462 Bulletin of the World Health Organization | June 2005, 83 (6)
Abstract Two surveys of maternal mortality conducted in Egypt, in 1992–93 and in 2000, collected data from a representative sample of health bureaus covering all of Egypt, except for five frontier governorates which were covered only by the later survey, using the vital registration forms. The numbers of maternal deaths were determined and interviews conducted. The medical causes of death and avoidable factors were determined. Results showed that the maternal mortality ratio (MMR) had dropped by 52% within that period (from 174 to 84/100 000 live births). The National Maternal Mortality Survey in 1992–93 (NMMS) revealed that the metropolitan areas and Upper Egypt had a higher MMR than Lower Egypt. In response to these results, the Egyptian Ministry of Health and Population (MOHP) intensified the efforts of its Safe Motherhood programmes in Upper Egypt with the result that the regional situation had reversed in 2000. Consideration of the intermediate and outcome indicators suggests that the greatest effect of maternal health interventions was on the death-related avoidable factors “substandard care by health providers” and “delays in recognizing problems or seeking medical care”. The enormous improvements in these areas are certainly due in part to extensive training, revised curricula, the publication of medical protocols and services standards, the upgrading of facilities, and successful community outreach programmes and media campaigns. The impact on the utilization of antenatal care (ANC) has been less successful. Other areas that remain problematic are inadequate supplies of blood, drugs and equipment. Although the number of maternal deaths linked to haemorrhage has been drastically reduced, it remains the primary cause.
The drop in maternal mortality in the 1990s in response to Safe Motherhood programmes was impressive and the ability to tailor interventions based on the data from the NMMS of 1992–93 and 2000 was clearly demonstrated. To ensure the continuing availability of information to guide and evaluate programmes for reducing maternal mortality, an Egyptian national maternal mortality surveillance system is being developed.
Keywords Maternal mortality/trends; Cause of death; Risk factors; Prenatal care/standards; Maternal health services; Egypt (source: MeSH, NLM). Mots clés Mortalité maternelle/orientations; Cause décès; Facteur risque; Soins prénataux/normes; Service santé maternelle; Egypte (source: MeSH, INSERM). Palabras clave Mortalidad maternal/tendencies; Causa de muerte; Factores de riesgo; Atención prenatal/normas; Servicios de salud materna; Egipto (fuente: DeCS, BIREME).
Bulletin of the World Health Organization 2005;83:462-471.
Voir page 470 le résumé en français. En la página 470 figura un resumen en español.
1 Maternal and Child Health Care, London School of Hygiene and Tropical Medicine, London, England. 2 John Snow, Inc., 21 Misr Helwan Agricultural Road, Maadi, Cairo, Egypt. Correspondence should be sent to this author (email: rgipson@jsiegypt.com). 3 National Maternal Mortality Study, John Snow, Inc., Cairo, Egypt. 4 Healthy Mother/Healthy Child Team Project, United States Agency for International Development, Cairo, Egypt. 5 Central Agency for Public Mobilization and Statistics, Cairo, Egypt. 6 Department of Pediatrics and Obstetrics, School of Medicine, George Washington University, Washington, DC, USA. 7 Ministry of Health and Population, Cairo, Egypt. Ref. No. 04-016360 (Submitted: 14 July 2004 – Final revised version received: 17 December 2004 – Accepted: 21 December 2004)
National maternal mortality ratio in Egypt halved between 1992–93 and 2000 Oona Campbell,1 Reginald Gipson,2 Adel Hakim Issa,3 Nahed Matta,4 Bothina El Deeb,5 Ayman El Mohandes,6 Anna Alwen,2 & Esmat Mansour7
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Introduction Maternal mortality is a major global concern that affects families and thus society. Surveys to determine the causes of maternal deaths (MD) are the primary tools on which interven- tions have been based. Two national maternal mortality surveys
(NMMSs) were performed in 1992–93 and 2000 in Egypt. The results from these surveys indicated that the maternal mortality ratio (MMR) in Egypt had decreased by 52% from 174/100 000 live births in 1992–93 to 84/100 000 live births in 2000 (1, 2).
Policy and Practice
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Policy and Practice Oona Campbell et al. Maternal mortality rates in Egypt
Various interventions were implemented in Egypt by the Maternal and Child Health Directorate/Ministry of Health and Population (MCH/MOHP) with assistance from the Child Survival Project funded by the United States Agency for Inter- national Development (USAID), between 1985 and 1996. A primary goal of this nationwide effort was to reduce the 1989 maternal mortality rate (220/100 000 live births) by 15% by 1995 (3). Many of the interventions were later refocused based on the results of the NMMS of 1992–93.
The MotherCare Egypt Project took over from the Child Survival Project, focusing between 1996 and 1998 on pilot studies in three districts in Upper Egypt (4). Building upon these results, the Healthy Mother/Healthy Child Project (HM/ HC) started work in Upper Egypt (in Aswan and Luxor) in June 1998, covering all districts (5). This paper reviews the shifts in causes and avoidable factors related to maternal deaths and analyses the impact of Safe Motherhood programmes in Egypt on the MMR through their effect on intermediate indicators.
Methods Egypt can be divided into three distinct regions: metropolitan (Cairo, Alexandria, Port Said and Suez), the north (Lower Egypt) and the south (Upper Egypt). It is estimated that one-third of its population lives below the poverty line (6). Compared to other developing countries, Egypt belongs to the middle level on a scale of socioeconomic development. The poverty is most se- vere in Upper Egypt, which is home to 41% of all poor people in Egypt (6). Urban governorates had the lowest densities of poor people, followed by urban Lower Egypt and urban Upper Egypt, which is the poorest of urban locations. Regions with higher than average levels of relative poverty were rural Lower Egypt followed by rural Upper Egypt, which was the poor- est region of the country (7). All regions were comparable in other relevant respects (e.g. religion and languages). Detailed socioeconomic and demographic data on all regions have been published elsewhere (8).
