Maternal death refers to the death of women during pregnancy, childbirth, and the first 42 days of the postpartum period from any cause related to or aggravated by pregnancy (1). Globally, approximately half a million maternal deaths occur every year (2). Ethiopia is one of the six countries which have contributed to more than 50% of all maternal deaths across the world.
This article aims to provide a comprehensive overview of maternal mortality in Ethiopia, examining the trends, causes, and challenges in reducing maternal deaths. It will also explore the progress made towards achieving the Millennium Development Goals (MDGs) and Sustainable Development Goals (SDGs) related to maternal health.
Ethiopia's reduced maternal mortality rate
Methodology
This review includes 19 health facility-based studies from Ethiopia, which were reported between 1980 and 2012 (13-31). The literature search strategy used for this systematic review was focusing on electronically accessible studies in different data bases. The majority of the studies included were retrieved from local journals, MEDLINE and PUBMED.
From the studies included, the following information was abstracted: name of authors, study period, study design, study location, major conclusion drawn with regard to causes of maternal deaths, the number and proportion of maternal deaths, the number of maternal deaths and the case fatality rate of specific causes.
The selected studies were cross sectional and cohort by design. The focus of interest for this review was causes of maternal mortality during the study period. Health facility- based studies that addressed causes of maternal mortality as proportion or case fatality rate and published in either electronically accessible or local journals between 1980 and 2012 in Ethiopia were included.
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In this review, hypertensive disorder of pregnancy means preeclampsia or eclampsia. Maternal deaths due to hemorrhage include both antepartum and postpartum hemorrhage.
To estimate the proportion of maternal mortality due to direct obstetric causes, the total number of (actual values) maternal deaths in each study was added as denominator and similarly, the actual number of maternal deaths due to a specific cause in each study was added as numerator. Data were summarized in the form of table and bar graphs.
Trends in Maternal Mortality Ratio (MMR)
According to Hogan et al (2), the global estimate of maternal mortality ratio (MMR) decreased from 422 (95%CI: 358-505) in 1980 to 251 (95% CI: 221-289) per 100,000 live births in 2008. After two years, the World Health estimate for 2010, however, was more than double of the estimate made by Hogan et al (521/100,000 live births) (3). The World Health Statistics 2013 also showed that the MMR in some high income countries ranges from 3-5/100,000 live births. It was also reported that more than 50% of all maternal deaths worldwide occurred in three Asian (India, Pakistan, Afghanistan) and three African (Nigeria, Ethiopia, and the Democratic Republic of Congo) countries (2, 4).
Figure 1 shows the mean maternal mortality ratio (MMR) trend for the nation as estimated by the three EDHSs (2000, 2005, 2011) (9-11), WHO (3, 4) and by the Institute for Health Metrics and Evaluation (2). The mean MMR estimates in both WHO et al and Hogan et al data demonstrated a continuous down-going trend. The WHO et al MMR estimation for 2010 in particular was nearly half of the EDHS 2011 estimate (350 vs 676), and it is the ever lowest MMR estimate for the nation.
Figure 1: Trend of the national maternal mortality ratio as estimated by the Ethiopian demographic and health surveys (EDHS) (10-12), World Health Organization (WHO) (2, 3) and Hogan et al (1)
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In a closer assessment, neither the national nor the small scale studies’ estimates demonstrated a significant change in MMR over the last three decades.
The international community declared its commitment several times to reduce maternal and neonatal mortality in low income countries like Ethiopia. Ethiopia, as UN member country that signed several international agreements, has adopted the MDGs.
Causes of Maternal Mortality
Traditionally, the causes of maternal mortality have been classified as direct and indirect, each contributing to about 70%-80% and 20%-30% of the total maternal deaths, respectively (4-7). The majority of these fatal obstetric complications occur during labor and immediately after birth. What is not exactly known in Ethiopia is the contribution of each of these common causes to the overall maternal mortality.
The summary of findings from studies done between 1980 and 1999 showed that the top four causes of maternal mortality were abortion related complications (31%), obstructed labor/uterine rupture (29%), sepsis/infection (21%) and hemorrhage (12%).
