Journal of Women Health Care and Gynecology

2024 Volume 3, Issue 1

DOI: 10.59657/2993-0871.brs.24.025

Research Article Open Access

Determinants of Maternal Mortality in Nekemte Town Government
Hospitals, Eastern Wollega, Oromia Region, Ethiopia, 2022 G.C
Lili Asefa Merga1**, Tewodros Kassahun Tarekegn2*, Kirubel Tesfaye Hailu3*, Feven Negasi
Abriha3, Hamlet Mulu Aberha2, Buure Ayderuss Hassen2, Michael Yefrashowa Betemariam2,
Damise Dugasa Gessifata1, Sanyi Beyena Garbi1, Rediet Habtu Lebelo4, Helen Assefa Berhe5,
Solomon Endale Dagnachew2, Birukti Gebreyohannes Habtezgi2, Surafel Alemayehu Tsegaye6
1
Department of Medicine, Wollega University, Oromia, Ethiopia
2
Department of Medicine, Hayat Medical College, Addis Ababa, Ethiopia.
3
Department of Medicine Jimma University Oromia Region, Ethiopia
4
Department of Medicine, Mekelle University, College of Health Science, Mekelle. Ethiopia.
5
Department of Medicine, Addis Ababa University, Tikurs Anbessa, College of Health Sciences, Ethiopia.
6
MPH Candidate at the Harvard T.H. Chan School of Public Health in Boston, Massachusetts, USA.
*Corresponding author: Tewodros Kassahun Tarekegn.
Abstract
Background: Maternal mortality is defined by World health organization as the demise of a woman during maternity in
the first 42 days of cessation of pregnancy, regardless of site & time of the pregnancy, from any reason linked to gravidity
or its management, but not from unintentional causes. The Sustainable Development Goal puts an ambitious target of
achieving maternal mortality rate of 70 per 100,000 live births in 2030, while Ethiopian Health sector transformation
plan targets to decrease to 199 per 100000 Live births.
Objective: This study aimed to assess determinants of maternal mortality in Nekemte town Government Hospitals from
September 2017 August 2022 G.C.
Methods: Institution-based case–control study was used to identify determinants of maternal death. A total of 216 samples
(54 cases and 162 controls) with a case to control ratio of 1:3 was selected. Cases are mothers who died during their
maternity period where as controls are mothers who survived. Data was edited for accuracy, readability, consistence and
completeness; thereafter it was coded and entered into Epi Info version 7.2.5.0 and exported to SPSS 20 computer software
programs for cleaning and descriptive analysis. Bivariate logistic regression analysis was done & variables with p-value
<0.25 was transferred to Multivariate analysis & variables with P-value < 0.05 was considered as statistically significant &
AOR with 95% CI was used to control for possible confounders & to interpret the result. Finally, the results were
summarized & presented by using tables, graphs & charts.
Result: More than two third (75.93%) of death occurred during post-partum period. Determinants of maternal death
include: age group of 20-34 (OR 2.127, 95% (0.374, 12.102)), being from rural area (OR 6.615, 95% CI (0.14, 0.562)),
prolonged labour, Haemorrhage (OR=1.91, 95% CI (0.33, 2.27)), Pregnancy induced hypertension (OR=1.28, 95% CI
(1.01, 3.31) and comorbidities (OR=18.458, 95%CI (3.639, 93.615)).
Conclusion: Most of the women died in the postpartum period, mainly because of direct obstetric causes, of which
Haemorrhage was the leading cause of death and followed by sepsis and Pregnancy induced hypertension.

Keywords: maternal mortality; determinants; trends; nekemte specialized hospital; WURH

Introduction solely on the timing of the death in relationship to

Maternal mortality is defined by World health
organization (WHO) as the demise of a woman
during maternity in the first 42 days of cessation of
pregnancy, regardless of site & time of the pregnancy,
from any reason linked to gravidity or its
management, but not from unintentional causes [1].
Estimates of maternal mortality are therefore based
pregnancy. Maternal health has become one of the
major public health concerns for developing countries
following the first safe motherhood conference held
in Kenya in 1987 [2]. In the post Millennium
Development era (MDG) era, the Sustainable
Development Goal (SDG) puts an ambitious target of
achieving MMR of 70 per 100,000 live births (LB) in
2030 [3].While some progress have been made,

