Factors Associated With Maternal Mortality In South East Botswana

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FACTORS ASSOCIATED WITHMATERNAL MORTALITY IN SOUTH EASTBOTSWANATUDUETSO M. MOKGATLHEA mini-thesis submitted in partial fulfillment of therequirements for the degree of Masters in Public Health at theSchool of Public Health,University of the Western CapeSupervisor: Professor Ehimario IgumborNovember 2012i

FACTORS ASSOCIATED WITH MATERNAL MORTALITY IN SOUTHEAST BOTSWANATUDUETSO MOKGATLHEKEYWORDS Maternal mortality Maternal death Maternal health Pregnancy-related death Risk factors Cause of death Case control study Quantitative study Record review Botswanaii

ACKNOWLEDGEMENTSThis mini-thesis would not have been possible without the contribution of variouspeople and I gratefully appreciate their assistance.I owe thanks to my supervisor, Professor Ehimario Igumbor for his wise guidance,valuable feedback, support and encouragement throughout this work. Additionally, Iwould like to thank Ms. Corinne Carolissen and Ms. Janine Kader, for their timelyresponses to enquiries and helpfulness. I am also grateful for my colleagues at UWCfor the moral support.I must also thank Ms. Thipe and Ms. Kasule from the Ministry of Health.Additionally, I would like to express my gratitude to Princess Marina Hospital andBamalete Lutheran Hospital for granting me permission to access the requiredinformation. At PMH, I would specifically like to thank Dr. Petr and Ms. Moatsheand at BLH, Ms. Sello.I must also acknowledge the contribution made by members of my family. Myhusband, Boitshoko for believing in me and encouraging me to apply for this MPH.Our children- Lindile, Sandile, Andile and Khetiwe- for being my inspiration. Mymother, Irene and my siblings for cheering me on and for their support. My motherin-law, Nursey, for babysitting when I needed to travel to Cape Town. Dr. LuckyMokgatlhe for helping set up the database and his family for babysitting.Lastly but not least, I thank God for being a guiding light throughout this work andfor giving me the strength to keep going until the end.iii

TABLE OF CONTENTSTitle PageiKeywordsiiAcknowledgementsiiiTable of ContentsivAbstractxDeclarationxii1.0 CHAPTER ONE: INTRODUCTION11.1. Background Information11.2. Problem Statement31.3. Purpose42.0 CHAPTER TWO: LITERATURE REVIEW52.1. Definition of Maternal Death52.2. Maternal Mortality Statistics62.3. Causes of Maternal Death82.4. Factors Associated with Maternal Mortality102.5. Maternal Characteristics Associated with Maternal Mortality112.6. Health Facility Characteristics Associated with Maternal Mortality142.7. Methods Used for Studying Maternal Mortality162.8. Policies/ Interventions to reduce maternal mortality173.0 CHAPTER THREE: METHODOLOGY193.1. Aim and Objectives193.1.1. Aim19iv

3.1.2. Objectives193.2. Study Design193.3. Study Population and Sampling203.4. Data Collection213.5. Data Analysis213.5.1. Data Checking213.5.2. Data Preparation223.5.3. Data Analysis223.6. Validity233.7. Ethical Considerations244.0 CHAPTER FOUR: RESULTS264.1. Description of the Study Sample264.2. Maternal Characteristics284.2.1. Demographic Characteristics284.2.2. Obstetric Characteristics344.3. Health Facility Characteristics444.4. Causes of Maternal Death494.5. Maternal Risk Factors Associated with Maternal Mortality504.5.1. Demographic Risk Factors504.5.2. Obstetric Risk Factors514.6. Health Facility Risk Factors Associated with Maternal Mortality534.7. Multiple Logistic Regression Model555.0 CHAPTER FIVE: DISCUSSION5.1. Hospital and Annual variations575.2. Demographic Profile595.3. Obstetric Profile615.4. Health Facility Profile635.5. Causes of Maternal Death64v

