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Maternal mortality in Kassala State - eastern Sudan: community-based study
using Reproductive age mortality survey (RAMOS)
BMC Pregnancy and Childbirth 2011, 11:102doi:10.1186/1471-2393-11-102
Abdalla A Mohammed (email@example.com)
Mahgoub H Elnour (firstname.lastname@example.org)
Eltayeb E Mohammed (email@example.com)
Samah A Ahmed (firstname.lastname@example.org)
Ahmed I Abdelfattah (email@example.com)
29 July 2011
16 December 2011
16 December 2011
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Maternal mortality in Kassala State – eastern Sudan :
community-based study using Reproductive age
mortality survey (RAMOS)
Abdalla A Mohammed1§, Mahgoub H Elnour2, Eltayeb E Mohammed3
Samah A Ahmed4, Ahmed I Abdelfattah1
1Department of Obstetrics and Gynecology, University of Kassala, P.O. Box 266,
2 Kassala State Ministry of Health, 3111 Kassala, Sudan
3Department of Community Medicine, University of Kassala, P.O. Box 266, Kassala,
4Reproductive Health, Ministry of Health, Kassala State, 3111 Kassala, Sudan
§Corresponding author: Mohammed A.A. P.O. Box 266 Kassala Sudan. Fax
+249411823501 e-mail: firstname.lastname@example.org
The maternal mortality ratio in Sudan was estimated at 750/100,000 live births. Sudan
was one of eleven countries that are responsible for 65% of global maternal deaths
according to a recent World Health Organization (WHO) estimate. Maternal mortality
in Kassala State was high in national demographic surveys. This study was conducted
to investigate the causes and contributing factors of maternal deaths and to identify
any discrepancies in rates and causes between different areas.
A reproductive age mortality survey (RAMOS) was conducted to study maternal
mortality in Kassala State. Deaths of women of reproductive age (WRA) in four
purposively selected areas were identified by interviewing key informants in each
village followed by verbal autopsy.
Over a three-year period, 168 maternal deaths were identified among 26,066 WRA.
Verbal autopsies were conducted in 148 (88.1%) of these cases. Of these, 64 (43.2%)
were due to pregnancy and childbirth complications. Maternal mortality rates and
ratios were 80.6 per 100,000 WRA and 713.6 per 100,000 live births (LB),
respectively. There was a wide discrepancy between urban and rural maternal
mortality ratios (369 and 872\100,000 LB, respectively). Direct obstetric causes were
responsible for 58.4% of deaths. Severe anemia (20.3%) and acute febrile illness
(9.4%) were the major indirect causes of maternal death whereas obstetric
hemorrhage (15.6%), obstructed labor (14.1%) and puerperal sepsis (10.9%) were the
major obstetric causes.
Of the contributing factors, we found delay of referral in 73.4% of cases in spite of a
high problem recognition rate (75%). 67.2% of deaths occurred at home, indicating
under utilization of health facilities, and transportation problems were found in 54.7%
There was a high illiteracy rate among the deceased and their husbands (62.5% and
Maternal mortality rates and ratios were found to be high, with a wide variation
between urban and rural populations. Direct causes of maternal death were similar to
those in developing countries. To reduce this high maternal mortality rate we
recommend improving provision of emergency obstetric care (Emoc) in all health
facilities, expanding midwifery training and coverage especially in rural areas.
World Health Organization (WHO)s 10th revision of the International Statistical
Classification of Diseases and Related Health Problems (ICD-10) defines maternal
mortality as "the death of a woman while pregnant or within 42 days of termination of
pregnancy irrespective of the duration and the site of the pregnancy, from any cause
related to or aggravated by the pregnancy or its management but not from accidental
or incidental causes" . Every year, approximately 358,000 women die from
complications of pregnancy and childbirth worldwide. Sub-Saharan Africa and South
Asia accounted for 87% of global maternal deaths . According to a recent WHO
estimate, Sudan is one of 11 countries that are responsible for 65% of global maternal
deaths, with a maternal mortality ratio of 750/100,000 live births . Because there is
no accurate vital registration system in Sudan, maternal mortality estimates in Sudan
were based on indirect and direct sisterhood estimates as in the demographic surveys
conducted in the past four decades [3-5] and WHO estimates [2, 6-8].
