Mortality after near-miss obstetric complications in Burkina Faso: medical, social and health-care factors

Objective

To investigate mortality in women in Burkina Faso in the 4 years following a life-threatening near-miss obstetric complication and to identify the medical, social and health-care-related causes of death.

Methods

In total, 1014 women were recruited after hospital discharge and followed for up to 4 years: 337 had near-miss complications and 677 had uncomplicated pregnancies. Significant differences in mortality between the groups were assessed using Fisher’s exact test. The medical causes of death were identified from medical records and verbal autopsy data; social and health-care-related factors associated with death were identified from interviews with the deceased women’s relatives.

Findings

In the 4 years, 15 (5.3%) women died in the near-miss group and 5 (0.9%) died after uncomplicated pregnancies (P < 0.001). More than half the deaths after a near miss, but none after an uncomplicated delivery, were pregnancy-related. Indirect factors contributed to many of these deaths, particularly human immunodeficiency virus infection. Relatives’ accounts suggested that the high cost and poor quality of health care, a lack of follow-up care and an unmet need for contraception contributed to the excess mortality in the near-miss group.

Conclusion

Women in Burkina Faso who initially survived a near-miss obstetric complication had an increased risk of all-cause and pregnancy-related death in the ensuing 4 years. The likelihood of survival over the longer term could be increased by offering a continuum of care that addresses the indirect and social causes of death and supplements the emergency intrapartum obstetric care provided by current safe motherhood programmes.     

A prospective study of maternal,fetal and neonatal deaths in low- and middle-income countries

Objective

To quantify maternal, fetal and neonatal mortality in low- and middle-income countries, to identify when deaths occur and to identify relationships between maternal deaths and stillbirths and neonatal deaths.

Methods

A prospective study of pregnancy outcomes was performed in 106 communities at seven sites in Argentina, Guatemala, India, Kenya, Pakistan and Zambia. Pregnant women were enrolled and followed until six weeks postpartum.

Findings

Between 2010 and 2012, 214 070 of 220 235 enrolled women (97.2%) completed follow-up. The maternal mortality ratio was 168 per 100 000 live births, ranging from 69 per 100 000 in Argentina to 316 per 100 000 in Pakistan. Overall, 29% (98/336) of maternal deaths occurred around the time of delivery: most were attributed to haemorrhage (86/336), pre-eclampsia or eclampsia (55/336) or sepsis (39/336). Around 70% (4349/6213) of stillbirths were probably intrapartum; 34% (1804/5230) of neonates died on the day of delivery and 14% (755/5230) died the day after. Stillbirths were more common in women who died than in those alive six weeks postpartum (risk ratio, RR: 9.48; 95% confidence interval, CI: 7.97–11.27), as were perinatal deaths (RR: 4.30; 95% CI: 3.26–5.67) and 7-day (RR: 3.94; 95% CI: 2.74–5.65) and 28-day neonatal deaths (RR: 7.36; 95% CI: 5.54–9.77).

Conclusion

Most maternal, fetal and neonatal deaths occurred at or around delivery and were attributed to preventable causes. Maternal death increased the risk of perinatal and neonatal death. Improving obstetric and neonatal care around the time of birth offers the greatest chance of reducing mortality.     

Improving mortality data in Jordan: a 10 year review

Problem

Before 2003 there was substantial underreporting of deaths in Jordan. The death notification form did not comply with World Health Organization (WHO) guidelines and information on the cause of death was often missing, incomplete or inaccurate.

Approach

A new mortality surveillance system to determine the causes of death was implemented in 2003 and a unit for coding causes of death was established at the ministry of health.

Local setting

Jordan is a middle-income country with a population of 6.4 million people. Approximately 20 000 deaths were registered per year between 2005 and 2011.

Relevant changes

In 2001, the ministry of health organized the first meeting on Jordan’s mortality system, which yielded a five-point plan to improve mortality statistics. Using the recommendations produced from this meeting, in 2003 the ministry of health initiated a mortality statistics improvement project in collaboration with international partners. Jordan has continued to improve its mortality reporting system, with annual reporting since 2004. Reports are based on more than 70% of reported deaths. The quality of cause-of-death information has improved, with only about 6% of deaths allocated to symptoms and ill-defined conditions – a substantial decrease from the percentage before 2001 (40%). Mortality information is now submitted to WHO following international standards.

