Female Reproductive Age Mortality  in in Kassala (Role of Malaria)

Abdalla Ali Mohammed1, Ahmed Ibrahiem Abdelfattah1 & Mahgoub Hassan Elnour2.

 

 

ABSTRACT

Objectives :

To determine the mortality rates ,causes and contributing factors in women in reproductive age in Kassala Province.

 

Setting:

A refuge ,acute internally displaced people (IDP) camps, a town slums and an urban area, of total population of 214.100 in Kassala Province, East Sudan.

 

Method:

Community –based retrospective study ,using reproductive age mortality Survey (RAMOS) and verbal autopsy . Data was processed using SPSS for Windows Version11.

 

Results:

121 deaths of female aged15-45 years, in four population sectors (refugees, IDP, slum dwellers & urban population) were identified. Slum dwellers show the highest reproductive age mortality rate 314/100,000women in reproductive age, while urban sector shows the lowest rate 199per 100,000WRA.

Malaria is the major cause of death in three sectors with exception of IDP sector where pregnancy related causes contribute to 70% of death .

Maternal mortality rate is highest in IDP population and slum dwellers(168&126 per100,000WRA)and lowest in urban population(47per 100,000WRA). Maternal mortality ratio is very high in slum dwellers, IDP and refugee population (1207,1192&914 per 100,000 live birth respectively),and 376 per100,000 live births in urban population.

Malaria was found to be the major cause of indirect maternal deaths in all sectors.

 

Conclusion:

This study shows a high discrepancy in reproductive age mortality and maternal mortality between different population sectors in the same location. Malaria is the commonest cause of death in women in reproductive age especially in urban and semi urban settings.

 

 

 

 

 

 

1Assistant Professor of Obstetrics & Gynaecology, Faculty of Medicine and Health Sciences, University of Kassal.

2Medical Officer, Director General, state Ministry of Health, Kassala State.

Introduction. Kassala State is located to the East of Sudan, boarders Eritrea to the east. It covers 42,330 Km2, its population is estimated ab 1,584,000, with an annual growth rate of 2.51% between 1998-20031. The sex ratio of males per 100 female is 97.8. The crude birth rate is 37.8% while the crude death rate is 10.2%. The population comprises Hadandawa, Bani Amer, Amarar, Bisharien, Rashaida and Halanga tribes which coexist with northern tribes and Falata tribes of West African origin.

Urban population constitute 19.3% of the total population of the State.

Over the last 30 years, Kassala State has faced influx of cross boarder migrants from Ethiopia and Eritrea and internally displaced seasonal migrants.  The later boarder conflict of 1997 lead to another wave of internally displaced people (IDPs), to settle near the main towns of the State. Now, IDP constitutes 10% of the State population2. Sudan has hosted refugees in Eastern Sudan States, mainly from Ethiopia and Eritrea. Currently, Sudan hosts 110,000 refugees, 89,687 of whom in Kassala State3.  They constitute 6 % of the population. The general health facilities in Kassala are moderate. The current ratio is 5 hospitals and 79 beds for 100,000 people4.The proportion of births attended by skilled health personnel is 53%. The maternal mortality in Kassala State is 556\100,000 live birth5. The under 5 mortality rate is 148 and infant mortality is 101\10, 0006. Malaria, diarrhea and tuberculosis are the common diseases in the State. The prevalence of death rate associated with malaria is 32 \10004. 

In a hospital based study done at Kassala New Hospital for (Obstetrics & Gynaecology hospital), indirect causes of maternal death  was found to be 58.3% with 30.2% of all deaths were due to complicated malaria and 20.8% due to anaemia, which is also malaria related7. It was also noted that the majority of deaths came from refugees, IDPs and slum dwellers8.9. This study was conducted to study maternal mortality on community based level in the four major population sectors in Kassala, namely urban, refugees, IDPs and slum dwellers, to investigate the causes and differences between sectors.

