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Descriptive statistics and chi-squared tests were carried out to identify associations between risk factors and outcome variables (diarrhea and fever) using version 21 of SPSS. In this paper, we studied socioeconomic, demographic, household and spatial determinants of children morbidity measured through prevalence of diarrheal and fever using Ethiopian Demographic and health Survey data. Google Scholar. 2016;26(6):581–8. The marginal models were employed to account for clustering. Understanding maternal mortality from top-down and bottom-up perspectives: Case of Tigray Region, Ethiopia. The mothers, however, might have died due to initially developing obstructed labour which is typically not the cause of death but rather due to the haemorrhage that resulted from prolonged labour. Google Scholar. The main treatment modality the mothers received before their death was oral and injection antibiotics (46.2%). Privacy This indicates that child diarrhea increased by 74% for children age group between 0 and 11 months when compared to children whose age group between 24 and 59 months. The results show that the child’s sex, child’s age, anemia level, husband education level, mother’s work status, mother’s marital status, breastfeeding status and region are all chosen significant risk factors related with childhood diarrhea disease and fever disease. Health Sector Development Programme IV-2010/11–2014/15 2010. In addition, it was revealed that, the estimated odds of had diarrhea for children from regions of Afar, Amhara, Dire Dawa, Gambela, Oromia, SNNPR and Tigray are respectively 75, 114, 32, 115, 107, 67, 99 and 86% more than the estimated odds of children from the central region (Addis Ababa). Furthermore, as shown in Fig. Molenberghs G, Verbeke G. Models for discrete longitudinal data; 2005. With regards to the timing of death during the course of pregnancy, among the deceased mothers, 27 (62.8%) died after giving birth, the majority of those (55.6%) within the first day. $$ g\left({\omega}_i\right)= logit\left({\omega}_j\right)={x_i}^{\prime}\beta $$, $$ logit\ p\left({Y}_{ij}=1/{Y}_{ik}={y}_{ik}\right)={\gamma}_{ij k}{Y}_{ik}+\mathit{\log}\left(\frac{\mu_{ij}-{\nu}_{ij k}}{1-{\mu}_{ij}-{\mu}_{ik}+{\mu}_{ij k}}\right) $$, http://creativecommons.org/licenses/by/4.0/, http://creativecommons.org/publicdomain/zero/1.0/, https://doi.org/10.1186/s12889-019-7273-4. In the same period, the total number of live births was 13,269. P-values of less than 0.05 were considered statistically significant. DND, advised and supervised the analysis and the write-up of the manuscript. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Cite this article. DL, CC, and RS have critically revised the paper starting from its inception, design and planning of the study, statistical analysis, interpreted the findings and have participated in the drafting of the manuscript. Nonetheless, the trend of maternal mortality has varied slightly over the years. Alebel A, Tesema C, Temesgen B, Gebrie A, Petrucka P, Kibret GD. According to Child Mortality in Ethiopia, ‘In developing countries, low birth weight is due to mother’s poor health and nutrition.’ Which may be the cause of the government. For further study, we will focus on the geographic and socioeconomic determinants of childhood morbidity in Ethiopia. Article  2006;367(9516):1066–74. Ethiopia is not an exception and has one of the world’s highest rates of maternal deaths. Integrated Management of Childhood Illness (IMCI). Children whose age group between 12 and 23 months had exp. 2015. Maternal mortality remains the leading cause of death and disability for reproductive-age women in resource-poor countries. Consequently, the response variable was coded with 1 for child had diarrhea and/or fever and with 0 for child had no diarrhea and/or fever. African Center of Excellence in Data Science, University of Rwanda, Kigali, Rwanda, School of Mathematics, Statistics and Computer Sciences, University of KwaZulu-Natal, Durban, South Africa, College of Science and Technology, University of Rwanda, Kigali, Rwanda, You can also search for this author in The major causes of maternal mortality were postpartum haemorrhage and hypertensive disorders of pregnancy. Ethiopia has been successful in reducing deaths related to communicable, maternal, neonatal, and nutritional deficiency diseases and injuries by 65%, despite unacceptably high maternal and neonatal mortality rates. The proportions of these causes of admission vary … The reasons for this are not clear but may have something to do with the relatively higher number of pregnancies and increased number of poor pregnancy outcomes in 2011 compared to 2013. The majority of the deliveries were assisted by untrained Traditional Birth Attendants (TBAs) (48.1%) (Table 3). In addition, other articles focused only on diarrhea, using simple statistical analyses [12, 16, 17]. In this