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Background: The paper’s primary purpose is to determine changes in magnitude and causes of institutional maternal mortality in Mozambique. We also describe shifts in the location of institutional deaths and changes in availability of prevention and treatment measures for malaria and HIV infection. Methods: Two national cross-sectional assessments of health facilities with childbirth services were conducted in 2007 and 2012. Each collected retrospective data on deliveries and maternal deaths and their causes. In 2007, 2,199 cases of maternal deaths were documented over a 12 month period; in 2012, 459 cases were identified over a three month period. In 2007, data collection also included reviews of maternal deaths when records were available (n = 712). Results: Institutional maternal mortality declined from 541 to 284/100,000 births from 2007 to 2012. The rate of decline among women dying of direct causes was 66 % compared to 26 % among women dying of indirect causes. Cause-specific mortality ratios fell for all direct causes. Patterns among indirect causes were less conclusive given differences in cause-of-death recording. In absolute numbers, the combination of antepartum and postpartum hemorrhage was the leading direct cause of death each year and HIV and malaria the main non-obstetric causes. Based on maternal death reviews, evidence of HIV infection, malaria or anemia was found in more than 40 % of maternal deaths due to abortion, ectopic pregnancy and sepsis. Almost half (49 %) of all institutional maternal deaths took place in the largest hospitals in 2007 while in 2012, only 24 % occurred in these hospitals. The availability of antiretrovirals and antimalarials increased in all types of facilities, but increases were most dramatic in health centers. Conclusions: The rate at which women died of direct causes in Mozambique’s health facilities appears to have declined significantly. Despite a clear improvement in access to antiretrovirals and antimalarials, especially at lower levels of health care, malaria, HIV, and anemia continue to exact a heavy toll on child-bearing women. Going forward, efforts to end preventable maternal and newborn deaths must maximize the use of antenatal care that includes integrated preventive/treatment options for HIV infection, malaria and anemia.
Two similar national cross-sectional surveys of health care facilities conducted five years apart are the data sources for this secondary data analysis. Table 1 summarizes key aspects of the two surveys: the Needs Assessment in Maternal and Neonatal Health in Mozambique, 2007–2008 and the Needs Assessment for Emergency Obstetric and Neonatal Care in Mozambique, 2012. Further information about the methodology of the surveys can be found in the final reports [2, 23]. Differences and similarities between the 2007 and 2012 national health facility assessments Both surveys were designed to provide the Ministry of Health and its partners with information for planning and strategic decision-making; to assess progress on the reduction of maternal mortality using indicators for monitoring emergency obstetric care [24]; to provide inputs for implementing interventions to reduce early neonatal mortality, prevent unwanted pregnancies, and to better understand the relationship between the availability of resources, quality of care and their impact on maternal newborn morbidity and mortality. The 2007 assessment was designed to collect information on a more ambitious range of topics, including investigating facility capacity to repair obstetric fistula, availability of maternity waiting homes, and interviews with service users. The 2012 health facility survey had twice the sample size but a more limited substantive scope. In both surveys the causes of maternal deaths that were collected as part of the summary of service statistics were defined by the parameters set out by WHO in the ICD-10 that allows for direct and indirect causes of maternal death [3]. Some variation in the cause-of-death options occurred across the two surveys. In 2007 all deaths were categorized as falling into one of the following underlying causes of death: antepartum or postpartum hemorrhage, prolonged or obstructed labor, uterine rupture, postpartum sepsis, severe pre-eclampsia, eclampsia, abortion complications, ectopic pregnancy, other direct causes, HIV/AIDS, malaria and other indirect causes. The questionnaire did not allow for undetermined causes of death; it is likely that they were assigned to either the “other direct” or “other indirect” categories. In 2012 the causes of death were virtually the same except that retained placenta was added to the questionnaire (and in this analysis retained placenta was combined with postpartum hemorrhage), and indirect causes were broken down into the following mutually exclusive categories: malaria, severe anemia, malaria + severe anemia, HIV/AIDS, HIV/AIDS + malaria, HIV/AIDS + anemia, other indirect causes, reflecting the growing awareness of the high rates of co-infection and co-morbidities. Finally, a category for unknown or unspecified causes of death was added. In both surveys, clinical definitions were covered during the training of data collectors, all of whom had a medical or