 

Method.  All deaths among women of reproductive age (WRA, 15 to 45 years of age) are reviewed to identify the cause of each death and ways to prevent such deaths. It is a retrospective, community-based survey, in two phases, as described by WHO, Grubb, Fortney and Bartlett10,11,12,13,14,15,16. Phase 1 death identification  in which all deaths in the community are identified, and deaths of female aged 15 to 45 are selected. Multiple sources for identification of deaths are used. This include asking people in the

  

Table 1: The total population of sector studied:

 

Sector

Urban area

Slum Dweller

Refugee camp

IDP camp

Total

Population

88,709

69,276

36,575

19,540

214,100

WRA*

21,199

16,557

6,142

4,158

48,056

Expected LB

2,727

1,739

547

587

5,600

  * women in reproductive age

 

community (such as health care providers; religious leaders; grave diggers; and community leaders) if deaths among WRA have occurred. When deaths are identified decedent's identification, age, and gender and full address of the household and the respondents are recorded. In phase 2, death review is conducted, through structured questionnaire, conducted by 5th year medical students, using standard verbal autopsy questionnaire17. 

 

Table 2: No of deaths:

Sector

Urban area

Slum Dweller

Refugee camp

IDP camp

Total

All deaths

42

52

17

10

121

Maternal deaths

10

21

5

7

43

Percentage of Maternal deaths

23.8

40.3

29.4

70

35.5

 

A refugee, acute internally displaced people (IDP) camps, a town slums and an urban area, of total population of 214,100 in Kassala Province, East Sudan. Data was processed using SPSS for Windows Version 11.

 

Results. The demographic characteristics of the population sectors studied are shown in table 1. The internally displaced people in this sector constitute 12.3%, refugees 41% of those in the state while the urban sector constitutes 25% of the town population.

121 deaths of WRA  in four population sectors (refugees, IDP, slum dwellers & urban population) were identified. Slum dwellers show the highest reproductive age mortality rate 314/100,000 WRA, while urban sector shows the lowest rate 199 per 100,000 WRA.

Table 3: Rates of deaths:

Rate

Urban area

Slum Deweler

Refugee camp

IDP camp

Reproductive age mortality rate1

199

314

268

240

Maternal mortality rate1

47

126

81

168

Maternal mortality ratio2

367

1207

914

1192

1per 100,000 WRA

2per 100,000 LB

 

Malaria is the major cause of death in three sectors with exception of IDP sector where pregnancy related causes contribute to 70% of deaths. Maternal mortality rate is highest in IDP population and slum dwellers (168 &126 per 100,000 WRA respectively) and lowest in urban population (47 per 100,000 WRA). Maternal mortality ratio is very high in slum dweller, IDP and refugee population (1207, 1192 & 914 per 100,000 live births respectively), and 367 per 100,000 live births in urban population

 

Table 4: Major causes of reproductive age deaths:

Sector

Urban area

Slum Deweler

Refugee camp

IDP camp

No 1

Malaria (35.7%)

Malaria (15.4%)

Malaria

23%

 

Malaria (20%)

No 2

Pregnancy Related (23.8%)

Pregnancy Related (40.3%)

Pregnancy Related (29.4%)

Pregnancy related (70%)

 

Discussion. Every day, 1,600 women die due to complications of pregnancy and childbirth. This is 585,000 at a minimum, die every year world wide. 90% of these deaths occur in Asia and Sub-Saharan Africa, 10% in other developing region and less than 1% in developed countries18,19. Between 25% and 33% of all deaths of women in reproductive age are due to complications of pregnancy or child-birth20. More than 600 women die every year worldwide due to pregnancy and childbirth complications. 99% of these occur in developing countries. 40% of these deaths occur in Africa, where only 20% of the world births take place.

In Sudan, maternal mortality ratio is estimated as 660 per 100,000 live births18. In safe Motherhood Survey conducted in 1999, maternal mortality for Kassala State was found 553 per 100,000 live births5. This data on maternal mortality was obtained by indirect sisterhood method. Figures obtained give a general national or State estimate, but it will not show inter-sectoral variation of mortality. This study was conducted using reproductive age mortality survey (RAMOS). Results from RAMOS are most useful for evaluating the magnitude of maternal mortality and other causes of death among WRA, assessing the importance or burden of maternal causes of deaths relative to other causes of death, and conducting a needs assessment for health care service quality improvement to prevent maternal deaths.