Maternal mortality in Kassala State was estimated to be high in all of these surveys. In
a national household health survey conducted in 2006, the maternal mortality ratio
was found to be 1,414 per 100,000 live births . The causes of maternal mortality
was mainly derived from hospital data ; however, only 16.2% of deliveries occur in
hospitals . This study was conducted to investigate the causes of maternal deaths
on a community basis. It also looked at the rates and contributing factors of maternal
deaths and compare the maternal deaths between urban and rural areas in the State.
We conducted a reproductive age mortality survey (RAMOS) in Kassala State from
2004 - 2006. The study consisted of a retrospective community-based survey with two
phases of data collection: death identification and interviews of respondents from the
deceased household using a standard verbal autopsy questionnaire .
At the time of the study, the population of Kassala State was 1,768,603, with 70% of
people living in rural areas. Of these, 424,465 were women of reproductive age
(WRA), and there were 49,521 annual expected live births. Reproductive health
services were delivered through primary health care system that composed of primary
health care units, health centers and rural hospitals. There were three tertiary
hospitals. The majority of health centers and rural hospitals were poorly staffed, and
cannot deliver emergency obstetric care (Emoc). Deliveries were conducted by
certified village midwifes at home and the majority of deliveries in the rural areas
were conducted by traditional birth attendants.
We selected four areas in the state that represented the urban\rural ratio, remoteness
and population diversity. We used a methodology similar to that used by Bartlett in
Afghanistan in her purposive study area selection . The selected areas were
considered the primary sampling unit (PSU) of the study. The population of these
areas was 335,394 (19% of the total population). These areas consisted of 130 villages
and neighborhoods and 21,450 households. Villages and neighborhoods constitute the
secondary sampling units (SSU) in this study.
The sample size was chosen based on the expected number of maternal deaths. Based
on the maternal mortality in Kassala State in previous studies, we expected 268
annual maternal deaths in the state. We sought to detect 5-8% of these deaths, or
between 40 and 80 deaths, over the three years of the study, which is sufficient as
recommended by World Health Organization (WHO) .
Simple randomization using random tables was used to select 32 villages and
neighborhoods, which constituted our study sample. The population of the study
sample was 105,105 (31.3% of the PSU). Table 1 summarizes the demographic data
of the SSU & PSU.
In phase one of this study, deaths were identified by trained field investigators who
interviewed key informants in the community and asked about deaths of women of
reproductive age (WRA) who died during the period from January 1, 2004 to
December 31, 2006. The key informants were persons known to have access to
detailed information about the local community such as community leaders, health
workers or primary school teachers. The key informants were asked by field
investigators to recall women deaths in their surroundings. To minimize recall error,
each key informant was asked to give a list of female deaths, from which a single list
was developed. Field investigators collected data on a death identification form that
included the location name, name of data collector, name and age of the deceased,
name of household members who attended the last illness and death of the deceased,
date of death and household address. They prepared lists from different independent
key informants. Different lists were attained for each village, and a final list was
constructed. The research team examined the collected forms and selected suitable
respondents for interview. The respondents were adult members of the household of
the deceased, close relatives or neighbors or a local health worker who attended the
Phase two consisted of verbal autopsies in which trained interviewers visited the
households of the deceased and interviewed predetermined respondents using a
standard verbal autopsy questionnaire . A narrative history of the circumstances
surrounding the death was recorded from the respondent, and structured questions
were asked regarding personal information, socio-economic background, place of
death, treatment received for illness before death and symptoms of the deceased. An
informed verbal consent was received from the deceased first of kin and from a
Data on the cause of death were analyzed using SPSS version 12 in relation to socio-
economic characteristics of the household, place of death, birth attendant and type of
treatment received. Each author (A.A.M., M.H.E & S.A.M) independently assigned
the cause of death by reading the collected data. Denominator data was obtained from
Kassala State Expanded Program of Immunization (EPI) data as shown in Table 1.
