Background
Maternal mortality remains as a major Public Health challenge despite numerous strategies devised by the international community to curb it. Globally, maternal mortality is the leading cause of death among females aged 15-49 years old. More than 1500 women die each day from pregnancy related causes resulting in an estimated 550 000 maternal deaths annually [
1]. In 2010, estimates developed by the WHO, UNICEF, UNFPA and the World Bank [
2] suggest that worldwide, about 260 women die per 100 000 live births and most of these deaths occur in sub-Saharan Africa. These estimates indicate that Africa recorded the highest Maternal Mortality Ratio (MMR) of 620 per 100 000 live births, whilst Europe recorded the lowest MMR of 21 maternal deaths per 100 000 live births. Globally, Greece recorded the lowest maternal deaths by country with 2 per 100 000 live births compared with the alarmingly high MMR of 1400 deaths per 100 000 live births in Afghanistan [
2]. In sub-Saharan Africa, Cape Verde recorded the lowest MMR of 94 whilst Chad and Somalia recorded the highest MMR of 1200 [
2]. These figures show a very large discrepancy in maternal health, with sub-Saharan Africa experiencing the poorest outcome.
To respond to this challenge, the Millennium Development Goal 5 (MDG 5), which aims to improve maternal health was developed. The target is to reduce by three-quarters the MMR between 1990 and 2015 and achieve universal access to reproductive health care by 2015. A study by Hogan and colleagues, in 2010, found that there was a decrease in the global MMR estimates from 320 in 1990 to 251 in 2008 per 100 000 live births [
3]. Even in the presence of this change, very few countries are on track to achieve MDG 5 [
3]. This stagnation calls for different innovations and strategies to tackle this global menace.
A study by Thonneau
et al., (2004) [
4] carried out in twelve maternities in Benin, Ivory Coast and Senegal, found that hypertensive disorders and post-partum haemorrhage caused 29% and 15% respectively of maternal mortalities in these three African countries. These were the highest causes of maternal mortality among this group [
4]. Inconsistency in clinical diagnosis of the causes of maternal deaths has also been reported as a possible reason for why this challenge remains unabated [
5]. Infectious diseases related to maternal mortalities are often under-diagnosed whilst hypertensive disorders related to pregnancy (including Eclampsia) are in most cases, over-diagnosed [
6].
Ghana's MMR continues to be unacceptably high despite efforts made in an attempt to meet MDG 5. The Ministry of Health has been called on to treat maternal mortality as a national emergency [
7]. Estimation of Maternal Mortality Ratio in Ghana varies widely by source and method of estimation [
8]. Figures from the WHO, UNICEF and UNFPA for Ghana indicate 740 maternal deaths in 1990, 590 in 1995, 540 in 2000 and 560 in 2005 per 100 000 live births [
9,
10]. This contrasts lower estimation from the Ghana Statistical Service which were 214 in 1992 and 378 per 100 000 live births between 2000 and 2005 [
11]. This high level of uncertainty and discrepancy makes MMR unsuitable for monitoring maternal mortality/maternal health trends in short term [
12].
The causes of maternal mortality are usually sub-grouped into direct obstetric and indirect causes. Direct causes of maternal mortality as indicated in previous studies conducted in Ghana include haemorrhage (postpartum and ante partum), abortion, miscarriage, sepsis, obstructed labour, ectopic pregnancy, (Pre-) eclampsia and embolism [
11,
13‐
15]. The indirect causes of maternal mortality are mostly infectious and non-infectious diseases and other miscellaneous causes. These indirect causes include mainly malaria, HIV/AIDS, hepatitis, respiratory infections, anaemia, sickle cell disease, meningitis, cerebrovascular diseases and others [
11,
13‐
15].