public health background. Definitions of severe obstetric complications could be found in the 2012 data collectors’ manual but were not included in the 2007 manual. Data collectors were expected to extract the cause of death from the registers and logbooks found in the facility. Diagnostic test results were not a prerequisite for assigning cause of death, and we do not know how many reported diagnoses were confirmed with diagnostic tests. No systematic physician review of these causes of death took place in 2007 or 2012. In addition to the service statistics, a maternal death review (MDR) was a second source of information on maternal deaths available only for 2007. It collected demographic characteristics, obstetric history, and details related to each woman’s clinical condition and medical treatment. This module was completed for 712 of the 2,199 women identified in the summary of service statistics. An MDR was completed for every maternal death whose clinical records and files could be located (see Table 3). Patient records were supplemented by death reports performed by the Maternal Death Audit Committee, if the cases were audited, and if case notes and reports were available. At the end of the questionnaire, the data collector was given the opportunity to reassign a cause of death only if their conclusion differed from that which was found in the patient’s records. All MDRs were further reviewed by a team of physicians before data entry; the final cause appears in Table 3. No attempt was made to reconcile the cause of death as it appeared in the MDR with that in the summary of service statistics (see Table 2). Number of weighted and unweighted institutional maternal deaths and overall and cause-specific institutional maternal mortality ratios, by year a2007 unweighted number of institutional deliveries = 312,537, weighted = 478,308. 2012 required no weighting, number of institutional deliveries = 161,986 bIn 2012 other direct causes included suicide (rat poisoning), polyhydramnios, pyomyosites, complications from anesthesia or surgery cIn 2012 other indirect causes included intoxication with tradtional medicines, asthma, pulmonary edema, respiratory insufficiency, meningitis, meningoencephalitis, choked, brain tumor, hepatitis, cardiovascular disease, kidney failure dIn 2007 unspecified or unknown causes of death were grouped with “other” direct or indirect causes. wt = weighted; unwt = unweighted Distribution of 2007 causes of death according to data source and percent of maternal death reviews for which malaria, anemia, HIV infection, or any one of the three morbidities contributed to the woman’s condition During the secondary data analysis, several questions in the review were used to determine if any evidence existed of HIV infection, malaria or anemia, and whether one or more played a role in the woman’s condition. If one or more of these questions below indicated that a woman was HIV infected, had a diagnosis of malaria or anemia, she was coded accordingly. Responses were pre-coded but an optional “other” category existed and these “other” responses were re-coded. The review questions were: The MDR data were not weighted since almost no reviewed deaths occurred at the low level health centers and posts. The health facility itself was the unit of analysis for the assessment of the availability of infrastructure, equipment and drugs. This paper presents a descriptive comparison of the 2007 and 2012 data. Secondary analysis was performed using Stata version 13 and SPSS version 17. For the 2007 data, we show weighted and unweighted numbers, but rates or percentages are based on weighted data, with the exception of the MDR data as stated above. Weights were calculated as the inverse of the probability of selection and adjusted by facility non-response. The 95 % confidence intervals are shown for the institutional MMR estimates in Table 2; all figures for Table 2 were calculated within Stata and took into account the weighting and provincial stratification. Although some of the confidence intervals include a negative integer, for practical purposes the lower bound was zero. These intervals should be considered informal testing as the two datasets were not merged. The institutional mortality ratios use as their numerator only deaths that occurred after admission to the facilities surveyed, and the denominator is based on the number of deliveries taking place in the same facilities over the same 12 or three month time period, depending on the survey. The protocols for the primary data collection were approved (see Table 1) by local entities but the current secondary data analysis did not meet the regulatory definition of research with human subjects per the U.S. Code of Federal Regulations Title 45, Part 46.102(f), since the dataset obtained was completely de-identified. Similarly, the use of informed consent was deemed unnecessary for the secondary data analysis, however, permission to use the data from the two surveys was granted by the Ministry of Health’s National Directorate for the Promotion of Health and Disease Control, by UNFPA/Mozambique (a major funder of both surveys) and the University of Eduardo Mondlane, the assessment implementing partner in 2012.
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