Our study was a retrospective cohort study to assess maternal mortality rate and associated risk factors at four tertiary hospitals in Burundi, namely, the Centre Hospital-University of Kamenge (CHUK), Military Hospital of Kamenge (MHK), Prince Regent Charles Hospital (PRCH), and Clinical Hospital Prince Louis Rwagasore (CHPLR), from January 2020 to December 2021. One measure of healthcare quality in a nation and a country is maternal mortality (MM). In Burundi's tertiary hospitals, the maternal mortality rate and related risk factors were evaluated using a variety of techniques. Facility-based analyses go beyond simple statistical analysis to identify the cause of maternal death as well as other contributing factors like delays and care delivery gaps. Hence, it was essential to carry out this retrospective cohort study to assess maternal mortality rate (MMR) and associated risk factors at CHUK, MHK, PRCH, and CHPLR hospitals in Burundi.
This study is the first to examine the risk variables related to MMR in four tertiary hospitals in Burundi (2020–2021). A total of 30,264 women gave birth at the CHUK, MHK, PRCH, and CHPLR referral hospitals between January 2020 and December 2021. 125 of the women passed away due to conditions that were either directly or indirectly related to the pregnancy, childbirth, or their care. The mean age of women with maternal deaths was 33 years. In this study, for the deliveries in 2020–2021, there were 31,067 live births. After the conventional calculation of MMR was extrapolated, this equates to 402 deaths for every 100,000 live births. The poor caliber of obstetric care is reflected in these high rates. Other referral facilities, such as Médecins Sans Frontières, gave contrasting reports of an MMR of 208 (range 8-360) deaths/100,000 live births for the Kabezi district of Burundi in 2011[16]. According to our research, MMR has been more prevalent in Burundi during the past decade.
Our findings suggest a significant association between MMR and direct and indirect causes of maternal death, (F (8, 116) = 2.18, p < .05). There was a significant association between MMR and haemorrhage and uterine rupture, where in both cases p is less than 0.05. There was a significant association between MMR and community-level characteristics, (F (7, 117) = 9.91, p < .05). Additionally, there was a significant association between MMR and type of delay, (F (3, 121) = 2.76, p < .05). Whereas, second delay (delayed identification and arrival at the referral hospitals for treatment) was significantly associated with MMR, with p = 0.005. Our results suggest significant implications for MM risk management approach, including early detection, effective reduction, and prevention.
Haemorrhage was responsible for 12 deaths. Obstetric haemorrhage deaths continue to occur despite numerous treatments and prevention measures being in place. Obstetric haemorrhage was determined to be the primary global cause of direct maternal deaths in recent studies[17, 18]. Since uterine atony is the primary cause of all obstetric haemorrhages, the hospital must make sure that every woman undergoing delivery receives active management of the third stage of labor. In the same way, medical personnel should always be prepared to act quickly and cooperatively in the case of an obstetric haemorrhage. This can be accomplished by teaching basic life-saving techniques including intrauterine balloon tamponade, abdominal aortic compression, and bimanual uterine compression to every healthcare professional working in CHUK, MHK, PRCH, and CHPLR maternity units. A standard operating process and access to safe blood should be in place for monitoring women who have emergency obstetric procedures.
Pre-eclampsia/eclampsia caused 9 maternal deaths. This is consistent with earlier research's results that the majority of fatalities were brought on by severe cases of pre- and eclampsia[19]. Additionally, a shortage of qualified staff and delays in CHUK, MHK, PRCH, and CHPLR have had a severe impact on the obstetric care of patients with pre-eclampsia/eclampsia. This was the case in the vast majority of Burundian ANC clinics. Eclampsia-related fatalities can be avoided along the entire spectrum of obstetric treatment. Blood pressure readings and urine tests for proteinuria at the antenatal clinic can help detect pregnant women who have hypertensive disorders so that the illness can be appropriately managed before it worsens, progresses to eclampsia, and ultimately results in death. However, this is not the situation in the majority of Burundian prenatal facilities. Additionally, inadequate ANC has been identified in recent research to identify pregnancy-related hypertension disorders[20]. To lower the risk of MM in women, strict ANC attendance should be emphasized.
Malaria was the cause of 5 maternal deaths at CHUK, MHK, PRCH, and CHPLR in the years 2020–2021. Regional disparities in MM can be explained by malaria, which is the first non-obstetric cause of the condition[21]. If infection prevention and control guidelines are not followed while providing obstetric care, this disease, which is widespread in sub-Saharan Africa, can develop. Pregnant women who have malaria are more likely to experience anemia, which increases the risk of newborn mortality and contributes to maternal death during delivery from haemorrhage. Malaria also increases the risk of stillbirth, premature birth, and low birth weight. Maternal mortality can be caused by malaria directly or indirectly. Malaria infections claim the lives of 10,000 pregnant women each year. Additionally, anemia, which increases a woman's risk for post-partum haemorrhage, the leading cause of maternal death, is a major result of malaria[22]. These findings highlight the significance of requiring strict adherence to malaria infection prevention and control practices from all medical personnel caring for pregnant and lactating patients.
