Determinants of potential life-threatening maternal conditions (PLTCs) in Tigray, northern Ethiopia: a case‒control study – Nature.com 01:08 

Scientific Reports volume 14, Article number: 30022 (2024) 

Abstract

Globally, potentially life-threatening maternal conditions (PLTCs) are significant public health threats. Ethiopia had the highest prevalence of PLTC (17.55%). However, there is limited evidence on the determinants that increase the occurrence of PLTC in Ethiopia. Therefore, this study aimed to identify determinants of the PLTC in Tigray, northern Ethiopia. A case‒control study was carried out between January 21 and April 20, 2024. Data were collected from 1027 participants (341 cases and 686 controls) through interviews and card reviews. Bivariate and multivariate logistic regression analyses were performed via SPSS version 24 to identify factors associated with the PLTC. In this study, variables such as having no formal education (AOR: 2.78; 95% CI 1.50–5.15), not in a marital union (AOR: 4.33; 95% CI 1.23–15.23), alcohol intake during pregnancy (AOR: 1.77; 95% CI 1.13–2.76), a history of stillbirth (AOR: 3.02; 95% CI 1.81–5.04), twin birth (AOR: 2.24; 95% CI 1.03–4.86), chronic hypertension (AOR: 11.37; 95% CI 3.71–34.88), prior cesarean section (CS) (AOR: 2.40; 95% CI 1.27–4.50), malaria during pregnancy (AOR: 4.10; 95% CI 1.25–13.45), not taking foliate (AOR: 4.10; 95% CI 1.25–13.45), induced labor (AOR: 7.33; 95% CI 4.31–12.47), and CS delivery (AOR: 2.39; 1.59–3.6) were increased risk of PLTC. However, completing recommended prenatal care visits (AOR: 0.59; 95% CI 0.41–0.86) was associated with lower odds of developing PLTC. Therefore, governmental and nongovernmental organizations, programmers, and healthcare providers should use the underlying evidence for the prevention and management of the PLTC.

Introduction

Globally, an estimated 287,000 maternal deaths occurred in 2020. Specifically, Sub-Saharan Africa is the only region with a very high maternal mortality rate, accounting for approximately 70% of global maternal deaths. In the first five years of the Sustainable Development Goal (SDG) era, there has been no significant maternal mortality reduction, despite there being many initiatives, especially in sub-Saharan Africa1. More than 50% of global maternal deaths occur in six countries; Ethiopia is one of them2. Reducing maternal mortality has long been considered an important indicator of maternal health. Nevertheless, in terms of the suffering caused by maternal morbidity, maternal mortality is only “the tip of the iceberg.” Therefore, the continuum of pregnancy from normal to death is overlooked when assessing maternal health on the basis solely of maternal mortality3. Maternal mortality is of limited value for assessing risk factors for maternal complications because of its rarity4.

In 2009, the World Health Organization (WHO) proposed a framework for severe maternal morbidity analysis5. It defines categories of morbidity with increasing severity: nonlife-threatening, potentially life-threatening conditions (PLTCs), life-threatening conditions, and maternal death. Additionally, a research team developed standardized diagnostic criteria for these particular situations. On the basis of these criteria, the PLTC should focus on hemorrhagic disorders, hypertensive disorders, other system disorders, and severe management indicators6. Since then, the majority of studies on maternal morbidity have concentrated on maternal near misses7,8,9,10,11, which are more complicated and difficult to manage.

In addition, various studies12,13,14,15,16 have investigated maternal morbidity in separate entities rather than as a collective entity (conditions). Studying conditions has the following advantages over studying them separately: (i) Maternal health is interrelated, and conditions often influence one another; studying them together allows for a better understanding of how they interact and affect maternal health17. (ii) By assessing multiple conditions, researchers can identify shared risk factors and create more effective screening tools. This could lead to early risk detection and the use of multiple risk management techniques18. (iii) Healthcare professionals can create more complete care plans that consider a mother’s condition overall by knowing how various conditions are linked to one another and using this knowledge to inform their management techniques.19. (iv) Examining these disorders collectively may make it easier to allocate healthcare resources efficiently by highlighting the need for integrated care models that handle several problems at once20. Hence, we conducted a comprehensive examination of pregnancy-related issues at the hospital using the WHO’s definition of PLTC standards6.

