Global dominance of non-institutional delivery and the risky impact on maternal mortality spike in 25 Sub-Saharan African Countries

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Abstract

Background

Despite 70% of global maternal death occurring in Sub-Saharan Africa (SSA) and the high rate of non-institutional delivery (NID), studies that inspect the connections are needed but lacking. Thus, we investigated the urban–rural burden and risk factors of NID and the correlate with maternal mortality to extend strategies for sinking the mortality spike towards sustainable development goal (SDG-3.1) in SSA.

Methods

Secondary analysis of recent (2014–2021) cross-sectional demographic-health-survey (DHS) were conducted across 25-countries in SSA. Primary outcome was institutional versus non-institutional delivery and secondary outcome was maternal-mortality-ratio (MMR) per 100,000 livebirths and the lifetime risk (LTR), while predictors were grouped by socio-economic, obstetrics and country-level factors. Data were weighted to adjust for heterogeneity and descriptive analysis was performed. Pearson chi-square, correlation, and simple linear regression anlyses were performed to assess relationships. Multivariable logistic regression further evaluated the predictor likelihood and significance at alpha = 5% (95% confidence-interval ‘CI’).

Results

Prevalence of NID was highest in Chad (78.6%), Madagascar (60.6%), then Nigeria (60.4%) and Angola (54.3%), with rural SSA dominating NID rate by about 85%. Odds of NID were significantly lower by 60% and 98% among women who had at least four antenatal care (ANC) visits (aOR = 0.40, 95%CI = 0.38–0.41) and utilized skilled birth attendants (SBA) at delivery (aOR = 0.02, 95%CI = 0.01–0.02), respectively. The odds of NID reduces by women age, educational-level, and wealth-quintiles. Positive and significant linear relationship exist between NID and MMR (ρ = 0.5453), and NID and LTR (ρ = 0.6136). Consequently, 1% increase in NID will lead to about 248/100000 and 8.2/1000 increase in MMR and LTR in SSA respectively.

Conclusions

Only South Africa, Rwanda and Malawi had achieved the WHO 90% coverage for healthcare delivery. ANC and SBA use reduced NID likelihood but, MMR is significantly influenced by NID. Hence, strategic decline in NID will proportionately influence the sinking of MMR spike to attain SDG-3.1 in SSA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41256-025-00409-x.

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Determinants of antenatal care utilisation in sub-Saharan Africa: a systematic review

Ijeoma Okedo-Alex, Ifeyinwa Akamike, Obumneme Ezeanosike … (2019)

Objectives To identify the determinants of antenatal care (ANC) utilisation in sub-Saharan Africa. Design Systematic review. Data sources Databases searched were PubMed, OVID, EMBASE, CINAHL and Web of Science. Eligibility criteria Primary studies reporting on determinants of ANC utilisation following multivariate analysis, conducted in sub-Saharan Africa and published in English language between 2008 and 2018. Data extraction and synthesis A data extraction form was used to extract the following information: name of first author, year of publication, study location, study design, study subjects, sample size and determinants. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist for reporting a systematic review or meta-analysis protocol was used to guide the screening and eligibility of the studies. The Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was used to assess the quality of the studies while the Andersen framework was used to report findings. Results 74 studies that met the inclusion criteria were fully assessed. Most studies identified socioeconomic status, urban residence, older/increasing age, low parity, being educated and having an educated partner, being employed, being married and Christian religion as predictors of ANC attendance and timeliness. Awareness of danger signs, timing and adequate number of antenatal visits, exposure to mass media and good attitude towards ANC utilisation made attendance and initiation of ANC in first trimester more likely. Having an unplanned pregnancy, previous pregnancy complications, poor autonomy, lack of husband’s support, increased distance to health facility, not having health insurance and high cost of services negatively impacted the overall uptake, timing and frequency of antenatal visits. Conclusion A variety of predisposing, enabling and need factors affect ANC utilisation in sub-Saharan Africa. Intersectoral collaboration to promote female education and empowerment, improve geographical access and strengthened implementation of ANC policies with active community participation are recommended.