In Ghana, several interventions targeting the reduction of maternal mortality have been implemented. Notable among these is the user fee exemption policy instituted in 2003. This policy exempts all pregnant women from paying for delivery costs at public, mission and private health facilities [
16]. Evaluation of this intervention between 2003 and 2006 showed dramatic reduction of direct maternal deaths but no significant impact on indirect maternal deaths [
17]. Thus, maternal mortality can be prevented in many cases but this demands not only a comprehensive understanding of the causes, but also, more importantly, an understanding of how the different causes are distributed in various groups with different characteristics. A number of studies have been conducted on maternal mortality in Ghana [
8,
11,
13‐
15,
18,
19]; however, only one [
11] attempted to analyze causes of maternal mortality with respect to socio-demographic groups, and did so with limited detail. The study reported percentage distribution of maternal deaths by cause of death, according to age and region. Much emphasis was put on abortion in the analysis. The study did not report the maternal mortality cause-specific risks associated with the different socio-demographic groups. Thus, detailed analysis of the causes of these mortalities, stratified by various socio-economic and demographic characteristics, is essential for formulating specific interventions to deal with these causes in different socio-demographic groups. This would help to accelerate Ghana and other similar nations in sub-Saharan Africa, towards the realization of Millennium Development Goal 5. The aim of the study is, therefore, to assess and analyse the causes of maternal mortality according to socio-demographic factors in Ghana.
Results
The mean age of women who died from pregnancy-related causes was 29.3years (SD 7.6). Table
1 shows how maternal deaths are distributed according to age group, educational level, marital status and residence status. The results (Table
1) show an inverse trend in maternal mortalities with increasing educational level. Thus 54.9% of maternal deaths occurred in women whose education ended at the basic level whilst 2.1% were ascribed to those whose education ended at the tertiary/higher level. Most maternal deaths occurred among people that resided in rural areas (64.1%) compared to those in urban residence (35.9%) as well as the married (83.6%) compared to single women (16.4%).
Table 1
Socio-demographic characteristics of 605 women who died from pregnancy-related causes in Ghana between 2000 and 2005
Age group(years) | | |
12-14 | 3 | 0.5 |
15-19 | 62 | 10.2 |
20-24 | 115 | 19.0 |
25-29 | 133 | 22.0 |
30-34 | 116 | 19.2 |
35-39 | 106 | 17.5 |
40-44 | 55 | 9.1 |
45-49 | 15 | 2.5 |
Total
|
605
|
100
|
Highest Educational level
| | |
Never Attended | 208 | 34.4 |
Basic Education | 332 | 54.9 |
Senior High School | 52 | 8.6 |
Tertiary/Higher Education | 13 | 2.1 |
Total
|
605
|
100
|
Residence
| | |
Urban | 216 | 35.9 |
Rural | 389 | 64.1 |
Total
|
605
|
100
|
Marital Status
| | |
Single | 99 | 16.4 |
Married | 506 | 83.6 |
Total
|
605
|
100
|
Table
2 shows the causes of maternal mortality. Haemorrhage (22.8%) was the highest cause of maternal mortality. The other top causes were infectious diseases (13.9%), abortion (13.7%), miscellaneous (13.6%) and other non-infectious diseases (12.4%). Maternal deaths were highest in the age group 25-29years (22.0%) followed by 30-34years (19.2%) and 20-24years (19.0%).
