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ASSESSMENT OF MATERNAL MORTALITY RISK FACTORS AMONG REFERRED OBSTETRIC CASES IN UNIVERSITY OF BENIN TEACHING HOSPITAL (UBTH), EDO STATE.
CHAPTER ONE
ABSTRACT
Background: Maternal mortality remains a grave public health crisis in Nigeria, and tertiary health institutions such as University of Benin Teaching Hospital (UBTH) serve as the final referral points for the most complex and life-threatening obstetric emergencies. Referred obstetric cases constitute a particularly high-risk population for maternal death, as they arrive having experienced delays in recognition, transportation, and prior management of obstetric complications. Identifying the risk factors for maternal mortality within this referred population is essential for designing effective interventions across the referral continuum.
Objective: This study assesses the risk factors for maternal mortality among referred obstetric cases managed at University of Benin Teaching Hospital, Edo State.
Methods: A retrospective descriptive study design was used. Case records of all referred obstetric admissions that resulted in maternal death at UBTH over a five-year period (2019–2023) were reviewed. Data were extracted using a structured data extraction form and analysed using SPSS version 26, with binary logistic regression used to identify independent risk factors for maternal mortality.
Expected Findings: Haemorrhage, eclampsia, and sepsis are anticipated as the leading direct causes of maternal death, with referral delays, low educational status, unbooked status, and late gestational age at first ANC contact as key risk factors.
Conclusion: Addressing maternal mortality among referred cases at UBTH requires strengthening the obstetric referral system, improving community-level emergency recognition, and expanding access to comprehensive emergency obstetric care across Edo State.
Keywords: Maternal mortality, risk factors, referred obstetric cases, UBTH, Edo State, emergency obstetric care, three delays, Nigeria.
1.0 INTRODUCTION
1.1 BACKGROUND TO THE STUDY
Maternal mortality which is defined as the death of a woman from any cause during pregnancy or within 42 days of the end of her pregnancy due to complications arising from or exacerbated by pregnancy or childbirth, is one of the most visible and distressing markers of health system failure in any community (WHO, 2023). In 2020, around 287,000 women died as a result of pregnancy-related conditions globally, and nearly 70% of these were from sub-Saharan Africa (WHO, 2023). This has a disproportionate impact on Nigeria, which is the most-populous nation in Africa and has an estimated maternal mortality ratio (MMR) of 512 per 100,000 live births, among the 10 countries with the highest MMRs in the world (WHO, 2023; Alkema et al., 2022).
The vast majority of direct maternal deaths in Nigeria are due to preventable conditions, with obstetric haemorrhage, hypertensive disorders of pregnancy (particularly eclampsia and pre-eclampsia), sepsis and infections, unsafe abortion and obstructed labour accounting for more than 80% of the deaths nationally (Say et al, 2014). All these can be easily managed with early access to skilled obstetric care and proper facilities. Their lethality in Nigeria is not a reflection of their clinical intractability, it is a reflection of failing health systems in ensuring access to health care at its time of need, quality care, and functioning health referral system.
The University of Benin Teaching Hospital is a tertiary health care establishment, established and one of the oldest in the southern part of Nigeria characterized as a Federal tertiary institution. It has a maternity unit which is the highest referral centre for obstetric emergencies in Edo State and referred obstetric cases from neighbouring Delta, Ondo and Kogi States. The hospital receives a large number of referrals, including women who have had the three delays as described in the literature: women take too long to decide to seek care, women take too long to reach a health care facility, and women receive the wrong care at the health care facility (Thaddeus & Maine, 1994). Women who come to UBTH as referred patients due to one or more of these are a highly vulnerable population to be assessed for mortality and are a significant proportion of the total maternal mortality.
There is a lack of data on maternal mortality risk factors among referred obstetric cases at the institution level in UBTH; however these are of critical importance to understanding. The aim of this study is to fill that gap by making a systematic retrospective analysis of maternal deaths in the period of five years of referrals at UBTH.
The “three delays” model of maternal deaths, which was first described by Thaddeus and Maine (1994), continues to be the most popular conceptual approach for analyzing pathways to maternal deaths in LMICs. First delay in seeking care due to lack of awareness of danger signs, economic reasons, decision making authority in the family, and cultural beliefs regarding the seeking of healthcare. Distance to and cost of transport, road condition and geographical distribution of health facilities explains the second delay in access to health care facility. The third delay in seeking proper treatment relates to inadequate facility infrastructure, staff and manpower, availability of drugs and materials and clinicians’ competence.