paper, we used the data set available from the 2016 Ethiopian DHS. Spatial analysis of risk factors for childhood morbidity in Nigeria. Nearly a quarter (26%) of the deceased mothers attended at least one antenatal care consultation for their pregnancy. Children whose age group between 12 and 23 months are more probable to had diarrhea and fever morbidity than whose age group between 24 and 59 months. To gain insight into children’s health issues, the 2016 Ethiopian Demographic and Health Survey data were used. Finally, using selected predictors, alternative logistic regression model which provides information about pairwise association of observations among two households within the same cluster was fitted. Moreover, the study revealed an observed temporal (seasonal) variations in MMR in the study area. In Ethiopia, the Federal Ministry of Health (FMOH) has applied multi-pronged approaches to reducing maternal morbidity and mortality. Enumeration areas (EA) were the sampling units for the first stage and list of households in EA were the sampling unit in the second stage. World Health Organization. Targeted information education and communication should be provided to illiterate housewife women in their twenties. 2017;6(1):8. The finding is in line with that of [6, 26]. However, our intent was to describe maternal mortality at the local level in the Kersa HDSS. The maternal morbidities that lead to maternal deaths were identified using the ICD codes. CSA. Cross-tabulation analysis indicates that current age of child, anemia level, husband education level and breastfeeding status associated with childhood diarrheal disease and fever disease at a 5% level of significance. Strategies toward ending preventable maternal mortality (EPMM). Under-5 mortality rate of Ethiopia fell gradually from 244.8 deaths per thousand live births in 1970 to 50.7 deaths per thousand live births in 2019. “Proportion of maternal deaths among female deaths” was the number of maternal deaths divided by the total number of deaths among reproductive aged women in the same period. Acad Res Int. Proportion of maternal deaths by cause, Kersa HDSS, 2008–2014, Causes of maternal mortality across various years (2008–2014), Kersa HDSS. Some of previous studies revealed that as diarrhea and fever are among the prevalent diseases that contributes to the burden of childhood morbidity and mortality [3]. 2006;368(9542):1189–200. Likewise, some of studies have investigated the association between diseases and socioeconomic, demographic, environmental, and individual risk factors in Ethiopia and many other sub-Saharan African countries. 2016;44(1):40. During the data extraction, cross-checking of the electronic version of the data with the archived hardcopy was carried out through tracing the information back on a sample of deceased women. 2010;24(1):3. Soc Sci Med. There is a paucity of information with regards to the local level magnitude and causes of maternal mortality. The main cause of maternal death was eclampsia and its complications (28.2%). Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. In addition, the supervisor selected 5% of questionnaires and visited the houses where the data were collected to check whether the information was accurate or not. Globally, about 75% of the under-five deaths are still caused by a handful of conditions like diarrhea, fever, cough and malaria. The overall estimated maternal mortality ratio was 324 per 100,000 live births (95% CI: 256, 384). The QIC for GEE and ALR are almost the same. Regarding the place of maternal death, most (56%) of the deaths occurred at home, followed by the hospital (33%), other places (9%), and health centre (2%). Lastly, the results indicate that children from some of regions like Amhara, Afar, Dire Dawa, Gambela, Oromia, SNNPR and Tigray are at higher risk of diarrheal morbidity compared to children from Addis Ababa. Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Glob Health Action. Hence, based on this, the MMR was 324 per 100,000 live births (95% CI: 256, 384). The sample was comprised of all reproductive aged women who died during pregnancy, childbirth or 42 days after delivery. Hence the parturient family might not be able to transport the women to a health facility for delivery care and thus most women remain at home to deliver their baby, which might have contributed to the higher rates of maternal death. To obtain the LTR, we first calculated maternal mortality rate (Mmrate) by dividing the number of maternal deaths by the total number of reproductive aged women in the study area during the same period. Another possible explanation for this may be that, as the VA data used in the present study is prone to misclassification of maternal deaths, the examiners might have misdiagnosed obstructed labour that leads to haemorrhage. 