title: Understanding maternal mortality from top-down and bottom-up perspectives: Case of Tigray Region, Ethiopia.
abstract: BACKGROUND
  Unacceptably high levels of preventable maternal mortality persist as a problem across sub-Saharan Africa and much of south Asia. Currently, local assessments of the magnitude of maternal mortality are not often made, so the best available information for health planning may come from global estimates and not reflect local circumstances.
  
  
  METHODS
  A community-based cross-sectional survey was designed to identify all live births together with all deaths among women aged 15-49 years retrospectively over a one-year period in six randomly selected districts of Tigray Region, northern Ethiopia. After birth and death identification, Health Extension Workers trained to use the WHO 2012 verbal autopsy (VA) tool visited households to carry out VAs on all deaths among women aged 15-49 years. All pregnancy-related deaths were identified after processing the VA material using the InterVA-4 model, which corresponds to the WHO 2012 VA. A maternal mortality ratio (MMR) was calculated for each District and expressed with a 95% confidence interval (CI).
  
  
  RESULTS
  The MMRs across the six sampled Districts ranged from 37 deaths per 100 000 live births (95% CI 1 to 207) to 482 deaths per 100 000 live births (95% CI 309 to 718). The overall MMR for Tigray Region was calculated at 266 deaths per 100 000 live births (95% CI 198 to 350). Direct obstetric causes accounted for 61% of all pregnancy-related deaths. Haemorrhage was the major cause of pregnancy-related death (34%). District-level MMRs were strongly inversely correlated with population density (r(2) = 0.86).
  
  
  CONCLUSIONS
  This simple but well-designed survey approach enabled estimation of maternal mortality in Tigray Region on a local, contemporary basis. It also provided insights into possible local variations in MMR and their determinants. Consequently, this approach could be implemented at regional level in other large sub-Saharan African countries, or at national level in smaller ones to monitor and evaluate maternal health service interventions.
authors: Tigray Regional Health Bureau, Mekelle, Ethiopia.
authors: Hagos
authors: H
authors: Godefay
authors: Umeå Centre for Global Health Research, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden ; Institute of Applied Health Sciences, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK ; MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors: Peter
authors: P
authors: Byass
authors: Umeå Centre for Global Health Research, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
authors: John
authors: J
authors: Kinsman
authors: College of Health Sciences, Mekele University, Mekele, Ethiopia.
authors: Afework
authors: A
authors: Mulugeta