A 4-Year Review of Maternal Mortality in Federal Teaching Hospital Katsina

Background: Maternal deaths are catastrophic events with awful socio-economic, emotional, and psychological trauma to the family and the society at large. Maternal mortality has remained a global concern, though not uniformly distributed throughout the world as low- and middle-income countries (LMIC) account for 94% of all maternal deaths globally. Most maternal deaths are potentially preventable, as pregnancy and puerperium are largely physiological processes and the leading causes of maternal mortality are either preventable and or treatable. However, there is no prevention of any negative outcome without a proper assessment of the causes associated with it.

Methodology: This was a retrospective study that reviewed maternal mortality in Federal Teaching Hospital (FTH) Katsina, Katsina State. Data was obtained from the hospital electronic health record (EHR). Relevant information was extracted using a proforma. Data obtained was inputted into SPSS version 25 and analyzed.

Result: Maternal mortality ratio over the study period was 1200.76. Majority were in the age group of 20-29years 40(37.4%), lived in a rural community 72(67.3%) and had no formal education 76(71.0%). Almost half 45(42.1%) of the maternal death over the period of review occurred in a grand multiparous woman and quite majority of them were not booked for antenatal 73(68.2%). Hypertensive disorders were the leading cause of maternal mortality, accounting for almost half (46.7%) of all the maternal death over the study period. Majority 48(44.8%) of the deaths occurred within 24 hours of presentation in our facility.

Conclusion: Maternal mortality at the FTH Katsina is still high despite the decreasing trend in developed countries over the years. The major cause of death was hypertensive disease in pregnancy, accounting for almost half of all maternal deaths. Lack of formal education, lack of antenatal care, high parity and rural dwellers and late presentation were significant predictors of maternal mortality.

Maternal deaths are catastrophic events with awful socio-economic, emotional, and psychological trauma to the family and the society at large [1, 2, 3]. Maternal mortality ratio (MMR) is not only reflective of the inequalities in access to health care but also the general socio-economic development of any society [1]. Maternal mortality is potentially preventable but has remained a global concern, though not uniformly distributed throughout the world as low- and middle-income countries (LMIC) account for 94 percentage of all maternal deaths globally [4]. Sub-Saharan Africa (SSA) as a region is mostly affected having the worst maternal mortality ratio. This is partly due to its poor living conditions, high rate of infections, and bad health care system [3-8]. Nigeria has one of the highest MMR in the world with an estimated MMR of 814 deaths per 100,000 live births [9]. Though there has been a considerable reduction in the global MMR, towards achieving a global target of less than 70 per 100,000 live births, however, the estimates in Nigeria indicate that there was an increase in MMR [1, 10]. This is due to the fact that the country's average indicator for attaining safe motherhood has remained the same over the past decade. Birth control usage rate has remained low at 10%; antenatal clinic attendances have remained at 64 percentage; and skilled birth attendance has remained among the lowest in SSA at 33 percentage [9]. It's not surprising therefore that Nigeria has made no significant progress in reducing MMR over the last decade, given the dismal maternal and reproductive health indicators [9]. Variations in MMR exist across the different geopolitical zones in Nigeria with the Northern regions having higher rates when compared with their Southern counterparts. This disparity is due to different socio-economic backgrounds and levels of implementation of healthcare strategies designed to reduce maternal deaths by various state governments [1]. Nigeria is a country which is characterized by many problems ranging from poverty, insecurity, political instability, geographical barriers and decayed social infrastructures including health facilities [9]. Therefore, the country is fighting challenges of health socio-demographic which include low life expectancy, high maternal and infant mortality, high fertility rate and communicable diseases [11]. 

Globally, more than 200 million women get pregnant annually, yet safe deliveries that are celebrated worldwide sometimes turns tragic to many women and families. Most maternal deaths are preventable, as pregnancy and puerperium are largely physiological processes and the leading causes of maternal mortality are either preventable or treatable [2, 3, 4, 12]. However, there is no prevention of any negative outcome without a proper assessment of the causes associated with it. The documentation of maternal mortality data in Federal Teaching Hospital Katsina can help to unmask useful information about the patterns and trends of maternal deaths in the institution. This in turn can assist in designing interventions specifically targeted at combating prevalent causes of maternal deaths in the institution. 

1. Prevalence of maternal mortality in FTH Katsina
2. To determine the most prevalent cause of maternal mortality in FTH Katsina
3. To describe the demographic characteristics of women who died from obstetric causes.

This was a retrospective study that reviewed maternal mortality in FTH. Data was obtained from the hospital electronic health record (EHR). This includes record of all patients that delivered including total number of live birth and those that died as a result of pregnancy and its complications from January 1st 2020 to December 31st 2023. Relevant information was extracted using a proforma. Data obtained was imputed into SPSS version 25 and analyzed.

The total number of live births over the study period was 8911 while the total number of maternal deaths over the same period was 107. This gives a maternal mortality ratio of 1200.76.

Table 1: Socio-demographic characteristics of the women

Table 1 Showed the sociodemographic characteristics of the women who died over the period of review. Majority were in the age group of 20-29years 40(37.4 percentage), live in rural community72 (67.3 percentage) and had no formal education 76(71.0 percentage).

Table 2: Obstetrics characteristics of the women

⃰Undelivered until death or admitted in peuperium.