© 2024 Tewodros Kassahun Tarekegn, et al. 1

Journal of Women Health Care and Gynecology
according to WHO estimate in 2015, the Maternal
Mortality Ratio (MMR) dropping by 43.9%
worldwide between 1990 and 2015, it remains
unacceptably high in developing countries
particularly in sub-Sahara African countries
[4]Furthermore, the 2011 Ethiopian demographic
and health survey (EDHS) (676/100,000) showed
that there is an increase of MMR from 2005 EDHS
(673/100,000), but EDHS 2016 reveals decreasing
trends (412/100000). The effects of maternal
mortality have impacts on children and remaining
families. For instance, the infant and under-five
survival are highly correlated with child nutrition and
other important child health care practices
demanding maternal involvement [5]. The causes of
maternal mortality are multi-factorial. An in-depth
analysis on the trends of maternal health in Ethiopia
pointed to demographic, behavioral, nutritional, and
health services related factors are associated with poor
maternal health outcomes [6]. Yet, the key factors
attributable for the death of mothers are related to
low facility deliveries, poor competence of providers,
lack of emergency obstetric services at facilities, and
inefficient referral systems for obstetric emergencies
and in this regard, several studies reported limited
utilization of key maternal health services in Ethiopia
[7].
Statement of the problem
Maternal mortality is a global health problem and has
devastating effects on the family she leaves behind and
country level [8]. Pregnancy related complications
account about five million maternal deaths with the
global estimate for lifetime risk of maternal deaths 1
in 74 [9] and an estimated 295 000 maternal deaths
occurred in 2017, yielding an overall MMR of 211 per
100 000 LBs [10]. Developed countries have ratios less
than 10-20 per hundred thousand live births. The
corresponding ratios for developing countries range
in the several hundred; reaching up to eight hundred
or more in some countries. Over 99% of maternal
deaths occur in low- and middle-income countries due
to extreme poverty resulting in lack of access to quality
healthcare and education of women [11]. Which is 14
times higher than that in developed regions. The
majority of maternal deaths occur in Sub-Saharan,
accounting for 62 % of maternal deaths and has the
highest MMR, at 510 maternal deaths per 100,000
live births [12]. There was significant regional
disparity; with women in sub-Saharan Africa having a
lifetime risk of 1 in16 [13]. Maternal mortality ratio is
© 2024 Tewodros Kassahun Tarekegn, et al.
ISSN:2993-0871 BioRes Scientia Publishers
the health indicator showing the largest disparity
between developed and developing countries. It
becomes one of the major public health concerns for
developing countries [14]. The adult lifetime risk of
maternal mortality, the probability that a 15-year-old
woman will die eventually from a maternal cause in
Sub-Saharan Africa is the highest at 1 in 38; and 1 in
3,700 among women in developed countries [15].
Ethiopia is categorized under the countries with high
maternal mortality, EDHS 2016 reports the maternal
mortality is high as 412 per 100,000 live births. Levels
of maternal mortality indicate the quality of maternity
services rendered. A country’s level of maternal
mortality is indirect evidence that shows Quality of
service delivery and referral system, Number,
distribution, and training of the types of providers
required, including midwives and obstetrician-
gynecologists, Leadership and financing, well-
functioning health system, how health institutions are
well organized & equipped, emergency obstetric
services are highly responsive, the care given to
mothers is of high standard [16].
The effects of maternal mortality have impacts on
children and remaining families. For instance, the
infant and under-five survival are highly correlated
with child nutrition and other important child health
care practices demanding maternal involvement [5].
Seventy-three percent of all maternal deaths were
attributable to direct obstetric causes; (hemorrhage,
PIH, Abortion, sepsis) deaths due to indirect causes
accounted for 27.5 % (anemia and malaria) [13].
Some of the factors mentioned as contributory to
maternal deaths are lack of intensive care unit facility,
not having antenatal care, absence of blood
transfusion services, and lack of essential supplies at
hospitals, delayed diagnosis and surgical interventions
and delayed seeking of health care. Residence in rural
areas, presence of co morbidity, women who were
referred from health institutions and women who had
prolonged labor had increased likelihood of maternal
death and most death (74.8%) occurred during post-
partum period; from post-partum period of the first
three days [17]. Sustainable Development Goal (SDG)
puts an ambitious target of achieving MMR of 70 per
100,000 live births (LB) in 2030 [3]. While some
progresses have been made, according to WHO
estimate in 2015, the Maternal Mortality Ratio
(MMR) dropping by 43.9% worldwide between 1990
and 2015, it remains unacceptably high in developing
countries particularly in sub-Sahara African countries
[4]. In Ethiopia the reports also show that there is
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Journal of Women Health Care and Gynecology
great disparity, targeted 267per 100,000 live births,
achieved is 412 per100,000 live births [16]. Maternal
age (younger than 20 and over 30), parity (primipara
and grand multipara), marital status (single) and
occupation, places of delivery, previous C/S, showed
a significant association with the risk of maternal
death. However, other equally important factors like
Gravidity, delivery attending physician, presence of
Obstetric complications and Distance from the
hospital and Residency area of patients have been
given little attention, and thus are not well studied or
understood [18].
Significance of the Study
Maternal death is widely regarded as one of life’s most
tragic outcomes. There is a big pain in the death of a
woman who is engaged in the act of creating life, and
her death is an incomparable loss for any children
who are left behind.
Therefore, the aim of this study is to assess
determinants of maternal mortality which is essential
to assess existing status as well as monitor changes
effected by interventions in government hospitals in
Nekemte town It will also identify variation in
relation to age groups, residence (rural, urban),
gravidity, parity and duration of labor as a result helps
health professionals to work on early identification
and detection of obstetric risk factors and
complication and to give appropriate intervention to
reduce maternal death. Information generated from
this study can be used by health professionals, health
care planners, managers and policy makers to save
women’s lives by improving the quality of care
provided. It is intended that this information will help
or contribute to change policies and practices that will
lead to improvements in maternal health. It is also
intended that this study can be used as input for
WURH, researchers and academicians.
Determinants of Maternal Deaths
According to the World Health Organization (WHO)
document from Millennium Development Goals
(MDG) to Sustainable Development Goals (SDG), an
estimation of 303, 000 maternal deaths occurred
worldwide from pregnancy and its complications
which is equivalent to 830 mothers dying every day
(more than 1 life lost every 2 minutes) in 2015.
Nearly, all of these deaths are preventable in nature if
appropriate interventions are taken [21]. The
determinant factors were presence of obstetric
complications, presence of obstructed labor and
© 2024 Tewodros Kassahun Tarekegn, et al.
ISSN:2993-0871 BioRes Scientia Publishers
preexisting medical problems were risk factors for
maternal death [31].
Socio-demographic Determinants
Many studies showed that the risk of maternal death
is significantly associated with the occupation, age,
education (of the mother and husband), substandard
or no ANC service and visit, place of residency,
maternal obstetrics characteristics (gravidity and
parity), and preexisting Problems [28]. Although the
overall risks of maternal death are highest among
young adolescents and older women of reproductive
age, the highest number of deaths is in the middle
group of women around age 25 years. Study in Ghana
shows the age group with the highest number of
deaths was30 to 35 with 24.7 percent, followed closely
by the 30-34 age groups with 23.4 percent. Indeed, the
age group of 30-39 accounted for nearly half of the