5.6. Maternal Risk Factors Associated with Maternal Mortality675.6.1. Demographic Risk Factors675.6.2. Obstetric Risk Factors685.7. Health Facility Risk Factors Associated with Maternal Mortality705.8. Multiple Logistic Regression Model715.9. Limitations726.0 CHAPTER SIX: CONCLUSION736.1. Conclusion736.2. Recommendations74REFERENCES77APPENDICES85Appendix 1 Data Abstarction Schedule- Cases85Appendix 2 Data Abstraction Schedule- Controls87Appendix 3 UWC Research and Ethics Committees Approval89Appendix 4 MOH Health Research Unit Research Permit90Appendix 5 PMH Institutional Review Board Approval92Appendix 6 BLH Permission Letter93vi

LIST OF TABLESTable 1.1. Demographic, socio-economic and health services information forGaborone and South East3Table 2.1. The MMR of different countries in 20087Table 2.2. MMR for Botswana: 2006-20108Table 4.1. Distribution of cases and controls according to year and health facility inSouth East from 2007 to 200927Table 4.2. Health facility maternal mortality ratios according to year in South Eastfrom 2007 to 200928Table 4.3. Demographic characteristics of the maternal deaths (cases) and thecontrols and t-test and chi-square test (p 0.05) comparing their proportions in SouthEast from 2007 to 200929Table 4.4. Obstetric characteristics of the maternal deaths (cases) and the controlsand chi-square test (p 0.05) comparing their proportions in South East from 2007 to200936Table 4.5. Health facility characteristics of the maternal deaths (cases) and thecontrols and chi-square test (p 0.05) comparing their proportions in South East from2007 to 200945Table 4.6. Causes of maternal mortality in South East from 2007 to 200950Table 4.7. Demographic risk factors for maternal deaths in South East from 2007 to200951vii

Table 4.8. Obstetric risk factors for maternal deaths in South East from 2007 to 200952Table 4.9. Health facility risk factors for Maternal Mortality in South East from 2007and 200954Table 4.10. Multiple logistic regression analysis showing risk factors included andexcluded from the model55viii

LIST OF FIGURESFigure 4.1. Age groups of cases and controls30Figure 4.2. Education received by the cases and controls32Figure 4.3. Employment status of cases and controls33Figure 4.4. Marital status of cases and controls34Figure 4.5. Parity of the cases and controls38Figure 4.6. Admission during pregnancy of the cases and controls39Figure 4.7. ANC attendance by the cases and controls40Figure 4.8. Complications at admission among the cases and controls41Figure 4.9. Specific complications among the cases and controls42Figure 4.10. Type of delivery for cases and controls43Figure 4.11. Type of ANC Provider for the cases and controls46Figure 4.12. Referral pattern of the cases and controls at the time of delivery47Figure 4.13. Type of health facility for delivery for the cases and controls48Figure 4.14. Proportion of direct and indirect causes of maternal mortality in SouthEast between 2007 and 200949ix

ABSTRACTFactors Associated with Maternal Mortality in South East Botswana.T. M. MokgatlheMasters in Public Health Minithesis, School of Public Health, University of theWestern CapeBackground: Maternal mortality is a significant public health problem world-wide,as it is an important indicator for the functioning of the health system. The maternalmortality ratio for Botswana is higher than other countries with comparableeconomic growth, despite impressive access to health services. In order to developrelevant programs and policies to reduce maternal mortality, the factors associatedwith maternal mortality were studied. The study aimed to describe the maternal andhealth services factors associated with maternal mortality in South East Botswana.Methodology: A quantitative case-control study was used to retrospectively reviewmedical records for 71 cases of maternal deaths and 284 controls randomly selectedfrom mothers who delivered in the same year and at the same health facility, inSouth East Botswana from 2007 to 2009. Information was collected on the maternaland health services characteristics of the cases and controls including age, level ofeducation, marital status, parity, utilization of health facilities that consist ofantenatal care (ANC), type of delivery, complications during pregnancy, type ofhealth facility and ANC provider. Data was analyzed using Predictive AnalysisSoftware (PASW) Version 18. Two-sample t- test, Pearson’s Chi-square test and theFisher’s exact test were used to test the difference between the proportions of thevarious categories of variables in cases and controls. Univariate logistic regressionanalysis was applied to identify the risk factors associated with maternal deaths. Amultivariate logistic regression model was estimated to see the joint effects of theidentified risk factors for maternal mortality. Hosmer and Lemeshow test was used totest the goodness of fit of the model.Results: The mean age of the maternal deaths was 28.0 5.3 years and they hadtaken place at a hospital (100%). A large number of deaths occurred before deliveryx