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Causes of maternal mortality in Sub-Saharan Africa: A systematic review of studies published from 2015 to 2020

Reuben Musarandega, Michael Nyakura, Rhoderick N. Machekano … (2021)

Background Maternal deaths remain high in Sub-Saharan Africa (SSA) and their causes of maternal death must be analysed frequently in this region to guide interventions. Methods We conducted a systematic review of studies published from 2015 to 2020 that reported the causes of maternal deaths in 57 SSA countries. The objective was to identify the leading causes of maternal deaths using the international classification of disease – 10th revision, for maternal mortality (ICD-MM). We searched PubMed, WorldCat Discovery Libraries Worldwide (including Medline, Web of Science, LISTA and CNHAL databases), and Google Scholar databases and citations, using the search words “maternal mortality”, “maternal death”, “pregnancy-related death”, “reproductive age mortality” and “causes” as MeSH terms or keywords. The last date of search from all databases was 21 May 2021. We included original research articles published in English and excluded articles that mentioned SSA country names without study results for those countries, studies that reported death from a single cause or assigned causes of death using computer models or incompletely broke down the causes of death. We exported, de-duplicated and screened the searches electronically in EndNote version 20. We selected the final articles by reading the titles, abstracts and full texts. Two authors searched the articles and assessed the risk of bias using a tool adapted from Montoya and others. Data from the articles were extracted onto an Excel worksheet and the deaths classified into ICD-MM groups. Proportions were calculated with 95% confidence intervals and compared for deaths attributed to each cause and ICD-MM group. We compared the results with WHO and Global Burden of Disease (GDB) estimates. Results We identified 38 studies that reported 11 427 maternal and four incidental deaths. Twenty-one of the third-eight studies were retrospective record reviews. The leading causes of death (proportions and 95% confidence intervals (CI)) were obstetric hemorrhage: 28.8% (95% CI = 26.5%-31.2%), hypertensive disorders in pregnancy: 22.1% (95% CI = 19.9%-24.2%), non-obstetric complications: 18.8% (95% CI = 16.4%-21.2%) and pregnancy-related infections: 11.5% (95% CI = 9.8%-13.2%). The studies reported few deaths of unknown/undetermined and incidental causes. Conclusions Limitations of this review were the failure to access more data from government reports, but the study results compared well with WHO and GDB estimates. Obstetric hemorrhage, hypertensive disorders in pregnancy, non-obstetric complications, and pregnancy-related infections are the leading causes of maternal deaths in SSA. However, deaths from incidental causes are likely under-reported in this region. SSA countries must continue to invest in health information systems that collect and publishes comprehensive, quality, maternal death causes data. A publicly accessible repository of data sets and government reports for causes of maternal death will be helpful in future reviews. This review received no specific funding and was not registered.

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Does facility birth reduce maternal and perinatal mortality in Brong Ahafo, Ghana? A secondary analysis using data on 119 244 pregnancies from two cluster-randomised controlled trials

Sabine Gabrysch, Robin Nesbitt, Anja Schoeps … (2019)

