Background
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 [
1]. Yet, maternal mortality remains the global challenge with 275,288 deaths occurring due to pregnancy and complications in 2015 [
2]. The Millennium Development Goal (MDG) set the target in 2000 in reducing maternal mortality by 75% for World Health Organization (WHO) member countries [
3]. While some progress has been made, according to WHO estimate in 2015, the Maternal Mortality Ratio (MMR) dropping by 44% worldwide between 1990 and 2015 [
3], it remains unacceptably high in developing countries particularly in sub-Sahara African countries [
4,
5]. In one of these countries, Ethiopia, the MMR remains high, ranging from 266–1667 per 100,000 Live Births (LB) [
3,
5‐
10].
Maternal mortality is the most sensitive indicator of the health disparities between poorer and richer nations, and for overall development. The effects of maternal mortality also have impacts on children and remaining families [
11‐
15]. For instance, the infant and under-five survival is highly correlated with child nutrition and other important child health care practices demanding maternal involvement [
12].
The causes of maternal mortality are multifactorial. An in-depth analysis on the trends of maternal health in Ethiopia pointed to demographic, behavioural, nutritional, and health services related factors are associated with poor maternal health outcomes [
16]. 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 [
17‐
20]. In this regard, several studies reported limited utilization of key maternal health services in Ethiopia [
21‐
24]. The reasons for low maternal health services utilization were related to range of factors such as women’s sociodemographic factors, cultural factors, communal factors, limited access to health facilities, and poor quality of care in health facilities [
25‐
28]. These complex and interlinked factors can be characterised by the three delays model [
29]. The model comprises delay in deciding to seek care (delay 1), delay in reaching the health facility (delay 2), and delay in receiving quality care once at the health facility (delay 3). In dealing with the first delay, the government established Health Development Army (HDA) in 2010 with the aim of expanding the achievements of the Health Extension Programme (HEP) deeper into communities, improving community ownership and scaling up best practices [
30]. In response to delay two, along with other strategies, the Ethiopian government introduced an innovative free ambulance services in providing ambulances in every rural district that can serve the communities on 24–hours, 7–days basis to transfer any woman in labour or experiencing other obstetric difficulties to the appropriate health facility [
31]. Moreover, Maternal Death Surveillance and Response (MDSR) and Respectful Maternity Care (RMC) was launched to mitigate the challenges owing from delay in receiving quality maternal health services [
32,
33]. As part of the Health Sector Transformation Plan (HSTP), Ethiopia aspires to reduce MMR to 177 death per 100,000 LB in 2020 [
32]. Moreover, in the post-MDG era, the Sustainable Development Goal (SDG) puts an ambitious target of achieving MMR of 70 per 100,000 live births (LB) in 2030 [
34]. Hence, in order to track future targets and assess the impact of government initiatives, understanding the past and present trends and causes of maternal mortality in Ethiopia is vital.
Measuring maternal mortality is difficult in low-income countries because of limited registration of births and deaths [
35]. It becomes difficult as maternal mortality is relatively a rare event besides the challenge in avoiding the technical problems related to bias and the high demand of cost to carrying out sufficiently large surveys to measure the rate per unit time or per birth with reasonable precision [
36,
37]. Most of the previous studies in Ethiopia were based on a single data sources, or sub-national study, or without identifying the causes of maternal mortality [
6‐
8,
10,
38]. Unlike these studies, the GBD study provides a unique opportunity for its use of standardised methodology using several sources of data. This study used GBD study 2013 to investigate the trends and causes of maternal mortality between the years 1990 and 2013 in Ethiopia.
Discussion
This study found that maternal mortality in Ethiopia over the period 1990–2013 was considerably high and remained above the Millennium Development target goal set in 2000. The 2013 MMR estimate for this study (497 per 100,000LB) showed that while there was a decrease in MMR in the previous two decades, the decline was not significant. The finding based on the GBD data was higher than that estimated by WHO [
46] (353 per 100,000LB), and reports in Northern Ethiopia [
7] (266 per 100 000 LB), Southwest Ethiopia (425 per 100,000LB) [
6]; however, it was lower than that reported by the EDHS 2016 report (412 per 100,000) [
10], and a study from Southern Ethiopia [
8] (1667 per 100,000 LB). The differences with the present findings and studies in northern and southwest Ethiopia might be due to the differences in the sample size of study population and the sources of data, and maternal mortality estimation methodology. For instance, while the GBD 2013 estimate employed several sources of data, the studies in the northern and southwest Ethiopia were solely based on verbal autopsy. The difference between the GBD 2013 estimate and the WHO estimate was due to several reasons [
47]. Firstly, GBD 2013 involved many site-years of data while the WHO estimate included subnational data from urban and rural areas. Secondly, there was a difference in assumptions while addressing stochastic fluctuation and small numbers. Thirdly, it could be attributed from the time period differences between the two estimates. The differences between the present findings and the EDHS 2016 report could be likely due to the time differences although the later report relied on small number of events (maternal deaths) occurred in 7- years preceding the survey [
10].
