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

Figures & data

Table 1. Sociodemographic characteristics and pregnancy details of 30 cases of maternal death in Bosaso District, Puntland State, Somalia.

	N (%)		Ns (%)
Age		Parity
15 – 20	5 (16.7)	1–3	6 (20.0)
21 – 25	1 (3.3)	4–6	9 (30.0)
26 – 30	8 (26.7)	7–9	7 (23.3)
31 – 35	8 (26.7)	≥ 10	8 (26.7)
36 – 40	6 (20.0)	Place of death
41 – 45	1 (3.3)	Home	18 (60.0)
46 – 50	1 (3.3)	Hospital	9 (30.0)
Woman’s education		Health centre	1 (3.33)
None	6 (20.0)	Private hospital	1 (3.33)
Madrasah	17 (56.7)	En route	1 (3.33)
Primary	4 (13.3)	Time of the death
High School	3 (10.0)	Ante-partum	1 (3.3)
Husband’s education		Intra-partum	3 (10.0)
Madrasah	7 (23.3)	Postpartum	26 (86.7)
Primary	7 (23.7(23.3)3)	Place of delivery
High School	13 (43.3)	Home	19 (73.1)
Technical School	3 (10.1)	Hospital	5 (19.3)
Working for income		MCH	1 (3.8)
Yes	13 (43.3)	Private hospital	1 (3.8)
No	17 (56.7)	Delivery outcome
Married		Stillborne child in singleton pregnancy	16 (61.5)
Yes	30 (100)	Live birth in singleton pregnancy	7 (27.0)
No	0 (0)	Live birth in twin pregnacy	4 (3.8)*
Husband’s occupation		Stillborn child in twin pregnancy	2 (7.7)
Shop/store owner/manager	2 (6.7)
Labourer/Informal sector	3 (10.0)
Constriction industry	5 (16.7)
Soldier	3 (10.0)
Teacher	3 (10.0)
Transportation	3 (10.0)
Technical	6 (20.0)
Farmer	1 (3.3)
Government/Formal sector	1 (3.3)
Food Catering Business	3 (10.0)

*The four live births belong to three pregnancies.

Table 2. Causes of maternal death among 30 women in Bosaso District, Puntland State, Somalia.

	Ns	%
Direct obstetric deaths
Haemorrhage	13	43.3
Antepartum	1
Intrapartum	2
Postpartum	10
Eclampsia	8	26.7
Obstructed labour	4	13.3
Sepsis	3	10.0
Subtotal	28	93.3
Indirect obstetric deaths
Anaemia	2	6.7

Table 3. Sequence of health care seeking among 30 cases of maternal death in Bosaso District, Puntland State, Somalia.

	First contacted health care provider	Second contacted health care provider	Third contacted health care provider
Hospital	0	12	4
Private hospital	0	1	4
Pharmacy	5	1	0
Community/Village health worker	2	2	2
Maternal and child health centre	7	7	2
Traditional birth attendant	16	3	2
Spiritual healer	0	1	0
No contact	0	3	16

Table 4. Ranking order of contributing factors among 30 cases of maternal death as per reviewer in Bosaso District, Puntland State, Somalia.

	Number of cases in which factor contributed
	Reviewer
Ranking order of contributing factors	1	2	3
1. Delay in decision making process	30	30	30
2. Delay in getting to see professional health staff	30	30	29
3. Lack of knowledge of treatment possibilities	29	30	29
4. Delay in reaching medical facility	30	28	29
5. Not recognizing severity of the problem	30	28	28
6. Substandard primary care	28	30	28
7. Obstruction in getting care	29	29	27
8. Substandard obstetric referral procedure	28	30	24
9. People essential for decision making not available	26	25	27
10. Disagreement in decision making	20	23	13
11. Lack of transport	19	19	12
12. Lack of money	20	14	16
13. Different perception of the condition	9	7	9

Table 5. Determined cause, reported symptoms and experienced delays among 30 verbally autopsied cases of maternal death in Bosaso District, Puntland State, Somalia.

