, is used as referral center for HPs, the most proximal health facility to the community and serving approximately 5,000 people. HCs are also serving as practical training sites for health extension workers (HEWs), who are health care providers working in HPs. Primary district hospitals provide inpatient and ambulatory services, including comprehensive emergency obstetric care for a population of up to 100,000. Secondary level health care consists of a general hospital and provides general health services for an average of 1,000,000 people. It serves as referral center for primary level healthcare and training center for health officers, nurses and emergency surgeons. Tertiary level health care is the highest level and has a specialized hospital, which serves an average of five million people. It provides specialized services and is used as a referral center for general hospitals [21]. CS is provided in hospitals at all levels, in primary hospitals by emergency surgical officers (health officers trained in emergency surgery) [22] in consultation with obstetricians and in general and tertiary hospitals by obstetricians. Cases are referred to higher levels of care based on severity. In the last two decades, significant maternal and child health improvements have been observed as the government of Ethiopia invested mainly in health system strengthening. As a result, in 2016, the MMR reduced to 412 per 100,000 live births from a very high baseline of 1,400 per 100,000 live births in 2000 (a 69% reduction). Total fertility rate dropped from 7.7 to 1990 to 4.1 in 2014, which may be explained by an increased contraceptive prevalence rate from 3–42% in the same period. In Ethiopia, trends of maternal health utilization have been increasing over the last two decades. For example, antenatal care from skilled providers increased by 46% over the last 14 years (from 28% in 2005 to 74% in 2019). Over the same period, births in health facilities increased by 43% from 5% in 2005 to 48% in 2019, and the percentage of women who meet the Safe Motherhood Program’s recommendation of receiving postnatal care checks within two days of birth increased to 34% in 2019 from 4.6% in 2005 [23, 24]. Generally, all public and private health facilities, which offered EmONC services, were included in the survey. All 293 private and public hospitals in Ethiopia were among the 3,804 facilities in the survey. This analysis used data of the 293 hospitals’ maternal health indicators, such as number of obstetric complications, maternal deaths, total births, live births and number of CS. The majority of the hospitals were located in the four largest regional states: Oromia (24.9%), SNNPR (20.5%), Amhara (19.1%) and Tigray (13.3%). Slightly more than half, 160 (54.6%), were primary district hospitals, while specialized tertiary hospitals accounted for 30 (10.2%) (Table 1). Regional distribution of hospitals in the 2016 Ethiopian EmONC survey All maternal deaths and all births by CS in the 293 hospitals in 2015 were included in the analysis, irrespective of the type, managing authority and location of the hospitals. Hospitals were included in the survey according to the following eligibility criteria: (1) the hospital provided delivery services in the last 12 months; and (2) the hospital was functional at the time of the data collection period. EPHI collected data about performance of the EmONC signal functions in all Ethiopian hospitals using a standardized questionnaire. Data from hospitals’ registers and patient records included number and mode of births, number of women admitted with specific obstetric complications, and number of all maternal deaths. The dependent variable is MMR in hospitals. The association between CS rates and magnitude of MMR was calculated. Assessment of the association between the dependent and the independent variables was performed by taking regional variation into account. Healthcare professionals with at least a bachelor degree were recruited and deployed to conduct data collection. During recruitment, factors such as prior experience with data collection, clinical experience and level of education were considered. They were given intensive training on interview techniques, survey tools, field procedures and a detailed review of the questionnaire. The survey was conducted under close supervision of the Technical Working Group (TWG) consisting of Averting Maternal Death and Disability (AMDD), Ethiopian Ministry of Health (MOH) and other collaborators including UNICEF, JHPIEGO, JSI, and the Ethiopian Midwives Association (EMA). In addition, regional coordinators supervised the data collection process and conducted spot-checking to ensure data quality. Initially, descriptive analysis, including frequency tables, percentages and ratios, was conducted to present facility specific characteristics, MMRs and CS rates. Then, Pearson’s correlation coefficient was performed to assess linear association between MMRs and CS rates, considering regions as covariate. Data analysis was performed with Stata version 15 software. The direction of a linear association between variables was measured using Pearson’s correlation coefficient and an association was declared statistically significant at p-value < 0.05.
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