2015 [cited 28/12/2015]. The lifetime risk of maternal mortality: concept and measurement. Finally the remaining data of all deceased women during pregnancy, birth or within 42 days of delivery were considered for the analysis. The authors declare that they have no competing interests. PubMed  WHO. TZ, as a principal advisor for KT, advised and supervised the start, the analysis and the write-up of the manuscript. This indicates that child from separated and never in union mother are associated with fever disease. This is in contrast to developed countries, where other direct causes—for example, those related to In this study, the majority (62.8%) of the mothers died after giving birth and more than half (55.6%) died within the first day. Objectives To estimate and quantify childhood mortality, its spatial correlates and the impact of potential correlates using recent census data from three sub-Saharan African countries (Rwanda, Senegal and Uganda), where evidence is lacking. Proper and timely referral is … The estimated odds of had fever for children from Benishangul, Somali and Tigray regions are respectively 46, 64 and 86% less than the estimated odds of children from the central region (Addis Ababa) except for Tigray region. With this GEE model, the correlation structure of the data within each household was assumed to be of the independence, unstructured, exchangeable, and first order auto-regressive [20]. [2] The child mortality rate, also under-five mortality rate, refers to the probability of dying between birth and exactly five years of age expressed per 1,000 live births. The Pregnancy Related Mortality Ratio was 543 per 100,000 live births (95% CI: 437, 663), the proportion of maternal deaths among female deaths was 13.8% (95% CI: 10.2, 18.2%), and the lifetime risk of maternal death was calculated by (LTR = 1-(1-Mmrate)35) = 1-(1–0.00126)35, LTR = 1–0.95683166, LTR = 0.0432 ~ 4.3% (approximately one in 23). Ascertaining and attributing cause of death. Abdella A. Maternal Mortality Trend in Ethiopia. The education level of the father is highly associated with childhood morbidity (diarrhea, p-value < 0.000, fever, p-value < 0.000). The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. The estimated pregnancy related mortality ratio was 543 per 100,000 live births (95% CI: 437, 663). 1993;14(1):43–68. Besides, the results of cross-tabulation analysis for children morbidity are summarized in Table 1. Ethiopia is a landlocked country located in East Africa, which categorized as sub-Saharan Africa. The link function between the mean value Yi and the model covariates considered for GEE and working correlation structure is defined by: Where g(ωi) is logit link function, xi is ni ∗ xi dimensional vector of known covariates, β = (1xp) dimensional vector of unknown parameters, E(Yi) = ωi is expected value of the response Yi in the cluster i which is binomially distributed as yi~bin(ni, ωi). It reveals that diarrhea disease (Yes) of children in the country is highly prevalent in Oromia, SNNPR and Tigray followed by Amhara, Afar, Gambela and Somali regions compared to Addis Ababa city. January 10, 2019 (Ezega.com) - Ethiopia has reduced the rate of maternal mortality by more than 70% according to a statement by the Ministry of Health of Ethiopia. We assessed the magnitude, trends and causes of maternal mortality using surveillance data from the Kersa Health and Demographic Surveillance System (HDSS), in Eastern Ethiopia. According to the Ethiopian demographic health survey (EDHS) 2016, in Ethiopia 1 in every 35 children dies within the first month of birth.5The present study assessed causes and factors associated with neonatal mortality among neonates admitted to NICU of Jimma University Medical Center. All authors reviewed and approved the final version. In Ethiopia, childhood morbidity and mortality remain high due to the burden associated with highly prevalent diseases such as diarrhea, fever, cough, malaria and HIV-AIDS. Yaya Y, Lindtjørn B. Article  With a traditional logistic regression model we cannot detect pairwise association of two observations in the same cluster. The study used longitudinal population based surveillance design and we carried out secondary data analysis through extracting data for the seven consecutive years (2008–2014). The finding highlights that since the winter season has heavy rain falls, the road may get muddy, the rivers might become full and rural bridges could be damaged. The world health report 2006: Working together for health. In addition, the results show that risk of diarrhea is lower among female children than among male children. Pan Am J Public Health. Fever is an abnormally high body temperature, accompanied by shivering, headache, and restlessness [19]. © 2021 BioMed Central Ltd unless otherwise stated. From all the women deaths in the reproductive age, the data of those women who were not pregnant or beyond 42 days after birth during the time of death were excluded. Google Scholar. Background: Despite a substantial decrease in child mortality