deaths in the cases. While, in Ethiopia the EDHS
2016, shows highest number of deaths was 30-34
followed by 40-44. The 30-39 age groups accounted
for the highest number of deaths due to the fact that
they were ‘multi-gravid’, thus they had given births
multiple times in the past [30]. According to the
World Health Organization (WHO) document from
Millennium Development Goals (MDG) to
Sustainable Development Goals (SDG), an estimation
of 303, 000 maternal deaths occurred worldwide from
pregnancy and its complications which is equivalent
to 830 mothers dying every day (more than 1 life lost
every 2 minutes) in 2015. Nearly, all of these deaths
are preventable in nature if appropriate interventions
are taken [21]. Worldwide most maternal deaths do
not have well-defined causes, but nearly 73.0 percent
of all maternal deaths were attributable to direct
obstetric causes; deaths due to indirect causes
accounted for 27.5 percent (95 percent confidence
interval 19.7–37.5) of all deaths. The major causes of
maternal mortality are as follows: Hemorrhage, 27.1
percent (95 percent confidence interval 19.9–36.2);
more than 72.6 percent of deaths from hemorrhage
were classified as postpartum hemorrhage,
Hypertension, 14.0 percent (95 percent confidence
interval 11.1–17. 4), Sepsis, 10.7 percent (95 percent
confidence interval 5.9–18.6), Abortive outcomes, 7.9
percent (95 percent confidence interval 4.7–13.2),
Embolism and other direct causes, 12.8 percent [22].
Hypertensive Disease
Women in pregnancy or the puerperium can suffer
from preeclampsia, eclampsia, and chronic
hypertension. Eclampsia and preeclampsia tend to
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occur more frequently in the second half of
pregnancy; less commonly, they can occur up to six
weeks after delivery. Medication can alleviate the
symptoms and their negative effects, but the only cure
is expedited delivery. The etiology of the condition
remains unclear but the overall aggregate prevalence
rate of preeclampsia and eclampsia was 6.7 % (95 %
CI = 5.8 %–7.6 %) [23].
Obstetric Hemorrhage
Women can experience anomalous or excessive
bleeding because of an early pregnancy loss, a
placental implantation abnormality, or an
abnormality in the process of childbirth. The
systematic review by Creswell and others finds a global
prevalence of 0.5 percent for placenta Previa (95
percent confidence interval 0.4 percent to 0.6 percent
(27). An equivalent systematic review for placental
abruption has not been published, but most papers
on this condition suggest an approximate prevalence
of 1 percent [24]. WHO indicates that every year
around 14 million mothers in the world suffer from
vaginally bleeding following delivery. Based on world
health organization data, probability of maternal
mortality caused by postpartum hemorrhage is 1 in
1000 deliveries in developing countries, including
Ethiopia. Moreover; all most all (99%) of maternal
mortality due to vaginal bleeding following delivery
occur in low- and Middle-income countries (29).
World health organization reported that hemorrhage
is the first leading case of maternal mortality globally
[25]. Two different studies which were done in Jima
and Kersa revealed that postpartum hemorrhage was
the first leading cause of maternal mortality which
accounts for 54% and 46.5% maternal mortality
respectively [26].
Comorbidity
The study found that the indirect causes of maternal
death, when combined, are the most common cause
of maternal death. A breakdown of deaths due to
indirect causes suggests that more than 70 percent are
from preexisting medical conditions, including
HIV/AIDS, exacerbated by pregnancy. The
proportion of deaths due to indirect causes was
highest in Southern Asia, 29.3 percent (95 percent
confidence interval 12.2 percent to 55.1 percent),
followed by Sub-Saharan Africa, 28.6 percent (95
percent confidence interval 19.9 percent to 40.3
percent); indirect causes also accounted for nearly
25.0 percent of the deaths in the developed regions.
The overall proportion of HIV/AIDS maternal
© 2024 Tewodros Kassahun Tarekegn, et al.
ISSN:2993-0871 BioRes Scientia Publishers
deaths is highest in Sub-Saharan Africa, 6.4 percent
(95 percent confidence interval 4.6 percent to 8.8
percent) [27]. When they are expecting their first baby
or when they have had many pregnancies, when they
live far away from health facilities, or when they do
not benefit from support from their families and
friends. The risk of maternal deaths has two
components: the risk of getting pregnant, which is a
risk related to fertility and its control or lack of
control; and the obstetric risk of developing a
complication and dying while pregnant or in labor.
The obstetric risk is highest at the time of delivery.
The determinants of these risks share many
similarities, but also have specific characteristics [29].
The accessibility and availability of good quality
family planning and legal abortion services are key
determinants of maternal mortality in many LICs.
Quantitative models suggest that preventing
pregnancy with contraception has a bigger role to play
in reducing maternal mortality than does inducing
abortion when pregnant with an unintended
pregnancy [15]. The WHO health system building
blocks offer a starting point for classifying health
system determinants and include the following:
Quality of service delivery and referral system,
Number, distribution, and training of the providers
required, including midwives and obstetrician-
gynecologists, Completeness and responsiveness of
the health information system, including the
adequacy of the Maternal Death Surveillance and
Response, Ease of access to essential medications,
such as magnesium sulphate, misoprostol, and
oxytocin, and the supplies necessary for blood
transfusions [2].
Antenatal care (ANC) from a skilled provider is
important to monitor pregnancy and reduce
morbidity and mortality risks for the mother and
child during pregnancy, delivery, and the postnatal
period (within 42 days after delivery). Urban women
were more likely than rural women to have received
ANC from a skilled provider (90 percent and58
percent, respectively) and to have had four or more
ANC visits (63 percent and 27 percent, respectively).
The percentage of women who used a skilled provider
for ANC services and who had four or more ANC
visits for their most recent birth in the five years
preceding the survey increases greatly with women’s
education. Among women with no education, 53
percent obtained ANC services from a skilled
provider and 24 percent received four or more ANC
visits compared with 98 percent and 73 percent,
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Journal of Women Health Care and Gynecology
respectively, of women with more than a secondary
education. The use of ANC services by a skilled
provider and proper number of ANC visits also
increases steadily with household wealth [3].
Conceptual framework
Figure 1: Conceptual framework for the study on determinants of maternal mortality in WURH and Nekemte specialized
hospital, 2022.
Objectives of the Study
General objective
To identify determinants of maternal mortality in
government hospitals in Nekemte town from
September 2017-August 2022 G.C., Nekemte,
Eastern Wallaga, Oromia Region, Ethiopia, 2015
E.C.
Specific objectives
To identify the Socio-demographic determinants of
maternal mortality in government hospitals in
Nekemte town from September 2017-August 2022
G.C. To identify the obstetric related determinants of
maternal mortality in government hospitals in
Nekemte town from September 2017-August 2022
G.C.
Methods
Study area and Period
The study was conducted at Nekemte specialized
hospital and Wallaga university referral hospital
which are located in Nekemte town. Nekemte town is
located 328 Km from Finfinne in the western
direction, East Wallaga Zone, Oromia regional state,
Ethiopia. WURH is one of the teaching hospitals
found in western part of the country that runs under
Wallaga University and serves catchment population
of about 14 million and is located 12km west of
© 2024 Tewodros Kassahun Tarekegn, et al.
ISSN:2993-0871 BioRes Scientia Publishers
Maternal death is believed to be influenced by
different factors such as Socio-demographic factor,
pregnancy complications, obstetric and delivery
history, health seeking behaviour.
Nekemte city on the way to Ghimbi and NSH is one
of the oldest public hospitals found in western part of
the country that runs under Oromia Regional state.
Currently the hospital serves as referral site and
provides specialized care for the western parts of
