Patterns and determinants of maternal mortality in Zimbabwe: 1999-2016.

Abstract

Maternal mortality remains unacceptably high in Zimbabwe. Some of the causes are highly preventable and can be easily dealt with through a better understanding of the underlying issues. This thesis aimed to characterize women who died in maternity, establish the causes of death and explore the circumstances leading to death. It was observed that collecting valid and reliable data that answer the study questions would be technically challenging, expensive and time-consuming. As a practical and innovative response, the researcher triangulated quantitative secondary data from the national maternal death notification system and a massive national survey. To fill in the gaps in understanding the emerging patterns, qualitative data were collected from twenty-four (24) focus group discussions with women of child-bearing age and twelve (12) key informant interviews with community birth attendants in twenty-one (21) districts. In total, this study used data collected from thirty-two (32) districts in both rural and urban areas. Univariate and bivariate techniques were used to establish common trends and patterns in the demographic, socio-economic, antenatal, intra-partum and post-partum characteristics of women of child-bearing age. Significance was tested for categorical variables using the Chi-square test at the 0.001, 0.01 and 0.05 levels. Demographic techniques were used to estimate maternal mortality rates for each category per 1,000 woman-years of exposure. The results showed that demographic and socio-economic factors of maternal mortality in Zimbabwe include age (p<0.05); marital status (p<0.001); fertility (p<0.01); employment and occupational characteristics (p<0.001) and; religion (p<0.001). In the antenatal period, maternal mortality was influenced by booking status (p<0.001); time of booking (p<0.001) and; number of antenatal care visits (p<0.001). During labour and delivery, maternal outcomes were influenced by mode of delivery (p<0.001); gestation at delivery (p<0.001); place where labour starts (p<0.001); intra-partum complications (p<0.001); place of delivery (p<0.001); number of infants born (p<0.001) and; referral characteristics (p<0.001). In the post-partum period, the main factors were post-delivery complications (p<0.001); postnatal care and referral characteristics (p<0.001). The qualitative enquiry revealed that maternal deaths are shaped by the way pregnancy and obstetric complications are perceived, interpreted and dealt with by individuals, communities and the health system. Although social norms, myths, beliefs, attitudes, practices and the state of health care do not necessarily cause maternal death, they determine the level of risk, which is further moderated by delays. Thus, the study’s original contribution to the body of scientific knowledge is that it demonstrates that in Zimbabwe, the time between the onset of obstetric complications and getting the appropriate attention is the ultimate determinant of maternal outcomes. Furthermore, it demonstrates that the three-delay framework needs to be updated to four-delays so that it can adequately reflect the unfolding reality in the developing world. The author recommends interventions that help women, households and communities to recognize the danger signs of pregnancy early, decide to seek institutional care on time, reach treatment facilities quickly, and improve institutional capacity to provide basic and comprehensive emergency obstetric care.