Recognizing and understanding the risk factors associated with PLTCs is crucial, as previous studies indicate that this knowledge may enhance maternal health care strategies and outcomes21,22,23. Reducing maternal mortality to less than 70 per 100,000 live-born women by the end of 2030 is one of the SDGs, which indicates the recognition of improving maternal health worldwide24. Addressing all causes of maternal morbidities is one of the five strategic objectives to achieve this maternal mortality reduction on the basis of the WHO recommendations in the SDGs25.

Most studies conducted in other countries rely on patients’ records for assessing the PLTC rather than patient interviews26,27,28,29. These studies may be subject to information bias due to incomplete and low-quality secondary data at health facilities. Additionally, the cross-sectional study design that was employed30 has clear drawbacks with respect to determining cause‒and‒effect relationships. In addition, inconsistent findings exist across the literature, even for particular risk factors, such as maternal age and prenatal visit31,32.

In Ethiopia, available studies have shown the highest burden of PLTC, which ranges from 10.4 to 17.55%33,34,35. The five major causes of maternal death in Ethiopia, accounting for 83.82% of all maternal deaths, have also been included in the PLTC36. However, there is a dearth of evidence on its predictors using the standardized WHO identification criteria of the PLTCs. Therefore, this study aimed to identify factors associated with the PLTCs in Tigray, northern Ethiopia.

Methods

Study setting and design

This case–control study was conducted in Tigray, northern Ethiopia. The health system structure in Ethiopia is divided into three levels: primary, which includes primary hospitals, health centers, and health posts; secondary, which includes general hospitals; and tertiary, which includes referral hospitals. In Tigray Region, there are two referral hospitals, 14 general hospitals, 24 primary hospitals, 232 health centers, and 741 health posts. General and referral hospitals provide comprehensive diagnosis and management of PLTCs. This study was conducted in those hospitals based on the service provision levels.

Study populations

Women, who were admitted to selected hospitals during labor or within the first 42 days of pregnancy termination, from January to April 2024, composed the study population. The cases included all women who were admitted to the selected hospitals due to at least one of the 26 PLTC diagnostic criteria proposed by the WHO Research Group on Maternal Morbidity and Mortality6. Cases were selected after the obstetrician/gynecologist made the diagnosis as part of the routine case for the woman. Women who were admitted for normal delivery services (women without maternal complications) were considered controls. Two controls per case were recruited from the same hospital. Twelve women who developed PLTC after being interviewed and classified into the control group were transferred from their category group to cases. The diagnostic criteria for PLTC are described in Table 1.Table 1 Criteria for identifying potentially life-threatening maternal conditions.

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Sample size and sampling techniques

We used Epi Info version 7 software to calculate the sample size for unmatched case‒control studies. We considered the following assumptions when calculating the sample size: a confidence interval of 95%, a power of 80%, and a 2:1 control-to-case ratio. The sample size was calculated from various exposure variables associated with the PLTC to take the maximum sample size. The variables that resulted in the maximum sample size were subsequently calculated on the basis of a prior history of pregnancy complications31. According to that study, 10.8% of the controls and 23.6% of the cases had a history of pregnancy complications. After 10 nonresponse rates were considered, the total sample size was 359, of which 120 cases and 239 controls. However, this study is part of a large cohort study, “Assessment of the impact of potentially life-threatening maternal conditions on women’s health-related functioning and disability,” carried out at general and referral hospitals in Tigray, northern Ethiopia. PLTC episodes were considered exposure. Women who had been exposed to those events were also considered as ‘cases’. The non-exposed group comprised women who had delivered without complications at the same hospital. Those women were considered the “control group.” Therefore, the greatest sample size (total = 1027: 341 cases and 686 controls) of the cohort study was taken to increase precision, statistical power, generalizability, enhance validity, and provide a more reliable statistical test.

