1. Background

Worldwide, about 830 women die from pregnancy and childbirth-related complications every day [1]. It has been reported that in 2015, about 303,000 women died during and following pregnancy and childbirth, and most of these deaths could have been prevented [1]. The high number of maternal deaths in some parts of the world reflects inequities in access to health services and highlights the gap between the rich and the poor [2]. Almost all maternal deaths (99%) occur in low- and middle-income countries (LMICs) [3]. More than half of these deaths occur in Sub-Saharan Africa (SSA) and about a third in South Asia [2, 4]. These are usually fragile, humanitarian, and postconflict areas [5]. Despite the decline in the global trend of maternal mortality ratio (MMR), estimated at 5.4% between 1990 and 2015, this is not the case for SSA where the decline is still very low and has remained stagnant in some areas [1, 4, 6].

Also, the burden of maternal death is quite significant; most women who die lose between 39.8 and 41.5 years of life [7]. Many women also get sequelae after a near miss event; it has been estimated that for every maternal death about 6 women suffer severe morbidities, some of which occur lifelong [8, 9]. Because of the high burden of maternal morbidity and mortality, ending preventable maternal mortality is a priority under the Sustainable Development Goals (SDG) agenda. In fact, SDG target 3.1 aims to reduce the average global MMR to less than 70 maternal deaths per 100,000 live births by 2030 [10].

A key requirement for further advances in the reduction of maternal deaths through effective policy and health program decisions is to understand the causes of deaths. By definition, a maternal death refers to the death of a woman during pregnancy or within 42 days of delivery or termination of pregnancy, due to any cause related to, or aggravated by the pregnancy or its management, but excluding deaths from incidental or accidental causes [11]. This allows the identification of maternal deaths based on their causes, as either direct or indirect [12]. In a large World Health Organization (WHO) systematic analysis, 73% of all maternal deaths worldwide were due to direct causes, and 23% to indirect causes. Among the direct causes, haemorrhage accounted for 27.1%, hypertensive disorders 14.0%, sepsis 10.7%, abortion 7.9%, and others 12.8% [13]. Indirect causes varied greatly, but the overall proportion of HIV deaths was highest in SSA [13]. However, the causes of maternal deaths are usually influenced by some non-medical factors, which lead to a delay in accessing maternal healthcare services. The “three delays” model has been widely used to understand the factors that contribute to maternal death. The first delay is the delay to decide to seek care, the second delay is the delay to reach the health facility, and the third delay is the delay to receive care at the health facility [14].

In Uganda, slow progress has been made in reducing maternal deaths, despite the relevant increase in skilled birth attendance from 59% [15] to 73% [16] and antenatal care attendance from 95% to 97% between 2011 and 2016. The maternal mortality ratio only declined from 438 deaths [15] to 336 deaths per 100,000 live births [15]. Most of the women who die are from rural and hard-to-reach areas, and they are usually uneducated and HIV positive; they generally delay seeking care and lack male partner support [17]. The leading causes of maternal death are direct obstetric causes and include haemorrhage, infection, hypertensive disorders, and abortion complications [8, 16]. HIV/AIDS also contributes significantly to indirect maternal deaths at some tertiary hospitals in Uganda [18].

Uganda is one of the countries with a very high maternal mortality ratio in Sub-Saharan Africa, estimated at 336 deaths per 100,000 live births [16]. It is recommended by the Ministry of Health (MoH) that all maternal deaths are reviewed, following the development of maternal death review (MDR) guidelines in 2004, based on WHO guidance “Beyond the numbers” [19]. MDR helps to identify the direct and indirect causes of maternal death and the underlying factors. Consequently, the potentially avoidable factors, missed opportunities, and substandard care are identified, and actionable recommendations are made to avert a reoccurrence of deaths under similar circumstances.

Although maternal death reviews are done in most of the facilities in northern Uganda, and in particular, at Lacor Hospital, a significant number of women continue to die due to pregnancy and delivery-related complications. Very few studies have been carried out to determine the factors that contribute to these delays in central and western Uganda. However, no studies are available for northern Uganda. Therefore, this study aimed at exploring the main factors affecting maternal deaths in northern Uganda, after a 20-year-old conflict, and designing a predictive model for estimation of the risk at admission of the mothers in the hospital.

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