(59.0%). The causes of maternal death included both direct (73%) and indirectcauses (27%). Direct causes were the leading causes of death and they were abortion(22.5%) and haemorrhage (18.3%). The maternal characteristics associated withmaternal mortality were having complications at delivery (OR 20.91), not receivingANC (OR 6.31) and delivering by caesarean section (OR 2.66). The health facilitycharacteristics associated with maternal mortality were delivering outside the healthfacility (OR 14.78), having been referred from another facility (OR 8.62) anddelivering at a general hospital (OR 5.91). The data produced a model with good fitthat included one maternal risk factor and three health facility risk factors. Thesewere being admitted with preterm labour, delivering at a general hospital or beforearrival at the health facility and having been referred from another health facility.Conclusion: Maternal mortality was associated with both maternal and healthfacility risk factors. The model developed may be used to identify and manage highrisk women to reduce the number of maternal deaths. It was recommended that, thecurrent system should continue to be monitored and evaluated through the MaternalMortality Monitoring System (MMMS). Furthermore, the referral and managementof complications needs to be strengthened through a multi-sectoral approach.xi

DECLARATIONI declare that Factors Associated with Maternal Mortality in South East Botswana ismy own work, that it has not been submitted before for any degree or examination inany other university, and that all the sources I have used or quoted have beenindicated and acknowledged as complete references.Tuduetso M. MokgatlheNovember 2012Signed: . . . . . . . . . . . . .xii

1.0 CHAPTER ONE: INTRODUCTIONThis chapter sets the context of the study by providing background informationwhich includes an overview of the maternal mortality situation worldwide and inBotswana. It also briefly describes the demographic, socio-economic and healthservices profile of the study area, South East Botswana. Furthermore, the problemstatement and the purpose of the study are presented.1.1. Background InformationMaternal mortality is a worldwide problem which is more pronounced in thedeveloping countries than in the developed countries (Alvarez, Gil, Hernández andGil, 2009). According to the World Health Organisation (WHO) (2010), in 2008 thematernal mortality ratios (MMR) ranged from 2 maternal deaths per 100,000 livebirths in Greece to 1400 maternal deaths per 100,000 live births in Afghanistan. Highlevels of maternal mortality are a health and developmental concern as it is anindicator not only of the health of women but also of the status of the health caresystem in a country. This is because, a maternal death is a representation of a largenumber of other women who experience morbidity (WHO, 2004a). This is ofimportance as most of these deaths are considered preventable (WHO, 2004a).In 2008 (WHO, 2010), there were approximately 358,000 maternal deathsworldwide, of which 99% were from developing countries and 57% were from subSaharan Africa. The report also estimates the MMR for sub-Saharan Africa to be 640deaths per 100,000 live births, which is 40 times that of Europe (16 deaths per100,000 live births) and 28 times that of North America (23 deaths per 100,000 livebirths). Additionally, sub-Saharan Africa has MMRs as high as 1000 and 1200deaths per 100,000 live births in countries such as Guinea-Bissau and Chad,respectively (WHO, 2010). In Southern Africa, countries such as Angola and1