Based on the healthcare referral system in Ethiopia, women with potentially life-threatening maternal conditions get comprehensive diagnosis and management services in general or at referral hospital levels. So we selected all the referral hospitals and eight general hospitals that provide comprehensive diagnosis and management services for PLTCs. From the general hospitals, we excluded six hospitals: four hospitals because of security issues (invaded with armed forces) and two hospitals due to a lack of comprehensive diagnosis and management service provision for PLTCs.

The sample size was proportionally allocated for each hospital on the basis of the number of deliveries, according to the Tigray Regional Health Bureau 2023 report. Cases were recruited consecutively until we obtained the required sample. In the control selection process, we included two controls per case using a simple random sampling method from the same hospital where the cases were diagnosed. This approach was selected to minimize time-related biases, ensuring that the controls were contemporaneous with the cases and thus reflective of the same temporal and environmental factors that could influence outcomes.

Data collection tools, techniques, and quality assurance

The questionnaire was prepared by reviewing various articles, the Ethiopia Demographic Health Survey, and the WHO survey, which were then adapted to the local context to maintain validity5,6,37. The World Health Organization’s PLTC diagnostic criteria were used for the data extraction checklist. For case and control identification from medical records, the PLTC data extraction tool was developed. Fourteen BSc midwives who had experience in obstetric care and who could speak the local language were recruited as data collectors. Four midwives who had a second degree were recruited as supervisors. The interviews were performed when the patient became stable. Different variables, such as socio-demographic, lifestyle like alcohol consumption during current pregnancy, access and utilization of health services, birth preparedness, and knowledge on obstetric danger signs, were collected through face-to-face interviews. On the other hand, medical records review was used to extract data that could not be obtained through interviews, such as the diagnosis of medical and obstetric problems, laboratory investigations, and management.

Supervisors and data collectors received one-day training on the objectives of the study, informed consent, confidentiality of the information, record review, and interviewing techniques. A pretest was conducted with 5% of the total sample size. Then, corrections were made to the questionnaire accordingly. Supervisors and the first author verified the consistency and completeness of the data every day.

Ethics approval and consent to participate

Ethical clearance was obtained from Mekelle University, College of Health Sciences, IRB (MU-IRB 2129/2023) to confirm that all methods were performed in accordance with the relevant guidelines and regulations. An official letter of cooperation was obtained from the Tigray Regional Health Bureau to the selected hospitals. Permission from each chief executive officer of the hospitals was also received. A one-page consent letter was attached to the cover page of the questionnaire as an information sheet, which contains a detailed description of the purpose of the study, the risks and benefits of participants in the study, voluntary participation, the right to withdraw from the study, and the privacy and confidentiality of the collected information. Finally, informed consent was secured before the interviews were conducted.

Outcome and exposure variables

The exposure variable consisted of the following main sections: socioeconomic and demographic characteristics of the mothers; reproductive health and obstetric characteristics; awareness and perceptions of safe motherhood; past chronic medical history; delays in obstetric care, and alcohol consumption during pregnancy.

Potentially life-threatening maternal conditions (PLTCs) are severe maternal morbidity that results in at least one of the following: hemorrhagic disorders (abruptio placentae, placenta accreta/increta/percreta, ectopic pregnancy, PPH, and ruptured uterus); hypertensive disorders (severe preeclampsia, eclampsia, severe hypertension, hypertensive encephalopathy, and HELLP syndrome); other systemic disorders (endometritis, pulmonary edema, respiratory failure, seizures, sepsis, shock, thrombocytopenia < 100.000, and thyroid crisis); and severe management indicators (blood transfusion, central venous access, hysterectomy, intensive care unit (ICU) admission, prolonged hospital stay (> 7 postpartum days), nonanaesthetic intubation, return to the operating room, surgical intervention)6.