The annual rate of decline by -1.6% (95% UI: -2.8 to -0.3) was far lower than the targeted annual decline (5.5%) to achieve the MDG five goal. This minimal change in maternal mortality is likely due to the high proportion of deliveries occurred at home. In this regard, the EDHS report between 2000 and 2016, showed that only 5–28% of deliveries occurred in health facilities [
10,
38,
40,
48,
49]. This is suggestive of the need for rigorous efforts in terms of improving facility delivery and women’s access to emergency obstetric care services.
This study found that the major causes of maternal mortality were other direct maternal causes such as anaesthesia, embolism (air, amniotic fluid, and blood clot), and the condition of peripartum cardiomyopathy followed by complications of abortion. This is inconsistent with two reviews which reported that abortion related complications and obstructed labor/uterine rupture accounted for the top leading causes of maternal mortality in Ethiopia [
19,
50]. The differences in the present finding and the previous reviews is likely to be due to the inclusion of hospital-based studies. As a result, this may have led to an overestimation in some of the causes of deaths, with obstructed deaths and complications of abortions were more likely to be reported for health facilities.
This study found that mortality due to HIV related causes was relatively stable with a small decline, over time. This reduction may have resulted from the introduction of the Prevention of Mother-To-Child Transmission (PMTCT) of HIV/AIDS services since 2001 [
51]. A study conducted in Ethiopia also suggested that there was a remarkable improvement in terms of potential coverage of PMTCT services between 2006 and 2010 [
52]. Furthermore, the national HIV prevalence has shown a decline in the general population including pregnant women [
53].
As reported by other previous studies [
5,
54], a higher number of deaths occurred during postpartum period over the study period. The occurrence of a higher number of deaths in this period could be due to two main reasons. Firstly, it could be due to the unpredictability of complications and the necessity to advanced lifesaving services to lessen these complications during delivery and the immediate postpartum period. The second reason could be due to lack of quality obstetric services at health facilities for women attending facility delivery. For instance, research suggests that health providers in Ethiopia may have limited competency in terms of managing postpartum haemorrhage and utilization of partograph for monitoring labour progress [
55,
56]. Another study from Northwest Ethiopia also reported the lack of basic signal functions necessary for routine and emergency maternity care services [
57]. This suggests the need to enhance accessibility of emergency obstetric care to women in Ethiopia. A recent study conducted in Wolisso district of Ethiopia reported that no deaths occurred amongst mothers who used the ambulance services to reach facilities providing emergency obstetric services [
58]. In this respect, the roles of Health Extension Workers (HEW) and Women’s Developmental Army (WDA) were vital in terms of organising women’s use of skilled birth attendance by arranging ambulance services and timely referral of labouring mothers to health facilities [
59].
The present study also showed that although the decline in MMR varied across age groups, with a higher number of maternal deaths among the age groups of 20–24 and 25–29 years old in 2013. This finding likely reflects the high fertility rate in these age groups of women and thus the potential of increased maternal mortality [
40]. In this regard, the EDHS 2016 report pointed to high rates of maternal mortality in these specific age categories [
10]. The higher rate of young adolescents of 10–14 years are dying over the study period could be associated with high prevalence of early marriage and unmet need for family planning services. This suggests that programs that aim to reduce pregnancy amongst young adolescents could reduce the risk of maternal mortality arising from childbirth complications due to gynaecological immaturity and incomplete pelvic growth.
The present study has strengths due to use of robust methodology and multiple sources of data that enabled us to see the overtime trends of maternal mortality in Ethiopia. However, the study had some limitations. Firstly, as there was no vital registration system in Ethiopia, the modelling was based on limited sources of data, which may influence the results. Secondly, as indicated in the large gaps in the 95% uncertainty intervals, the estimate was made on relatively smaller sample size. Thirdly, while it was possible to see the mortality differences across different age groups, the present estimate could not show the MMR in terms of other women’s sociodemographic status such as urban-rural residence, wealth and educational status.
Conclusion
While there has been a reduction in the MMR in Ethiopia over the last 23 years, the annual rate of reduction is far lower than targets set. The MMR trends observed in 2013 showed that Ethiopia did not achieve the MDG target of reducing MMR to 267 per 100,000LB. In 2013, the top five causes of maternal mortality included other direct maternal causes such as anaesthesia, embolism (air, amniotic fluid, and blood clot), and the condition of peripartum cardiomyopathy, complications of abortions, maternal haemorrhage, hypertensive disorders, and maternal sepsis and other maternal infections such as Influenza, malaria, tuberculosis and hepatitis. Most of the maternal mortality occurred during the postpartum period and majority of the deaths occurred at the age groups of 20–25 and 25–29 years in 2013. The findings of the study highlights the need for comprehensive efforts using multisectoral collaborations from stakeholders in reducing maternal mortality in Ethiopia.
Acknowledgement
We would like to acknowledge the Institute of Health Metrics and Evaluation, University of Washington for providing access to the country specific GBD study 2013 data.