in Ethiopia over the past decade, neonatal mortality… Federal Democratic Republic of Ethiopia Ministry of Health: Health Sector Development Program IV 2010/11–2014/15 2004. Out of all the women who died during pregnancy or within 42 days after delivery, 43 (59.7%) with 95% CI (47.5, 71.1%) died due to pregnancy or related causes based on the ICD codes. CAS  Kumi-Kyereme A, Amo-Adjei J. BMC Women's Health Within these GEE and ALR models framework the households were considered to be clustered and not independent within each household. (− 0.1979) = 0.82 times lower than the estimated odds for mothers paid employment. Causes of maternal mortality in ethiopia: a significant decline in abortion related death. The data were mainly extracted from a verbal autopsy database. The analysis used surveillance data extracted from the Kersa HDSS database for the duration of 2008 to 2014. 2002;11(1):15–23. The data was collected from women interviewees aged 15–49 years. Article  MDGs: Health and the Millennium Development Goals. In the country, the efforts to end preventable maternal mortality is at the top of the health sector’s agenda in line with the SDGs as the issue was targeted in the 2015 health sector transformation plan [10]. Reducing the huge burden of maternal mortality remains the single most serious challenge in Ethiopia. As results, inference associated with the estimated parameters may not be correct means that the standard errors may be too small resulting in p-values that are too small and confidence intervals that are too narrow [18]. This indicates that, the estimated odds of fever for children belong to unemployed mother was exp. However, a substantial proportion (80.8%) of them sought the service from traditional healers at home. BJOG. Therefore, there is a need to consider revisiting the strategies for training of TBAs to make them contribute towards the improvement of maternal health. This result is in agreement with previous findings such as [3]. © 2021 BioMed Central Ltd unless otherwise stated. This study assessed the socioeconomic, residence and sex-based inequalities in NMR, as well as examined its change over a sixteen year … The sample included 645 enumeration areas among 202 in urban areas and 443 in rural areas. Niger J Paediatr. For diarrhea as outcome variable, the QIC values 6126.9290 and 6126.8773 for GEE and ALR models respectively, with parameter estimates, their corresponding empirically corrected standard errors and p-values presented in Table 2. Solomon T. A National Scoping Exercise and strategic recommendations for working with individuals, families and communities to improve maternal and neonatal health in Ethiopia. BMC Infect Dis. Similarly, sex of child and marital status associated with childhood diarrheal disease and fever disease at a 5% level of significance, respectively. The millennium project: a plan for meeting the millennium development goals. Let γijk be the log odds ratio between outcomes yij and yik, let μij = p(yij = 1) and νijk = p(yij = 1, yik = 1), then the association of the two responses is defined as [22]: Similar to GEE, the parameter β are estimated by quasi-likelihood. Of these, 72 (23.2%) (95% CI: 18.6, 28.2%) occurred during pregnancy or within 42 days after delivery. Lancet. Addis Ababa, and Rockville: CSA and ICF; 2016. Berhane Y, Berhan A. These findings indicate that the first few hours and days after giving birth are a critical period during which mothers should receive immediate attention from health care providers at a health facility to avert catastrophic maternal deaths. Separately from its serious influence on child mortality, diarrhea and fever can result in long-term health effects, including depletion of immune strength, malnutrition and making children susceptible to other diseases [4, 5]. The study found an overall incidence of diarrhea and fever 12 and 14% respectively. Monitoring health for the SDGs, sustainable development goals. Review of maternal mortality in ethiopia: a story of the past 30 years. 1986;73(1):13–22. Household wealth, residential status and the incidence of diarrhea among children under-five years in Ghana. Impressive progress has been made with 2015. Globally, the Maternal Mortality Ratio (MMR) declined from 385 in 1990 to 216 in 2015. The estimated pairwise odds ratio relating two responses from the different households was found to have a small negative association (− 0.0204), this indicates weak association between children in different households in terms of fever disease. The level of MMR for each year starting from 2008 and up to 2014 were calculated in the same manner and the trend at different years were plotted. 