Table 2 above shows that almost half 45(42.1 percentage) of the maternal death over the period of review occurred in grandmultiparous women and quite majority of them were unbooked pregnancy 73(68.2 percentage).

Table 3: Mortality characteristics of the women

⃰Others with frequency of occurrence of 1 are missed abortion, epistaxis in pregnancy, shoulder dystocia, pyelonephritis with dyselectrolytaemia, DVT, acute fatty liver, IUFD with transverselie in labour, breech presentation in labour, ureteric injury in post-hysterectomy patient due to uterine rupture.; +APH; Antepartum Haemorrhage: PPH; Post Partum Haemorrhage; # Peripartum cardiac failure; $ Vaso Occlusive Crisis.

Table 3 above shows hypertensive disorders as the leading cause of maternal mortality, accounting for almost half 50(46.7 percentage) of all the maternal death over the study period. Though majority 48(44.8 percentage) of the deaths occurred within 24 hours of presentation in our facility, only 11.2 percentage deaths occurred in less than 3 hours of hospital presentation.

The maternal mortality ratio over the four-year period was 1200.76/100,000 live births, which is far more than the SDG target of less than 70 per 100,000 live births by 2030. However, the MMR is comparable with 2020 estimate of MMR in Nigeria of 1047/100,000 live births by the United Nations Maternal Mortality Estimation Inter-Agency Group (MMEIG) – comprising WHO, the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA), the World Bank Group and the United Nations Department of Economic and Social Affairs, Population Division (UNDESA/Population Division) [13]. In a study by Abdulkadir et al in Northwestern Nigeria, a similar MMR of 1362/100,000 live births were reported [11]. Report from Lagos [12] showed a much higher MMR of 2674.4/100,000 live births. The higher MMR recorded in Lagos might be due to the densely populated nature of the city. Considerably lower MMR have been reported in some developing and developed countries; 604, [2] 139.3,[6] 129.34[14] and 17.4[15] per 100,000 live births in Ghana, South Africa, Nepal and United States of America respectively. 

The most common cause of maternal mortality in this study was hypertensive disorders in pregnancy, occurring in 46.7 percentage of all the maternal mortality. This was distantly followed by puerperal sepsis accounting for 15 percentage, Obstetric haemorrhage occurred in 3.7 percentage of all the mortality cases. Similar report was documented from various studies reported by Olamijulo et al,[1] Baofor et al,[2] Hansda et al [3] and Olamijulo et al [12] where hypertensive disorders in pregnancy accounted for nearly half of maternal deaths. This implies `that any strategy developed to reduce maternal deaths in FTH Katsina must also target hypertensive disorders in pregnancy. It is worthy of note that 67.3 percentageof maternal deaths over the study period were inhabitants of rural communities, 68.2 percentage did not book for antenatal at all while 22.4 percentage booked their pregnancy in a primary health care and only 9.3% booked their pregnancy in FTH Katsina. The general poor health seeking behavior of the populace, inadequate distribution of health facilities in rural communities, together with extreme poverty in Nigeria are the possible responsible factors for poor booking status noted in this study. A booked pregnant woman will likely benefit from early diagnosis of pregnancy-induced hypertension (PIH). The treatment for PIH will then be treated timely, thereby preventing complications responsible for the high mortality from hypertensive disorders in pregnancy. The admission-death interval was within 24 hours in 44.8 percentage of cases. In a study conducted an in tertiary hospital in India, where the leading cause of maternal death was also hypertensive disorders (39.5 percentage), close to half (38.8 percentage) of the maternal death also occurred within the 24 hours of presentation to hospital [3]. This may suggest late presentation of patient together with late referral from peripheral hospitals. Critical evaluation of the current management protocols for hypertensive complications in pregnancy at both referring and tertiary hospitals is therefore urgently needed to identify gaps in their operations for redress. There may be the need to train and retrain doctors, midwives and other care givers on the national treatment guidelines and protocols for the management of hypertensive disease in pregnancy, especially on the use of magnesium sulfate to prevent eclampsia. Supportive supervision of referral centers has to be intensified so that preeclampsia is recognized, treated and referred early. Obstetrics haemorrhage was reported as the commonest causes of maternal mortality by Abdulkadir et al [11] and Situala et al. [14] Hypertensive disorders ranked second in these studies.

In this review, we identified lack of formal education, poor antenatal clinic visit, illiteracy, rural dwellers, high parity and late presentation of patients or late referral of patients from peripheral hospitals as factors associated with maternal death, which have also been reported in other similar studies [2, 3, 16]. This underlines the need for government to play its part in combating high maternal deaths in our environment. This includes improvement of health service delivery to rural dwellers, making policies to mandate formal education for all children, alleviation of poverty, awareness, at all levels, emphasizing the importance of antenatal care and limitation of family size by embracing effective family planning method.

Maternal mortality at FTH Katsina is still high despite the decreasing trend in developed countries over the years. The major cause of death is hypertensive disease in pregnancy, accounting for almost half of all maternal deaths. Lack of formal education, lack of antenatal care, high parity and rural dwellers and late presentation were significant predictors of maternal mortality. Improved female education, regular antenatal care, improved health facilities in rural communities, improved uptake of modern contraceptive to ensure limited family size and better management of complications of hypertensive disease in pregnancy may reduce maternal death.