Tanzania also had MMRs as high as 610 and 790 deaths per 100,000 live births,respectively. In Botswana, the MMR was estimated to be 190 deaths per 100,000live births in 2008, with a range of uncertainty from 84 to 380 deaths per 100,000(WHO, 2010). The Central Statistics Office (CSO) (2011a) reported an MMR of 163deaths per 100,000 live births in 2010.Botswana is a developing country in Southern Africa. It is a landlocked, semi-aridcountry of 582, 000 square kilometres (Ministry of Finance and DevelopmentPlanning, 2003). According to the preliminary results of the 2011 census, thepopulation of Botswana was 2, 038, 228 (CSO, 2011b). The population isconcentrated in the South Eastern parts due to favourable conditions for agricultureand the location of the country’s capital city in this region (Ministry of Finance andDevelopment Planning, 2003).Botswana has a fast growing economy, and as a result the national government hasbeen able to deliver high level services with respect to health. Primary health careservices are delivered through a decentralized system managed by the Ministries ofHealth (MOH) and Local Government. The former, oversees all hospitals and thelatter, is in charge of clinics, health-posts and mobile stops (Ministry of Finance andDevelopment Planning, 2003). This study will assess records from Gaborone, whichis a major urban centre and the surrounding rural areas in South East Botswana. Thepopulation of this area is 320, 167 (CSO, 2011b). According to the Central StatisticsOffice (2007), 100% of the population live within 5km of a health facility inGaborone, and within 15km of a health facility in South East. The information forthe study population is summarised in Table 1.1., below. Due to the close proximityof the South East district to Gaborone, some of the population commutes daily toGaborone for employment and school.2

Table 1.1. Demographic, socio-economic and health services information forGaborone and South EastInformationGaboroneSouth 2,843Central Statistics Office, 2011bUnemployment14.5%19.8%Central Statistics Office, 2008Health facilities2 hospitals1 hospitalPersonal communication with24 Clinics10 ClinicsK. Baeti, 3 June 20084 Healthposts36 Mobile stopsAccess to health 100% within 5km66% within 8kmfacilities100% within 15kmNationalfemaleadult81.3%Central Statistics Office, 2007aCentral Statistics Office, 2007bliteracyrate1.2. Problem StatementBotswana is an upper middle income country, whose economic growth has enabledthe country to develop a comparably well-functioning health system. Despite theprovision of free health care services and access to health facilities, in 2008, theMMR was relatively high at 190 (WHO, 2010 and CSO, 2011a). Although the MMRfor Botswana is lower than that for low income countries, it is higher than that of anumber of countries in the same income group such as, Mauritius (36 deaths per100,000 live births) (WHO, 2010). There is a need to determine the leading causes ofmaternal mortality and the factors (maternal and health services) associated withmaternal mortality. This information would provide insight into the reasons for thiscomparatively high MMR and thus inform strategies for reducing it.3

1.3. PurposeThis study aims to provide information on the factors that are associated withmaternal mortality in South East Botswana. Letamo and Rakgaosi (2003) providedinsight on an important aspect of factors associated with maternal mortality, withrespect to women who do not deliver at a health facility in Botswana. This studywould complement their study as it would provide information on the factors that areassociated with maternal mortality for women who deliver at the health facilities.Although such studies have been carried out in other parts of the world includingcountries in Africa, there is no documented comprehensive study to date that hasbeen conducted in Botswana. This is particularly important as access to healthcarefacilities (Cham, Sundby and Vangen, 2005) and use of traditional birth attendants(Aggarwal, Pandey and Bhattacharya, 2007), were associated with maternalmortality in these countries. These factors may not apply to Botswana, as 95% of thepopulation live within 8km of a health facility (CSO, 2007a) and approximately 95%of deliveries take place at a health facility and are attended by a skilled healthpersonnel (CSO, 2009a). Furthermore, these studies show conflicting findings. Forexample, where some studies reported increased maternal mortality with maternalage (Evjen-Olsen, Hinderaker, Lie, Bergsjø, Gasheka and Kvåle, 2008), others foundno association (Høj, da Silva, Hedegaard, Sandström and Aaby, 2002). Therefore,this study will provide information about the factors associated with maternalmortality specific to Botswana. These findings will also be communicated tostakeholders such as the Safe Motherhood Initiative, who have indicated interest insuch a study (Personal communication with B. Thipe, 23 February 2009), which maythen be used to design appropriate interventions and policies that are relevant toBotswana.4