Knowledge of obstetric danger signs is evaluated by counting the total number of correct spontaneous danger signs mentioned among the nine danger signs. A woman who answered at least 4 correct danger signals was considered to have good knowledge38. However, if a woman could give one to three danger signs, she was taken to have poor knowledge, and if she could not mention any danger signs at all, she was considered to not know. The list of nine danger signs included the following: (1) convulsions; (2) severe vaginal bleeding; (4) fast or difficult breathing; (5) severe headache with blurred vision; (6) too weak to get out of bed; (7) fever; (8) reduced fetal movement; and (9) swelling of the fingers, legs, and face.

Birth preparedness and complication readiness (BPCR): Mothers who arranged at least two of the five BPCRs (arranged for transportation, identified skilled birth attendants, saved money, identified the place of delivery, and identified blood donors in case of emergency) were considered well prepared. The remaining mothers were considered less prepared or not prepared39.

Data analysis

The data were imported into SPSS version 24.0 after being downloaded from the KoBo Toolbox for mobile data collection. Descriptive statistics (frequency, percentage, mean, and standard deviation) were calculated for comparing cases and controls. The wealth index was computed via principal component analysis (PCA) from socioeconomic variables such as ownership of livestock, farmland, floor, wall, and roof materials; ownership of housing; number of people in a household and number of rooms in the household; durable asset ownership; bank account; and access to utilities and infrastructure (sanitation facility and source of water supply). Both bivariate analysis and the multivariable conditional method of logistic regression analysis were performed. Variables with P values ≤ 0.05 in the bivariate analysis were included in the multivariable model. Finally, adjusted odds ratios (AORs) with 95% confidence intervals and P values ≤ 0.05 were considered statistically significant. The presence of multicollinearity was also examined via the variance inflation factor (VIF) by considering the above-five cut-off points. However, there was no multicollinearity effect among the variables since the maximum value of the variance inflation factor (VIF) was 3.40. The fitness of the multivariable logistic regression model was tested via the Hosmer–Lemeshow goodness-of-fit test, and the model was adequately fitted for the final model (p = 0.34).

Results

Sociodemographic and economic characteristics

A total of 1027 participants (341 cases and 686 controls) were interviewed, for a response rate of 99%. The mean (SD) ages of the cases and controls were 28.03 (5.36) and 28.89 (6.23) years, respectively. A total of 78 (22.9%) cases and 104 (15.2%) controls were aged ≥ 35 years. More than half of the cases and controls were urban dwellers (68.6% and 79.4%, respectively). Approximately 14.1% of the women with PLTC and 7.9% of the controls had no formal education. With respect to the wealth index, women who were diagnosed with PLTC were more likely to have the lowest wealth status than controls (26.1% and 17.0%, respectively). Similarly, women who were diagnosed with PLTC were more likely to have used alcohol during pregnancy than controls were (80.6% and 71.7%, respectively) (Table 2).Table 2 Sociodemographic and economic characteristics of PLTCs in Tigray, Ethiopia, 2024.

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Reproductive and obstetric characteristics

The proportions of grand multigravida among the PLTC group and control groups were 66 (19.4%) and 97 (14.1%), respectively. Similarly, the rates of previous abortions among the cases and controls were 22.6% and 18.4%, respectively. In terms of age at marriage, 29.9% of the cases and 23.9% of the controls had an early marriage (Table 3).Table 3 Reproductive and obstetric characteristics of mothers admitted to the hospital in Tigray, North Ethiopia.

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Preexisting medical disorders

Among the cases, chronic hypertension was the most common condition 44 (12.9%), followed by having a history of malaria infection during the indexed pregnancy 13 (3.8%) (Table 4).Table 4 History of chronic medical disorders and infectious diseases among women admitted to hospitals in Tigray, northern Ethiopia.

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Maternal health service-related characteristics

Approximately 33.1% of the cases and 25.1% of the controls had not booked on time and completed the recommended ANC follow-up. With respect to folate supplementation, less than 50% of the patients were compliant, and approximately 57.7% of the controls had a compliance history. The majority of controls (71%) gave birth spontaneously through the vagina, followed by cesarean section (19.2%) and instrumental delivery (9.6%), whereas 46.3% of cases gave birth through cesarean section. More than 20% of the cases and 10.8% of the controls had no knowledge of the obstetric danger signs (Table 5).Table 5 Maternal health service-related characteristics of women admitted to public hospitals in Tigray, northern Ethiopia.