Lessons learnt

After 10 years of mortality surveillance in Jordan, the reporting has improved and the information has been used by various health programmes throughout Jordan.     

Causes of pediatric mortality and case-fatality rates in eight Médecins Sans Frontières-supported hospitals in Africa

Setting:

Eight pediatric hospital in-patient wards in remote, rural and/or insecure areas in Africa.

Objectives:

To describe, in children aged <5 years, 1) overall and individual mortality rates, 2) the 10 most common causes of mortality, and 3) their case-fatality rates.

Design:

Retrospective analysis of routinely collected standardized program data for 2010.

Results:

During 2010, 21 357 children aged <5 years were admitted and 1520 died, resulting in an overall in-patient mortality rate among under-fives of 7%. This remained the same after considering the three most common causes of mortality per hospital. One hospital with a neonatal unit showed a mortality rate of 14%. Of the 10 most common causes of mortality in the eight hospitals, severe malaria, acute lower respiratory tract infection and neonatal infection counted for about 77% of total deaths. Ranking the 10 most common causes of mortality according to case-fatality rates, septicemia, meningitis, low birth weight with pathology, neonatal infection and neonatal asphyxia were the most common (case-fatality rates 15–40%).

Conclusion:

Despite widely different contexts, mortality rates for pediatric in-patients were consistently under 10%. To further reduce mortality, emphasis should be placed on treating sepsis and introducing implementable and/or adapted care packages for neonatal-related pathologies.     

Traffic-Related Air Pollution and Perinatal Mortality: A Case–Control Study

Background

Ambient levels of air pollution may affect the health of children, as indicated by studies of infant and perinatal mortality. Scientific evidence has also correlated low birth weight and preterm birth, which are important determinants of perinatal death, with air pollution. However, most of these studies used ambient concentrations measured at monitoring sites, which may not consider differential exposure to pollutants found at elevated concentrations near heavy-traffic roadways.

Objectives

Our goal was to examine the association between traffic-related pollution and perinatal mortality.

Methods

We used the information collected for a case–control study conducted in 14 districts in the City of São Paulo, Brazil, regarding risk factors for perinatal deaths. We geocoded the residential addresses of cases (fetal and early neonatal deaths) and controls (children who survived the 28th day of life) and calculated a distance-weighted traffic density (DWTD) measure considering all roads contained in a buffer surrounding these homes.

Results

Logistic regression revealed a gradient of increasing risk of early neonatal death with higher exposure to traffic-related air pollution. Mothers exposed to the highest quartile of the DWTD compared with those less exposed exhibited approximately 50% increased risk (adjusted odds ratio = 1.47; 95% confidence interval, 0.67–3.19). Associations for fetal mortality were less consistent.

Conclusions

These results suggest that motor vehicle exhaust exposures may be a risk factor for perinatal mortality.     

Peer Reviewed: All-Cause Mortality in Tianjin,China, 1999-2004

Introduction

We analyzed trends of major causes of death in Tianjin, China, from 1999 through 2004 to better inform disease prevention and control programs and policies.

Methods

To report all-cause deaths among Tianjin residents from 1999 through 2004, we standardized mortality rates to the world population in 2000. We analyzed age, sex, and geographic distribution of deaths from different causes and the leading causes of death in Tianjin.

Results

The 5 leading causes of death in Tianjin were cardiovascular disease, cerebrovascular disease, malignant neoplasm, chronic lower respiratory disease, and injuries and poisoning. Mortality in Tianjin declined from 0.60% in 1999 to 0.48% in 2004. Noncommunicable diseases accounted for more than 80% of all deaths. Infant and maternal mortality in Tianjin were low. Life expectancy of Tianjin residents increased every year but was consistently longer in women. When deaths from the main chronic diseases are not considered, life expectancy lengthens substantially.

Conclusion

Chronic diseases are the leading cause of death in Tianjin, China. China should commit additional resources to supporting chronic disease prevention and control programs, including proven special health promotion projects.     

Perinatal Mortality and Associated Risk Factors: A Case Control Study

Background

Perinatal mortality is reported to be five times higher in developing than in developed nations. Little is known about the commonly associated risk factors for perinatal mortality in Southern Nations National Regional State of Ethiopia.

Methods

A case control study for perinatal mortality was conducted in University hospital between 2008 and 2010. Cases were stillbirths and early neonatal deaths. Controls were those live newborns till discharged from the hospital. Subgroup binary logistic regression analyses were done to identify associated risk factors for perinatal mortality, stillbirths and early neonatal deaths.

