Moyo et al. BMC Pregnancy and Childbirth (2018) 18:101 https://doi.org/10.1186/s12884-018-1717-1 RESEARCHARTICLE Open Access Access factors linked to maternal deaths in Lundazi district, Eastern Province of Zambia: a case control study analysing maternal death reviews Nkumbula Moyo1,2*, Mpundu Makasa2, Mumbi Chola2 and Patrick Musonda2 Abstract Background: Access factors associated with maternal death are important to understand because they are considered to be an essential measure of women’s health and indicative of the performance of health care systems in any community globally. This study aimed to analyse the access risk factors linked to maternal deaths in Lundazi district of the Eastern Province of Zambia using secondary data obtained from maternal death reviews and delivery registers. Methods: This was a case-control study with cases being recorded maternal deaths for Lundazi district (n = 100) while controls were randomly selected Lundazi District Hospital deliveries (n = 300) for the period 2010 to 2015. STATA™ (Stata Corporation, Texas, TX, USA) version 12.0 was used to analyse data. Odds ratio and 95% confidence intervals with associated p-values were used to analyse disparities between cases and controls while bivariate and multivariate regression analyses were done to show associations. Results: The likelihood of experiencing maternal death was 94% less among women who completed their scheduled antenatal care visits than those who did not (OR 0.06, 95% CI = 0.01–0.27, p = < 0.001). Delayed referral associated with maternal deaths and complications were 30% (30) for cases, 12% (37) for controls and 17% (67) for both cases and controls. Long distances, unskilled deliveries were 3%, (15) for both cases and controls with 13% (13) for cases and 1% (2) for controls only. Conclusion: Antenatal care is important in screening for pre-existing risk conditions as well as complications in early stages of pregnancy that could impact adversely during pregnancy and childbirth. Delay in seeking health care during pregnancy could be minimised if health services are brought closer to the communities to reduce on distances covered by pregnant women in Lundazi. Maternal education appears to influence antenatal health care utilisation because greater knowledge and understanding of the importance of antenatal care might increase the ability to select most appropriate service. Therefore, there is need for Lundazi District Health Office to scale up interventions that motivate women to make at least four scheduled antenatal care visits during pregnancy as recommended by the World Health Organization. Keywords: Maternal deaths, Maternal death review, Access factors, Verbal autopsy, Delays * Correspondence: [email protected] 1Macha Research Trust, Choma, Zambia 2Department of Public Health, School of Medicine, University of Zambia, Lusaka, Zambia © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Moyo et al. BMC Pregnancy and Childbirth (2018) 18:101 Page 2 of 9 Background by another district of Chama district within Eastern Maternal death is death of a woman while pregnant or Province of Zambia. within 42 days of termination of pregnancy, irrespective The 2012 Zambia National Health Policy estimates of duration and site of pregnancy, from any cause related that 80% of Zambian population use traditional and to or aggravated by the pregnancy or its management alternative services for their day-to-day health care. In but not from accidental or incidental causes [1]. Under Eastern province of Zambia, it was established that cul- the Sustainable Development Goal (SDG) number 3.1, tural and traditional norms still persist in communities the target is that by 2030 the global maternal mortality among women throughout the period prior to preg- ratio should have reduced to less than 70 per 100,000 nancy, during pregnancy, nutrition, after delivery and live births for every country including Zambia [2]. While during breastfeeding that affect uptake of antenatal care some districts may have done considerably well in redu- services [8]. These practices may put the health of preg- cing maternal mortality, Lundazi district in the Eastern nant women and their child at risk. Antenatal care is im- province of Zambia is one of the districts still struggling portant for the maintenance of good health of a to reduce maternal mortality to acceptable levels [3]. pregnant woman and the unborn child. WHO recom- Results from the 2013–2014 Zambia Demographic and mends four or more scheduled antenatal care visits as it Health Survey (ZDHS) conducted by Central Statistical improves maternal and neonatal outcome and reduce Office (CSO) in conjunction with Ministry of Health of death. In resource limited communities, basic antenatal Zambia indicate a national