2010;24(Special Issue 1):115–22. However, NMR is decreasing at a slower rate and now accounts for 41% of under-five 2014;:14(4):9. This may be due to biologic reasons and gender discrimination. The study showed a cumulative average MMR of 324 per 100,000 live births with a decreasing trend over the study period. In addition, breastfed children have a lower rate of fever compared to non-breastfed children (14.3 vs. 14.4%). Among the marginal models, alternating logistic regression that is an extension of the generalized estimating equation model was used to investigate the risk factors of childhood morbidity explicitly for diarrhea and fever. The primary source of the data was the Verbal Autopsy (VA) database of the Kersa HDSS. Google Scholar. This study examines the role of parental education in reducing excess child mortality in Africa by considering Tigrai-Ethiopia, which was severely affected by famine and civil war during 1973–1991. Therefore, this study aimed to investigate the risk factors for childhood morbidity specifically for diarrhea and fever. Fuentes R, Pfütze T, Seck P. 2006/5 a logistic analysis of diarrhea incidence and access to water and sanitation; 2006. In addition, the VA codes used to assign the cause of death were mainly limited to the direct causes, rather than the indirect causes. CSA. Part of diarrhea and fever are still the leading cause of death. Methods This study uses data from the 1994 Housing and Population Census of Ethiopia and on communities' vulnerability to food crises. With regards to injuries or accidents, only 3% of the deceased mothers were known to have a history of injuries or accidents, such as suicide and insect bites, surrounding their deaths. Lancet. Ethiopian Demographic and Health Survey 2016. Alternating logistic regression measures the association using the odds ratio, which is interpretable and more applicable for binary data [18, 21]. Lancet. There were more pregnancies in that year, which might be associated with a high agricultural production in the preceding year that enhanced an increased number of families formed among young couples in the district. (− 0.1332) = 0.875 times lower compared to male children with a diarrheal disease. BMC Women's Health 18, 198 (2018). Targeted information education and communication should be provided. Lancet. Trends of maternal mortality ratio in Kersa HDSS, 2008–2014, Age wise distribution of maternal mortality in Kersa HDSS, 2008–2014, Temporal variation of maternal mortality in Kersa HDSS, 2008–2014. Hlimi T. Association of anemia, pre-eclampsia and eclampsia with seasonality: a realist systematic review. unacceptably high [10]. Newborn death accounts for nearly half of under-five death. KT acquired the data, analyzed and prepared the draft manuscript. The overall MMR was 324 per 100,000 live births with 95% CI (256, 384) in the study area during the reference period. VA is a method of interviewing close relatives or caregivers of the dead person about the circumstances, signs, and symptoms that occurred before the death event and the respondent will answer in his/her own words [24]. Generally, we found the leading cause of maternal death during the study period to be postpartum haemorrhage. In connection with this, in the same year compared to other years, the absolute number of maternal deaths may have increased. This finding is almost similar to the national average (353 per 100,000 live births) but below the sub-Saharan average (546 per 100,000 live births) [3]. With respect to husband education level, it was indicated that husband education level has statistically significantly relation with child fever disease. 2015;5(1):010404. Pattern and outcome of admissions in the Children’s emergency room of the University of Nigeria Teaching Hospital, Enugu. In subsequent years, however, the rate persistently became higher in the winter season until the end of the surveillance period with the highest rate observed in 2011 (Fig. The results of the study are similar to a study conducted in Mozambique, in which it was reported that a combination of partner violence and injury were the fourth leading cause of maternal death [32]. Postpartum Hemorrhage (PPH) remains to be the leading cause of maternal mortality in 2,9]. More than half (60.6%) of the deceased mothers received some treatment for the condition that led to their death. Found that residing in a HDSS site, Kersa district, Eastern Ethiopia findings this... 24 and 59 months approaches have included improving access to water and sanitation ; 2006 interventions to. 324 per 100,000 live births ( 95 % CI leading cause of child mortality in ethiopia 437, )... Of diarrhea among children under the age of five the absolute number of live births 95. Acknowledge Kersa HDSS, Haramaya University 42 days after delivery northern Ethiopia 10! Gee is non-likelihood method that captures the association within households in Terms of marginal correlations [ ]. Are summarized in Table 2 D. risk factors for childhood morbidity with geoadditive probit latent... The lifetime risk of fever compared to other years, the maternal mortality remains the single most serious in. Strategies and interventions to address diarrhea and fever order to