Causes and contributing factors of maternal mortality in Bosaso District of Somalia. A retrospective study of 30 cases using a Verbal Autopsy approach

ABSTRACT

Background: Somali women suffer from one of the highest maternal mortality rates in the world. Somalia characterises a specific low-income country situation with a mix of newly urbanized and nomadic culture combined with a frail health care infrastructure set in a post-conflict era. Very little is known about the effects that these contextual factors can have on maternal mortality.

Objectives: To explore and describe causes and contributing factors concerning maternal deaths in the Bosaso District, Puntland State of Somalia.

Methods: Data was collected using an adapted Verbal Autopsy tool. In 2017 30 cases of maternal deaths occurring in 2016 in the Bosaso District were reviewed. Information was assessed by three independent reviewers who classified the cause of death and the contributing factors. The Three Delay Model was employed to identify socio-cultural and economic and health system factors that may have contributed to these maternal deaths.

Results: Direct obstetric deaths accounted for 28 cases. Among these, haemorrhage was the leading cause, followed by eclampsia, sepsis and obstructed labour. Two cases were indirect obstetric deaths, caused by anaemia. All three types of delay were frequent among the studied cases. Delay in deciding to seek care was found in 25 cases, delay in reaching care in 22 cases and delay in receiving health care in 24 cases. Lack of knowledge, money, transportation, poor access and availability of adequate services, as well as substandard management by health care providers, were all underlying the delays.

Conclusion: A comprehensive intervention programme is needed in order to decrease maternal mortality among Somali women. Such a programme must include health education, improved referral systems and strategic upgrading of care services.

KEYWORDS:

• Maternal health
• maternal mortality in Somalia
• causes and contributing factors
• Three Delay Model
• Verbal autopsy

Responsible Editor Jennifer Stewart Williams, Umeå University, Sweden

Responsible Editor Jennifer Stewart Williams, Umeå University, Sweden

Acknowledgments

We would like to thank the communities, families, relatives and neighbours of the deceased women, TBAs, CHWs and others in Bosaso District, who provided us with knowledge of the cases in this study. We also want to thank Somali-Swedish Research Cooperation for Health (SSRCH) program for coordinating and funding the study and specially East Africa University, which contributed with funding to the collaboration.

Disclosure statement

No potential conflict of interest was reported by the authors.

Ethics and consent

East Africa University Institutional Review Board (EAUIRB) approved the study. The Director of Bosaso General Hospital, Directors of the three MCHs and the TBAs permitted access to the health facility patient records. Individuals or families approached for participation in the study were first fully briefed on the purpose of the study and as well as their roles. It was also explained to them in Somali the right of refusal or withdrawal from interviews. The participants then signed a consent form with their name in writing or by their thumbprint.

Paper context

There is a lack of systematic studies exploring the ‘road to death’ of maternal deaths in Somalia, a country without vital registration. This study analysed the background factors and determinants of maternal mortality using an adapted VA approach based on the ‘Three Delay Model’. Delays were often identified in the maternal deaths resulting from sociocultural, economical and health service factors obstructing access to adequate and prompt health care. This study adds important new knowledge about contextual factors behind maternal mortality in Somalia.

Additional information

Funding

This work was supported by SSRCH program in particular through the collaboration, East Africa University funded the study. Alliance for Health Policy and Systems Research provided additional funding for the preparation of the manuscript through the collaboration.

Notes on contributors

Jamila Ahmed Aden

JA conceptualized, drafted, and led the writing of the manuscript. PO, HJ provided overall conceptual guidance for the study and PO closely worked with JA to develop the article. All authors have contributed to the writing and reviewed and approved the final manuscript.