Figure 8 summarizes the direct causes of maternal mortality before and after year the 2000 in Ethiopia (13, 15, 20-22, 24, 26, 27). In short, there has been a significant drop in the proportion of maternal mortality due to abortion and infection in the year 2000 and beyond. The maternal deaths due to obstructed labor/uterine rupture remained to be the leading cause.
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Figure 8: Comparison of the causes of maternal mortality in Ethiopia in the 1980-1999 and 2000+ with 1992 and 1996-2002 WHO report for Sub-Saharan Africa (SSA) and Africa, respectively
The top four causes of maternal mortality in the year 1980-1999 were abortion related complications (31%), obstructed labor/uterine rupture (29%), sepsis/infection (21%) and hemorrhage (12%). Abortion and infection related maternal deaths have declined significantly in the last decade. Obstructed labor continues to be the major cause of maternal deaths; maternal deaths due to hypertensive disorders and hemorrhage showed an increasing trend.
Table 1 provides a summary of the trends and causes of maternal mortality in Ethiopia.
| Cause of Death | 1980-1999 (%) | 2000+ (%) |
|---|---|---|
| Abortion-related complications | 31 | Declined significantly |
| Obstructed labor/uterine rupture | 29 | Leading cause |
| Sepsis/infection | 21 | Declined significantly |
| Hemorrhage | 12 | Increasing trend |
| Hypertensive disorders | N/A | Increasing trend |
Figure 1 shows the proportion of abortion related maternal mortality in Ethiopia between 1980 and 2008. Although there were variations in sample size, geographical location, timing of report and the design among the studies, the trend line demonstrated that the gross estimate of maternal mortality due to abortion was decreasing.
Figure 3 shows the proportion of maternal mortality due to obstructed labor or uterine rupture in different public hospitals between 1980 and 2012. The highest proportion of obstructed labor/uterine rupture related maternal deaths were reported from Jimma and Ambo hospitals in the 1980s-1990s (15, 16, 29, 31) and early 2000s (22, 24); about half to one-third of all maternal deaths during each study period were due to obstructed labor or uterine rupture.
The proportion of maternal mortality in Ethiopia due to hypertensive disorders between 1980 and 2012 is presented in Figure 4. Although the setup, design and timing vary among the included studies, an overall increasing trend of maternal deaths due to hypertensive disorders is observed.
With regard to maternal deaths due to hemorrhage (Figure 6), four studies (13, 16, 17, 21) reported 7%-10% while six studies (15, 20, 26, 27, 29, 31) reported 12%-28%. The overall trend of maternal deaths due to hemorrhage seems increasing.
As presented in Figure 7, infection was one of the major contributors for the high maternal mortality in Ethiopia in the 1980s-1990s and early 2000s. Particularly, the reports from Jimma and Ambo hospitals showed that more than a quarter of maternal deaths were due to infection. Among single hospital-based studies, relatively low proportion of maternal deaths due to infection was reported from Atat Hospital (20).
Challenges and Opportunities
On the other hand, the continuity of high maternal mortality due to obstructed labor with or without uterine rupture, hemorrhage and hypertensive disorders may be explained by the fact that the majority of the pregnant women came to health facility very late and usually with advanced complications (11, 12, 22, 36, 37). Ethiopian demographic and health surveys had also showed that the majority of pregnant women had no antenatal care and 95% in the 1995-2000 and 90% in the 2006-2011 gave birth at home unattended by skilled health personnel (38, 39). It was also pointed out that for postpartum hemorrhage, there are only two hours in which to intervene to prevent maternal death. Death from a ruptured uterus may take one day, and from eclampsia two days (40, 41).
The biggest challenge in the last three decades and perhaps in the years to come is obstructed labor and its complications. Several individual studies in Sub Saharan Africa (44-47) and the WHO systematic review for Africa (34) showed that obstructed labor with or without uterine rupture accounted for less than 5% of maternal mortality, which was more than two-fold less than the Ethiopian figure in the national study (13%) and more than six-fold less than the finding of this review for the year 2000-2012 (36%). This shows that the maternal mortality due to obstructed labor was unacceptably high in Ethiopia; and it was probably the reflection of the high prevalence of home delivery, especially in the rural areas (39).
