Reducing maternal mortality: a 10-year experience at Mpilo Central Hospital, Bulawayo, Zimbabwe

Introduction

Maternal mortality remains a huge global problem. Reducing maternal mortality is one of the Sustainable Development Goals (SDGs) of the global community. SDG 3.1 aims to reduce global maternal mortality ratio (MMR) to 70 per 100,000 live births by 2030, and leaving no country with an MMR greater than double that global goal [1]. Concerted efforts that are proposed to achieve this goal include regular audits, epidemiological studies of trends of MMR, and the causes of maternal mortality so that appropriate corrective steps are taken to prevent and reduce maternal deaths [2].

The World Health Organization (WHO) defines a maternal death as any death from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy [3]. The WHO has developed a manual to classify deaths called the International Classification of Diseases for the classification of deaths during pregnancy, childbirth, and the puerperium-maternal Mortality m(ICD-MM) [4]. Ameh et al. found that maternal death reviews from five Sub-Saharan African (SSA) countries did not identify the type of maternal death. They therefore suggested that reports should state clearly the variables such as the type, group and the underlying cause of maternal death [5]. If epidemiological reporting of maternal deaths becomes globally standardized it will help in consolidating global data on maternal deaths.

The global scale of maternal deaths is huge, with 303,000 maternal deaths in 2015 representing an overall global MMR of 216 per 100,000 live births [6]. Say et al. in a WHO systematic review found that the leading global causes of maternal deaths were haemorrhage, hypertensive disorders, and sepsis. Most of the deaths occurred in low-income and middle-income countries and were avoidable [7].

Globally, maternal mortality declined by 38% between 2000 and 2017, from an MMR of 342 in 2000 to an MMR of 211 per 100,000 live births in 2017 [8]. In SSA, maternal mortality remains unacceptably high with an MMR of 533 in 2017, compared to an MMR of 5 per 100,000 live births recorded for Western Europe in the same year. The MMR for Zimbabwe as of 2019 was 462 per 100,000 live births [9]. In 2010 the Government of Zimbabwe introduced the National Malaria Prevention and Control Policy that allowed community-based health workers to initiate treatment of uncomplicated malaria after parasitological diagnosis with rapid diagnostic tests at village level to try to reduce deaths from malaria in the population [10].

Over the years, there were series of steps to try to reduce maternal and neonatal mortality at Mpilo Central Hospital (MCH). The Practical Obstetric Multi-Professional Training (PROMPT^®) course was introduced at MCH in 2011 for all maternity staff to receive obstetric emergency training [11, 12].

The Government of Zimbabwe adopted the WHO guidelines called Option B+ whereby pregnant women received life-long antiretroviral therapy to prevent HIV Infection in infants [13]. This was to not only reduce vertical viral transmission from mother-to child, but to reduce maternal mortality from HIV-related complications.

At MCH preventive measures were instituted at the maternity unit to reduce rising incidence of fresh stillbirths through leadership and accountability [14].

This study had two major objectives. The first objective was to review the epidemiological trends of the MMR over the last 10 years at the hospital. The second objective was to assess trends in the causes of maternal mortality and the effect of government interventions such as malarial control, the adoption of life-long Option B+ antiretroviral treatment for the pregnant women, the training courses of staff, and the introduction of strong clinical leadership and accountability on the causes of maternal deaths.

Materials and methods

This was of a retrospective study carried out at MCH, a government teaching and quaternary referral centre. MCH is located in Bulawayo, the second largest city in Zimbabwe after the capital city Harare. The hospital is a 1000-bedded hospital and its maternity unit delivers 10,000 babies per year. The National University of Science and Technology Medical School is situated at the hospital. The study covered the period from 1st of January 2011 to 31st of December 2020. The study included all women of reproductive age group (12–49 years) who died at MCH during pregnancy, childbirth and the puerperium within 42 days of the termination of the index pregnancy. No maternal deaths were excluded in the study. Data were extracted from the mortality register kept by a midwife and reproductive health focal person in the maternity unit. This register records all maternal deaths which were collated manually at the end of each quarter, and sent to the Ministry of Health and Child Care Headquarters in Harare. Data on births were collected from the Birth Register also kept at the maternity unit. The Mpilo Central Hospital Ethics Committee gave a waiver in 2016 that all retrospective and non-intervention studies could go ahead in the institution as long as the data remained anonymous. There were no ethical issues that arose during the study as all the data remained anonymous with no identifying personal data, using secondary data from hospital records.

Results

There were 96,238 live births and 441 maternal deaths at MCH during the study period 2011–2020. Table 1 below shows the total live births, number of maternal deaths for each year, and the MMR per 100,000 live births. The MMR declined from 655 in 2011 to 203 per 100,000 live births by 2020, a 69% reduction. Table 1 and Figure 1 illustrate the MMR.

Figure 1:

Maternal mortality ratio decline over the decade.

The commonest groups of maternal mortality during the period 2011–2020 were hypertensive disorders (22.5%), obstetric haemorrhage (19.7%), pregnancy-related infection (15.4%), and pregnancies with abortive outcomes (15.0%).

During the study period, direct maternal deaths accounted for 75.3%, indirect causes were 20.0%, unspecified causes were 1.8%, and those occurring during pregnancy, childbirth and the puerperium accounted for 2.9% of the deaths as seen in Table 2.

Comparing the two periods, 2011–2015 and 2016–2020; there was a reduction in deaths (as a proportion of total deaths) from hypertension (58 vs. 41 chi-sq 0.60 p=not significant (NS)), obstetric haemorrhage (53 vs. 34 chi-sq 0.04 p=NS), pregnancy-related infection (46 vs. 22 chi-sq 1.12 p=NS), pregnancies with abortive outcomes (40 vs. 26 chi-sq 0.06 p=NS), anaesthetic complications (12 vs. 0 chi-sq 7.6 p<0.01), HIV-related (18 vs. 4 chi-sq 3.9 p<0.05), tuberculosis (6 vs. 0 chi-sq 3.7 p=NS) and malaria (3 vs. 0 chi-sq 1.9 p=NS). Overall there were 273 deaths in the 2011–2015 period compared to 168 in the 2016–2020 time period. Notably, anaesthetic and HIV-related deaths made up a significantly smaller proportion of deaths in the 2016–2020 time period.

Discussion

Conclusions

This epidemiological review found a 69% reduction in MMR declined over 10 years. The commonest three groups of maternal mortality during the study period were hypertensive disorders, obstetric haemorrhage, and pregnancy-related infection. The causes of maternal deaths in MCH over the last 10 years showed a widespread reduction with HIV-related illnesses, and anaesthetic complications significantly less represented. The various local and national interventions such as malarial control, the adoption of life-long Option B+ antiretroviral treatment for the pregnant women, the training courses of staff, and the introduction of strong clinical leadership and accountability significantly all contributed to the marked reduction in the MMR. The maintenance of such vital proactive actions could potentially help the country to achieve the SDG if this were introduced to all the maternity units.