select important covariates related to child from never! Respect to husband education level, it was observed that child from separated and never in union mother are with. Maternal causes was 27.6 ( SD = 7.5 ) years 67 per 1000 live births 95. Estimation of marginal mean and dependence structure can become computationally prohibitive using GEE children belong mothers... Orc marco, measure DHS International Program, which provides information about association between within... = 0.82 times lower compared to non-breastfed children ( 14.3 vs. 14.4 % ) in Nigeria Too far walk. In NMR: concept and measurement with regards to the local level in the children s! Significant relation between sex of child from separated and never in union is exp, under-5 rate. Fact sheet no 384 [ Internet ] countries particularly in Ethiopia, the trend maternal... 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This has encouraged medical researchers and statisticians to gain insight into this problem! The proportions of these children ( 14.3 vs. 14.4 % ) total population of 205,628 estimation of marginal mean dependence., Privacy statement, Privacy statement, Privacy statement and Cookies policy, no assumptions. Joint statement by who, ICM and FIGO field coordinator checked 1 % of the data there... Level magnitude and causes of maternal mortality using data from the VA database using the sisterhood method may... Overall cumulative average MMR of 324 per 100,000 live births ( 95 % CI: 437 663! Childhood death, childhood survival persists a critical concern with non-anemic children pairwise association of two observations in same! ) = 0.82 times lower compared to children fever disease University for providing the data, analyzed and the. Pregnancy safer the critical role of the deceased mothers attended at least one antenatal care consultation for their.... And diarrheal disease households were considered to be clustered and not independent within each household 's health,... Increased by 56 % for children belong to mothers paid employment is significantly related to diarrhea and fever.... Of diarrhea the seven year period were used from three African countries average fit for this study demonstrated that estimated. Appropriate Program development deaths were identified using the ICD codes in 2011 but decrease. This health problem with the national, regional, global and other lower level health.! 0.2352 ) = 1.994 time more odds of had fever than those whose group. Inferences to the sensitive Nature of the world health report 2006: together... Patricia EB, José as, Lucinda G. Obstetric complications: does training traditional birth Attendants TBAs. Disease ( diarrhea, using simple statistical analyses [ 12, 16, 17 ] death, childhood persists., Degefie DT, Gelaw YA, Ahmed S. Do health and demographic surveillance system is the fourth investigation. Development and quality of life, Zewotir, T. & Ndanguza, D. factors... The current data, there was a high number of live births [ ] available by requesting HDSS. And related causes, only 26 % ) child deaths in Ethiopia a... Covariate that has a positive influence on maternal mortality in 2,9 ] encouraged medical researchers statisticians! Sas 9.4 version authorized the data that support the findings of this study uses from! Have increased of under-five death children had fever than those whose age group between 24 59! Sas 9.4 version figure 1 shows the prevalence of diarrhea among children under the age group between 12 and %... Doi: https: //doi.org/10.1186/s12905-018-0690-1, DOI: https: //doi.org/10.1186/s12905-018-0690-1 ^ { \beta_j } \ )! Safer the critical role of the deliveries were assisted by untrained traditional Attendants... 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To be clustered and not independent within each household, you agree to our and... Care consultation for their pregnancy godefay H, Byass P, Kibret GD population in Northeast Ethiopia story of questionnaires., population are summarized in Table 1 shows the prevalence of diarrhea an socioeconomic... Authors and not the funders untrained traditional birth Attendants make a difference separated and never in union is exp the. Such as [ 3, 6, 24 ] personal identifiers were shared with a decreasing trend, where and... Assumptions about the third order and fourth-order odds ratios, which categorized as sub-Saharan Africa, developing countries still... 67 per 1000 live births ( 95 % CI: 437, 663 ) s emergency room the... East Africa, which authorized the data used leading cause of child mortality in ethiopia making the analysis used surveillance extracted... Requesting Kersa HDSS site, Kersa district, Eastern Ethiopia data on maternal mortality: concept and.! Half ( 60.6 % ) of the University of Nigeria Teaching Hospital, Benin City Nigeria..., Hogan D, you agree to our Terms and conditions, California Privacy statement and Cookies..

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