Ethiopia. Services provided at both hospitals include:
internal medicine, surgery, obstetrics and gynecology,
pediatrics, outpatient services, emergency & intensive
care, Cancer treatment and Orthopedics. The study
was conducted from November 19-24, 2022 G.C on
among charts of women who visited for utilization of
antenatal, delivery and to 42 days postpartum, from
September 2017 —August 2022 G.C.
Study Design
Institution based unmatched case–control study was
used.
Source Population
All charts of mothers who visited WURH and
Nekemte specialized hospital (NSH) for utilization of
antenatal, delivery and to 42 days postpartum, from
September 2017-August 2022 G.C.
Study Population
Cases: Mothers who died during pregnancy, delivery
and 42 days after delivery at WURH and NSH from
September 2017-August 2022 G.C. those with fully
registered variables.
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Journal of Women Health Care and Gynecology
Controls: Alive mothers who visited WURH and
NSH for utilization of antenatal, delivery and to 42
days postpartum, from September 2017 —August
2022 G.C. those with fully registered variables.
Study unit
Selected case and controls that are with fully
registered variables
Inclusion Criteria
All mothers who died during their maternity period
and control which came for utilization of antenatal,
delivery and to 42 days postpartum, and survived.
Exclusion criteria
Cases and controls that are registered on the log book
but whose charts were missed Charts that didn’t
include the assessment of admission and status of
mother (dead or alive) during discharge was excluded
from the study.
Sample size determination
Sample size was determined using Epi Info version
7.2.5.0 considering the following assumptions: 95%
CI, 80% power, 1 case to 3 control ratios (1: 3),
percent of controls represented as 45.42%, and Odds
ratio of 2.594 taken from unmatched case-control
study done at Borena Zone, Oromia Region, Ethiopia
[28] in which variables of (Place of residence,
Husband’s education, Parity, ANC attendance and
Place of delivery) were included with place of
residence providing largest sample size. So, a total of
216 (54 cases and 162 controls) sample size was
determined.
Sampling procedures
Charts of both cases (all charts of mothers who died
during pregnancy, delivery, and up to 42 days after
delivery in WURH and NSH from September 2017-
August 2022 G.C. and controls (all charts of mothers
who visited WURH and NSH for maternal health
service utilization from September 2017-August 2022
G.C. and survived were selected from delivery ward,
maternity wards, gynaecology, intensive care unit and
operation theatre. Individual cases and controls
fulfilling the inclusion criteria were selected
retrospectively from the most recent death (for cases)
and control until the determined Sample size is
achieved. For each selected case, three controls which
are nearby to the cases were selected. If controls are
more than three, simple random sampling. i.e.,
Lottery method was used. Charts that had missing
values of more than 30% were replaced by immediate
© 2024 Tewodros Kassahun Tarekegn, et al.
ISSN:2993-0871 BioRes Scientia Publishers
candidates. When cases are replaced the control
group is also replaced with controls nearer to cases.
The first case was identified from registration book
from respective wards and all cases that fulfil the
inclusion criteria were included in the study.
Study Variables
Dependent Variable
Maternal death
Independent Variables
Mothers Socio demographic character, Age, Religion,
Residence, Distance of residence, Obstetric and
delivery history, Parity, Gravidity, Duration of
Labour, Mode of delivery, Delivery attending
physician, Obstetric complication, comorbidity
Operational definitions
Cases: Mothers who died during pregnancy, delivery
and 42 days after delivery those with fully registered
variables.
Controls: A live mothers who visited WURH and
NSH for utilization of antenatal, delivery and to 42
days postpartum those with fully registered variables.
Presence of co morbidity = the presence of at least one
medical disease was considered.
Prolonged labour = duration of labour more than 24
hours.
Direct obstetric death-results from obstetric
complications of pregnancy, like from Haemorrhage,
sepsis, and hypertensive disorders (pre-
eclampsia/eclampsia). Co-morbidities - results from
pre-existing disease (e.g., diabetes, cardiac disease,
malaria, tuberculosis, HIV or a new disease that
develops during pregnancy and is unrelated to
pregnancy-related conditions, but is aggravated by the
physiologic effects of pregnancy.
Data collection and Quality assurance
Data was collected by using a structured data
collecting checklist adapted from Maternal Death
Surveillance and Response Technical Guidelines of
Ethiopia. It consists of socio-demographic data,
obstetric and delivery history, presence of
commodities, cause of death, antenatal and intra-
natal risks, and presence of complications and was
collected from medical record chart. Three midwives
were recruited and trained. The training covers: the
contents of the tool, ethical considerations and way of
extraction of necessary information from chart. One
supervisor, monitor and follow data collection while
the principal investigator supervised the overall data
collection process. To assure the quality of data
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Journal of Women Health Care and Gynecology
pretest was performed on 5% of the samples at before
data collection was begun. Every day, the filled
checklists were reviewed and checked for
completeness and consistency with close supervision.
Data processing and analysis
Data was edited for accuracy, readability, consistence
and completeness; thereafter it was coded and entered
into Epi Info version 7.2.5.0 and exported to SPSS 20
computer software programs for cleaning and
descriptive analysis. Bi variate logistic regression
analysis was done & variables with p-value <0.25 were
transferred to Multivariate analysis & variables with
P-value < 0.05 were considered as statistically
significant & AOR with 95% CI was used to control
for possible con founders & to interpret the result,
model adequacy was assessed using Hosmer–
Lemeshow goodness-of-fit tests and p-value > 0.05 was
taken as the model fits the data. Finally, the results
were summarized & presented by using tables, graphs
& charts
Ethical consideration
Prior to data collection, ethical clearance was
obtained from the Ethical Review Committee of
Figure 2: Age distribution frequency of mothers during their maternity in Gov’tal hospitals in Nekemte town from
Sep.2010 to Aug.2014 E.C
Although 41(75.93%) of cases were from rural area,
only 75 (46.58%) of controls were from rural areas.
Twenty-five (46.3%) of cases came from 51-150km
distance whereas 66 (40.74%) controls came from
same distance.
Obstetric and delivery history
Regarding to obstetric and delivery history, 122
(56.48%) were gravid 2-5 and 59 (27.31%) were
© 2024 Tewodros Kassahun Tarekegn, et al.
ISSN:2993-0871 BioRes Scientia Publishers
WURH NSH. In order to establish anonymous
linkage only the codes, and not the names of the
participant from the chart, was registered on the
checklist.
Result
A total of 54 cases (died women) and 162 controls
(survived women) were included in this study.
Variables such as, educational status, marital status,
occupation, ANC follow up and income were
included in the checklists but they are incomplete in
99% of charts: As a result, they were excluded from
the analysis.
Socio-demographic and related factors
Age distribution
Majority, 133 (61.57%) of women in this study were
in the age group of 20-34 years. While the least, 36
(16.67%) age group were age less than 20 years old.
Of all women included in this study 33 (61.11%) of
deaths were from among 20 to 34 years’ age group,
while those of age group less than 20 years’ account
for the least number 8(14.81%).
Primigravida. Similarly, 56.79% and 55.56% of the
controls and cases were gravid 2 to 5 respectively.
Eighteen (33.33%) of cases and only 24, (14.81%) of
controls were lasted for more than 24hrs on labour.
Out of all women included in this study 110 (50.93%)
delivered by SVD and majority of them were attended
by midwives. But ninety-three (57.41%) of controls
and 20 (37.04%) of cases delivered by vaginal delivery
and Cesarean section respectively.
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Figure 3: Frequency distribution of mode of delivery of mothers at WURH and NSH from September 2017=August 2022
G.C.