As presented in another article (48), although more than half of African countries achieved 50%-99% health facility delivery, it was only 10% of women in Ethiopia who gave birth in health facility.
Progressing Toward the Sustainable Development Goals
Ethiopia has accomplished remarkable reductions in NMR and MMR in the past two decades. This progress has situated the country nearer to the SDG targets, although continued progress will be necessary to reach these ambitious targets.
The SDG target for maternal mortality is for global MMR to be less than 70 maternal deaths per 100,000 live births. Each country has a national target of a two-thirds reduction from 2010 levels of MMR by 2030, with no country’s MMR to exceed 140 maternal deaths per 100,000 live births. Given Ethiopia’s high baseline MMR, the country’s national SDG target is 140 maternal deaths per 100,000 live births.
Equity Trends for Key Reproductive, Maternal, Newborn, and Child Health Indicators in Ethiopia
Narrowing existing equity gaps in key indicators - including family planning, antenatal care coverage, in-facility delivery, cesarean section (C-section), and postnatal care - will be crucial in continuing Ethiopia’s rapid progression through the transition framework and achieving SDG targets. Considering Ethiopia’s widely diverse demographics across regions - especially with regards to pastoralist and agrarian settings - identifying subnational trends is particularly important in the country.
Family Planning
In 2000 in Ethiopia, family planning was generally only available to the most affluent communities, as demand satisfied by modern methods was 38.7% for the wealthiest quintile, but under 10% for all others. This resulted in an absolute gap in demand satisfied of 33.6% in 2000 between the richest and poorest wealth quintiles. This gap remained at 33.0% in 2016, but considering the low baselines in coverage for poorer wealth quintiles, this indicates greater relative progress for these communities.
Antenatal Care
Coverage of ANC has seen slightly different trends across equity dimensions. While the CAGR for ANC4+ coverage has been higher among the poorest wealth quintile than the richest quintile, this margin has not been high enough to narrow the gap in the past two decades. In 2000, there was a 30.6% absolute gap in ANC4+ coverage between the wealthiest and poorest quintiles, but by 2019 this had expanded to a 50.3% absolute gap. This translates to 70.4% of mothers in the wealthiest quintile receiving four or more antenatal care visits compared with only 20.1% of mothers in the poorest wealth quintile.
In-facility delivery
In Ethiopia in 2000, facility-based delivery was almost entirely limited to the wealthiest communities. In-facility delivery rates were 22.7% among the wealthiest quintile, 3.2% for the second wealthiest quintile, and near 1% for the poorest three quintiles. There have been dramatic improvements for in-facility delivery coverage in recent decades, though disparities across wealth quintiles have expanded. In 2019, in-facility delivery coverage was 85.9% among the wealthiest quintile and 19.7% among the poorest quintile. The absolute gap between the richest and poorest quintiles has therefore expanded from 22.0% in 2000 and 66.2% in 2019.
Cesarean section
Disparities in in-facility delivery coverage has translated to gaps in C-section rates across many equity gradients, with this procedure being far more common among wealthier, urban communities. In 2000 almost all C-sections occurred among births for the wealthiest quintile, as 3.6% of births to the wealthiest women were via C-section wereas less than 0.2% of other births were by C-section. In 2019, this procedure still occurred substantially more frequently among wealthier women than poorer women, accounting for 14.3% of births among the wealthiest quintile and 1.6% among the poorest.
Postnatal Care
In line with other health service indicators, disparities in postnatal care (PNC) coverage levels have similarly improved. This is likely linked to trends seen for in-facility delivery across wealth quintiles. In 2019, 50.7% of mothers in the wealthiest quintile received PNC within four hours of birth as compared with only 11.3% of mothers in the poorest quintile. This absolute gap of 39.4% is larger than the 17.5% absolute gap seen in 2011.
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