This study shows the large discrepancy of reproductive age mortality between the three vulnerable sectors of the population and the urban sector, although all live in the same locality. This is mainly due to failure of the health services to cope with the increasing umber of refugees and IDP.

Malaria is a public health problem throughout the world. Of the estimated 300 million cases each year worldwide, more than 90% occur in Sub-Saharan Africa. Malaria causes maternal anaemia, as well as spontaneous abortions, stillbirths, and low birth weight in newborns. This study shows the role of malaria as either a leading cause or a second cause of death in women in reproductive age. It also shows that when maternity health services improved, as in urban sector, malaria shows the highest percentage of death.

In urban sector, improvement of reproductive health services results in maternal mortality to be below the national estimate, and the SMS estimate for the State.

 

Conclusion: This study shows the big toll of malaria on health of female in reproductive age, the high discrepancy in reproductive age mortality, and maternal mortality between different population sectors in the same location. It also discusses the causes of these deaths.

 

 

 

 

 

 

 

References:

1.                 UNFPA\CBS population Data Sheet for Sudan by the States, 2002.

2.                 Kassala State ANA Report 2002.

3.                 WFP\UNHCR\COR JFAM- Assistance to Eritrean Refugees in central\eastern Sudan (draft) , June 2003.

4.                 Federal MoH, annual Health Statistical Report 2001.

5.                 Safe Motherhood Survey 2001.

6.                 UNICEF Multiple Indicator Cluster Survey (MICS)  2000.

7.                 Mohammed AA, Abdelrahiem SI & Elnour MH 2002 “ Maternal Deaths at Kassala New Hospital (Eastern Sudan)” Journal of the Arab Board of Medical Specializations. Vol. 4 No. 2.

8.                 World Health Organization. Studying Maternal Mortality in Developing Countries: Rates and Causes. WHO/FHE/87.7. Wessel H., Reitmaier P., Dupret A., Cnattungius S., Bergstrom S. Deaths among women of reproductive age in Cape Verde: causes and avoidability. Acta Obstetrica Gynecologica Scandinavica. 1999;78:225-232.

9.                 Grubb G., Fortney J., Saleh S., Gadalla S., El-Baz A., Feldblum P., Rogers S. A comparison of two cause-of-death classification systems for deaths among women of reproductive age in Menoufia, Egypt. International Journal of Epidemiology, 17 (2):385-391.

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12.            Bartlett L., Khan T., Sultana M., Jamieson M., Wilson H. The burden of mortality due to reproductive health-related causes among Afghan refugees in Pakistan, 1999-2000 (abstract). In Conference 2000: Findings on Reproductive Health of Refugees and Displaced Persons: proceedings. Washington, D.C., December 5-6, 2000. Reproductive Health for Refugees Consortium, 2001, pg.18.).

13.            Bouvier­Colle en al. Reasons for the underreporting of maternal mortality in France, as indicated by a survey of all deaths of women of childbearing age. International Journal of Epidemiology 1991, 20:717­721.

14.            Mohammed AA, Abdelrahiem SI, & Abdelfattah AI 2001 “Reproductive Age Mortality in a Refugee and Internally Displaced People’s Camps in Kassala- Eastern Sudan” The 4th Congress of the Arab Associations & the Annual Congress of the Lebanese Society of Obstetrics & Gynaecology.20-22 Sept 2001. Beirut Lebanan.

15.            Mohammed AA, Abdelrahiem SI & Elnour MH 2000 “Audit of Maternal Deaths” Sudanese Obstetrical & Gynaecological Society, Police Hospital, Khartoum Nov. 2000.

 

16.            Walker, GJ et al Maternal mortality in Jamaica Lancet 1986, 1(8479):486-488

17.            Campbell OMR, Ronsmans C. Verbal autopsies for maternal deaths. Geneva, WHO, 1995 (Report on a world Health Organization Workshop, London 10-13 January 1994.

18.            WHO\UNICEF. Revised 1990 Estimates of Maternal Mortality: A New Approach by WHO and UNICEF. WHO, Geneva 1996.

19.            UNICEF. The Progress of the Nations. New York, 1996.

Graham W, Murray S. “A Question of Survival? Review of Safe Motherhood”. Ministry of Health, Kenya , 1997.