Results

A total of 1356 newborns (452 cases and 904 controls) were included in this analysis. The adjusted perinatal mortality rate was 85/1000 total delivery. Stillbirths accounted for 87% of total perinatal mortality. The proportion of hospital perinatal deaths was 26%. Obstructed labor was responsible for more than one third of perinatal deaths. Adjusted odds ratios revealed that obstructed labor, malpresentation, preterm birth, antepartum hemmorrhage and hypertensive disorders of pregnancy were independent predictors for high perinatal mortality. In the subgroup analysis, among others, obstructed labor and antepartum hemorrhage found to have independent association with both stillbirths and early neonatal deaths.

Conclusion

The perinatal mortality rate was more than two fold higher than the estimated national perinatal mortality;and obstructed labor, malpresentation, preterm birth, antepartum hemmorrhage and hypertensive disorders of pregnancy were independent predictors. The reason for the poor progress of labor and developing obstructed labor is an area of further investigation.     

The worldwide incidence of preterm birth: a systematic review of maternal mortality and morbidity

Objective

To analyse preterm birth rates worldwide to assess the incidence of this public health problem, map the regional distribution of preterm births and gain insight into existing assessment strategies.

Methods

Data on preterm birth rates worldwide were extracted during a previous systematic review of published and unpublished data on maternal mortality and morbidity reported between 1997 and 2002. Those data were supplemented through a complementary search covering the period 2003–2007. Region-specific multiple regression models were used to estimate the preterm birth rates for countries with no data.

Findings

We estimated that in 2005, 12.9 million births, or 9.6% of all births worldwide, were preterm. Approximately 11 million (85%) of these preterm births were concentrated in Africa and Asia, while about 0.5 million occurred in each of Europe and North America (excluding Mexico) and 0.9 million in Latin America and the Caribbean. The highest rates of preterm birth were in Africa and North America (11.9% and 10.6% of all births, respectively), and the lowest were in Europe (6.2%).

Conclusion

Preterm birth is an important perinatal health problem across the globe. Developing countries, especially those in Africa and southern Asia, incur the highest burden in terms of absolute numbers, although a high rate is also observed in North America. A better understanding of the causes of preterm birth and improved estimates of the incidence of preterm birth at the country level are needed to improve access to effective obstetric and neonatal care.     

Use of verbal autopsy to determine mortality patterns in an urban slum in Kolkata, India

Objective

To define mortality patterns in an urban slum in Kolkata, India, in the context of a cholera and typhoid fever project.

Methods

In a well-defined population that was under surveillance for 18 months, we followed a dynamic cohort of 63 788 residents whose households were visited monthly by community health workers to identify deaths. Trained physicians performed verbal autopsies and experienced senior physicians assigned the primary cause of death according to the International classification of diseases, 10th edition. We tabulated causes of death in accordance with Global Burden of Disease 2000 categories and assessed overall and cause-specific mortality rates per age group and gender.

Findings

During 87 921 person–years of follow-up, we recorded 544 deaths. This gave an overall mortality rate of 6.2 per 1000 person–years. We assigned a cause to 89% (482/544) of the deaths. The leading causes of death, in descending order, were cardiovascular diseases (especially among adults aged over 40 years), cancer, respiratory ailments and digestive disorders. Most deaths in children under 5 years of age were caused by tuberculosis, respiratory infections and diarrhoeal diseases.

Conclusion

Although the most common causes of death in children were infectious, non-communicable diseases were predominant among adults. There is a need for continuing interventions against infectious diseases in addition to new and innovative strategies to combat non-infectious conditions.     

Causes of Child Mortality (1 to 4 Years of Age) From 1983 to 2012 in the Republic of Korea: National Vital Data

Objectives:

Child mortality remains a critical problem even in developed countries due to low fertility. To plan effective interventions, investigation into the trends and causes of child mortality is necessary. Therefore, we analyzed these trends and causes of child deaths over the last 30 years in Korea.

Methods:

Causes of death data were obtained from a nationwide vital registration managed by the Korean Statistical Information Service. The mortality rate among all children aged between one and four years and the causes of deaths were reviewed. Data from 1983-2012 and 1993-2012 were analyzed separately because the proportion of unspecified causes of death during 1983-1992 varied substantially from that during 1993-2012.