Obstetric complications induced hypertension which accounted for 23.53%.

Ninety-six (59.6%) of controls and only 3 (5.56%)
cases have no obstetrics complications. Majority of
women, 34 (28.57%) with obstetrics complication
have obstetric haemorrhage (of which APH and PPH
are predominant causes followed by pregnancy
From among cases with obstetric complication
18(33.96%) have obstetric haemorrhage while
27.27% of controls have pregnancy induced
hypertension. Anemia accounts for the least
complications in both groups.

Table 1: Frequency Distribution of Obstetric History of Women on Study Done At WURH And NSH From
September 2017-August 2022 G.C.
Variables Categories Controls (N= 162) Case (N= 54) Total(N=216)
Gravidity Primigravida 45(76.27%) 14(23.73%) 59
2-5 92(75.41%) 30(24.59%) 122
>5 25(71.13%) 10(28.57%) 35
Para-0 5(50%) 5(50%) 10
Parity Primipara 11(84.6%) 2(15.38%) 13
2-5 65(75.58%) 21(24.42%) 86
>5 3(50%) 3(50%) 6
Duration of <3hrs 0 1 1
Labor in hrs 4-24hrs 138(79.77%) 35(20.23%) 173
>24hrs 24(57.1%) 18(42.9%) 42
Mode of delivery SVD 93(84.55%) 17(15.45%) 110
Instrumental 31(64.52%) 17(35.42%) 48
Caesarean section 38(65.52%) 20(34.48%) 58
Attending Health MW 86(86.87%) 13(13.13%) 99
Professional Senior 44(64.71%) 24(35.29%) 68
Others 30(63.83%) 17(36.17) 47

© 2024 Tewodros Kassahun Tarekegn, et al. 8

Journal of Women Health Care and Gynecology ISSN:2993-0871 BioRes Scientia Publishers

Figure 4: Obstetrics complications at governmental hospitals in Nekemte town from September 2017-August 2022 G.C.

Bi variate analysis was used to assess association
between various factors and maternal death. Factors
which have association with maternal death (p value
< 0.25) were; age 20-34 years, living in rural area,
Distance from the hospital, mode of delivery,
presence of obstetrics complications, para 2-5,
prolonged labour for more than 24hrs, delivery
attended by seniors and others, and presence of co-
morbidities. Several factors which were found not to
have a significant association with maternal death
were; age less than 20 and greater than 34 years, urban
residence, primi gravida and primi para, para -zero,
gravidity and parity, greater than five, duration of
labour less than 24 hours and precipitated labour,
having anemia, OL, uterine rupture and
Malpresentation. In bi variate analysis, those
variables having p- value less than 0.25 were further
analysed in multi variate logistic regression.