The MOHP conducted the surveys between 1 March 1992 and 28 February 1993 and 1 January to 31 December 2000, with the assistance of the Egyptian Central Agency for Public Mobilization and Statistics (CAPMAS). The methods for carrying out the two surveys were essentially identical and the results were comparable. Data for the 1992–93 survey were obtained from a selection of 122 health bureaus in 21 gover- norates. In 2000, five more frontier governorates were added, and Luxor City had become a governorate, bringing the total to 27 governorates, covering the whole of Egypt.
Guidance on survey design, strategy and dissemination was provided by a central advisory group and a reproductive age mortality study-based (RAMOS) methodology was used (9). Advantage was taken of Egypt’s virtually complete registra- tion of adult deaths, to obtain a population-based sample of deaths among women aged 15–49 years. In 18 governorates, one-third of health bureaus were randomly selected; all health bureaus in the remaining nine governorates were included as these were of particular interest to the MOHP for various rea- sons. The participation of 149 health bureaus in the 27 Egyptian governorates enabled an overall statistical estimation of MMR to be made with an accuracy of plus or minus 10%.
Deaths related to pregnancy were identified at the se- lected health bureaus using a one-page screening questionnaire
filled in within 48 hours of the death. The selected health bu- reaus sent weekly reports to CAPMAS on all deaths of women aged 15–49 years during the period of the survey. MDs were confirmed by non-local, university-educated CAPMAS field- workers who conducted in-depth home interviews with rela- tives of the deceased, using a 44-page verbal autopsy (Box 1) based on the Basic Support for Institutionalizing Child Survival (BASICS) questionnaire and the WHO Verbal Autopsy for Infants (10–12). Inter-gender interviews were not prohibited. Health-care providers involved in caring for the mother were interviewed using an 11-page questionnaire administered by a designated local advisory group in the governorate, composed of the Undersecretary of the Health Directorate, the MCH Director, one obstetrician and one paediatrician. All question- naires had been pre-tested in a pilot study conducted in Kalyubia Governorate, Lower Egypt. Interviews were not conducted in 54/772 cases in 1992–93 and 5/585 cases in 2000 because of failure to locate the home of the deceased.
Completed household questionnaires were checked by the CAPMAS field supervisors who also repeated 2–3 of the household interviews conducted by each field interviewer, thus double-checking the quality of data for 62 maternal deaths. Local advisory groups reviewed all cases, including medical re- cords, to determine the cause of death, and made assessments of avoidable factors. Causes of maternal deaths were categorized as either direct or indirect in accordance with WHO Interna- tional Classification of Diseases, tenth revision (13). More than one cause of death and more than one avoidable factor could be assigned, but a single main cause of death was decided upon by consensus by the local advisory group. The technical advi- sory group, composed of the 13 Chairs of Egyptian university departments of obstetrics and gynaecology, met monthly to review cases and finalize reports. An anaesthesia consultant re- viewed all cases in which anaesthesia had been given.
All interviewers, doctors from the selected health bureaus and panel members received training. Interviewers received 10 days of continuous training, which included role-play, survey tools and 7 days of practical fieldwork. The training stressed the need for confidentiality. The 173 directors of the selected health bureaus had three half-day training sessions which em- phasized the importance of accurate completion of question- naires and recording of detailed addresses. The 112 members of the local advisory groups attended two 1-day training work- shops. Refresher training was provided if a need was indicated by the results of quality control measures used in the data validation process.
Box 1. Headings of the main sections of the 44-page household questionnaire
1. Identification of the deceased woman 2. Relatives and health provider attending the death 3. Brief summary; overall description of the case 4. Details about the death and circumstances related to the death 5. Details relating to the antenatal care visit(s) 6. Delivery details 7. Outcome of the “current” delivery 8. Past medical history of the deceased 9. Personal history of the deceased and husband 10. Household details
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Policy and Practice Maternal mortality rates in Egypt Oona Campbell et al.
Data were double-entered and validated using EPI- INFO, and analysed using Stata and Excel software.
To calculate the MMR in the 18 sampled governorates, the proportion of deaths in women (FD) that were classified as maternal deaths (MD) was multiplied by the total number of women who had died based on the most recently available data (1998, obtained through CAPMAS), and divided by the total number of live births (LB) in 2000. For the remaining nine governorates, the total number of confirmed MDs was divided by the total number of live births:
[(MD2000/FD2000) × FD1998]/LB2000 × 100 000
Results In 1992–93 and 2000, a total of 7487/8497 deaths (15–49 years) were reported among women. Of these, 825 (11%) and 639 (7.5%), respectively, were pregnancy-related; 772 (94%) and 585 (92%), respectively, were categorized as MDs and 53 (6%) and 54 (8%), respectively, were due to non-maternal causes. MDs comprised 10.3% and 6.9% of deaths among women of reproductive age in 1992–93 and 2000, respectively. The overall MMR was reduced from 174/100 000 to 84/100 000 live births (1, 2, 14, 15).
Table 1 shows the individual, direct and indirect causes of MD. The major cause of death in both survey periods was haemorrhage (30%); postpartum haemorrhage (PPH) caused 22% of MDs in 1992–93 and 27% in 2000. However, the absolute numbers of deaths caused by PPH remained ap- proximately the same (161 MDs in 1992–93 and 157 deaths in 2000). Deaths caused by antepartum haemorrhage (APH) were substantially reduced from 50 (7%) deaths in 1992–93 to only 19 (3%) in 2000.