In Nigeria, the three delays are omnipresent and interconnected. Research in different states consistently shows that women suffer significantly higher mortality risks when they reach tertiary health care after having crossed the first and second delays because when delays occur in receiving the right care, the outcomes are poorer (Oladapo et al., 2020). UBTH’s obstetric cases make up a high proportion of cases referred to the hospital from primary health facilities and secondary health facilities of Edo State and beyond as emergency referrals. These women are often admitted in critical condition with complications such as ruptured uterus, severe anaemia as a result of haemorrhage, eclampsia with end organ damage, and overwhelming sepsis, all of which have a high case fatality rate even if the woman receives optimal care on admission.
The national Demographic and Health Survey (NPC & ICF, 2019) mentions unbooked status (no prior ANC care), rural residence, low education level, high parity, low quintile of household wealth and low age of pregnancy as key risk factors for maternal mortality. Institutional-level elements that influence the maternal deaths for clients referred for delivery also include inadequate blood bank capacity, lack of intensive care unit (ICU) facilities, shortage of staff, and drug shortages in the teaching hospitals in Nigeria (Oladapo et al., 2020; Ujah et al., 2020). As a tertiary referral hospital, UBTH has more resources and systems issues, but it has greater capacity to serve lower-level facilities than does UBTH’s most critical obstetric admission, which has an impact on maternal mortality outcomes.
1.2 STATEMENT OF THE PROBLEM
Maternal deaths in referred obstetric patients at UBTH has become a sentinel event which signifies that the general obstetric referral system in Edo State is also having its own shortcomings and that the capacity to provide obstetric care in UBTH itself is also not up to standard. That UBTH is the referral hospital of last resort in the state, yet maternal mortality happens when a woman referred to it has reached last resort, after experiencing one (or more) of the three delays. So far, there is no systematic knowledge of obstetric cases that present to UBTH and likely to die around specific risk factors, clinical, sociodemographic, and referral-related.
This type of evidence is not available to UBTH’s obstetric team, the hospital management, nor the Edo State Ministry of Health, if it exists, to identify the most critical intervention points along the maternal death trajectory or to strengthen the referral system at its weakest links or implement targeted clinical protocols that manage the most common complications segregating from maternal death along the maternal mortality trajectory for the referred cases if they were present. In view of this gap in the evidence, this study used a systematic retrospective analysis of five years of maternal mortality data from referred admissions to UBTH.
1.3 OBJECTIVES OF THE STUDY
The general objective is to assess the risk factors for maternal mortality among referred obstetric cases managed at University of Benin Teaching Hospital, Edo State.
Specific objectives are to:
- Determine the maternal mortality ratio among referred obstetric cases at UBTH over the study period (2019–2023).
- Identify the leading direct and indirect causes of maternal death among referred obstetric cases at UBTH.
iii. Assess the sociodemographic risk factors for maternal mortality among referred obstetric admissions at UBTH.
- Evaluate the clinical and obstetric risk factors associated with maternal mortality among referred cases.
- Examine the referral-related factors (source of referral, time from onset to referral, mode of transport) associated with maternal death at UBTH.
1.4 RESEARCH QUESTIONS
- What is the maternal mortality ratio among referred obstetric cases at UBTH between 2019 and 2023?
- What are the leading direct and indirect causes of maternal death among referred obstetric cases at UBTH?
iii. What sociodemographic characteristics are significantly associated with maternal mortality among referred obstetric admissions at UBTH?
- What clinical and obstetric factors are associated with maternal mortality among referred obstetric cases at UBTH?
- What referral-related factors are significantly associated with maternal death among referred obstetric cases at UBTH?
1.5 RESEARCH HYPOTHESES
H01: There is no significant association between unbooked status and maternal mortality among referred obstetric cases at UBTH.
H02: There is no significant relationship between the duration of pre-referral delay and maternal death among referred obstetric admissions at UBTH.
H03: There is no significant association between the primary obstetric complication and the risk of maternal death among referred cases at UBTH.
1.6 SIGNIFICANCE OF THE STUDY
The significance of this study extends across multiple levels of the maternal health system in Edo State and nationally. For the clinical team at UBTH, the findings will provide an evidence base for developing improved triage protocols, emergency obstetric care pathways, and risk stratification tools specifically tailored to the profile of referred obstetric cases received at the institution. This may lead to faster initiation of life-saving interventions and improved survival rates.