Table 2: Bi Variate Analysis of Factors Associated with Maternal Death on Study Done at WURH And NSH From
September 2017-August 2022 G.C.
Variables Categories Controls Case (N= Total COR (95 % CI)
(N=162) 54) (N=216)
Age in Years <20 28(77.7) 8(22.3) 36 0.46(0.16, 1.35)
20-34 100 (75.2) 33(24.8) 133 1.49 (1.20, 4.22)
>34 34(72.3) 13(27.7) 47 1
Residence Rural 75(64.5) 41(35.5) 116 6.6 (0.14, 0.65)
Urban 86(86.9) 13(13.1) 99 1
<10 16(76.2) 5(23.8) 21 1
Distance From Nov-50 62(78.5) 17(21.5) 79 0.53 (0.25, 1.11)
NSH in Km 51-150 66(72.5) 25(27.5) 91 0.41 (0.20,0.84)
>150 18(72) 7(28) 25 0.72 (0.18, 2.84)
Primigravida 45(76.3) 14(23.7) 59 1
Gravidity 02-May 92(75.4) 30(26.6) 122 2.21 (1.21, 6.31)
>5 25(71.4) 10(28.6) 35 1.87 (0.82,4.26)
Para-0 24(75) 8(25) 32 1
Parity Primipara 24(80) 6(20) 30 0.45(0.12,1.58)
02-May 101(73.7) 36(26.3) 137 32.02 (6.45,82.03)
>5 13(76.5) 4(23.5) 17 1.21 (1.06,5.76)
Duration of <24 138(79.3) 36(20.7) 174 1
Labor in hrs >24 24(57.1) 18(42.9) 42 1.69(0.622,4.602)
VD 93(84.5) 17(15.5) 110 1
Mode of Instrumental 31(64.6) 17(35.4) 48 0.39 (0.18,0.82)
delivery Caesarean section 38(65.5) 20(34.5) 58 0.46 (0.24,0.90)
Attending MW 86(86.9) 13(13.1) 99 2.709(0.939,7.82)
Health Senior 44(64.7) 24(35.3) 68 0.35 (0.19,0.66)
Professional Others 30(63.9) 17(36.2) 47 4.452(2.541,7.80)
Hemorrhage 16(47) 18(58) 34 5.6(0.5, 53)

© 2024 Tewodros Kassahun Tarekegn, et al. 9

Journal of Women Health Care and Gynecology ISSN:2993-0871 BioRes Scientia Publishers

PIH 96(99) 01(1) 97 1.27 (1.14 ,5.27)

Anemia 1(50) 1(50) 2 0.48(0.15, 1.45)
Obstructed labor 9(60) 6(40) 15 0.74 (0.45, 3.77)
Malpresentation 4(80) 01(20) 5 2.55 (0.32, 20.30)
Sepsis 04(40) 06(60) 10 0.27 (0.14,0.53)
Uterine Rupture 436.4) 7(63.6) 11 5.6(0.59, 53.3)
Comorbidity 3(25) 9(75) 12 18.5(3.6, 93.6)

Further analysis with logistic regression was done to
identify the factors that are independently associated
with maternal mortality. Determinants of Maternal
Death were; Being in the age group of 20 -34 is risk
than being in the age group of >34. Women in the age
group of 20 – 34, have 2.05 times risk than being in
the age group of >34 for maternal death (OR 2.05,
95% (1.02, 5.54)). Women who midwives attended
their deliveries were more likely to die 2.709 times
than those who were attended by seniors (AOR
2.709,95%CI (0.939,7.82)). Women who lasted for
more than 24 hours are more likely to die 1.69 times
than those lasted for 3 to 24 hours (AOR 1.692, 95%
CI (0.622,4.602)). Women who came from rural area
are more likely would die 6.6 times than women who
came from urban area (OR 6.615, 95% CI (0.14,
0.562). Women having gravid and para 2-5 more
likely would die 2.21 and 32.01 times than the others
respectively with (OR=2.21, 95% CI 1.21, 6.31) &
OR=32.01, 95% CI (6.45, 82.03). Women who had
uterine rupture were 5.625 times would more likely to
die than women who have obstetric haemorrhage
(OR 5.625,95% CI (0.593,53.377)). Women who had
comorbidity were 18.458 times more likely they
would die than women who didn’t have co morbid
diseases. (OR= 18.458, 95% CI (3.639, 93.615).

Table 3: multi variate of factors associated with maternal mortality in study at WURH and NSH from September
2017-August 2022 G.C.
Variables Categories Controls Case Total COR (95 % CI) AOR (95 % CI)
Age in Years 20-34 100(75.18) 33(2481) 133 1.49 (1.20, 4.22) 2.05 (1.02,5.54)
Residence Rural 76(64.95) 41(35.04) 117 6.6 (0.14, 0.65) 5.45(1.34, 22.08)
Gravidity 2-5 92(75.40) 30(24.59) 122 2.21 (1.21, 6.31) 2.21 (1.21,6.31)
Parity 2-5 101(73.72) 36(26.27) 137 32.02(6.45,82.03) 2.01(1.36,6.34)
Duration of Labor in hrs >24 24(57.14) 18(42.85). 42 1.69(0.622,4.602) 3.39(2.15, 5.21)
Attending Health Professional midwife 30(63.83) 17(36.16) 47 2.709(0.939,7.82) 2.49(3.15,5.13)
Hemorrhage Yes 16(47.05) 18(52.94) 34 5.6(0.5, 53) 2.19(1.03,6.33)
PIH Yes 18(64.28) 10(35.71) 28 1.27 (1.14 ,5.27) 1.27(1.01,3.13)
comorbidity Yes 159(77.94) 45(22.05) 204 18.5(3.6, 93.6) 1.28(2.17,16.61)