2.0 CHAPTER TWO: LITERATURE REVIEWThis Chapter examines and reviews selected literature and provides informationabout maternal mortality studies worldwide and with respect to Botswana. It starts byproviding the various definitions of maternal death. Then it describes global maternalmortality statistics, including Botswana. It also discusses the causes of maternalmortality and the maternal and health facility risk factors associated with maternalmortality in different countries. It concludes by briefly describing the methods usedto study maternal mortality and the various policies and interventions for reducingmaternal mortality.2.1. Definition of Maternal DeathAccording to WHO (2004b), a maternal death is:the death of a woman while pregnant or within 42 days of the end of thepregnancy, irrespective of the duration and the site of the pregnancy, fromany cause related to or aggravated by the pregnancy or its management, butnot from accidental or incidental causes (WHO 2004b: 98).Most studies use this definition of maternal death. However, some studies have alsoincluded late maternal death, as also defined by WHO (2004a) to include deaths thatoccur between 42 days and one year of termination of pregnancy as a result of directand indirect obstetric causes. For example, Høj et al. (2002) defined late maternaldeath if it had occurred between 43 and 91 days postpartum. Another definition ofmaternal mortality is pregnancy-related death, which is a modification of thematernal death to include all deaths irrespective of the cause of death (WHO, 2004b).In Botswana, for the Safe Motherhood Initiative and Maternal Death Notification,the definition used is deaths within 42 days after termination of pregnancy (MOH,2006).5

2.2. Maternal Mortality StatisticsMaternal mortality data may be determined through a variety of sources such as civilregistration, sisterhood estimates, disease surveillance, sample registration,household surveys and reproductive-age mortality studies (WHO, 2005; WHO,2010). The sources are described and their limitations are discussed. It is importantto note that, although civil registration is the preferred data source, it may also resultin misidentification and misclassification leading to underreporting (WHO, 2010).They advance the reason that measuring maternal deaths by its nature is complex.For example, a maternal death may be missed in early pregnancy as it is notassociated with a birth. In their literature review of studies that used civil registrationas a data source, they established that the underreporting of maternal deaths may beas high as 220%. It should be noted that most of these studies were carried out indeveloped countries. They suggest that, additional investigations such as theConfidential Enquiry into Maternal Deaths should be carried out even in thepresence of a functioning civil registration system (WHO, 2010).Maternal mortality ratio is usually used to measure maternal mortality and is definedas the number of maternal deaths divided by the number of live births in a givenpopulation (WHO, 2005). It indicates the risk of a woman dying relative to the livebirths (WHO, 2005). Other measures of maternal mortality are the maternal mortalityrate (MMRate), Adult Lifetime Risk of Maternal Death (WHO, 2005) and theproportion among deaths of females of reproductive age (PMDF) (WHO, 2010),however, these are less frequently used in the literature.Worldwide, the MMR of different countries varies greatly (WHO, 2010), as can beseen in Table 2.1 below. In developed countries such as Sweden and Australia, theMMR is as low as 5 and 8 deaths per 100,000 live births, respectively. In contrast,the MMR of developing countries such as those of sub-Saharan Africa may be ashigh as 1,200 deaths per 100,000 live births, for both Chad and Somalia (Alvarez etal., 2009; WHO 2010). It is important to note that these variations may also exist6