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Birth preparedness and complication readiness (BPCR) plan

Only 42.8% of the cases and 53.4% of the controls had good practice with the BPCR plan. With respect to the percentages of each BPCR component, approximately seven out of ten controls and 58% of cases saved money in cases if needed, whereas only 15.2% of cases and 15.6% of controls identified blood donors if needed (Fig. 1).

figure 1
Fig. 1

Clinical characteristics of potentially life-threatening maternal conditions

Approximately half of the patients (170/341) had more than one component of the PLTC. The main conditions diagnosed in the PLTC patients were 269 (78.9%) with hypertensive disorders, 162 (47.5%) with hemorrhagic disorders, 124 (36.4%) with severe management indicators, and 83 (24.3%) with other systemic disorders. Among the 26 components of the PLTC, the most common cause was severe preeclampsia (n = 162), followed by postpartum hemorrhage (n = 93), blood transfusion (n = 84), and severe hypertension (n = 74) (Fig. 2).

figure 2
Fig. 2

Determinants of potential life-threatening maternal conditions

In the bivariate logistic regression model, age, residence, marital status, educational status of women and their partner, religion, occupation, hard work during pregnancy, alcohol use, distance from a health facility, wealth index, gravida, parity, road access, history of stillbirth, early marriage, twin pregnancy, previous history of CS, chronic hypertension, history of malaria during the indexed pregnancy, time of ANC booking, foliate supplementation intake, type of labor on set, mode of delivery, knowledge of the obstetric danger sign, practice of the BPCR plan, ambulance used for transportation, and delays in obstetric care were significant predictors of the PLTC. Finally, in the multivariable logistic regression model, the following variables remained statistically significant: not in marital union (AOR: 4.33; 95% CI 1.23–15.23), their partner had no formal education (AOR: 2.78; 95% CI 1.50–5.15), alcohol intake during pregnancy (AOR: 1.77; 95% CI 1.13–2.76), prior history of stillbirth (AOR: 3.02; 95% CI 1.81–5.04), twin pregnancy (AOR: 2.24; 95% CI 1.03–4.86), chronic hypertension (AOR: 11.37; 95% CI 3.71–34.88), prior CS (AOR: 2.40; 95% CI 1.27–4.50), history of malaria infection during the indexed pregnancy (AOR: 4.10; 95% CI 1.25–13.45), not taking foliate supplementation (AOR: 4.10; 95% CI 1.25–13.45), and the recommended prenatal visits used (AOR = 0.59; 95% CI 0.41–0.86). The determinants of the PLTC are summarized in (Table 6).Table 6 Logistic regression analyses of PLTC determinants among admitted women in Tigray, North Ethiopia.

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Discussion

In our study, for women who were not in a marital union, their partner had no formal education, alcohol intake during pregnancy, prior history of stillbirth, twin pregnancy, chronic hypertension, prior CS, women who were diagnosed with or treated for malaria during the index pregnancy, not taking foliate supplementation, induced labor onset, current mode of delivery of CS, no or low BPCR practice, initiation and completion of ANC visit, and no perceived that all women are at risk were determinants of PLTC.

The findings of our study indicated that women who were not in marital unions had an increased risk of PLTC after adjustment for potential confounders. This is in line with other studies in Latin America and the Caribbean40, Maryland41 and New York State42. On the other hand, there was no relationship between women’s marital status and PLTC7,43. Support from a partner during pregnancy might decrease the probability of adverse pregnancy outcomes44. This may be due to adequate maternal health service utilization. Women who live in marital unions have a high probability of maternal service utilization, such as complete ANC follow-up45. Women whose partners had no formal education (AOR = 2.78, 95% CI 1.50–5.15) or secondary education (AOR = 1.59, 95% CI 1.08–2.33) were more likely to develop PLTC than women whose partners attended college and above. There are other studies in line with these results11. This may be due to low maternal health service utilization. Women whose partners had a high educational status had a high probability of maternal health service utilization46. Higher-educated women’s spouses are more likely to take the initiative to seek professional medical attention and schedule prenatal visits for their wives. They are also more likely to give birth in places with skilled care providers and advanced facilities47. These findings suggest a need for targeted interventions for at-risk populations, particularly unmarried women and those with low educational backgrounds among their partners. Programs that provide education on maternal health and support services could be beneficial.