Discussion haemorrhage accounts for 22.8% of maternal

Most (96.3%) of the maternal deaths were due to
obstetrics determinants in which haemorrhage was
the leading cause followed by PIH, which is consistent
with studies done in different countries, as well as
Ethiopia. A systematic review done on causes of
maternal death in Ethiopia shows nearly 92.4% of all
maternal deaths between 1990 and 2013 were due to
direct obstetric causes(38). Haemorrhage was the lead-
ing direct cause of maternal death worldwide,
representing 27.1% of maternal deaths, similarly 25.7
% of direct maternal death was due to haemorrhage
in Ethiopian between 1990 and 2013. In this finding,
haemorrhage was about 38.5% (OR=1.91, 95% CI
(0.33, 2.27)) which is almost similar with worldwide
as well as study done at national level. In Ghana,
mortality, which is nearly similar with our finding
[33]. PIH accounts for (14.0%) (14)(25)(20) of direct
cause worldwide and a systemic review done in
Tanzania showed that death from hypertensive
disorders of pregnancy accounts for 20% which is
slightly higher than our current study findings. In
Ethiopia, PIH accounts 10.3% of maternal death, also
the study conducted at Tigray Ayder hospital and
JUSH reveals 19.2% and 19% of maternal death
respectively, which is slightly greater than current
study. This is might be due to low ANC follow up as
well as they present after complication developed
[34,32,33].
The study done in Tigray region of Ayder hospital
showed other direct causes of maternal death like

