This study evaluated the DOCFR and determinant factors among women who were admitted to Ethiopian hospitals with direct maternal morbidity in 2015. Overall, the DOCFR among women who were admitted to hospitals was found to be 0.64% (435/68,002). Prolonged labour was the leading cause of direct obstetric morbidity followed by hypertensive disorders. Hypertensive disorders of pregnancy, maternal haemorrhage, ruptured uterus and prolonged labour were the predominant direct causes of maternal deaths. The DOCFR was significantly higher among mothers who were admitted with postpartum haemorrhage and ruptured uterus. The DOCFR was also unacceptably high among mothers who experienced hypertensive disorders and sepsis. Significant regional variation was observed in the DOCFR, the highest being occurred in the Gambella region while the lowest was observed in Addis Ababa city administration, the capital city of Ethiopia.
The current study showed that in 2015, a large proportion (20.3%) of women who gave birth in hospitals experienced the direct obstetric complications (68,002/335,054). This finding is unsurprising as an estimated 15% of all pregnancies ended in obstetric complications [1]. Consistent with findings of an Eritrean study [18], our finding revealed that hypertensive disorders of pregnancy were the leading cause of maternal mortality. Similarly, our study revealed that postpartum haemorrhage, prolonged labour and postpartum sepsis were the predominant causes of maternal mortality. Our finding is supported by Brazil’s findings [19], findings in Kenya [20] and several small scale studies conducted in Ethiopia [21,22,23].
This study demonstrated that the crude national DOCFR was within the WHO recommended level of less than 1% [9]. A significant reduction in the DOCFR was observed as compared to findings of a previous study where the national obstetric case fatality rate was 2% in 2008 [13]. This reduction might be explained by improved access to maternal health service, as the government of Ethiopia strengthened the health system while striving to achieve the Millennium Development Goals (MDGs) in reducing maternal mortality. The current finding is consistent with a study conducted in Indonesia, both in the magnitude and trends of the DOCFR [24].
Nevertheless, the current study demonstrated a considerable variation in the DOCFR among different direct causes of maternal deaths. Postpartum haemorrhage carried the highest DOCFR followed by ruptured uterus. The DOCFR for hypertensive disorders and postpartum sepsis also exceeded the recommended level. Our finding is consistent with the results of a systematic review conducted in sub-Saharan Africa where the case fatality rate of maternal haemorrhage, ruptured uterus, sepsis, and obstructed labour were higher than the recommended level [25]. Unlike our findings, a study conducted in six west African countries revealed higher DOCFR for sepsis (33.3%), ruptured uterus (30.4%) and hypertensive disorders of pregnancy (18.4%) [17]. This variation might be attributed to the differences in sample size and study settings. While study of the West African countries assessed the DOCFR in sample of women, our study included data of all women that our findings were highly representative.
Despite lower DOCFR at the national level, a significant regional variation was observed. The highest DOCFR was observed in the Gambella region where case fatality rate was 3.82% (95% CI: 1.42–8.13%). A considerably high DOCFR was found in the Afar, Harari and Somali regions, the lowest being in Addis Ababa city administration; the capital city of Ethiopia. Our finding is supported with the study conducted in six west African countries where the case fatality rate significantly varied among the regions involved in the study [17]. The observed variation might be occurred due to the limited access to maternal health service in the Gambella, Afar and Somali regions as these regions are found in most pastoral area of the country. Higher DOCFR than the recommended level was noted in the Harari region one of the urban settings with better access to health service. This might be attributed to poor quality of obstetric care among hospitals found in the region. The observed regional disparities in the DOCFR might also be attributed to the existing regional differences in the use of antenatal care services [26] and the low quality of antenatal care in Ethiopia [27]. The existing spatial differences of contraceptive use among Ethiopian regions could also be a cause for the observed disparities in the DOCFR among regions [28].
In the multivariate logistic regression analyses, several hospital-specific factors were significantly associated with the magnitude of the DOCFR. In the final model, the likelihood of observing DOCFR≥1 was significantly reduced among general hospitals than it was in primary hospitals. The odds of having one or higher DOCFR was also decreased among specialized hospitals though the reduction was not statistically significant. The probability of maternal death from obstetric complications is usually affected with the type and quality of management provided at the facility. According to the three tier healthcare delivery system of Ethiopia, since specialized and general hospitals are more equipped with medical supplies and qualified healthcare providers than primary hospitals [29], this finding might not be surprising.
Although the difference is not statistically significant, the odds of having DOCFR≥1 was reduced by 75% among hospitals that did not implement the MDSR initiatives. The MDSR is a health reform used to continuously notify, review, analyse and respond to maternal deaths in order to take action to prevent similar deaths in the future [30]. Although, MDSR was accepted at subnational level in many countries, it is not adequately institutionalised [31]. Several barriers including role confusion, high staff turnover and lack of necessary facilities impeded the implementation of the MDSR reform [32]. Furthermore, the observed association might reflect the situation of private hospitals where quality of the service is better but the reform was not yet well institutionalized.
However, the odds of having DOCFR≥1 among public hospitals was two times higher as compared to private hospitals counterparts. This might be explained by the better health service utilization rate at private facilities than public counterparts [33]. This difference might also be observed due to better quality of the service as more standardized maternal health service is provided in private sector [34]. The observed difference in the magnitude of death might also be attributed to that most of the private hospitals (faith based and missionary) are mainly located in rural areas where women can accessed to treatment before sequel to severe complications [35].
The current study showed higher odds of having DOCFR≥1 among hospitals where formal payment for service was not required. Studies indicated that officialising the user charges creates financial barriers and reduces utilisation of maternal health service [36]. Access to the maternal health services is also limited with an informal payments for purchasing essential medicines [37]. On the other hand, introduction of user fee exemption reforms increased maternal health services utilization [38]. Improved access to the health service of good quality significantly decreases the maternal mortality rate [39]. Higher risk of DOCFR in hospitals where service are rendered for free might be attributed to the higher maternal mortality in public hospitals where maternity services are rendered free of charge as opposed to private hospitals.
Strength and limitation of the study
This study has several strengths. In this study, we used a national representative data collected from all hospitals found in Ethiopia. Therefore, the findings of this study are highly generalizable and can apply to all regions of Ethiopia. These findings might also be useful for other low-income countries with similar demographic and economic characteristics. From the commencement of the survey, experts from national and international partners were involved in the data collection and management processes hence the analysed data were of high quality. In the meantime, this study was suffered from the usual limitation of a cross-sectional study in that the causal relationship could not be concluded. This study did not investigate the maternal morbidity and mortality happened at the lower level of care including health centers and clinics. Although the majority of women who experienced obstetric complications are often referred to hospitals, few women might sometimes seek care from lower level facilities. Therefore, the findings of this study can only be generalized to hospitals in the country. The maternal deaths reported in this study represent only the numbers, which were registered on the hospital’s logbook. Therefore, the number of deaths might be affected by maternal deaths that happened at home, which accounts for the majority of maternal deaths in low-income countries. Similarly, we faced difficulties in comparing our findings with similar reports since there were limited similar studies available in Ethiopia.