Results:

The child (1-4 years) mortality rates substantially decreased during the past three decades. The trend analysis revealed that all the five major causes of death (infectious, neoplastic, neurologic, congenital, and external origins) have decreased significantly. However, the sex ratio of child mortality (boys to girls) slightly increased during the last 30 years. External causes of death remain the most frequent origin of child mortality, and the proportion of mortality due to child assault has significantly increased (from 1.02 in 1983 to 1.38 in 2012).

Conclusions:

In Korea, the major causes and rate of child mortality have changed and the sex ratio of child mortality has slightly increased since the early 1980s. Child mortality, especially due to preventable causes, requires public health intervention.     

Declining child mortality in northern Malawi despite high rates of infection with HIV

Objective

To determine whether routine surveys, such as the Demographic and Health Surveys (DHS), have underestimated child mortality in Malawi.

Methods

Rates and causes of child mortality were obtained from a continuous-registration demographic surveillance system (DSS) in Malawi for a population of 32 000. After initial census, births and deaths were reported by village informants and updated monthly by project enumerators. Cause of death was established by verbal autopsy whenever possible. The likely impact of human immunodeficiency virus (HIV) infection on child mortality was also estimated from antenatal clinic surveillance data. Overall and age-specific mortality rates were compared with those from the 2004 Malawi DHS.

Findings

Between August 2002 and February 2006, 38 617 person–years of observation were recorded for 20 388 children aged < 15 years. There were 342 deaths. Re-census data, follow-up visits at 12 months of age and the ratio of stillbirths to neonatal deaths suggested that death registration by the DSS was nearly complete. Infant mortality was 52.7 per 1000 live births, under-5 mortality was 84.8 per 1000 and under-15 mortality was 99.1 per 1000. One-fifth of deaths by age 15 were attributable to HIV infection. Child mortality rates estimated with the DSS were approximately 30% lower than those from national estimates as determined by routine surveys.

Conclusion

The fact that child mortality rates based on the DSS were relatively low in the study population is encouraging and suggests that the low mortality rates estimated nationally are an accurate reflection of decreasing rates.     

Birth attendants as perinatal verbal autopsy respondents in low- and middle-income countries: a viable alternative?

Objective

To assess the feasibility of using birth attendants instead of bereaved mothers as perinatal verbal autopsy respondents.

Methods

Verbal autopsy interviews for early neonatal deaths and stillbirths were conducted separately among mothers (reference standard) and birth attendants in 38 communities in four developing countries. Concordance between maternal and attendant responses was calculated for all questions, for categories of questions and for individual questions. The sensitivity and specificity of individual questions with the birth attendant as respondent were assessed.

Findings

For early neonatal deaths, concordance across all questions was 94%. Concordance was at least 95% for more than half the questions on maternal medical history, birth attendance and neonate characteristics. Concordance on any given question was never less than 80%. Sensitivity and specificity varied across individual questions, more than 80% of which had a sensitivity of at least 80% and a specificity of at least 90%. For stillbirths, concordance across all questions was 93%. Concordance was 95% or greater more than half the time for questions on birth attendance, site of delivery and stillborn characteristics. Sensitivity and specificity varied across individual questions. Over 60% of the questions had a sensitivity of at least 80% and over 80% of them had a specificity of at least 90%. Overall, the causes of death established through verbal autopsy were similar, regardless of respondent.

Conclusion

Birth attendants can substitute for bereaved mothers as verbal autopsy respondents. The questions in existing harmonized verbal autopsy questionnaires need further refinement, as their sensitivity and specificity differ widely.     

Exposing misclassified HIV/AIDS deaths in South Africa

Objective

To quantify the deaths from human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS) that are misattributed to other causes in South Africa’s death registration data and to adjust for this bias.

Methods

Deaths in the World Health Organization’s mortality database were distributed among 48 mutually exclusive causes. For each cause, age- and sex-specific global death rates were compared with the average rate among people aged 65–69, 70–74 and 75–79 years to generate “relative” global death rates. Relative rates were also computed for South Africa alone. Differences between global and South African relative death rates were used to identify the causes to which deaths from HIV/AIDS were misattributed in South Africa and quantify the HIV/AIDS deaths misattributed to each. These deaths were then reattributed to HIV/AIDS.

