The study was conducted in six (6) hospitals in Tigray, Ethiopia, from January 30 to March 30, 2016. Hospitals were randomly selected from 16 public hospitals in the region[14 ]. The study was a facility-based, unmatched case control design. Sample size was estimated using a double population proportion formula based on a study from Morocco that showed hypertensive disease contributing the most to MNM [15 (link)]. Based on the Morocco study, we hypothesized the proportion of chronic hypertension to be double in cases (63.9%) and controls (47%) at a 95% confidence level and 80% power of the test, with a 1:2 ratio for cases and controls. Final sample size was 308, of which 103 were cases and 205 controls.
We considered MNM as a condition meeting any of the five disease-specific criteria proposed by Filippi [16 (link)]. In sampled hospitals, using medical notes, any woman diagnosed with at least one of the following complications was considered as a case: severe obstetric hemorrhage leading to shock; hypertensive diseases of pregnancy, including eclampsia and severe preeclampsia; dystocia, including uterine rupture and impending rupture; infections, including hyper- or hypothermia or a clear source of infection and clinical signs of shock, and; anemia, including low hemoglobin (<6 g/dl) or clinical signs of severe anemia in women without hemorrhage. Women not meeting the above criteria were considered as controls. Cases were sequentially recruited whereas controls were selected through systematic sampling. Data was collected using a structured questionnaire, administered in-person by nurse midwives. Socio-demographic characteristics, obstetric history, and knowledge of pregnancy-related danger signs were collected.
Questionnaire was based on tools validated by the World Health Organization (WHO) and in different literature and adapted to include context-specific factors [11 –13 , 15 (link), 17 (link)]. Questionnaire was prepared in English, translated to Tigrigna, and back-translated to English separately by two individuals to ensure consistency. Data was collected by 12 nurse midwives with experience in obstetric care. Data collection was supervised and data checked for consistency and completeness. Incomplete and unclear questionnaires were returned to interviewers to be completed.
We considered MNM as a condition meeting any of the five disease-specific criteria proposed by Filippi [16 (link)]. In sampled hospitals, using medical notes, any woman diagnosed with at least one of the following complications was considered as a case: severe obstetric hemorrhage leading to shock; hypertensive diseases of pregnancy, including eclampsia and severe preeclampsia; dystocia, including uterine rupture and impending rupture; infections, including hyper- or hypothermia or a clear source of infection and clinical signs of shock, and; anemia, including low hemoglobin (<6 g/dl) or clinical signs of severe anemia in women without hemorrhage. Women not meeting the above criteria were considered as controls. Cases were sequentially recruited whereas controls were selected through systematic sampling. Data was collected using a structured questionnaire, administered in-person by nurse midwives. Socio-demographic characteristics, obstetric history, and knowledge of pregnancy-related danger signs were collected.
Questionnaire was based on tools validated by the World Health Organization (WHO) and in different literature and adapted to include context-specific factors [11 –13 , 15 (link), 17 (link)]. Questionnaire was prepared in English, translated to Tigrigna, and back-translated to English separately by two individuals to ensure consistency. Data was collected by 12 nurse midwives with experience in obstetric care. Data collection was supervised and data checked for consistency and completeness. Incomplete and unclear questionnaires were returned to interviewers to be completed.
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