Our data showed that alcohol consumption during pregnancy is a strong predictor of the PLTC. This study is in parallel with other studies in Latin America and the Caribbean40,48. Chronic alcohol use puts mothers at risk for hepatic dysfunction and cardiovascular risk49. Studies have also shown that alcohol intake increases the risk of hemorrhage50 and pregnancy-induced hypertension51. Unlike this study, there was no significant relationship between alcohol consumption and severe maternal morbidity21. This difference may be related to the low dose used. The relationship between alcohol intake during pregnancy and the PLTC emphasizes the need for public health campaigns aimed at reducing alcohol consumption among pregnant women.

Compared with their counterparts, women with a prior history of CS and the current CS mode of delivery were at high risk of developing PLTC. Even though the CS delivery mode has been conducted as a required urgent action to prevent complications52, previous studies have reported that CS is significantly associated with a greater risk of PLTC development21,53. In contrast, a study conducted in Tanzania showed that prior CS is not a risk factor54. Women who have CS face a risk of a scar from the procedure and an increased chance of uterine rupture and hemorrhage while delivering their next baby vaginally. This study suggests that when evaluating medical evidence for CS, physicians must consider the potential adverse effects of the procedure. In other words, a CS should not be considered a method of birth for non medical reasons. Instead, it should be performed only when there are sufficient clinical indications55. Although there are CS risks involved, the rate of CS increases above the WHO’s recommended range of 5–15%. A cesarean section was used to deliver 44.3% of the babies in one of the hospitals in the study area56. To lower the rate to an acceptable level and lower the potential risks related to CS, nonmedical indications for the procedure should be prohibited55.

Compared with women not using ANC, ANC use, as recommended by the WHO and the Ministry of Health (ANC booking before 12 weeks and completing at least 8 contacts), has decreased by 41% of PLTC development. Another study in Brazil and Maryland reported a greater risk of severe maternal morbidity in women with insufficient ANC41,57. Although ANC in Tigray has significantly improved in recent decades (before the war crisis erupted), providing adequate ANC in terms of both timely initiation and complete contact is still challenging58. ANC may be the best avenue for women to obtain more information about their pregnancy. In addition, the danger signs of pregnancy and delivery should be discussed with healthcare providers46.

Our investigation revealed that induced labour was a greater risk factor for PLTC than spontaneous delivery, in line with previous research59,60. While often necessary for medical reasons, induced labour can carry risks, especially if not carefully monitored. This may lead to complications such as uterine hypersimulation, which can affect the fetal heart rate and increase the risk of cesarean delivery61. It also increases the risk of uterine rupture, admission to the ICU, and resuscitation62. Therefore, appropriate monitoring during the onset of labor is crucial to reduce or prevent PLTC events.

Another risk factor for a PLTC is a chronic history of hypertension. Similarly, studies conducted in Brazil and Maryland reported that women with a history of chronic hypertension have an increased risk of severe maternal morbidity41,57. This is one of the general medical conditions that should be taken into consideration when referring pregnant women to high-risk pregnancy care, as they require persistent vigilance63. Although many pregnant women perform well during pregnancy, chronic hypertension increases the likelihood of various pregnancy problems, such as superimposed preeclampsia, placental abruption, and cesarean section delivery. They should receive counselling regarding these risks, the expected need for monitoring, and how to handle any issues that may arise during pregnancy as part of family planning prior to conception64. The association with chronic hypertension highlights the importance of regular prenatal care and the management of existing health conditions to mitigate risks.