Table 2
Causes of maternal mortality among 605 women who died from pregnancy-related causes in Ghana between 2000 and 2005
Direct causes | | |
Haemorrhage(ante partum and postpartum) | 138 | 22.8 |
Abortion(Medical, Attempted, failed, other, unspecified) | 83 | 13.7 |
Hypertensive disorders of pregnancy(including Eclampsia) | 54 | 8.9 |
Sepsis | 42 | 6.9 |
Obstructed Labour | 27 | 4.5 |
Miscarriage | 20 | 3.3 |
Indirect causes
| | |
Other Infectious diseases* | 84 | 13.9 |
Other non-infectious diseases** | 75 | 12.4 |
Miscellaneous*** | 82 | 13.6 |
Total
|
605
|
100
|
Table
3 shows how the causes of maternal mortality are distributed with respect to age group, educational level, marital status and regional difference. Haemorrhage is highest in the age group 35-39 years (27.5%), followed by 30-34 years (22.5%) 25-29 years (20.3%) and 20-24 years (14.5%). In contrast, abortion is highest in the age group of 20-24 years (26.5%), followed by 15-19 years (20.5%), 30-34 years (16.5%) and 25-29 years (13.3%). Additionally, 28.6% of deaths from infectious diseases related to pregnancy occurred in the age group 20-24 years; 22.6% in the age group 25-29 years; 17.9% in the age group 30-34 with only 6.0% occurring in the age range of 40-44 years. There was no death from infectious diseases related to pregnancy within the age group 44-49 years. The major infectious diseases that caused pregnancy-related deaths were malaria 53.6%, viral hepatitis 13.1%, unspecified infections 7.1% and tuberculosis 2.4%. Deaths from miscellaneous causes were common between the ages of 25 and 44years (see Table
3). Miscellaneous causes comprised mainly obstetric deaths of unspecified causes 26.8%, rupture of uterus 17.1%, complications of obstetric surgery 14.6%, embolism 9.8%, complications of anaesthesia 4.8% and other complications of pregnancy, labour and puerperium. Maternal deaths from non-infectious diseases were highest among 25-29years (32.0%) and 20-24years old women (21.3%). Anaemia 41.3% was the major cause of death in the category of non-infectious diseases followed by diseases of blood and blood-forming organs 17.3%; respiratory diseases 14.6%; and circulatory diseases 12.0%.
Table 3
Variations in the causes of maternal mortality according to Socio-demographic characteristics of 605 women who died from pregnancy-related deaths in Ghana between 2000 and 2005
Age group(years) | | | | | |
12-14 | - | - | 2(2.4) | - | - |
15-19 | 7(5.1) | 9(10.7) | 17(20.5) | 8(9.8) | 8(10.7) |
20-24 | 20(14.5) | 24(28.6) | 22(26.5) | 10(12.2) | 16(21.3) |
25-29 | 28(20.3) | 19(22.6) | 11(13.3) | 15(18.3) | 24(32.0) |
30-34 | 31(22.5) | 15(17.9) | 14(16.9) | 17(20.7) | 9(12.0) |
35-39 | 38(27.5) | 12(14.3) | 5(6.0) | 17(20.7) | 11(14.7) |
40-44 | 12(8.7) | 5(6.0) | 7(8.4) | 14(17.1) | 5(6.7) |
45-49 | 2(1.4) | 0(0.0) | 5(6.0) | 1(1.2) | 2(2.7) |
Total
| 138(100) | 84(100) | 83(100) | 82(100) | 75(100) |
Educational level
| | | | | |
Never Attended | 53(38.4) | 37(44.0) | 23(27.7) | 28(34.1) | 33(44.0) |
Basic Education | 72(52.2) | 39(46.4) | 49(59.0) | 45(54.9) | 34(45.3) |
Senior High Sch. | 10(7.2) | 7(8.3) | 10(12.0) | 7(8.5) | 6(8.0) |
Tertiary/Higher | 3(2.2) | 1(1.2) | 1(1.2) | 2(2.4) | 2(2.7) |
Total
| 138(100) | 84(100) | 83(100) | 82(100) | 75(100) |
Residence
| | | | | |
Urban | 43(31.2) | 29(34.5) | 28(33.7) | 31(37.8) | 25(33.3) |
Rural | 95(68.8) | 55(65.5) | 55(66.3) | 51(62.2) | 50(66.7) |
Total
| 138(100) | 84(100) | 83(100) | 82(100) | 75(100) |
Marital Status
| | | | | |
Single | 9(6.5) | 9(10.7) | 35(42.2) | 14(17.1) | 13(17.3) |
Married | 129(93.5) | 75(89.3) | 48(57.8) | 68(82.9) | 62(82.7) |
Total
| 138(100) | 84(100) | 81(100) | 82(100) | 75(100) |
In all the causes of maternal mortality as seen in Table
3, mortality decreased with increasing educational level. Mortality was generally high for women who lived in rural areas as opposed to urban residence. In all the causes of maternal mortality, percentage of married women greatly outweighed that of single women (haemorrhage 93.5%/6.5%, infectious diseases 89.3%/10.7%, miscellaneous 82.9%/17.1% and non-infectious diseases 82.7%/17.3%) except for abortion which had comparable differences (57.8% and 42.2%) between married and single women respectively.