The number of MDs due to hypertensive disease dropped by 32 between 1992–93 and 2000, deaths due to sepsis by 22 and those due to abortion by 17. Pulmonary embolism and lack of anaesthesia had become more significant problems in 2000. However, the diagnosis of pulmonary embolism was based on case histories rather than on autopsies, which could result in mis- diagnosis. The numbers of MDs due to ruptured uterus, com- plications of caesarean section, ectopic pregnancy, obstructed labour and active uterine inversion remained fairly stable.
The ranking of the individual major causes of death remained fairly stable. After haemorrhage, hypertensive disease caused most deaths (15% in 1992–93 and 13% in 2000), followed by sepsis (8%), ruptured uterus (6%) and abortion (5%) in 1992–93. In 2000, the figures were ruptured uterus (8%), rheumatic heart disease (7%), sepsis (6%) and pulmo- nary embolism (6%).
In both 1992–93 and 2000, the major avoidable factor contributing to MDs was substandard care by obstetricians (334 (47%) deaths and 247 (43%) deaths, respectively) (Table 2). Although it was still the single most important factor, it caused 87 fewer MDs in 2000 than in 1992–93. In the earlier survey, the delay in recognizing the problem and seeking medical care was the second most important contributory factor. Although still a major concern in 2000 when it caused 172 deaths (30%), this was 132 fewer deaths than in 1992–93, and ranked third in importance. Although the contribution of absence of, or poor quality of, antenatal care to the MMR was reduced, in terms of absolute numbers, by 39 MDs in 2000, it became the second most important avoidable factor.
The lack of blood and drugs, and lack of supplies and equipment are the only two avoidable factors that notably con- tributed to more deaths in 2000 (45 and 92 MDs, respectively) than in 1992–93 (15 and 33 MDs, respectively) (Table 2). The number of deaths due to unavoidable factors had also increased in 2000.
Discussion The 52% reduction in the MMR between 1992–93 and 2000 in Egypt was a remarkable success worthy of detailed analysis. The relationship between observed decline in national figures and heightened community awareness as well as improved ac- cess to and quality of services should be examined closely.
Despite the overall decline in the MMR, the distribution of causes has not changed dramatically. Haemorrhage, both APH and PPH, continues to be the major cause of maternal deaths in Egypt as in many other countries. The changes in percentage contribution do not reflect the reduction of direct cause of death in real terms. Although haemorrhage contrib- uted to 30% of MDs in both survey periods, in real terms there were 36 fewer deaths related to haemorrhage in 2000, i.e. 5% fewer than in 1992–93. Thus, in order to assess the areas in which there have been improvements from one year to another it is important to look at actual numbers. Com- parative percentages are useful when determining which areas need more immediate attention when designing maternal care programmes. This area should be the focus of future interven- tions targeting further reduction.
It is encouraging that the contribution of delays in recog- nizing a problem or seeking medical care as a factor in mater- nal mortality decreased from 42% to 30%. This may indicate enhanced community awareness.
Deaths due to substandard care by health providers (in- cluding dayas (traditional birth attendants)) dropped from 505 (71%) to 386 (66%) reflecting a gradual improvement of health care services.
The increase in number of deaths related to a lack of blood or drugs and supplies is a cause for concern, but could indicate a greater proportion of deaths occurring in health-care facilities and consequently be linked to specific deficiencies within that system.
The reversal in the MMR between regions is shown in Table 3. Lower Egypt, a more urbanized and affluent area, had the higher MMR in 2000. As mentioned above, mater- nal health interventions were more extensive in Upper Egypt (1996–2000). This is not proof of the effectiveness of these interventions, but could be seen as circumstantial evidence for their success.
In order to analyse the possible reasons for improvement in certain areas, it is necessary to try to establish causal links between interventions, intermediate indicators and outcomes. Table 4 shows relevant intermediate indicators in Egypt. Table 5 summarizes the primary area of impact of each major pro- gramme component.
It is generally recognized that it takes from 3 to 5 years for programme activities to have a demonstrable impact on maternal mortality outputs or outcomes, ultimately leading to a change in the MMR. It is difficult to establish direct correla- tions between activities implemented in the field and proxy indicators and/or maternal mortality outcomes especially at the national level.
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Table 1. Direct and indirect causes of maternal deaths, Egyptian National Maternal Mortality Survey (ENMMS) 1992–93 and 2000
Causes of death No. of deaths, (%)a No. of deaths, (%)a ENMMS 1992–93 ENMMS 1992–93 ENMMS 2000 ENMMS 2000
Direct causes Haemorrhage 212 (30) 176 (30) Postpartum haemorrhage 161 (22) 157 (27) Antepartum haemorrhage 50 (7) 19 (3) Hypertensive diseases of pregnancy 110 (15) 78 (13) With convulsions 66 (9) 47 (8) Without convulsions 44 (6) 29 (5) Chronic hypertension 2 (0) Sepsis 59 (8) 37 (6) Puerperal sepsis 36 (6) Obstetric sepsis 1 (0) Abortion 32 (5) 15 (3) Spontaneous 19 (3) 9 (2) Induced 13 (2) 6 (1) Other 86 (12) 141 (24) Ruptured uterus 41 (6) 47 (8) Pulmonary embolism 7 (1) 33 (6) Anaesthesia 13 (2) 30 (5) Caesarean section 17 (2) 24 (4) Ectopic pregnancy 4 (1) 4 (1) Active uterine inversion 2 (0) Obstructed labour 3 (0) 1 (0) Total direct causes 499 448 (77)
Indirect causes Cardiovascular disorders 92 (13) 58 (10) Rheumatic heart disease 40 (7) Myocardial infarction/stroke 13 (2) Congenital heart disease 5 (1) Infectious and parasitic diseases 26 (4) 16 (3) Encephalitis 6 (1) Bacterial meningitis 4 (1) Tuberculosis 3 (1) Septicaemia 3 (0) Digestive disorders 9 (1) 16 (3) Liver failure 14 (2) Other digestive disorders 2 (0) Neoplasms 12 (2) 9 (2) Other neoplasms 6 (1) Acute leukaemia 3 (0) Respiratory disorders 6 (1) Anaemia 4 (1) 3 (1) Acute renal failure 3 (0) Neurological disorders 17 (2) 1 (0) Other 33 (4) Total indirect causes 193 (27) 116 (20) Unknown causes 26 (4) 16 (3) Total maternal deaths 718 (100) 580b (100)
a Percentages do not add up to 100 due to rounding. b Interviews could not be completed for 54 of 772 cases in 1992–93 and five of the 585 cases in 2000. The cause of death was confirmed to be unknown if the data were still insufficient after review by the technical advisory group.
