RELATIVE RISK OF WOMEN DYING FROM MATERNAL, INFECTIOUS OR NON-COMMUNICABLE CAUSES IN KINTAMPO, GHANA: A COMPETING RISKS ANALYSIS

ABSTRACT

Maternal, infectious and non-communicable causes of death combine to be simultaneously a major health problem for women of reproductive age (WRA) in low and middle-income countries (LMICs), particularly, sub-Saharan Africa (SSA). Yet, little is known about the relative risk of each of them when considered together and their demographic impacts. Consequently, the focus of research and funding has been on maternal health. However, the evolving demographic and health transitions in LMICs suggest a need for a comprehensive methodology to resolving women’s health challenges beyond maternal causes. Drawing on the eco-epidemiological model, this study examines the relative risks of women of reproductive age dying from the respective causes using competing risks analysis.

Deaths and person-years of exposure were calculated by age for WRA (15-49) in the Kintampo Health and Demographic Surveillance area from January 2005 to December 2014. Causes of death were diagnosed by means of physician coding and the 10th Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) using the verbal autopsy questionnaire. Identified causes of death were categorised into three broad groups: maternal, infectious and non-communicable diseases. The relative risk ratio was used to compare the likelihood of dying from infectious and non-communicable causes relative to the maternal cause of death and vice versa. Determinants of the causes of deaths were established using multinomial logistics regression. Furthermore, the gains in life expectancy as well as the decomposition of the total gains were estimated using multiple decrements together with the associated single decrement life table methods.

There were 1,259 deaths that occurred among WRA during the study period. Out of this, 846 deaths from maternal, infectious, and non-communicable causes, representing 67.2 percent of the total deaths were used for this study. The causes of death for the rest were mostly either unknown or there was no suitable respondent for the verbal autopsy interview and a few of the deaths were due to injuries. Infectious diseases were responsible for most of the causes of death (61.3%). Non-communicable diseases (29.9%) were the second highest and maternal (8.8%) causes contributed the least. The top five specific causes of death were malaria, HIV/AIDS, septicaemia, cardiovascular diseases and intestinal infection. There was an increased and worsening risk of dying from both infectious and NCD causes relative to maternal causes of death throughout the study period. Determinants of causes of death among WRA were complex and cut across distal and proximate factors. These included age, marital status, district of residence, season, and place of death as well as admission in the last 12 months before death, surgical operation in the last 24 months and the nature of death, whether sudden or not.

Averting any of the causes of death leads to improved life expectancy but eliminating infectious causes of death leads to the highest number of years gained. Infectious causes of death affected all ages and the gains in life expectancy assuming they were eliminated, were greatest among under-five-year-old female children but diminished with increasing age. In contrast, adult females, 60 years and above accounted for the greatest gains in life expectancy if mortality from non-communicable causes of death were eradicated from the population. With respect to the elimination of maternal mortality, the oldest group, 45-49, had the greatest gain in reproductive aged life expectancy.

This study has demonstrated the existence of a triple burden of maternal, infectious and non-communicable causes of death among the WRA in the two Kintampo districts of Ghana. Infectious causes of death are persistently high whilst deaths from non-communicable causes are rising and the level of maternal mortality is still unacceptably high. A cost-effective approach to screening and treating all WRA using the existing structures of the maternal health programme is recommended.