Findings

In South Africa, deaths from HIV/AIDS are often misclassified as being caused by 14 other conditions. Whereas in 1996–2006 deaths attributed to HIV/AIDS accounted for 2.0–2.5% of all registered deaths in South Africa, our analysis shows that the true cause-specific mortality fraction rose from 19% (uncertainty range: 7–28%) to 48% (uncertainty range: 38–50%) over that period. More than 90% of HIV/AIDS deaths were found to have been misattributed to other causes during 1996–2006.

Conclusion

Adjusting for cause of death misclassification, a simple procedure that can be carried out in any country, can improve death registration data and provide empirical estimates of HIV/AIDS deaths that may be useful in assessing estimates from demographic models.     

Low infant mortality among Palestine refugees despite the odds

Objective

To present data from a 2008 infant mortality survey conducted in Jordan, Lebanon, the Syrian Arab Republic, the Gaza Strip and the West Bank and analyse infant mortality trends among Palestine refugees in 1995–2005.

Methods

Following the preceding birth technique, mothers who were registering a new birth were asked if the preceding child was alive or dead, the day the child was born and the date of birth of the neonate whose birth was being registered. From this information, neonatal, infant and early child mortality rates were estimated. The age at death for early child mortality was determined by the mean interval between successive births and the mean age of neonates at registration.

Findings

In 2005–2006, infant mortality among Palestine refugees ranged from 28 deaths per 100 000 live births in the Syrian Arab Republic to 19 in Lebanon. Thus, infant mortality in Palestine refugees is among the lowest in the Near East. However, infant mortality has stopped decreasing in recent years, although it remains at a level compatible with the attainment of Millennium Development Goal 4.

Conclusion

Largely owing to the primary health care provided by the United Nations Relief and Works Agency (UNRWA) for Palestine Refugees in the Near East and other entities, infant mortality among Palestine refugees had consistently decreased. However, it is no longer dropping. Measures to address the most likely reasons – early marriage and childbearing, poor socioeconomic conditions and limited access to good perinatal care – are needed.     

Hypertension and diabetes-related morbidity and mortality trends in a municipality in the countryside of S?o Paulo

Objectives:

to identify the main causes for hospital admissions and deaths related to systemic arterial hypertension and diabetes mellitus (DM), and to analyze morbidity and mortality trends, in a municipality in São Paulo''s countryside, by comparing two three-years periods, 2002 to 2004 and 2010 to 2012.

Methods:

cross-sectional study which used secondary data regarding deaths from the Information System on Mortality and concerning hospital admissions from the DataSus Hospital Information System. Univariate and multivariate statistical analyses were conducted.

Results:

from 2002 to 2012, 325,439 people were admitted to hospitals, 14.7% of them due to circulatory system diseases (CSD) and 0.7% due to DM. The deaths distributed as the following: 29,027 deaths (31.5%) were due to CSD; 8.06% due to cerebrovascular diseases (CVD); and 2.75% due to DM. There was a significant association between admittance and death causes and patients'' gender and age in the three-year periods (p<0.001). The highest lethality in hospital admissions was found to be due to CVD (10%). That trend showed that mortality rates dropped, younger patients were admitted due to DM, and older patients were admitted due to CVD - they were more often females.

Conclusion:

the main causes for hospital admissions were the CSDs; main mortality causes were the CVDs in hypertensive and diabetic women. Those findings can back public policies which prioritize the promotion of health.     

Mortality from neglected tropical diseases in Brazil, 2000–2011

Objective

To describe mortality from neglected tropical diseases (NTDs) in Brazil, 2000–2011.

Methods

We extracted information on cause of death, age, sex, ethnicity and place of residence from the nationwide mortality information system at the Brazilian Ministry of Health. We selected deaths in which the underlying cause of death was a neglected tropical disease (NTD), as defined by the World Health Organization (WHO) and based on its International statistical classification of diseases and related health problems, 10th revision (ICD-10) codes. For specific NTDs, we estimated crude and age-adjusted mortality rates and 95% confidence intervals (CI). We calculated crude and age-adjusted mortality rates and mortality rate ratios by age, sex, ethnicity and geographic area.

Findings

Over the 12-year study period, 12 491 280 deaths were recorded; 76 847 deaths (0.62%) were caused by NTDs. Chagas disease was the most common cause of death (58 928 deaths; 76.7%), followed by schistosomiasis (6319 deaths; 8.2%) and leishmaniasis (3466 deaths; 4.5%). The average annual age-adjusted mortality from all NTDs combined was 4.30 deaths per 100 000 population (95% CI: 4.21–4.40). Rates were higher in males: 4.98 deaths per 100 000; people older than 69 years: 33.12 deaths per 100 000; Afro-Brazilians: 5.25 deaths per 100 000; and residents in the central-west region: 14.71 deaths per 100 000.

