Identification of maternal deaths, cause of death and contributing factors in Mangochi District, Malawi: a RAMOS study

Introduction: The recent World Health Organization (WHO) report on trends in Maternal mortality (MM), from 1990 to 2013, ranks Malawi as one of the fifteen sub-Saharan countries with the highest Maternal Mortality Ratio (MM) of above 500 per 100,000live births (WHO 2014b). Malawi has no registration system for recording births and deaths. MM estimates are based on direct sisterhood methods, (used in Demographic and Health Surveys) and WHO modelled estimates, which are both highly susceptible to inaccuracies because they are both indirect methods which do not identify individual deaths within a defined population. The difficulties in obtaining accurate MMR estimates highlight the need to explore other methodologies that give more reliable data on levels as well as the cause of maternal deaths (MDs). A Reproductive Age Mortality Survey (RAMOS) is one such approach and can provide more direct and complete estimation of MMR in countries without reliable vital registration or other data sources. This is the first RAMOS used in Malawi. The aim of this study was to identify the magnitude, causes of, and factors associated with MDs in the Mangochi district in Malawi. Methods: Deaths of women of reproductive age (WRA), (15 to 49 years) that occurred from December, 2011 to November, 2012 in the district were identified. Multiple data sources were used to identify deaths, including; health facilities, communities, mortuary records and police records. Classification the death as a MD or not was done according to the ICD-10 definition. Facility based audit were conducted for all facility based MDs and verbal autopsies for all MDs. Cause of death attribution was done in three ways, 1) by a panel of experts in maternal health using the WHO application of ICD-10 to deaths during pregnancy, childbirth and puerperium (ICD-MM) (WHO 2012c), 2) by health professionals working in health facilities and 3) by using an InterVA-4 computer model. Cause of death attributed by the three methods was then compared. The three delays model was used to identify delays associated with MDs. The number of MDs identified in this study was compared to the official register in the district. MMR was calculated based on three proxy denominators; 1) number of babies who received BCG vaccine, 2) live births from the census report and 3) live births calculated from general fertility estimates. Results: A total of 424 deaths of WRA were identified and 151 of these (35.6%) were identified to be MDs. Based on the three denominators, the MMR for the Mangochi district was within the range of 341-363 per 100,000 live births (95% CI: 289-425 per 100,000 live births). Only 86 MDs had been reported via existing registers, giving an underreporting rate of 43%. The highest MMR was in age group 25-29 years (494/100,000 live births (95% CI: 349-683 per 100,000). Most MDs (62.3% (94/151)) occurred in health facilities. Based on ICD-MM cause classification, 74.8% were direct MDs, 17.3% were indirect and 7.9% were due to unknown causes. The leading cause of direct MDs (n=113) was obstetric haemorrhage (35.8%) followed by pregnancy related infections (14.4%) and hypertensive disorders (12.6%). The most frequent indirect cause of MD (n=26) was malaria (56.7%). There was low level of agreement over the cause of death between the panel of experts and health the professionals (κ= 0.37), while a substantial level of agreement was observed between the panel of experts and the InterVA-4 model (κ= 0.66). Based on ICD-MM, health professionals identified contributory factors (morbidity group) to 15.1% of MDs (n=86) as the underlying cause of death. Substandard care for obstetric emergencies, lack of blood, lack of transport, failures to recognize the severity of a problem at community level and delays in starting the decision-making process to seek health care were frequently factors associated with MDs. Conclusion: The current MD reporting system in Malawi needs strengthening. The high numbers of health facility deaths, cause of MDs and their contributing factors in Mangochi reflect serious deficiencies in the quality of maternal care that need to be urgently rectified. Urgent orientation of health workers on ICD-MM is required to obtain accurate information on cause of MDs that can be used to design effective interventions. There is need to strengthen the referral system and educate women on obstetric danger signs