Anaemia significantly contributed to 7 maternal fatalities in this investigation. These results are consistent with recent research that found anaemia to be the primary factor in between 1 and 46% (mean 10.0%) of maternal fatalities across 23 investigations. In contrast, several reports—the majority of which came from Latin America. However, 52 studies were from Africa and 45 from Asia[23]—did not list anemia as a cause of mortality. Due to the potential for fast cardiac decompensation, acute onset anaemia during pregnancy considerably increases the risk of death. While chronic anaemia is thought to be a frequent contributing factor, especially to the effects of haemorrhage and infection, severe acute anaemias are thought to be a primary and quick cause of death, such as in Nigeria when associated with the acute haemolysis of sickle cell disease[24]. By increasing the susceptibility of the mother to infection, iron-deficiency anaemias may contribute to higher morbidity and death[25]. Individual exposure to anaemia and its correlations demands further research.
Third delay was responsible for causing 106 of the maternal deaths that occurred at CHUCK, MHK, PATCH, and CHPLR. Third delay includes delays in receiving treatment at the referral hospitals, delays in receiving referrals from other healthcare institutions, insufficient provider skill sets at the facility recommending the patient, and insufficient provider skill sets at the referral hospitals. While the lack of transport may have contributed to the delay in referral from another facility, the healthcare professionals may also have been unable to recognize the referral criteria for a lower facility's inability to provide the necessary continuation of care. Due to the high number of newly hired healthcare professionals working in lower-level facilities at the moment, this may be attributed to a lack of experienced staff. Deaths were also impacted by delayed referrals and a healthcare provider's lack of expertise. One of the patients arrived at CHUK late due to an inadequately repaired lower uterine section that was still bleeding. Deaths resulting from insufficient expertise also happened in MHK, PRCH, and CHPLR, where in some cases a novice doctor performing a caesarean section failed to stop bleeding in uterine atony, leading to a subtotal hysterectomy and the woman's unfortunate death. The majority of preventable maternal deaths, according to a study conducted in China[26], were caused by county institutions with inadequate knowledge and abilities. Further investigations are required to exhaust MM risk resulting from the third delay.
Severe bleeding also brought about 12 maternal deaths. Uterine rupture is the usual source of severe bleeding and was responsible for 14 maternal fatalities. Particularly in some cases, risk factors for uterine rupture include grand multiparity, fetal malposition, malpresentation, and fetopelvic disproportion. Another important factor that increases the risk of uterine rupture is a prior uterine scar. In this investigation, all uterine rupture-related maternal deaths occurred either at home, where the women had been giving birth for more than 24 hours or after being referred from another facility[15]. Women who are multiparous and those who have had uterine scarring need to be warned against attempting home deliveries. Patients at risk of uterine rupture should be sent much sooner to higher-level facilities such as CHUK, MHK, PRCH, and CHPLR referral hospitals, for the continuum of care from prenatal clinics and facilities lacking surgical rooms. To identify any deviations in labor's progression and take the necessary measures, emphasis should be placed on the usage of partographs.
According to this analysis, the second delay (delay in locating and getting to CHUK, MHK, PRCH, and CHPLR referral hospitals for treatment) and the first delay (delayed choice to seek proper medical attention for an obstetric emergency/health facility) each contributed to 14 and 5 maternal deaths, respectively. With respect to other studies, this contribution is less. The first delay was responsible for 90% of maternal deaths, according to research done in India[27]. Another study from Bangladesh[28] found that a number of factors contributed to maternal deaths, including untrained birth attendants or family members performing the delivery, understanding maternal complications slowly, delaying the decision to transfer the mother, and traditional myths that were influenced by lack of knowledge and education. These factors contributed to the delay in getting to a health facility and are closely tied to the under-empowerment of women. Lack of money and transportation were other factors that prolonged the journey to the medical center. Maternal mortality brought on by first- and second delays may be decreased with continued advocacy, financial incentives for traditional birth attendants to accompany pregnant women to medical facilities, and customized birth plans. Our startling findings may be used to pinpoint the primary contributing factor and the most critical cause of death given the rising incidence of maternal deaths and morbidity.
Our research has a number of important benefits. First, using a reasonably large sample size, we conducted a retrospective cohort study of pregnant women to examine the maternal mortality rate and associated risk factors at four tertiary hospitals in Burundi (2020–2021), which had seldom been studied before. Second, we used well-trained, experienced, and closely supervised staff at CHUK, MHK, PRCH, and CHPLR, which resulted in generally reliable clinical data and diagnoses, and diligent documentation of maternal morbidity and mortality. The study's striking findings may offer solutions for the susceptible subgroups in particular for effective MM reduction and early prevention.
However, there are a number of limitations. First, we identified MM cases primarily using complications-specific criteria that depended on clinical expertise, which may have affected the number of sociodemographic features. The study's striking conclusions could provide answers for susceptible subgroups, in particular, for effective MM reduction and early prevention. Second, we only had records of maternal deaths that happened up to the point at which women were discharged or transferred from CHUK, MHK, PRCH, and CHPLR (as opposed to up to 42 days after childbirth or pregnancy termination). Our striking findings may be used to identify the most important determinants for MM as well as the primary cause of death and MMR. Third, there is a potential that some data may be missing because this study is a retrospective study. As a result, the outcomes may vary from those of other studies. A prospective study will be preferable to determine the precise causes of MM. Fourth, because Burundi is a developing nation, the findings may vary, which reduces their external validity.