The study protocol was approved by the Kassala State Ethical Committee.
During the period 2004-2006, a total of 168 women aged 15-45 years were identified
as dead in phase one in the study area. One hundred forty eight (88.1%) households of
these women were visited, and respondents were interviewed. The reproductive age
mortality rate was calculated as 188/100,000 WRA. Sixty four cases were classified
as maternal deaths, that represent the proportion of maternal deaths among female of
reproductive age (PMDF) of (43.2%). Maternal mortality rate and ratio were found to
be 80.6/100,000 WRA & 713.6/100,000 live births (LB). Maternal mortality ratio in
rural and urban areas were 872 and 369/100,000 LB respectively. The majority of
deaths occurred in the 25-29 age group (Table 2). The deceased age ranged from 16-
43 years, with median age of 26.5 years and a standard deviation of 6.3 years.
Table 3 represents the causes of deaths. Twenty-six deaths (41.6%) were due to
indirect obstetric causes of which anemia, acute febrile illness and jaundice were the
major indirect causes. In 38 cases (59.4%), we found a direct obstetric cause of
maternal death. Severe anemia is the major cause of indirect maternal death and
accounts for 20.3% of cases.
forty three cases (67.2%) died at home with small number (04.7%) died on their way
to health facility. Forty five (70.3%) died in the postnatal period, 25% died
undelivered and only three (04.7%) in early weeks of pregnancy from complications
of abortion. Reproductive characteristics are shown in Table 4. Thirty-eight (59.4%)
cases did not receive antenatal care. Nearly 70% of those who died in the postpartum
period delivered at home, half delivered by non-skilled attendants, and a similar
number of pregnancies resulted in live birth. Three cases delivered on their way to the
hospital. Two of these cases were cases of obstetric hemorrhage. Vaginal delivery
constituted 93.3% of deliveries. There were three postoperative deaths; two were due
to sepsis following caesarean section for obstructed labor, and one was a case of a
Of the 45 deceased who gave birth before they died, 31 (68.9%) delivered at home,
and three (6.7%) delivered on their way to the hospital. Of these, 22 (49.9%) attended
by unskilled person .
All of the deceased were married women. Table 5 shows the demographic
characteristics of these deaths. The majority of cases were of low socio-economic
class. Fifty-three (82.8%) deaths occurred in the rural areas. Sixty (93.8%) cases were
not engaged in income generating activity. Of the deceased, 90.6% and 82.2% of their
husbands were either illiterate or had non-formal education i.e that they are able to
write and read without formal schooling.
The first phase delay: (delay in seeking medical care): In forty eight cases (75.0%)
the respondents recognized a medical problem at the same time there was a delay in
seeking medical care in 73.4%. They mentioned that there was no service available in
the nearby health facilities, including the hospitals and they cannot afford to go to the
tertiary hospital. The decision to seek medical care usually made by the husband or
male household leader, who is usually away during the day; therefore, the woman has
to wait until his returns at the evening to seek medical care. In one case, a woman
with postpartum hemorrhage due to retained placenta bled for seven hours while
waiting for her husband to return home. She died while being taken to the hospital.
The second phase delay: (Delay in reaching health facility): there were few paved
roads in the State, beside some seasonal rivers that delay reaching to health facilities.
Rural hospital were not equipped with ambulances. We found transportation problems
in 54.7% of cases.