For the Edo State Ministry of Health and State Primary Health Care Development Agency, the findings will highlight the referral system weaknesses including inadequate communication between referring facilities and UBTH, delayed transport, and suboptimal pre-referral management that most critically increase maternal mortality risk among referred cases. This evidence can inform investment in referral system strengthening through emergency transport schemes, referral communication protocols, and capacity-building at secondary health facilities.
For policymakers and programme planners at the national level, the study contributes to the evidence supporting Nigeria’s Saving One Million Lives programme and its successor initiatives by providing granular institutional data on maternal mortality risk factors in a high-volume tertiary referral centre. For academic and research audiences, the study adds to the limited body of institution-specific maternal mortality research from southern Nigeria, providing a comparative reference point for similar studies across the country.
1.7 SCOPE OF THE STUDY
This study is confined to case records of referred obstetric admissions resulting in maternal death at University of Benin Teaching Hospital, Edo State, over the five-year period from January 2019 to December 2023. It focuses on the identification and analysis of maternal mortality risk factors, including sociodemographic, clinical, obstetric, and referral-related variables. The study does not include obstetric cases admitted through UBTH’s own antenatal clinic or emergency department that were not referred from another facility. It also does not extend to neonatal mortality or perinatal outcomes, though these may be referenced contextually. Data are extracted retrospectively from hospital case records and registers.
1.8 LIMITATIONS OF THE STUDY
The retrospective design introduces the risk of incomplete or inaccurate records, as the quality of documentation in hospital case files may vary across the study period. Missing data fields in case records particularly for referral source, pre-referral duration, and mode of transport may limit the completeness of analysis of referral-related risk factors. Selection bias is inherent to a study confined to deaths, as the absence of a comparison group of referred cases who survived limits the ability to calculate risk ratios. Temporal changes in clinical protocols, staffing, or facility capacity at UBTH during the five-year period may confound trend analyses. These limitations will be addressed through systematic data extraction, multiple data source triangulation, and transparent reporting of missing data.
1.9 DEFINITION OF TERMS
Maternal Mortality: 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 (WHO, 2023).
Maternal Mortality Ratio (MMR): The number of maternal deaths per 100,000 live births in a given time period, used as the primary indicator of maternal mortality burden (WHO, 2023).
Referred Obstetric Case: A pregnant woman or recently delivered woman who has been transferred from a lower-level health facility to UBTH for management of an obstetric complication that exceeds the capacity of the referring facility.
Three Delays Model: A conceptual framework by Thaddeus and Maine (1994) that identifies three phases of delay contributing to maternal death: delay in deciding to seek care, delay in reaching appropriate care, and delay in receiving adequate care at the facility.
Direct Obstetric Death: A maternal death resulting from obstetric complications of the pregnant state pregnancy, labour, and puerperium from interventions, omissions, incorrect treatment, or a chain of events resulting from any of the above (WHO, 2023).
Indirect Obstetric Death: A maternal death resulting from a previous existing disease or disease that developed during pregnancy, which was not due to direct obstetric causes but aggravated by the physiological effects of pregnancy (WHO, 2023).
Unbooked Status: The condition of a pregnant woman who has received no antenatal care prior to her admission with an obstetric complication (Oladapo et al., 2020).
Eclampsia: The onset of seizures (convulsions) in a woman with pre-eclampsia, a hypertensive disorder of pregnancy characterised by new-onset hypertension and proteinuria after 20 weeks of gestation (Say et al., 2014).
REFERENCES
Alkema, L., Chou, D., Hogan, D., Zhang, S., Moller, A. B., Gemmill, A., & Say, L. (2022). Global, regional, and national levels and trends in maternal mortality between 1990 and 2015 with scenario-based projections to 2030. The Lancet, 387(10017), 462–474. https://doi.org/10.1016/S0140-6736(15)00838-7
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Say, L., Chou, D., Gemmill, A., Tunçalp, Ö., Moller, A. B., Daniels, J., & Alkema, L. (2014). Global causes of maternal death: A WHO systematic analysis. The Lancet Global Health, 2(6), e323–e333. https://doi.org/10.1016/S2214-109X(14)70227-X
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Ujah, I. A., Aisien, O. A., Mutihir, J. T., Vanderjagt, D. J., Glew, R. H., & Uguru, V. E. (2020). Factors contributing to maternal mortality in North-Central Nigeria: A seventeen-year review. African Journal of Reproductive Health, 9(3), 27–40. https://doi.org/10.2307/3583152
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