Provider level Skilled attendants at birth The accepted paradigm is that “risk of maternal deaths can be re- duced by skilled attendance at delivery” (16). “Skilled attendant” refers here to providers with midwifery and obstetric skills, thus excluding trained birth attendants. Attendance at delivery (from onset of labour to the immediate puerperium) can affect four di- rect causes of MD: obstructed labour, eclampsia, puerperal sepsis
and obstetric haemorrhage. Assuming access to and utilization of skilled attendants, Graham et al. have suggested that 16–33% of all MDs could potentially be avoided although this estimate has not been supported by any randomized trials (17).
According to the findings of Koblinsky et al. (18), among others, in countries where the majority of births take place at home without the presence of skilled attendants, it is apparently impossible to reduce maternal mortality to below 100/100 000
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Policy and Practice Maternal mortality rates in Egypt Oona Campbell et al.
Table 2. Avoidable factors contributing to maternal deaths from the 1992–93 and 2000 Egyptian National Maternal Mortality Surveys (ENMMS)
Avoidable factors Total (ENMMS 1992–93) No. (%)a Total (ENMMS 2000) No. (%)a
Substandard care from Obstetrician 334 (47) 247 (43) General practitioner 87 (12) 66 (11) Daya 84 (12) 47 (8) Midwife – 26 (4) Delay in recognizing problem or seeking medical care 304 (42) 172 (30) No antenatal care – 110 (19) Poor quality antenatal care 239 (33)b 90 (15) Lack of blood 45 (6) 92 (16) Lack of drugs, supplies and equipment in health facilities 15 (2) 33 (6) Lack of transportation 28 (4) 30 (5) Long distance to hospital (> 30 km) – 23 (4) Lack of anaesthetist/anaesthesia facilities – 24 (4) Unwanted pregnancy 36 (5) 14 (2) No avoidable factors 54 (8) 113 (19) Total 718 580c
a Percentages do not add up to 100% as each death can be due to more than one avoidable factor. b The ENMMS 1992–93 grouped “no antenatal care” and “poor quality antenatal care” into one category. c Interviews could not be completed for 54 of 772 cases in 1992–93 and five of the 585 cases in 2000.
Table 3. Female deaths, maternal deaths and maternal mortality ratios by region and governorate in the Egyptian National Maternal Mortality Survey (NMMS) 1992–93 and in 2000
Region or Maternal mortality (Lower–upper confidence Maternal mortality (Lower–upper confidence governoratea ratio 1992–93 limits) 1992–93 ratio 2000b limits) 2000
Metropolitanc 233 (197–276) 48 (40–56) Lower Egyptd 132 (118–148) 93 (86–100) Upper Egypte 217 (195–244) 89 (82–96) Frontierf 120 (78–161) Total/National 174 (162–187) 84 (80–89)
a The ENMMSs of 1992–93 and 2000 did not report on all 27 Governorates individually. The frontier regions were not included in the ENMMS 1992–93. The New Valley Governorate is a new settlement area with a big population influx. b The national MMR values are statistically significantly different between 1992–93 and 2000 (P-value < 0.0001). c Metropolitan: urban areas of Cairo, Alexandria, Port Said and Suez. d Lower Egypt: more developed parts of northern Egypt. e Upper Egypt: less developed rural parts of southern Egypt. f Frontier: sparsely populated areas bordering Israel, Libyan Arab Jamahiriya and Sudan.
live births. Graham et al. (17) have found that disaggregating the data for 50 developing countries revealed a definite nega- tive correlation between the MMR and the number of births attended by doctors. The correlation between MMR and attendance by midwives is also negative but much weaker. It is important to note that although these stand-alone statistics indicate a link, further work is required to confirm its existence. In Egypt, both the number of deliveries that took place in health-care facilities and assistance by skilled birth attendants increased by about 50% between 1992–93 and 2000 (27% and 40.7% and 49% and 60.9%, respectively (Table 4). The number of deaths caused by pregnancy-related hypertensive diseases, obstructed labour and sepsis decreased significantly between the two surveys (Table 1). A reasonable inference is that presence of skilled birth attendants at birth has contributed to reducing MMR in Egypt. The data available do not allow an assessment of the coverage of problematic births, but as 61% of all pregnant
women (general population) are assisted during the birth by skilled attendants, at least two-thirds of those with serious condi- tions should be covered. However, only certain complications such as sepsis and pre-eclampsia can be avoided or treated in most environments, others such as obstructed labour and haemorrhage can be dealt with only if the necessary blood, supplies and equip- ment, and referral and transportation are available.
Substandard care Substandard care was a major avoidable factor that caused maternal mortality in 1992–93 and it remained the second key factor in 2000. Access to ANC, recognizing danger signs and seeking professional care can be effective only if quality profes- sional services are available. Trained professionals. Although comparatively more deaths are linked to substandard care by obstetricians than to other profes- sional categories, this is probably in part due to complicated cases being attended by an obstetrician.