The third phase delay: forty four (68.8%) of them reported delay in receiving
medical care at the level of primary health facility. Respondents mentioned
unavailability of emergency drugs, absence of health workers and late referral to
To our knowledge, this is the first community-based study using a reproductive age
mortality survey (RAMOS) in any part of Sudan on the state level. The maternal
mortality ratio was found to be 714\100,000 live births. The proportion of maternal
deaths among female deaths (PMDF) in our study was 43.3%, which is high
compared to the reported national estimate of 19.4% . This high rate of maternal
mortality reflects poor maternity services. We found a wide discrepancy between
urban and rural areas (369 & 872/100,000 LB, respectively). Even in urban areas,
sectoral differences in maternal mortality were reported  in which slum dwellers
and internally displaced people camps around cities had a high maternal mortality
ratio compared to their neighboring inhabitants. More than 75% of deaths occurred
during childbirth and postpartum, which is consistent with the pattern of causes in
Sub-Saharan Africa. For example, in Eritrea, Ghebrehiwot  found that 16% of
maternal deaths occurred during pregnancy, 48% occurred during childbirth, and 36%
Indirect causes account for 20 to 25% of maternal deaths and are attributable to
illnesses aggravated by pregnancy  such as anemia, malaria and acquired immune
deficiency syndrome (HIV/AIDS). In our study, indirect causes constituted more than
40% of deaths, with severe anemia as the major cause. Anemia is highly prevalent in
Africa, with up to three-fifths of pregnant women having some degree of anemia and
approximately one-third classified as having severe anemia [14-17]. Anemia is
common in Eastern Sudan due to malaria, chronic illnesses and poverty  and is
the main risk factor for stillbirth in maternity hospitals in Kassala . Women,
especially those in rural areas in Kassala State, enter pregnancy in a state of
nutritional deficit and therefore are unprepared to cope with the extra physiological
demands of pregnancy. Mason et al. found anemia in 45% of pregnant women and
49% of children under age 5 in developing countries . Anemia is also an
underlying risk factor for 18% of maternal and 24% of perinatal mortality [21-22].
The direct obstetrical causes of death in our study, obstetric hemorrhage, obstructed
labor, sepsis and hypertensive disease with pregnancy, were similar to those of
developing countries . Abortion accounts for a small percentage of the deaths in
this study. This is primarily because the respondents have difficulty recognizing the
early menstrual history of the deceased. Also induced abortion for unwanted and out
of wedlock pregnancy were usually not revealed due to influence of culture and
The most common cause of maternal death was bleeding, which can kill even a
healthy woman within two hours if unattended. Anemia in pregnant women reduces a
woman’s ability to survive bleeding during and after childbirth. In this study,
hemorrhage is the second most common cause of death. These women likely faced
bleeding in a state of anemia.
The "Three Delays" model , which includes delays in the decision to seek care,
delays in reaching care, and delays in receiving care at the facility, were evident in
our study. Although problem recognition was high, we found that the delay in seeking
care was also high. In this study, 67.2% of deaths occurred at home. These patients
were either unable or did not want to reach the health facility.
During the period of the study, the state was affected by war, and roads were closed
by night. These factors likely contributed to transportation problems, which were
found in 54.7% of the cases.
Delay in receiving medical care at health facilities, primarily due to lack of
emergency obstetric care (Emoc) in almost all the health facilities in the rural settings,
was found in 68.8% of cases.
Domestic delivery is common in Sudan, which was estimated at 76.5% and 82%
nationally and in Kassala State, respectively . In rural settings in Kassala State,
almost all deliveries occur at home, and patients seek medical care if life-threatening
complications arise. More than half of those who died after delivery were delivered by
non-skilled birth attendants. Sudan Household Health Survey (SHHS) showed that
49.2% of births in the two years prior to the survey were delivered by qualified health
personnel. The majority of the qualified health personnel are village midwives, who
are on the margin of the health system in Sudan. They have no fixed jobs in the health
system and depend on the incentives given by parturient mothers. Inability of health
facilities to deliver effective Emoc led the community to lose trust in these hospitals,
and these health facilities became a distinct cause of delay. Other interactive factors
such as poverty, illiteracy and transportation problems were contributed to deaths in
This high percentage of maternal deaths could be effectively reduced by improving
the availability and use of Emoc in all health facilities. There is a need to expand
midwifery coverage by availability of a certified midwife in every village. We
recommend expansion of midwifery training by opening midwifery schools in remote
areas. Establishing maternity waiting home near the tertiary hospitals will enable
patients from rural areas with obstetric complications to stay in the town and avoid
long cost hospitalization. To overcome transportation problems, rural hospital needs
to be equipped with ambulances . Furthermore, improving non-health sector factors
such as poverty, female education and infrastructure is important to reduce maternal
mortality in the state.