Case #	Cause	Reported symptoms	Experienced delays
			Delay 1 (25)	Delay 2 (22)	Delay 3 (24)
1	Haemorrhage and sepsis	Bleeding, shortness of breath and offensive vaginal discharge.	Delivered at home by a TBA. Decided to seek medical help 6 days after recognition of the complication. Difficult for the husband to pay $150, family members helped	Seeking care at different providers including spiritual healer. Visited TB clinic twice and was referred second time to hospital	Needed blood transfusion, which was not available, so relatives donated blood, mother in law paid for the testing and bags.
2	Haemorrhage and retained placenta	Labour pains.	-	After 1.5–2 hours of bleeding the woman was transferred to the hospital by taxi.	Placenta was retained for 1.5–2 hours before transferred to the hospital,
3	Eclampsia	Generalized oedema.	Returned home and the husband made the decision to seek care again after 6 hours	Went to MCH clinic and was referred to the hospital, but went home instead and finally to the hospital.	-
4	Eclampsia and haemorrhage	Cramping. Generalized oedema.	Delivered at home by a TBA Decided to seek medical care after cramps had started.	Went to the MCH clinic, then referred to the hospital. Experienced transportation difficulties.	-
5	Haemorrhage and obstructed labour	Foetus not moving	Transport was not available at night. Not until in the morning 5 hrs. later.	Went to the local pharmacy, was referred to an ultrasound centre but this facility was closed because of mid-day break and the women returned home then went to the hospital.	Blood transfusion needed but was not readily available. Relatives and members of the public donated blood.
6	Haemorrhage	Bleeding and infection	Deliver at home by a TBA Stayed home for over two hours before deciding to seek medical care.	-	Seen at the hospital and received medicines and was then discharged and went home, then went to another health facility and received more medicines and was sent home. The women died after having returned home
7	Eclampsia	Cramping. Generalized oedema	Hospital stay was planned but escorts retuned home with the woman.	Sought care at three different facilities.
8	Eclampsia	Cramping, generalized oedema.	Decided to seek medical care after cramps had started.	Transported from home to the MCH clinic, from where she was transferred to the hospital. Then transferred to a private hospital. These health facility had no doctors thus the woman returned home and died.	The hospital was closed and the escorts took the woman to another health facility which was also closed.
9	Haemorrhage and obstructed labour	Labour pains and bleeding.	Decided to seek medical care after labour had started and had been bleeding for more than 12 hours .	Experienced transportation difficulties in the night.	Blood transfusion was needed but was not available. Relatives and members of public had no matching blood group.
10	Eclampsia and haemorrhage	Generalized oedema.	Decided to seek medical care after she was too week to move.	Seeking care a the local pharmacy three different times.	VHW in the local pharmacy could not help.
11	Anaemia	Tired and weak	Decided to seek care when too weak to move	Seeking care from two different health centres.	No active management at the MCH clinic or at the private hospital. The woman was seen at the outpatient clinic and was given tablets and sent home.
12	Eclampsia	General oedema, blurred vision	Sought medical care after her eyesight became blurred.	-	No active management at the pharmacy and no referral to an obstetric care provider.
13	Haemorrhage, hypertension and sepsis	Bleeding.	Delivered at home by a TBA. Stayed home for 10 days before receiving medical care.	Seeking care from traditional healers. Experienced difficulties in finding money for medicines.	The health care providers; the village health worker and others did not refer the woman to a MCH clinic or to the hospital.
14	Haemorrhage, anaemia	Prolonged labour, bleeding	Sought medical care after bleeding for an hour and noticing that the baby was not positioned properly.	Sought care at the MCH clinic, then referred to the hospital but returned home and called village health worker. After deciding to seek care again transport was not available.	No active management by the VHW and no referral to an obstetric care provider.
15	Haemorrhage, anaemia	Bleeding.	Delivered at home by a TBA. Then decided to seek care because of bleeding that started during labour.	-	-
16	Haemorrhage and sepsis	Offensive vaginal discharge, fever	-	-	No active management.
17	Sepsis	Abdominal pain, fever and shivering		Experienced money and transport difficulties among the relatives who was supposed to take her to the hospital	Medicines were given at the MCH clinic, but the woman was then sent home.
18	Haemorrhage and obstructed labour	Bleeding.	Called a TBA when she had lost a large amount of blood	Experienced transport difficulties for two hours.	Was delayed at the MCH clinic for three hours.
19	Obstructed labour	Prolonged labour.	No decision was made to seek care until after10 hours in labour.	Experienced transport difficulties in the night	No active management by the TBA and no referral to obstetric care provider.
20	Haemorrhage, hypertension.	Bleeding.	Sought medical care after she turned pale.	-	Stayed 10 days in the hospital but died when she returned home.
21	Haemorrhage, obstructed labour	Prolonged labour and bleeding.	Sought medical care after many hours of bleeding		Needed blood transfusion but the escort had no money so they searched blood donors but could not find anyone with a matching blood group.
22	Eclampsia.	Generalized oedema.	-	-	Died 30 minutes after giving birth, having returning home from the hospital where she had stayed the previous 10 days.
23	Haemorrhage.	Bleeding, followed by headache and fever.		The family sought care by the community health worker.	No active management was provided by the community health worker and no referral to an obstetric care provider was made.
24	Obstructed labour, hypertension.	High blood pressure and obstructed labour	Fist delay was made by the woman’s mother in deciding to seek care only after sixteen hours of labour.	Further delay due to visits at many health providers, e.g. the Community Health Worker.
25	Obstructed labour, haemorrhage	Prolonged labour and haemorrhage	The woman’s family decided to seek care only after thirty six hours of labour.	Long distance to health facility, took more than one hour to walk and other transportation was not available.	Ambulance was not available for the MCH
26	Anaemia, hypertension.	Hypertension anaemia, blood loss, poor appetite and weight loss.	The woman’s family decided to seek medical care only after thirty after onset of severe symptoms.		Blood transfusion needed but was not available. Relatives and members of the public donated the blood. Due to limited financial support, the women was discharged from the hospital.
27	Obstructed labour, haemorrhage	Fever, vomiting, prolonged labour and haemorrhage.	There was no first delay, the woman took a correct decision to seek care initially, but she then decided to return home after labour had decreased.		The Village Health Worker gave an injection to induce labour, which resulted in bleeding. A the decision to refer her to the hospital because of the bleeding was not made.
28	Eclampsia, obstructed labour	High blood pressure,	The woman’s oldest son and daughter refused to follow the doctor’s advice of making a caesarean section	The woman went to the MCH clinic, was then referred to the hospital, but returned home after she had refused to follow the doctor’s recommendation to make a caesarean section. The woman then called a TBA.
29	Sepsis and haemorrhage.	Fever and bleeding.	The women waited for one week to seek medical care despite bleeding	The woman sought care at multiple health care facilities e.g. the private hospital and was then referred to the referral hospital.	The woman was admitted to the hospital, and received a blood transfusion and then she returned home due financial limitations and limited family support.
30	Sepsis.	Bleeding, developed a rash after blood transfusion	The woman decided to seek medical care only after seven days of bleeding.	The woman sought care at the hospital, then she returned home and later sought medical care again.	Woman feels sick and got a skin rash after her blood transfusion in the hospital