because different sources were used for the estimations (WHO, 2010). Furthermore,for countries such as Botswana (MMR 190 deaths per 100,000 live births), wherethere was no appropriate national data on maternal mortality there is a possibility thatthe figure is an under-estimation. This can be seen by the wide range of uncertaintyof 84 to 380 deaths per 100,000 live births (WHO, 2010).Table 2.1. The MMR of different countries in 2008 (WHO, 2010)RegionCountryMMR(maternaldeathsper100,000 live births)DevelopedSweden5Australia8France8United Kingdom (UK)12United States of America24(USA)DevelopingSub- Saharan Malawi510Namibia180South cording to WHO (2010), overall there has been a decrease in MMR between 1990and 2008. Of the 172 countries included in the analysis, 85% (147 countries) haddecreased their MMR over this period, 13% (23 countries) had increased and 1% (27

countries) had not changed their MMR. They noted that, the countries with thelargest percentage increase, of which Botswana had the highest (133%), were inSouthern Africa, a region with the world’s highest HIV prevalence.The Central Statistics Office (2011a) has also reported the MMR of Botswana from2006 to 2010, as summarised in Table 2.2 below.Table 2.2. MMR for Botswana: 2006-2010 (CSO, 2011a)YearMMR(maternaldeathsper100,000 live births)20061402007183200819620091902010163The data shows that the MMR increased up to 2008 and then started to decline in2009. However, it should be noted that, even with this decline it may be difficult toattain the national target of 150 deaths per 100,000 live births by 2011, let alone theMDG target of 82 deaths per 100,000 live births (Government of Botswana and UN,2010).2.3. Causes of Maternal DeathMaternal deaths may be due to either direct or indirect obstetric causes. The directobstetric causes are those which are a result of complications due to being pregnantsuch as during labour and any events resulting from the pregnancy state, such asinterventions or omission of treatment (WHO, 2004b). These include haemorrhage,eclampsia and obstructed labour and sepsis (WHO, 2004a). The indirect obstetriccauses on the other hand are those causes that may be due to a pre-existing maternal8

condition or one that develops during pregnancy such as hepatitis, cardiovasculardisease, malaria and HIV/ AIDS (WHO, 2004a).The leading causes of death vary worldwide according to region (Khan, Wojdyla,Say, Gümezoglu and Van Look, 2006). In their systematic review of 34 datasets,they reported that in developed countries, the leading cause of death was other directcauses (21.3%), which were mainly complications of anaesthesia and caesareansections. In Africa and Asia, the leading cause of death was haemorrhage, whichaccounted for 33.9% and 30.8%, respectively. In Latin America and the Carribbean,hypertensive disorders were the leading cause of death accounting for 20.8% of thedeaths.Similar findings were observed by Ganatra, Coyaji and Rao (1998) Nagaya etal.(2000) in their studies in India and Japan, respectively. Both studies reportedhaemorrhage as the leading cause of death. In India, postpartum (PPH) andantepartum (APH) haemorrhage accounted for 36% of the maternal deaths. In Japan,haemorrhage was the cause of 38% of the maternal deaths.In Africa, varying results have been reported. Garenne, Mbaye, Bah and Correa(1997) reported haemorrhage (21%) as the second leading cause of death after sepsis(24%) in Senegal. In Kenya, Magadi, Diamond and Madise (2001), reported anaemiaas the leading cause of death, followed by PPH. However, if they had combined PPHand APH then haemorrhage would have been found to be the leading cause of deathas, APH was ranked fourth. Kazaura, Kidanto and Massawe (2006) reportedhaemorrhage (23.3%) as the second leading cause of death after eclampsia (23.5%).In Botswana, the Safe Motherhood Programme (MOH, 2007; 2008) observed similarfindings in their Maternal Mortality Reports for 2007 and 2008, as they foundhaemorrhage to be the leading cause of death in both years, accounting for 25% and28%, respectively. However, in 2010, CSO (2011a), the leading cause of death was9