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Table 4. Changes in the main intermediate indicators in Egypt between 1992–93 and 2000
Indicator EDHS 1992a EDHS 2000a % change
Contraceptive prevalence (%) 47.1 56.1 19% increase Total fertility rate 3.9 3.5 decrease Neonatal mortality rate (per 1000 live births) 33 24 27% decrease Infant mortality rate (per 1000 live births) 62 44 29% decrease Mortality rate for children under 5 years (per 1000 live births) 85 54 36% decrease Women receiving any ANCb (%) 52.9 52.9 35% increase No of ANCb visits: 1 ANC visit 12.3 3.2 2–3 ANC visits 17.4 9.1 4 ANC visits 22.5 36.7 Don’t know/missing 0.7 3.9 Presence at delivery of skilled attendant (%) 40.7 60.9 50% increase No. of institutional deliveries 27 49 82% increase No. of health units per 100 000 population 12 13 increased No. of hospital beds per 100 000 population 196 211 increased No. of primary health care facilities 3329 3575 increased No. of maternity units – 170 increased Women’s education: Completed secondary/higher education 13 22 increased Completed primary/some secondary 19 22 increased
a The Egyptian Demographic and Health Surveys (EDHS) results span a period of 5 years preceding the date of publication. The study group comprised all pregnant women in Egypt. b Antenatal care.
The number of deaths caused by substandard care by obstetricians had diminished by about one-third in 2000. Table 1 shows that the numbers of MDs due to APH, sepsis and pregnancy-related hypertensive diseases had dropped. Because abortion is illegal in Egypt it is most likely under-reported. However, if this was the case in both 1992–93 and 2000, the results remain comparable.
Diagnosis and treatment of (pre-)eclampsia with magne- sium sulfate has been strongly promoted in Egypt and detailed medical protocols have been developed. Infection control mea- sures have been a major concern at all levels of the medical profes- sion and the various MCH/MOHP programmes have increased their focus in this area. Although MDs due to sepsis have di- minished since 1992–93 (Table 1), it is still the third main, single cause of death.
Establishing competency-based field training and intro- ducing updated, detailed medical protocols are key components of the Safe Motherhood HM/HC programme in Egypt.
The health facility level The MCH programmes in Egypt have included components focused on strengthening facilities at the essential obstetric care and primary health care levels (e.g. provision of equipment, drugs and supplies and structural upgrades) as shown in Table 6 (web version only, available from: http://www.int/bulletin). The number of health units and the number of hospital beds per 100 000 inhabitants as well as the number of primary health care and maternity facilities had all increased between 1992 and 2000 (Table 4).
The number of deaths caused by lack of available blood had increased between 1992–93 and 2000. An Egyptian-Swiss project has recently restructured the Egyptian Blood Transfusion Service, but the various programmes that have attempted to correct the situation have only been running since 1998. State- of-the-art blood banks operating independently from hospitals
have been established; blood drives (in which vans drive around to collect blood donations) have been conducted; and detailed protocols have been put into place. Improvements to the system are continuing but are unlikely to show an impact for several more years (unpublished report, 2003).
The community level Antenatal care ANC comprises a variety of services, including providing pa- tients with information, treating existing conditions and screen- ing for risk factors (19). ANC is also seen as a proxy indicator for the socioeconomic status of women, thus obscuring the di- rect impact it may have on MMRs. A rise in utilization of ANC has been associated with better community awareness, but may also be linked to better access to care. The mass-media messages and campaigns as well as community outreach programmes in Egypt have stressed the importance of ANC and the recognition of danger signs that indicate the need for professional help.
According to the Egyptian Demographic and Health Surveys (EDHS), in both 1992 and 2000, 47.1% of pregnant women in Egypt received no ANC. However, the frequency of visits had increased; in 2000, 36.7% pregnant women made four or more visits to ANC facilities compared to 22.5% in 1992 (Table 4). The EDHS further reported that ANC was most likely to have been received by women of lower parity and/or by women in urban areas. More attendances for ANC increase the chances of detecting pregnancy-related problems. It also offers the medical staff a chance to educate women regard- ing the danger signs and measures to be taken. However, it is the subgroups most at risk (i.e. women in rural areas who have further to travel to hospitals and those of lower socioeconomic status and/or of high parity) that are least likely to receive ANC. Campaigns and programmes aimed at improving ANC cover- age have apparently not reached their goal although it is dif- ficult to assess their exact impact on the reduction of the MMR
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Table 5. Major maternal health interventions by the Egyptian Ministry of Health and Population 1985–2005 and their area of impacta
Intervention Programmeb Avoidable factor — category
Establishment of a daya training programme CSPE Providers
Introduction of a revised curriculum and pre-service training in nursing CSPE Providers and medical schools
In-service training to upgrade skills of health providers in MCHc CSPE Providers service delivery. A competency-based training method was pilot- tested in selected governorates
Introduction of service standards for improved clinical management CSPE Providers
Providing equipment to strengthen health and laboratory facilities CSPE Health facilities
Training laboratory technicians in the proper use of upgraded CSPE Providers MCHc laboratories
Initiation of the development of an improved, computerized health CSPE Health facilities information system
Implementation of systems for improved and decentralized planning, CSPE Health facilities management and supervision
Organization of mass media campaigns CSPE Communities
Development of standards of care MCEP Providers
Strengthening of institutional capacity to improve maternal health MCEP Health facilities
Increasing community awareness and participation MCEP Communities
Enhancement of national policy environment for maternal health MCEP Providers, health facilities and communities
a The Healthy Mother/Healthy Child (HM/HC) result package (later the HM/HC Project) (1998–2005) essentially undertakes the same tasks as the previous project, but on a larger scale. Further details and results of the activities described above can be found in the final reports of the respective projects (1, 2, 3). b CSPE, Child Survival Project Egypt (1985–96); MCEP, MotherCare Egypt Project (1996–98). c Maternal and child health.
in Egypt. Possibly more importantly, antenatal care has had an indirect influence by helping to raise the awareness of women of how to recognize danger signs and the necessity for seeking professional help. This would be reflected by the increased number of deliveries in health-care facilities (82% increase between 1992–93 and 2000), births attended by skilled atten- dants (Table 4) and 142 fewer deaths in 2000 than in 1992–93 caused by a delay in recognizing a problem or in seeking medical care (Table 2).