Table
4 and Table
5 represent crude and adjusted odds ratio for the different groups with respect to the cause of death. Married women had a significantly higher risk of dying from haemorrhage, compared with single women (aOR = 2.7, 95% CI = 1.2-5.7). On the contrary, married women showed a significantly reduced risk of dying from abortion compared to single women (aOR = 0.2, 95%CI = 0.1-0.4). Women aged 35-39years had a significantly higher risk of dying from haemorrhage (aOR 2.6, 95%CI = 1.4-4.9), whereas they were at a lower risk of dying from abortion (aOR 0.3, 95% CI = 0.1-0.7) compared to their younger counterparts (Table
5). The results of the logistic regression analysis revealed a peculiar trend with respect to age and infectious diseases. The risk of dying from infectious diseases seems to decrease with increasing age (see Table
4 and
5). In addition, the risk of dying from miscellaneous causes increased with increasing age (Table
5).
Table 4
Crude Odds Ratio(OR) and 95% Confidence Interval of causes of maternal mortality according to age group, educational level, regional difference and marital status of 602 women in the reproductive age 15-49 years
Age group(years) | | | | | |
12-14 | - | - | * | - | - |
15-19 | 0.6(0.2-1.5) | 0.6(0.3-1.5) | 1.6(0.8-3.3) | 1.6(0.6-4.2) | 0.9(0.4-2.3) |
20-24 | 1(Ref.) | 1(Ref.) | 1(Ref.) | 1(Ref.) | 1(Ref.) |
25-29 | 1.3(0.7-2.4) | 0.6(0.3-1.2) | 0.4(0.2-0.8) | .3(0.6-3.1) | 1.4(0.7-2.7) |
30-34 | 1.7(0.9-3.3) | 0.6(0.3-1.1) | 0.6(0.3-1.2) | 1.8(0.8-4.6) | 0.5(0.2-1.2) |
35-39 | 2.7(1.4-5.0) | 0.5(0.2-1.0) | 0.2(0.1-0.6) | 2.0(0.9-4.6) | 0.7(0.3-1.6) |
40-44 | 1.3(0.6-3.0) | 0.4(0.1-1.1) | 0.6(0.2-1.5) | 3.5(1.5-8.7) | 0.6(0.2-1.8) |
45-49 | 0.7(0.2-3.5) | - | 2.1(0.7-6.8) | 0.8(0.1-6.3) | 1.0(0.2-4.6) |
Educational level
| | | | | |
Never Attended | 1.1(0.3-4.3) | 2.6(0.3-20.6) | 1.5(0.2-12.0) | 0.9(0.2-4.1) | 1.0(0.2-4.9) |
Basic Education | 0.9(0.3-3.5) | 1.6(0.2-12.8) | 2.0(0.3-15.7) | 0.9(0.2-4.1) | 0.6(0.1-3.0) |
Senior High Sch. | 0.8(0.2-3.4) | 1.9(0.2-16.7) | 2.9(0.3-24.6) | 0.9(0.2-4.7) | 0.7(0.1-4.0) |
Tertiary/Higher | 1(Ref.) | 1(Ref.) | 1(Ref.) | 1(Ref.) | 1(Ref.) |
Residence
| | | | | |
Urban | 1(Ref.) | 1(Ref.) | 1(Ref.) | 1(Ref.) | 1(Ref.) |
Rural | 1.3(0.9-2.0) | 1.1(0.7-1.7) | 1.1(0.7-1.7) | 0.9(.6-1.5) | 1.1(0.7-1.9) |