maternal mortality ratio of care is an important determinant of maternal mortality 398 per 100,000 live births. In other words, for every when practiced as one of the basic components of ma- 1000 live births in Zambia, four women (3.98) died dur- ternal health care [9]. ing pregnancy, during childbirth, or within 2 months of Access to maternal health services, particularly facility childbirth during the 7 years preceding the 2013–14 childbirth remains challenging mainly in rural Zambia ZDHS [4]. and this leads to delays in seeking care. A number of fac- Lundazi is one of the districts with high mortality rates tors are attributed to challenges faced by public health because together with Nyimba district of Eastern Province officials in Zambia to effectively scale up outreach ma- of Zambia, maternal mortality ratio of 410 maternal ternal health services and targeted messages to create deaths per 100,000 live births was estimated [3]. This is awareness about maternal deaths. Zambia’s maternal more than the national level maternal mortality ratio of health services have been weakened by high disease bur- 398 per 100,000 reported in the 2013/2014 ZDHS. How- den, low literacy levels, inadequate qualified health staff, ever, information regarding local factors associated with poor transport network, lack of investment in maternity maternal deaths is not readily obtainable. There has been waiting shelters for expectant mothers to lodge in as no study conducted in the district to establish risk factors they await child birth among other factors [10]. which are associated with maternal death yet such infor- While scientific research on maternal mortality is fo- mation is valuable in implementing and evaluating mater- cused mainly on clinical factors, this approach may not nal health interventions. be most useful if we are to understand the problem of Maternal mortality is an important measure of factors associated with maternal death [1]. This ap- women’s health and indicative of the performance of proach does not take in to account the importance of health care systems [5]. Establishing local factors associ- economic, political and social micro structural factors ated with maternal death for any community is a and other social determinants of maternal health [6]. It significant step in strengthening interventions to reduce is important to note that while information generated maternal deaths [6]. It has also been observed that fac- from maternal death reviews and community verbal aut- tors associated with maternal death are a sensitive indi- opsies is available, it has not been prudently compiled cator of the status of women, access to care, adequacy and used to evaluate factors that are associated with and quality of healthcare in developing countries [5]. maternal death in Lundazi. This study was conducted to The majority of the people of Eastern Province are determine access factors linked with maternal deaths in poor with an overall incidence of poverty at 80% and ex- Lundazi utilizing secondary data collected through treme poverty at 66% [7]. The literacy levels of the maternal death surveillance and response reports and people for Eastern Province remain quite low at 47% for routine birth and death registration information. women and 73% for men [4]. The population for the province mostly live in rural areas where the road net- Methods work is poor and access to health facilities is a challenge The study was conducted in Lundazi at the District [7]. According to Provincial Health Profile for 2011– Health Office. It included information obtained from 2012, Lundazi district recorded the least antenatal cover- health facilities within Lundazi district that conduct de- age at 67% compared to 96% highest coverage recorded liveries and recorded maternal deaths during the period Moyo et al. BMC Pregnancy and Childbirth (2018) 18:101 Page 3 of 9 2010 to 2015. Lundazi district is situated about 755 km by These specifications were expected to give a power of 80% road to the eastern side of the Zambian capital city of and to detect odds ratio of 2.0 or greater, at a confidence Lusaka and has a population of 366,432 as projected from level of 95%, with the alpha (α) level of 0.05, and case to 2010 national census [4]. Maternal Death Surveillance and control ratio of 1:3. The national risk rate is 398 deaths Response (MDSR) reviews are conducted every quarter of per 100,000 live births. the year to examine factors and causes associated with maternal death. This process provides a platform for doc- Data analysis umenting what obstetricians, gynaecologists, midwives Data extraction checklist was developed to extract rele- and doctors propose as factors and cause for maternal vant information from MDSR reports and verbal autopsies death [11].