Trends in Maternal Mortality Due to Hypertensive Disorders of Pregnancy at Kenyatta National Hospital Between 2016 – 2020

Abstract

Background: The World Health Organization (WHO) identifies that global maternal mortality has declined significantly from 2000 to 2017 by 38% from 342 deaths to 211 deaths per 100,000 livebirths. This 2.95 percent yearly reduction is less than half of the 6.4% annual rate needed to achieve 70 maternal deaths per 100,000 live births globally. Hypertensive disorders of pregnancy (HDP) are becoming one of the leading direct causes of maternal death. However, this trend has not been effectively investigated in local Kenyan context. Purpose of the study: To determine maternal mortality rate, causes, patient characteristics and trend in HDP as compared with other causes of maternal mortality at Kenyatta National Hospital between 2016 and 2020. Methods: This was a time series study. Mortalities from 2016 to 2020 were investigated to understand the underlying trends, causes and characteristics of patients with specific emphasis on HDP. A structured data abstraction form was used to extract information from different sources including the inpatient registers kept in the obstetrics and gynaecology wards, labor ward as well as medical and obstetric intensive care units (ICU). Yearly MMR was estimated using the proportion of deaths annually over the total number of livebirths conducted at Kenyatta National Hospital. Bivariate and multivariate analysis were conducted to investigate factors associated with mortality due HDP. Level of significance was evaluated at 0.05. Results: The findings revealed that direct causes of mortality accounted for 60.2% of all maternal deaths. Among these direct causes, 51.2% of all direct maternal deaths were caused by HDP. The common types of HDP included eclampsia 109(33.4%), preeclampsia 42(12.9%) and HELLP 14(4.3%). Other direct causes included sepsis 78(23.9%), PPH 58(17.8%). Indirect causes of maternal mortality accounted for 39.8% with common causes including pulmonary embolism 27(12.9%), RVD 23(11.0%), cardiac disease 19(9.0) and cancer 18(8.6%). There were 69,190 livebirths and 536 maternal deaths between 2016 and 2020 giving a maternal mortality ratio of 775 per 100,000 livebirths. The findings have showed uneven distribution in trend of maternal mortality with peaks and troughs throughout the years from 2016 to 2020. In exploring the trends in MMR due to HDP in relation to other direct causes, in 2016, MMR due to other direct causes was higher, 279 per 100,000 compared to HDP with 212 per 100,000. The trend of MMR due to HDP has remained high over the years and from 2017, it has been higher compared to other direct causes. The findings established that those who were referred (AOR = 3.61, 95%CI:1.62 – 7.81, p<0.001) and those with preterm delivery (AOR = 6.71, 95%CI:2.42 – 18.2, p<0.001) and those who had history of hypertension (AOR =3.42, 95%CI:1.10 – 10.68, p=0.034) were associated with higher mortality due to HDP compared to other direct causes of mortality. The findings show that trend in mortality due to HDP remains high with higher mortality in HDP patients who were referred compared to those who were not referred. Conclusion and recommendations: Maternal mortality ratio from 2016 to 2020 have been uneven with peaks and troughs over the years. MMR due to HDP has remained high over the years. Referral status, history of hypertension and preterm delivery have been associated with higher mortality due to HDP. Thus, regular screening for HDP should be done during pregnancy and puerperium to initiate early treatment. Strengthening relationships with referring facilities as well as providing feedback on referred cases is also important.