found to be disease of the respiratory system (11%), followed by protozoal disease(9%) and eclampsia (7%).2.4. Factors Associated with Maternal MortalitySeveral studies have been carried out to determine the factors associated withmaternal deaths in countries such as the USA (Panchal, Arria and Labhsetwar, 2001),Japan (Nagaya et al., 2000), India (Ganatra, et al., 1998; Aggarwal et al., 2007),Kenya (Magadi et al., 2001), Tanzania (MacLeod and Rhode, 1998; Evjen-Olsen etal., 2008), Guinea-Bissau (Høj et al., 2002) and Senegal (Garenne et al., 1997).There are a number of variables that may be considered in the study of factorsassociated with maternal mortality depending on the setting. Some studies havedivided them broadly as maternal and hospital factors (Panchal et al., 2001).Maternal factors included age, race, payment source and marital status, whereashospital factors were admission type and hospital type. It can be appreciated that inthe USA race may play a role as a factor, whereas in a country like Botswana itwould not, and so would not be included as a variable. In contrast, in a setting suchas the Delhi slums, variables such as type of housing, type of toilet and the place ofdelivery would be of importance (Aggarwal et al., 2007).Other studies have even looked specifically at the health services factors, as was thecase in Japan (Nagaya et al., 2000), where factors such as pattern of transfer,staffing, facility operating hours and availability of laboratory and diagnosticservices were investigated. In their study in Guinea- Bissau, Høj et al., (2002),divided 20 factors into biological, demographic (including, age and parity),environmental (including access to water and toilets), effect of crowding (such asnumber of women per hut), availability and use of health system (place of deliveryand distance to health post) and obstetric factors (such as outcome of last birth). InTanzania, Evjen-Olsen et al., (2008), included factors such as religious affiliations ofthe husband and the wife and the education level of the husband and wife. In their10

ecological study, Alvarez et al., (2009), in addition to health-care system andeducational variables, also assessed economic indicators of countries such as publicexpenditure on health and education and the gross national income per capita.2.5. Maternal Characteristics Associated with Maternal MortalityStudies have shown varying risk factors for maternal mortality, in the differentsettings. Maternal characteristics that have been associated with mortality includerace (Panchal et al., 2001), ethnicity (Evjen-Olsen et al., 2008), age (Ganatra et al.,1998; Magadi et al., 2001; Aggarwal et al., 2007), education (Aggarwal et al., 2007;Alvarez et al., 2009), marital status (Garenne et al., 1997), gravidity (Ganatra et al.,1998) or parity (Aggarwal et al., 2007) and receiving antenatal care (Ganatra et al.,1998; Aggarwal et al., 2007).Race and ethnicity were found to be risk factors for maternal mortality in Maryland(USA) (Panchal et al., 2001) and in Tanzania (Evjen-Olsen et al., 2008),respectively. Panchal et al. (2001) observed that the odds ratio for AfricanAmericans and other races which were not African-American or Caucasian were 5.4and 12.2, respectively. Similarly, in Tanzania, the authors observed that there was ahigher odds ratio (OR) for ethnic groups (OR 13.6) which were not indigenous tothe study area (Evjen-Olsen et al., 2008). In contrast, in Guinea Bissau (Høj et al.,2002), although there appeared to be differences among the various ethnic groups,the results were not significant. This observation may indicate that it is the broadersocio-economic and environmental context in which the racial/ethnic groups arelocated that ascribes their increased risk of maternal deaths.Maternal age was indicated as a risk factor in Japan (Nagaya et al., 2000), India(Ganatra et al., 1998; Aggarwal et al., 2007), Kenya (Magadi et al., 2001) andTanzania (MacLeod and Rhode, 1998; Evjen-Olsen et al., 2008). In Japan, the risk ofmaternal mortality increased with maternal age especially for women aged over 35years. Both studies in India showed that women aged less than 20 years and those11

over 30 years were at a higher risk of maternal mortality compared to those between21 and 29 years of age (Ganatra et al., 1998; Aggarwal et al., 2007). Similar findingswere reported in Kenyan

current system should continue to be monitored and evaluated through the Maternal . which includes an overview of the maternal mortality situation worldwide and in Botswana. It also briefly describes the demographic, socio-economic and health . maternal mortality ratios (MMR) ranged from 2 maternal deaths per 100,000 live

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