© 2024 Tewodros Kassahun Tarekegn, et al. 10

Journal of Women Health Care and Gynecology
Sepsis (13.5%), Anemia (8%), uterine rupture (7%),
OL (16%) as well as study done at JUSH reveals Sepsis
(14. %), Anemia (28.3%), Uterine rupture (23.3%)
and OL (34.17%). According to our study Sepsis,
Anemia, Uterine rupture and OL accounts 21.15%,
1.9%, 7.69% and 9.62% respectively. The result of
our finding showed that sepsis is also other leading
cause of maternal death only preceded by
haemorrhage which might be due to late presentation
after home delivery and low post-natal care and follow
up [34, 38]. Associated factors touched in this study
were age group, residence area, distance from the
hospital, mode of delivery, as well as delivery
attending professionals. The study done in Tanzania
Shenyang national hospital in 2014 showed most
deaths (74.5%) occurs in age group of 20 – 34(38).
Also According to EDHS 2016 the most commonest
age group of maternal death were 20-34 (88%) (16).
Likewise, study done in Tigray region of Ayder
hospital and JUSH showed that most deaths (55%)
and (52,5%) were respectively occur in age group of
20 – 34 which is similar in terms of affected age
groups with this study (74.3%)(24)(26). Our study
differs only in percentage when compared to other
studies which might be due to sample size. Most death
occurred in this age groups which is more risk than
being in the age group of greater than 34 years.
Women in the age group of 20 – 34 has increased the
risk of maternal death by 2.127 times (OR 2.127, 95%
(0.374,12.102)). [16, 20, 33, 38]
Regarding obstetric history, the study done in
Tanzania and Kenya in 2014 showed that the women
who were gravida and para 2-5 accounted for 42.5%
& 49% respectively. As well a systemic review done in
MizanTepi Hospital & JUSH showed that most
maternal death were in gravid and para 2-5 which
accounts (26.4%) and (24.8%) respectively [20, 34,
38,42]. Similarly, in our study most deaths occur in
women with gravid & para 2-5 respectively (55.6%,
66.7%). This might be due over representation of this
category. The study done in Tanzania shinyanga
regional hospital in 2014 showed that 60% of women
who came from rural area were died. Likewise study
done in JUSH showed 75.8 % women who came from
rural area were died (14)(23). Similarly, in our study
more than three fourth (75.9%) with OR= 6.615,
95% CI (0.140, 0.582)) women who died came from
rural area. This might be because of women who came
from rural area are at higher risk than who came from
urban women. These imply that women who live in
rural area are poor at utilization of maternal health
© 2024 Tewodros Kassahun Tarekegn, et al.
ISSN:2993-0871 BioRes Scientia Publishers
services which might be due to different reasons like
lack of awareness or inaccessibility or unavailability of
maternal health services.
The study done in Ayder Hospital showed most of
mothers (44.5%) who were died came from distance
of 51-150 km, where as in JUSH most mothers (40%)
who were died came from 11-50km. According to our
current study most deaths (46.3%) were from 51-
150km which is similar with study done at Ayder
Hospital. [33, 34] A review in JUSH and MizanTepi
Hospital showed most maternal death (54.9%) and
(37.3%) respectively had length of labor > 24hrs, but
in this study most of deaths (64.8%) had labor that
had lasted for less than 24hr which might be due to
under reporting of time elapsed from time of onset of
labour to presentation to the hospital. Prolonged
labour (>24hrs), is the other most risk factor for
maternal death [20, 34]. When the duration of labor
is 24 hour or more, the mother is 2.96 times more
likely would die than women who had less than 24-
hour duration of labor with (OR= 2.96, 95% CI
(1.45,6.04)).
Regarding mode of delivery, study done in Tanzania
reveals that almost half of maternal death occurred
following SVD. But a review in JUSH and MizanTepi
hospital in Ethiopia showed (46%) and (36%) of
maternal death occurred following cesarean delivery
respectively. Our finding (37.4%) is similar with
JUSH and MizanTepi hospitals in which the most
deaths occurred in women who gave birth by cesarean
section [36][34] [38]. This may be due to associated
complications. Regarding birth attendants, study
done in Tigray region reveals majority of deaths
occurred in those attended by midwifes (38.7%),
whereas 25.8% and 6.5% maternal deaths occurred
in those who were attended by Seniors and Others
respectively [6]. Other study done in JUSH indicates
from total maternal deaths 91.3% were attended by
doctors, only 8.7% were attended by other health
professionals [14]. Our current study shows that from
total maternal deaths, half (44.4%) of death occurred
in those attended by seniors, whereas 31.5% and 24%
were attended by other professionals and midwives
respectively. When compared with the studies done
in Tigray region and JUSH, death was high in those
attended by seniors which is might be due to late
consultation and attendance of complicated cases.
Most (75.93%) of maternal deaths were occurred in
post-partum period which is nearly similar with the
finding in JUSH in which 68% of maternal death
occurred in the post-partum period. However, the
11
Journal of Women Health Care and Gynecology
study from maternity hospital of Nigeria shows about
61.9% of the maternal deaths occurred in post-
partum period which is lower than this finding. This
might be because of small sample size and shorter
study period which is only 84 maternal deaths and
two years respectively [20, 35]. Higher number of
maternal deaths in post-partum period implies that
the management following delivery and during
delivery might be poor. Prolonged period of labor due
to OL or due to not having timely intervention might
contribute a lot for death occurring in post-partum
period. The second period in which higher number of
deaths occurred is the intra-partum period (14.81%).
It is smaller than finding from JUSH which was 25%.
But it is almost similar with the findings of maternity
hospital of Nigeria which was 13.1% [20, 34]. In the
maternity hospital of Nigeria, 25% of women died
before reaching to intrapartum period but in our set
up antepartum death is only 9.26%, which is almost
similar with JUSH (7%). This is might be due to high
prevalence of death associated with abortion in
Nigeria, which is opposite to our current findings.
The other reason might be due to dramatic reduction
of maternal death related with abortion due to the
introduction of misoprostol or safe mother hood
services in our country [20, 34]. These implies that the
proper care during antenatal period reduce home
delivery, intra-partum period and after abortion save
the lives of many women in antenatal and
intrapartum period. The implication of these findings
is, management after terminating pregnancy might be
poor or the women might not utilize postpartum care
service.
Problem faced, strength and Limitation of study
Problem faced
Poor registration
Poor documentation of charts and log books
Registration of different age for a single person
Unreadable hand writings
Not writing women on the day of admission and
discharge on the log books
Not writing discharge summary sheet
Strength of study
Free of recall bias
Study design-case control is preferable for rare event
like maternal death and for determining associated
factors.
Limitation of study
Selection bias due to intentional selection of controls
© 2024 Tewodros Kassahun Tarekegn, et al.
ISSN:2993-0871 BioRes Scientia Publishers
Does not observe effect of some of socio demographic
variables like economy, education…due to 99%
missing of socio demographic variables.
Wider confidence interval-due to rarity of events and
lower sample size.
Conclusion
Most of the women died in the postpartum period,
mainly because of direct obstetric causes, of which
Haemorrhage was the leading cause of death and
followed by sepsis and PIH. Being age group 25-34
years, gravida and para 2-5, coming from rural area,
prolonged labour and delivery attended by midwives
and others are the main determinants factors for
maternal death.
Recommendation
To decrease the number of maternal death multi-
sectorial collaboration is important. Everybody
starting from a single individual to the higher officials
and organizations has a responsibility to alleviate the
problem. Based on the findings from this study the
following recommendations are made:
1. To East Wallaga zonal health department:
It should follow, monitor and evaluate IEC/BCC
provided by woreda health offices and health
institutions to increase awareness of the community
in rural part of area about complications of pregnancy
and strengthen the referral system to avoid delay in
intervention or to avoid prolonged labour.
2. To WURH and NSH:
NSH and WURH should strengthen service provision
to reduce death in intra-partum period and post-
partum period (particularly after operative delivery)
and to avoid prolonged labor.
NSH and WURH should improve the registration
system of events and place for the placement of
patient charts.
3. To health professionals:
Health professionals should have to improve timely
intervention given for women and Early consultation
of cases requiring senior interventions
4. To HEWs:
They should have to improve awareness of the rural
community about pregnancy
complications and simultaneous co morbidities.
5. To academicians and researchers:
They should dig out associated socioeconomic factors
for maternal death
12
Journal of Women Health Care and Gynecology
They should respond, why most women who came
from rural area would die most as compared to urban?
Why most women would die in post-partum period?
Abbreviations and Acronyms
ANC : Antenatal care
EDHS : Ethiopia demographic & household’s survey
HIV : Human Immune Deficiency syndrome
ICD : International Classification of Disease
JUSH : Jimma University specialized Hospital
LBs : Live births
LICs : Low-income countries
MDG : Millennium Development Goal
MMR : Maternal Mortality Ratio
NSH : Nekemte Specialized Hospital
OL : Obstructed Labor
PIH : Pregnancy Induced Hypertension
SDG : Sustainable development goal
WHO : World Health organization
WURH: Wallaga University Referral Hospital
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Cite this article: Lili A. Merga, Tewodros K. Tarekegn, Kirubel T. Hailu, Feven N. Abriha, Hamlet M. Aberha,
et al., (2024). Determinants of Maternal Mortality in Nekemte Town Government Hospitals, Eastern Wollega,
Oromia Region, Ethiopia, 2022 G.C., Journal of Women Health Care and Gynecology, BioRes Scientia Publishers.
3(1):1-14. DOI: 10.59657/2993-0871.brs.24.025
Copyright: © 2024 Tewodros Kassahun Tarekegn, this is an open-access article distributed under the terms of
the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in
any medium, provided the original author and source are credited.
Article History: Received: December 13, 2023; Accepted: December 29, 2023; Published: January 08, 2024
© 2024 Tewodros Kassahun Tarekegn, et al. 14