When compared twin births with singleton births, twin birth women have a 2.24-fold greater risk of PLTC. Other studies conducted in Australia and Maryland have also highlighted this study41,65. This is explained by the fact that women with twin pregnancies have a large placenta, which results in a decrease in placental perfusion. If placental tissue is in excess, it cannot be perfused adequately66 compared with that of women with singleton pregnancies, which increases the risk of PLTC, especially for pregnancy-induced hypertension. Moreover, it is most likely related to an increased risk of hemorrhage, operative delivery, and hypertensive disorders.

Women who never receive folic acid supplementation during pregnancy have an increased risk of PLTC development compared with those who have completed foliate supplementation. Insufficient folate intake during pregnancy is associated with an increased risk of complications during labor and delivery. In addition, increased dietary folate intake and folic acid supplementation during pregnancy reduce the risk of preeclampsia67. Low iron foliate intake increases obstetric haemorrhage68.

In our study, women with a history of stillbirth increased the risk of developing PLTCs. Another study on the relationship between previous stillbirths and maternal morbidity supports this finding69. Women with a previous history of stillbirth may experience chronic stress, psychological distress, and potential underlying medical conditions, such as diabetes or hypertension (pre-eclampsia), which can make subsequent pregnancies more complicated70. The increased risk of developing PLTCs in women with a previous stillbirth may be due to certain maternal health conditions that increase the risk of stillbirth69. Women who have experienced stillbirth in the past have a higher chance of developing the maternal condition in the next pregnancy. For example, women who have had a history of stillbirth are at a higher risk of developing preeclampsia, gestational diabetes, and placental insufficiency71. These maternal conditions can lead to serious health risks for both mother and fetus. Therefore, to prevent and manage any potential health complications, women with a history of stillbirth require close monitoring and specialized care during subsequent pregnancies.

This study indicated that women with low birth preparedness and complication readiness practices have a high risk of PLTC development. Another study conducted in Ethiopia indicated that there is no relationship between well-prepared birth and severe maternal morbidity7. Low birth preparedness can lead to inadequate planning for emergencies, a lack of access to healthcare facilities, or insufficient support during labor. This can delay necessary medical interventions in cases of complications, increasing the risk of adverse outcomes72.

This study revealed that women who disagree with the concept that “all pregnant women are at risk” are at high risk for PLTC development. If women do not recognize signs of potential complications or do not perceive their pregnancies as high risk, they may delay seeking care73. This can result in missed opportunities for early intervention and the management of conditions such as pregnancy-induced hypertension or chronic medical conditions. Targeted education about the importance of prenatal care, nutrition (including foliate intake), and the recognition of obstetric risks is essential. Support systems should be strengthened to improve birth preparedness and reduce anxiety related to previous pregnancy losses. Healthcare providers should actively engage with women who have these risk factors to provide tailored advice and interventions.

Having history of malaria infection during pregnancy is a risk factor for the development of potentially life-threatening maternal conditions. This result is similar to another study74. Malaria can alter the immune system, making pregnant individuals more susceptible to infections and complications. Malaria can cause anaemia due to the destruction of red blood cells. A pregnant woman with a history of malaria may have pre-existing anaemia or a reduced capacity to cope with additional blood loss during childbirth, increasing the risk of severe anemia and related complications75,76. Prior malaria infections can lead to chronic inflammation and changes in the placenta, which may increase the risk of placental malaria in subsequent pregnancies. This poses risks to maternal health77.

Discussions with the community, including the importance of preventive measures such as the use of insecticide-treated nets and antimalarial prophylaxis for pregnant women living within malaria epidemic areas, are important. These measures can help reduce the negative impact of malaria on mothers74.