Maternal mortality rates and ratios were found to be high, with a wide variation
between urban and rural populations. The proportion of maternal deaths among
female deaths (PMDF) was higher than expected. Indirect causes of maternal death
were high, and anemia was the major cause of indirect maternal death. Direct causes
of maternal death were similar to those in developing countries. To reduce this high
maternal mortality rate we recommend improving provision of Emoc in all health
facilities, expanding midwifery training and coverage especially in rural areas. To
overcome transportation problems, rural hospital needs to be equipped with
ambulances. Furthermore, improving non-health sector factors such as poverty,
female education and infrastructure is important to reduce maternal mortality in the
'The author(s) declare that they have no competing interests'.
AAM generated the idea of the research, performed the literature review and
contributed to writing and editing of the manuscript. MHE field supervisor,
contributed to analysis and writing of manuscript. SAA act as field supervisor and
financial director and contributed to analysis and writing of the manuscript. EEM &
AIA contributed with other authors in assignment of cause of maternal death from
verbal autopsy data. All author read and approved the final manuscript..
The authors acknowledge the Ministry of Higher Education and Scientific Research
of Sudan, the University of Kassala and the Kassala State Ministry of Health for
providing financial support for this study.
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Table 1 Denominator data of study area in Kassala State – East Sudan
Total population 1,768,603
Primary sampling unit
Total population 335,394
Urban 219,454 (65.4%)
Rural 115,940 (34.6%)
Number of villages and neighborhoods 130
Number of households 21,450
Women of reproductive age 80,494
Expected live births 9,391
Secondary sampling unit
Total population 105,105
Number of villages and neighborhoods 32
Number of households 5,795
Women of reproductive age 26,066
Expected live births 2,943
Table 2 Age distribution of 64 maternal deaths in Kassala State (2004-2006)
Age group n %
<20 16 25.0
20-24 5 07.8
25-29 22 34.4
30-34 10 15.6
35-39 8 12.5
40+ 3 04.7
Total 64 100.0
Table 3 Cause of maternal death in 64 cases in Kassala State (2004-2006)
Cause n %
Direct obstetric causes
Obstetric hemorrhage 10 15.6
Obstructed labor 9 14.1
Puerperal sepsis 7 10.9
HDP 5 07.8
Abortion 4 06.3
Miscellaneous 3 04.7
Severe anemia 13 20.3
Acute febrile illness 6 09.4
Jaundice 4 06.3
Miscellaneous 3 04.7
Total 64 100.0
HDP, hypertensive disease with pregnancy
Table 4: reproductive characteristics & pregnancy outcome in 64 maternal
deaths in Kassala State (2004-2006)
Characteristic n %
Parity (n = 64)
Nullipara 16 25.0
Multipara 32 50.0
Grandmultipara 16 25.0
Antenatal care (n=64)
Yes 21 32.8
No 43 67.2
Place of delivery (n=45)
Home 31 68.9
Health facility 11 24.4
On the way 3 06.7
Skill attendant at birth (n=45)
Yes 22 48.9
No 23 51.1
Mode of delivery (n=45)
Vaginal 43 93.3
Caesarean section 3 06.7
Pregnancy outcome (n=45)
Live birth 23 51.1
Still birth 18 40.0
Neonatal death 2 08.9
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Table 5: Demographic characteristics in 64 maternal deaths in Kassala State
Characteristic n= (64) %
Urban 11 17.2
Rural 53 82.8
Illiterate 40 62.5
Non-formal 18 28.1
Elementary 2 03.1
Secondary 3 04.6
Higher 1 01.6
Illiterate 31 48.4
Non-formal 28 43.8
Elementary 1 01.6
Secondary 3 04.6
Higher 3 04.6
Farmer 23 36.0
Worker 15 23.4
Sheppard 13 20.3
Other 13 20.3