A WHO worldwide ranking of causes of death by actual number showed that haemorrhage was the predominant cause, followed by sepsis, unsafe abortion, (pre-)eclampsia, obstructed labour and other direct causes (20). As stated by Bergsjo (21), the causes of haemorrhage differ and are mostly unpredictable. Sometimes, for example, in the early detection of placenta praevia, referral for sonographic investigation and management can prevent death. In Egypt, the number of deaths caused by PPH, but not the number caused by APH, was greater in 2000 than in 1992–93. The problem of dealing with haemorrhage was compounded by the increasing lack of available blood in emergency situations. It is possible that increased ANC atten- dance has led to a better recognition of the problem of APH whereas PPH, especially in the first 48 hours after delivery, may not yet be recognized by women or family members as a sign of danger. Furthermore, the traditional belief, still held in many rural areas, that a woman should not leave her home in the first 40 days postpartum needs to be addressed (at present, social workers are encouraged to make home visits).
Egyptian mothers who had been educated at least to sec- ondary level made more ANC visits (EDHS 1992 and 2000). Education may also induce women to seek medical care for
bleeding. Sepsis is not predictable and ANC can only assist by educating women on the dangers of giving birth in an unclean environment. Early detection of (pre)-eclampsia is possible and those at high risk should be followed more closely. But the number of women at low risk who might still develop the condition is extremely high and not all can be followed closely. Obstructed labour is unpredictable. Given that the estimated average interval from onset of major obstetric complications to death ranges from 2 hours (postpartum haemorrhage) to 6 days (sepsis) (22), and because most complications cannot be predicted, the usefulness of ANC seems to be more restricted than has often been implied.
Education and socioeconomic status Women’s general education improved during the 1990s, espe- cially in terms of the numbers who received higher education, and this has no doubt improved their socioeconomic status. This in turn, should lead to better medical coverage, better health conditions and an improved knowledge and use of contraceptive measures (Table 4). The lowest and highest age groups (15–19 and 40–50 years) as well as women who have had a large number of deliveries are most at risk. Longer and better education should reduce the number of early pregnan- cies and improved contraceptive measures should reduce the number of unwanted, late pregnancies.
Conclusion A documented, reduction in MMR over a relatively short time demonstrates the collective effect of an integrated national Safe Motherhood programme aimed at making improvements at
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Policy and Practice Oona Campbell et al. Maternal mortality rates in Egypt
the community, health-care delivery site and health-care pro- fessional levels. The intensive training received by the medical personnel apparently had a positive effect on reducing the MMR in the 1990s in Egypt. It is more difficult to quantify what direct impact infrastructural improvements, increased uti- lization of ANC and the presence of skilled attendants at birth have had.
In recent years, the Egyptian MOHP has focused its ef- forts and resources through the Safe Motherhood programme- HM/HC Project on a regional basis, starting in Upper Egypt and moving towards the north of the country. By addressing all aspects of the maternal health system within a defined area, the MOHP has demonstrated the collective effectiveness of implementing a multidisciplinary approach to MMR. Such a model of intervention may have global applications.
The majority of the above-mentioned intermediate indi- cators related to maternal deaths improved in Egypt between 1992–93 and 2000 with an associated reduction of the MMR. The network of adequate essential obstetric care and primary health care facilities has been improved, and long distance to a hospital and lack of transportation are now less of a barrier to care. However, the recognition of the value of preventive ANC services, and the recognition of emergency situations by pregnant women and family members, and seeking and receiv- ing appropriate medical care remain problematic. This may be linked to the perceptions in the community of the quality of ANC and emergency services available. Vast improvements in nearly all areas have been made and the reduction of the MMR between 1992–93 and 2000 of 52% is a clear indication that the measures taken have had a great impact. Reducing the MMR below 84/100 000 live births may necessitate a larger ef- fort for a smaller result. But it is clear that to further reduce the
WHO 05.19
Maternal mortality ratio
UAE
Fig. 1. Maternal mortality in selected countries
UAE = United Arab Emirates Source: ref. 23. Reproduced with permission of the copyright holder.
3
Kuwait 5
Qatar 10
Oman 14
Saudi Arabia 23
Jordan 41
Syrian Arab Republic
65
Tunisia 70
Egypt 84
Lebanon 100
Algeria 140
Morocco 230
Iraq 290
Yemen 350
WHO 05.20
Maternal mortality ratio
Belize
Fig. 2. Maternal mortality based on the Reproductive Age Mortality Study-based (RAMOS) method
aIncluding Macao and Hong Kong Special Administrative Regions. Data collected between 1993 and 2000.
140
Suriname 110
Honduras 110
Sri Lanka 92
Jamaica 87
Egypt 84
Chinaa 56
Thailand 44
Malaysia 41
Jordan 41
Cuba 33
Saudi Arabia 23
Korea, Republic of 20
MMR in Egypt, sustained training and monitoring of medical and administrative staff, an improved referral system, further community outreach programmes and awareness campaigns would be key measures.