Unlike another study7, our findings indicated that women who used ambulances were at an increased risk of PLTC compared with those using other means of transportation. This may indicate that women using ambulances are already in more critical situations, necessitating emergency transport. This could reflect a delay in seeking care or the severity of their conditions when they finally reach healthcare facilities. Women who rely on ambulances may come from lower socioeconomic backgrounds and face barriers to timely and appropriate prenatal care, which can lead to more severe complications. Geographic differences in healthcare access and quality may play a role. In areas with limited access to health facilities, ambulances might be the only option for transport, potentially indicating a higher baseline risk34,78. Emphasizing the importance of regular prenatal visits could help identify potential complications earlier, possibly reducing the need for ambulance transport in critical situations. Targeted campaigns may be necessary to educate women about when to seek medical help and the importance of timely care during pregnancy. The development of community-based programs that provide support and education about maternal health and emergency preparedness could empower women to seek timely care before emergencies arise79.

However, this study has the following limitations: the study employed an unmatched case‒control design, meaning that important variables were not matched between the controls and the cases to minimize confounding. It is also difficult to infer the findings of this study for the general population since the study population may not be representative of the general population.

Conclusion

This study revealed that women’s husband with no formal education, not in marital union, alcohol intake during pregnancy, prior history of stillbirth, twin birth, chronic hypertension, history of previous cesarean section, cesarean section mode of delivery, malaria infection during pregnancy, not attending prenatal care on the basis of the recommended number and time of initiation, not taking foliate supplementation, induced labor, low practice of BPCR, ambulances used for coming to health facilities, and not agree that ”all pregnant women are at risk’’ were factors associated with the PLTC.

Numerous preventable predictors have been identified. For the PLTC, governmental and nongovernmental organizations should focus on these problems. Attention to the early health care-seeking behavior of mothers in the study area is needed. Women suffer from PLTC, which can be easily addressed if it is treated in a timely manner. Both programmers and clinicians pay attention to adequate prenatal care services that contribute to preventing PLTC. All women who have chronic hypertension should receive preconception care to control complications. Care providers should pay attention to counselling in the context of faliate supplementation intake, the ability of pregnant women to sleep under a bed net, the advantages of a birth preparedness plan, and alcohol avoidance.

Data availability

When a reasonable request is made, the corresponding author can provide the datasets used and/or analysed in this study.

Abbreviations

CS:

Cesarean sectionBPCR:

Birth preparedness and complication readinessHELLP:

Haemolysis elevated liver enzymes and low platelet countPLTC:

Potentially life-threatening maternal conditionsPPH:

Postpartum hemorrhageICU:

Intensive care unitSDG:

Sustainable development goalSVD:

Spontaneous vaginal deliveryWHO:

World health organization

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Acknowledgements

We would like to thank Mekelle University, Tigray Regional health Bureau, and the administrations of the selected hospitals for their support, without which our study could not have been conducted. Finally, we would like to express our appreciation to the study participants for their voluntary participation and the data collectors and supervisors for their tireless participation in this study.

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Authors and Affiliations

  1. College of Medicine and Health Sciences, Adigrat University, Tigray, EthiopiaFitiwi Tinsae Baykemagn
  2. School of Public Health, College of Health Sciences, Mekelle University, Tigray, EthiopiaFitiwi Tinsae Baykemagn, Girmatsion Fisseha Abreha & Alemayehu Bayray Kahsay
  3. Department of Obstetrics and Gynecology, School of Medicine, Mekelle University, Tigray, EthiopiaYibrah Berhe Zelelow

Contributions

Fitiwi Tinsae: conceptualization, methodology, investigation, writing draft, writing review, editing, analysis, and administration of the project. Girmatsion Fisseha: conceptualization, methodology, supervision, writing-review and editing. Yibrah Berhe: conceptualization, methodology, supervision, writing-review and editing. Alemayehu Bayray: conceptualization, methodology, supervision, writing-review and editing. Finally, all the authors have read and approved the final manuscript.

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Correspondence to Fitiwi Tinsae Baykemagn.

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Baykemagn, F.T., Abreha, G.F., Zelelow, Y.B. et al. Determinants of potential life-threatening maternal conditions (PLTCs) in Tigray, northern Ethiopia: a case‒control study. Sci Rep 14, 30022 (2024). https://doi.org/10.1038/s41598-024-81415-w

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