CMHL1001 : Risk factors for maternal mortality in a Tertiary Hospital in Kenya – Health Care Assignment

Internal Code: MAS5566

Health Care Assignment:

The maternal mortality ratio (MMR) is defined as “the ratio of the number of maternal deaths during a given period per 100,000 live births during the same time- period”. The global MMR is 210 per 100,000 live births [1]. Despite worldwide declines since 1990, the MMR is
15 times higher in developing than developed regions [1]. Sub-Saharan Africa has the highest MMR at 500 per 100,000 live births. In developed regions, the MMR is 16 per 100,000 live births [1]. The target for Millennium Development Goal (MDG) Five is to reduce the global MMR by three quarters and to achieve universal access to reproductive health by 2015 [2]. In Kenya, the MMR has remained at 400-600 per 100,000 live births over the past decade – resulting in little or no progress being made towards achieving MDG Five [1,3]. The main direct causes of maternal death in developing countries include haemorrhage, sepsis, obstructed labour and hypertensive disorders [4]. The risk of death from haemorrhage is one in 1,000 deliveries in developing countries, compared with one in 100,000 in developed countries, and accounts for one-third of the maternal deaths in Africa [5]. A study in Canada found the increased risk of eclampsia among women with existing heart disease and anaemia [6]. A retrospective study undertaken at a tertiary hospital in Nigeria in 2007 found

that the most common risk factors for maternal mortality were primarily, haemorrhage, anaemia, eclampsia and malaria [7]. Risk factors for complications arising from infections include birthing under unhygienic conditions, poor nutrition, anaemia, caesarean section, mem-
brane rupture, prolonged labour, retained products and haemorrhage [8]. In developing countries, indirect causes of maternal death include both previously existing diseases and diseases that develop during pregnancy. These include HIV, malaria, tuberculosis, diabetes, and cardiovascular dis-ease, all of which and have an enormous impact on maternal and fetal outcomes during pregnancy [4]. Many individual and socioeconomic factors have been associated with high maternal mortality. These include lack of education, parity, previous obstetric history, employment, socioeconomic status, and types of care seeking behaviours during pregnancy. There is also evidence than
24 and older than 35 years [9]. A study in Tanzania found that low level of spouse education was a risk factor for maternal mortality [10]. Lack of knowledge regarding the need for skilled attendants is a barrier to women seeking care, especially during birth emergency-
cies. A survey conducted in Kenya in 2006 showed that 15% of pregnant women were not informed of the importance of hospital deliveries [11]. In Nigeria, a cross-sectional survey revealed that the most common risk factors for maternal death were primigravidity (19%),
and unbooked status (19%) [12]. Poverty has also been associated with adverse maternal outcomes, not directly, but as a contributor to maternal ability to access and utilise care where complications occur [13,14]. There is also evidence that contraceptive use is effective for the
primary prevention of maternal mortality in developing countries by about 44% [15]. Antenatal care (ANC) is very important during preg-
nancy. International organizations recommend a minimum of four visits, the administration of two doses of tetanus toxoid and folic acid supplementation during ANC attendance [16]. When women receive good care during the pre-partum period, they have been shown to
be at less risk of maternal morbidity and mortality, since they had a higher likelihood of using a professional health facility during birth [10,17]. In the Kenya Demographic and Health Survey (2008-2009), it was reported that 92% of women received ANC from a skilled provider (doctor, nurse, or midwife), especially those who were more educated and resided in urban areas [3]. The report further showed that 83% of
women who visited public hospitals were required to pay for antenatal services, which may explain why only 47% of antenatal women attended the recommended four visits [3]. Women had also been required to pay for delivery services until June 2013, when the Kenyan
government rolled out a program where pregnant women can receive free maternity services in public hospitals. Health systems functioning with adequate equipment, resources and trained personnel to handle maternal complications can reduce the risks of mortality. In Africa maternal deaths are associated with delayed referrals for women from lower level facilities, and where referral systems are not well equipped to handle emergency obstetric care [18]. The presence of skilled attendants during birth is also important in managing life-threatening com-
plications. In Kenya, the use of skilled attendants at delivery is currently 50% [19]. The Delay Model by McCarthy and Maine is a conceptual framework that has been used to assess factors contributing to maternal mortality in developing countries determinants
that contribute to the delay in deciding to seek care, the delay in reaching a health facility, and the delay in receiving quality care upon reaching a health facility. In Kenya, there has been insufficient progress made towards achieving MDG Five. The aim of this study is to
identify risk factors associated with maternal mortality in a tertiary level hospital in Kenya. Using a framework adapted from the Delay Model, this study analyses four sets of determinants: individual and socio-demographic, maternal history, reproductive or obstetric, and hospital admission/health system.


1. What was the hypothesis for this study (what did the researchers want to examine)? Please include the elements of PEO (Population, Exposure and Outcome).

2. What would be a suitable null hypothesis for this study?

3. Describe the rationale/justification for this study?

4. What are TWO advantages/strengths of this study? Your answer should be in particular reference to the paper you are assigned and please do not reiterate what authors have already mentioned.

5. What are TWO disadvantages/limitations of this study? Your answer should be in particular reference to the paper you are assigned and again, please do not reiterate what authors have already mentioned.

6. In your view, what are the ethical concerns in this particular study?

7. Explain if the authors have taken appropriate measures to address any ethics issues that may be relevant to the study.

8. Describe in detail who the participants were and how they were recruited into the study.

9. What level of evidence is the study design used in this study? Answer as per the NHMRC classification of ‘our version’ levels of evidence as mentioned in the Nearpod slides.

10. Do you think the study design was suitable to achieve the purpose of the study? Justify your answer.

11. According to the data reported in Table 1, please identify the mode group for occupation of mother. Justify your answer.

12. Using ‘maternal education’ and ‘maternal mortality’,

what could be a possible Type I statistical error?
what could be a possible Type II statistical error?

13. The authors reported “… mother’s age and mother’s education were significantly associated with mortality”. Please justify the authors’ findings.
14. The authors have also reported “Contraceptive use was protective (OR 0.3, 95%CI 0.1-0.6; p = 0.0007)”. Please justify the authors’ findings with interpreting the odds ratio in detail and comment on the significance of the result.

15. According to the information reported in Table 1 and Table 2, please fill in the table below by stating the types of variables.



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