Conclusion

NTDs are important causes of death and are a significant public health problem in Brazil. There is a need for intensive integrated control measures in areas of high morbidity and mortality.     

Maternal Deaths in a Tertiary Health Care Centre of Odisha: An In-depth Study Supplemented by Verbal Autopsy

Background:

Maternal mortality is a reflection of the care given to women by its society. It is tragic that deaths occur during the natural process of child birth and most of them are preventable.

Objectives:

The present study was undertaken to find out the causes and contributing factors of maternal deaths.

Materials and Methods:

All maternal deaths occurring in a year in the medical college and hospital were traced and interviews were taken from the relatives as well as the health care providers who were present at the time of death of the woman.

Results:

Out of the total maternal deaths, 72% belonged to 20-30 yrs age group, also 46.5% were illiterate, and majority deaths (60.5%) were from low socio-economics status. Direct causes were responsible for 76.7% of maternal deaths. Hypertensive disorders of pregnancy were most common (32.6%) cause of direct deaths, while malaria (9.3%) and anemia (7%) were most common indirect causes. Most of the women had to use their own resources to travel to health care facilities. Delays at different levels, often in combination, contributed to the maternal deaths.

Conclusions:

The study will serve as an eye-opener to the bottlenecks present in the community as well as in the health facility so as to take appropriate measures to prevent maternal deaths.     

Availability and quality of cause-of-death data for estimating the global burden of injuries

Objective

To assess the availability and quality of global death registration data used for estimating injury mortality.

Methods

The completeness and coverage of recent national death registration data from the World Health Organization mortality database were assessed. The quality of data on a specific cause of injury death was judged high if fewer than 20% of deaths were attributed to any of several partially specified causes of injury, such as “unspecified unintentional injury”.

Findings

Recent death registration data were available for 83 countries, comprising 28% of the global population. They included most high-income countries, most countries in Latin America and several in central Asia and the Caribbean. Categories commonly used for partially specified external causes of injury resulting in death included “undetermined intent,” “unspecified mechanism of unintentional injury,” “unspecified road injury” and “unspecified mechanism of homicide”. Only 20 countries had high-quality data. Nevertheless, because the partially specified categories do contain some information about injury mechanisms, reliable estimates of deaths due to specific external causes of injury, such as road injury, suicide and homicide, could be derived for many more countries.

Conclusion

Only 20 countries had high-quality death registration data that could be used for estimating injury mortality because injury deaths were frequently classified using imprecise partially specified categories. Analytical methods that can derive national estimates of injury mortality from alternative data sources are needed for countries without reliable death registration systems.     

Emergency obstetric care in Mali: catastrophic spending and its impoverishing effects on households

Objective

To investigate the frequency of catastrophic expenditures for emergency obstetric care, explore its risk factors, and assess the effect of these expenditures on households in the Kayes region, Mali.

Methods

Data on 484 obstetric emergencies (242 deaths and 242 near-misses) were collected in 2008–2011. Catastrophic expenditure for emergency obstetric care was assessed at different thresholds and its associated factors were explored through logistic regression. A survey was subsequently administered in a nested sample of 56 households to determine how the catastrophic expenditure had affected them.

Findings

Despite the fee exemption policy for Caesareans and the maternity referral-system, designed to reduce the financial burden of emergency obstetric care, average expenses were 152 United States dollars (equivalent to 71 535 Communauté Financière Africaine francs) and 20.7 to 53.5% of households incurred catastrophic expenditures. High expenditure for emergency obstetric care forced 44.6% of the households to reduce their food consumption and 23.2% were still indebted 10 months to two and a half years later. Living in remote rural areas was associated with the risk of catastrophic spending, which shows the referral system’s inability to eliminate financial obstacles for remote households. Women who underwent Caesareans continued to incur catastrophic expenses, especially when prescribed drugs not included in the government-provided Caesarean kits.

Conclusion

The poor accessibility and affordability of emergency obstetric care has consequences beyond maternal deaths. Providing drugs free of charge and moving to a more sustainable, nationally-funded referral system would reduce catastrophic expenses for households during obstetric emergencies.