Marital Status
| | | | | |
Single | 1(Ref.) | 1(Ref.) | 1(Ref.) | 1(Ref.) | 1(Ref.) |
Married | 3.3(1.6-6.8) | 1.7(0.8-3.5) | 0.2(0.1-0.3) | 0.9(0.5-1.7) | 0.9(0.5-1.7) |
Table 5
Adjusted Odds Ratio (each variable adjusted for the rest in one model*) and 95% Confidence Interval of causes of maternal mortality according to age group, educational level, regional difference and marital status of 602 women in the reproductive age 15-49 years
Age group(years) | | | | | |
12-14*
| - | - | μ | - |
-
|
15-19 | 0.9(0.3-2.3) | 0.9(0.4-2.2) | 0.8(0.4-1.9) | 1.4(0.5-3.9) | 0.9(0.4-2.3) |
20-24 | 1(Ref.) | 1(Ref.) | 1(Ref.) | 1(Ref.) | 1(Ref.) |
25-29 | 1.3(0.7-2.4) | 0.6(0.3-1.2) | 0.4(0.2-0.9) | 1.3(0.6-3.1) | 1.4(0.7-2.7) |
30-34 | 1.7(0.9-3.2) | 0.5(0.2-1.1) | 0.7(0.3-1.4) | 1.8(0.8-4.2) | 0.5(0.2-1.2) |
35-39 | 2.6(1.4-4.9) | 0.4(0.2-0.9) | 0.3(0.1-0.7) | 2.1(0.9-4.8) | 0.7(0.3-1.5) |
40-44 | 1.2(0.5-2.8) | 0.3(0.1-1.0) | 0.8(0.3-2.1) | 3.7(1.5-9.2) | 0.6(0.2-1.7) |
45-49 | 0.7(0.1-3.5) | - | 2.6(0.8-8.8) | 0.8(0.1-6.3) | 1.0(0.2-4.7) |
Educational level
| | | | | |
Never Attended | 1.2(0.3-4.6) | 2.3(0.3-18.9) | 0.8(0.1-7.0) | 1.1(0.2-5.7) | 0.9(0.2-4.6) |
Basic Education | 1.1(0.3-4.3) | 1.4(0.2-11.1 | 0.9(0.1-7.8) | 1.2(0.2-5.8) | 0.5(0.1-2.6) |
Senior High Sch. | 1.0(0.2-4.3) | 1.5(0.2-13.4) | 1.7(0.2-15.7) | 1.2(0.2-6.9) | 0.6(0.1-3.3) |
Tertiary/Higher | 1(Ref.) | 1(Ref.) | 1(Ref.) | 1(Ref.) | 1(Ref.) |
Residence
| | | | | |
Urban | 1(Ref.) | 1(Ref.) | 1(Ref.) | 1(Ref.) | 1(Ref.) |
Rural | 1.3(0.8-2.1) | 0.9(0.5-1.5) | 1.3(0.7-2.2) | 0.9(0.6-1.6) | 1.1(0.6-1.8) |
Marital Status
| | | | | |
Single | 1(Ref.) | 1(Ref.) | 1(Ref.) | 1(Ref.) | 1(Ref.) |
Married | 2.7(1.2-5.7) | 2.0(0.9-4.5) | 0.2(0.1-0.4) | 0.8(0.4-1.6) | 0.9(0.5-1.9) |
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
BOA was involved in study conceptualisation, data analysis, interpretation of results and drafting of the manuscript. KMM participated in designing the study, data analysis, drafting and review of the manuscript. MS also participated in data analysis, interpretation of results, drafting and critical review of the manuscript. GM contributed to the conception and design of the study and also helped to critically revise the content of the manuscript. All authors read and approved the final manuscript.