In the countries shown in Fig. 1, the rates of maternal mortality seem to correlate with the per capita income (see World Bank ranking, 24), and Kuwait and the United Arab Emirates have low MMRs by international standards. In this context, Egypt’s maternal mortality is lower than its per capita income would predict.
If the MMR in developing countries is assessed using a RAMOS-based method (Fig. 2), Egypt ranks in the middle. Clearly, the measures taken in the form of the Safe Motherhood programmes have yielded satisfactory results, placing Egypt on a level with socioeconomically comparable, successful coun- tries. However, it may also be inferred that further improving the MMR will be tightly linked to the improvement of Egypt’s overall economic situation.
The two surveys probably underreported deaths among women as well as maternal deaths, to some extent, for reasons such as the illegality of abortion and the sampling effect in 18 governorates (partially corrected through weighting). Also, when compared to the expected number of deaths among women, there was an unexpected deficit in the reported num- bers of deaths in women in the nine governorates in which all health bureaus were sampled. After correcting for this shortfall, the national MMR was calculated to be 94/100 000 live births. By and large, the surveys were comparable and clearly indicate the trend towards reduced maternal mortality in Egypt. These surveys were expensive and did not produce data in a timely fashion. A maternal mortality surveillance system is therefore be- ing put into place in Egypt. The maternal mortality surveillance
470 Bulletin of the World Health Organization | June 2005, 83 (6)
Policy and Practice Maternal mortality rates in Egypt Oona Campbell et al.
system will deliver a steady flow of reliable data that will help in establishing programmatic priorities and taking corrective actions. The impact of these has resulted in a further reduction of the maternal mortality in the past 3 years. O
Acknowledgements The Egyptian National Maternal Mortality Surveys in 1992–93 and 2000 were initiated by the Maternal and Child Health Pro- gramme of the Egyptian Ministry of Health and Population.
We wish to thank the Population and Health Division, United States Agency for International Development, Cairo,
Egypt, for their valuable contribution and assistance in mak- ing the surveys possible. The surveys were funded by USAID/ Egypt under the Healthy Mother/Healthy Child Project (1995–2005).
Technical support was provided by John Snow, Inc. and the London School of Hygiene and Tropical Medicine, England. The assistance of the Central Agency for Public Mobilization and Statistics was invaluable.
Competing interests: none declared.
Résumé
La mortalité maternelle en Egypte a baissé de moitié entre 1992-93 et 2000 Dans le cadre de deux enquêtes sur la mortalité maternelle réalisées en Egypte en 1992-93 et en 2000, des données ont été recueillies auprès d’un échantillon représentatif de bureaux de santé couvrant toute l’Egypte, à l’exception de cinq gouvernorats frontaliers couverts uniquement par l’enquête ultérieure, au moyen des formulaires sur les données d’état civil. Le nombre des décès maternel a été déterminé et des entretiens ont été organisés. Les causes médicales des décès et les facteurs évitables ont été déterminés. Les résultats ont fait apparaître une baisse de 52% du taux de mortalité maternelle au cours de cette période (de 174 à 84/100 000 naissances vivantes). L’enquête nationale sur la mortalité maternelle de 1992-1993 a montré que le taux était plus élevé dans les zones métropolitaines et en Haute Egypte qu’en Basse Egypte. Face à ces résultats, le Ministère égyptien de la santé et de la population a intensifié les activités de ses programmes pour une maternité sans risque en Haute Egypte et la situation dans cette région s’était inversée en 2000. Les indicateurs intermédiaires et de résultat indiquent que les interventions de santé maternelle ont surtout influé sur les facteurs de mortalité évitables « mauvaise qualité des soins dispensés » et « reconnaissance tardive des problèmes ou recours tardif aux soins ». Les améliorations
considérables dans ces domaines sont certainement dues en partie à la formation dispensée sur une grande échelle, à la révision des programmes d’études, à la publication de protocoles médicaux et de normes applicables aux services, à l’amélioration des installations et au succès des programmes de vulgarisation communautaires et aux campagnes médiatiques. Des effets moindres ont été obtenus sur l’utilisation des soins prénatals. Les autres domaines qui restent problématiques sont l’insuffisance des stocks de sang, de médicaments et de matériel. Si le nombre des décès maternels liés à des hémorragies a considérablement baissé, celles-ci restent la cause principale de mortalité.
Le recul de la mortalité maternelle dans les années 90 sous l’effet des programmes Pour une maternité sans risque a été impressionnant, signe de la capacité d’adapter les interventions en fonction des données de l’enquête nationale sur la mortalité maternelle de 1992-1993 et de 2000. Le système national de surveillance de la mortalité maternelle en cours de mise en place en Egypte aidera à assurer la disponibilité continue d’informations pour orienter et évaluer les programmes destinés à réduire la mortalité maternelle.