Summary Background Maternal and perinatal mortality are still unacceptably high in many countries despite steep increases in facility birth. The evidence that childbirth in facilities reduces mortality is weak, mainly because of the scarcity of robust study designs and data. We aimed to assess this link by quantifying the influence of major determinants of facility birth (cluster-level facility birth, wealth, education, and distance to childbirth care) on several mortality outcomes, while also considering quality of care. Methods Our study is a secondary analysis of surveillance data on 119 244 pregnancies from two large population-based cluster-randomised controlled trials in Brong Ahafo, Ghana. In addition, we specifically collected data to assess quality of care at all 64 childbirth facilities in the study area. Outcomes were direct maternal mortality, perinatal mortality, first-day and early neonatal mortality, and antepartum and intrapartum stillbirth. We calculated cluster-level facility birth as the percentage of facility births in a woman's village over the preceding 2 years, and we computed distances from women's regular residence to health facilities in a geospatial database. Associations between determinants of facility birth and mortality outcomes were assessed in crude and multivariable multilevel logistic regression models. We stratified perinatal mortality effects by three policy periods, using April 1, 2005, and July 1, 2008, as cutoff points, when delivery-fee exemption and free health insurance were introduced in Ghana. These policies increased facility birth and potentially reduced quality of care. Findings Higher proportions of facility births in a cluster were not linked to reductions in any of the mortality outcomes. In women who were wealthier, facility births were much more common than in those who were poorer, but mortality was not lower among them or their babies. Women with higher education had lower mortality risks than less-educated women, except first-day and early neonatal mortality. A substantially higher proportion of women living in areas closer to childbirth facilities had facility births and caesarean sections than women living further from childbirth facilities, but mortality risks were not lower despite this increased service use. Among women who lived in areas closer to facilities offering comprehensive emergency obstetric care (CEmOC), emergency newborn care, or high-quality routine care, or to facilities that had providers with satisfactory competence, we found a lower risk of intrapartum stillbirth (14·2 per 1000 deliveries at >20 km from a CEmOC facility vs 10·4 per 1000 deliveries at ≤1 km; odds ratio [OR] 1·13, 95% CI 1·06–1·21) and of composite mortality outcomes than among women living in areas where these services were further away. Protective effects of facility birth were restricted to the two earlier policy periods (from June 1, 2003, to June 30, 2008), whereas there was evidence for higher perinatal mortality with increasing wealth (OR 1·09, 1·03–1·14) and lower perinatal mortality with increasing distance from childbirth facilities (OR 0·93, 0·89–0·98) after free health insurance was introduced in July 1, 2008. Interpretation Facility birth does not necessarily convey a survival benefit for women or babies and should only be recommended in facilities capable of providing emergency obstetric and newborn care and capable of safe-guarding uncomplicated births. Funding The Baden-Württemberg Foundation, the Daimler and Benz Foundation, the European Social Fund and Ministry of Science, Research, and the Arts Baden-Württemberg, WHO, US Agency for International Development, Save the Children, the Bill & Melinda Gates Foundation, and the UK Department for International Development.

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Author and article information

Contributors

Oyewole K. Oyedele:

ORCID: http://orcid.org/0000-0003-4275-8111

mrokoyedele@gmail.com , ooyedele@ihvnigeria.org

Journal

Journal ID (nlm-ta): Glob Health Res Policy

Journal ID (iso-abbrev): Glob Health Res Policy

Title: Global Health Research and Policy

Publisher: BioMed Central (London )

ISSN (Electronic): 2397-0642

Publication date (Electronic): 27 February 2025

Publication date PMC-release: 27 February 2025

Publication date Collection: 2025

Volume: 10

Electronic Location Identifier: 10

Affiliations

[1 ]International Research Center of Excellence, Institute of Human Virology Nigeria, ( https://ror.org/02e66xy22) Abuja, Nigeria

[2 ]Department of Epidemiology and Medical Statistics, College of Medicine, University of Ibadan, ( https://ror.org/03wx2rr30) Ibadan, Nigeria

Author information

Oyewole K. Oyedele http://orcid.org/0000-0003-4275-8111

Article

Publisher ID: 409

DOI: 10.1186/s41256-025-00409-x

PMC ID: 11866781

PubMed ID: 40012017

SO-VID: 6c6861f6-b5d3-4836-a36a-8d6dc91beec3

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Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

History

Date received : 2 August 2024

Date accepted : 8 January 2025

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Keywords: non-institutional delivery,maternal mortality,global health,lifetime risk,correlation,regression,sub-saharan africa

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Keywords: non-institutional delivery, maternal mortality, global health, lifetime risk, correlation, regression, sub-saharan africa

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Global dominance of non-institutional delivery and the risky impact on maternal mortality spike in 25 Sub-Saharan African Countries

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Most cited references 30

Determinants of antenatal care utilisation in sub-Saharan Africa: a systematic review

Causes of maternal mortality in Sub-Saharan Africa: A systematic review of studies published from 2015 to 2020

Does facility birth reduce maternal and perinatal mortality in Brong Ahafo, Ghana? A secondary analysis using data on 119 244 pregnancies from two cluster-randomised controlled trials

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