Resumen
La razón de mortalidad materna en Egipto, reducida a la mitad entre 1992–1993 y 2000 En dos encuestas sobre la mortalidad materna realizadas en Egipto en 1992–1993 y en 2000, se emplearon los formularios del registro civil para reunir datos de una muestra representativa de oficinas sanitarias que abarcaban todo Egipto, salvo cinco prefecturas fronterizas incluidas sólo en la última encuesta. Se determinó el número de defunciones maternas y se realizaron entrevistas. Se determinaron asimismo las causas médicas de defunción y los factores evitables. Los resultados indican que la razón de mortalidad materna (RMM) disminuyó un 52% en ese periodo (de 174 a 84/100 000 nacidos vivos). La Encuesta Nacional de Mortalidad Materna correspondiente a 1992–1993 reveló que las zonas metropolitanas y el Alto Egipto tenían una RMM mayor que el Bajo Egipto. En respuesta a esos resultados, el Ministerio de Salud y Población redobló los esfuerzos de sus programas de Maternidad sin Riesgo en el Alto Egipto, como consecuencia de lo cual en el año 2000 la situación regional se había invertido. El análisis de los indicadores intermedios y de resultados lleva a pensar que el mayor efecto de las intervenciones de salud materna fue el que acusaron los factores de defunción evitables descritos como «atención inferior a la norma por los proveedores de salud» y «demoras en el reconocimiento de los problemas o la búsqueda
de atención médica». Las enormes mejoras registradas en estas áreas se deben en parte sin duda a las amplias actividades de formación emprendidas, la revisión de los programas de estudios, la publicación de protocolos médicos y de estándares para los servicios, la mejora de las instalaciones, y el éxito de los programas de extensión comunitaria y las campañas en los medios de comunicación. El impacto en el recurso a la atención prenatal ha sido menos satisfactorio. Otro aspecto aún problemático es el suministro insuficiente de sangre, medicamentos y equipo. Aunque el número de muertes maternas relacionadas con hemorragias se ha reducido drásticamente, este factor sigue siendo la causa principal de defunción.
La disminución de la mortalidad materna registrada en los años noventa en respuesta a los programas de Maternidad sin Riesgo fue muy notable, y demuestra claramente que es posible adaptar las intervenciones en función de los datos de las encuestas nacionales de mortalidad materna de 1992–1993 y 2000. A fin de garantizar la continua disponibilidad de información de utilidad para orientar y evaluar los programas de reducción de la mortalidad materna, se está desarrollando en el país un sistema de vigilancia nacional de dicha mortalidad.
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Table 6. “Pathway to survival”, summary of results of Egyptian National Maternal Mortality Survey (ENMMS) 1992–93 and 2000 and recommendations
Steps in pathway Findings of ENMMS, Findings of ENMMS, Recommendations 2000 to survival 1992–93 2000
Problem: • MMRa:174 • MMR: 84 • Mortality dramatically reduced; Level of mortality Major causes: Major causes: continue MOHPb activities to Major cause of death haemorrhage haemorrhage establish routine surveillance system Regional levels hypertensive disease hypertensive disease to monitor deaths and to obtain sepsis ruptured uterus governorate estimates and trends • MMRa: • MMRa: Upper Egypt (217) Upper Egypt (89) Lower Egypt (132) Lower Egypt (93) Metropolitan (233) Metropolitan (48) 92% avoidable causes 81% avoidable causes
Step 1: Recognition • Deaths during: • Death during: • More information on danger signs of problem: pregnancy (25%) pregnancy (24%) and the risks of home delivery Knowledge delivery + 24 hrs (39%) delivery + 24 hrs (49%) should be given at all contacts and Awareness postpartum (36%) postpartum (27%) tied to facility protocols Effect/vulnerability • 42% of deaths due to delay in • 30% of deaths due to delay in seeking care or nonadherence seeking care or non-adherence to medical advice to medical advice • 42% postpartum deaths and • 20% postpartum deaths and 65% sepsis deaths after 33% sepsis deaths after delivery at home delivery at home • 17% of women who died • 6% of women who died had contraceptive failure had contraceptive failure
Step 2: Decision • 71% sought health care • 93% sought care • Research on why home deliveries to seek care: • 36% died at home • 29% died at home at high risk for sepsis, haemorrhage Behaviour and cardiac disease Motivation Barriers
Step 3: Logistics to • 64% died in health facility • 62% died in health facility • Emergency referral procedures must provide quality care: • 4% died due to lack of • 5% died due to lack of be clear and known; providers Transport transportation transportation; 9% died during should receive specific training in Stabilization transportation stabilization, e.g. PPHc Referral • 13% died because first provider failed to manage and refer
Step 4: Quality care • Substandard care by obstetric • Substandard care by obstetric • Protocols for managing obstetric providers team contributed to 47% team contributed to 43% emergencies should be implemented Technical competence of deaths of deaths nationwide and their use supervised; Effectiveness of treatment • GPsd to 12% deaths • GPsd to 11% of deaths competency-based training modules Efficiency • 32% of CSe deaths occurred • 47% of CSe deaths occurred should be used for in-service and Safety in private clinics in private clinics pre-service training • 15% of deaths from ruptured • 31% of deaths from ruptured • Promotion and licensing; regulation uterus occurred in private clinics uterus occurred in private clinics of private clinics, especially surgery, • Dayas contributed to 12% • Dayas contributed to 8% to improve safety of deaths overall and 37% of of deaths overall and 17% of • Education for providers and deaths due to sepsis deaths due to sepsis community on misuse of oxytocins • 33% had poor quality ANCf • 19% had poor quality ANCf and risk of ruptured uterus • 5.7% fetuses/infants died; 43% • 5.0% fetuses/infants died; 34% • Dayas still need more effective of those whose mother died in of those whose mother died in training on infection prevention delivery or postpartum delivery or postpartum
Facility • 6% died from lack of blood • 16% died from lack of blood • Identify and correct problems in Continuity of care (14% APH,g 20% PPH,c (22% APH,g 31% PPH,c blood supply Availability of supplies, 11% CSe). 38% CSe) • Recruit, train and retain more equipment, drugs, • 2% due to lack of equipment, • 6% due to lack of equipment, anaesthetists in district hospitals blood, anaesthetists supplies and drugs supplies and drugs • 4% due to lack of anaesthetists
a MMR = maternal mortality ratio. e CS = caesarean section. b MOHP= Ministry of Health and Population. f ANC = antenatal care. c PPH = postpartum haemorrhage. g APH = antepartum haemorrhage. d GP = general practitioner.