KASSEP
Prospective Phase 1
Kano State Surveillance for Evidence and Policy
Prospective Maternal Mortality Statistics Report — Phase 1 Descriptive & Inferential
Study Period: August 1st 2024 – July 31st 2025
Table 1: Baseline Characteristics of the Study Population
| Characteristic | Observed | Weighted |
|---|
| Deliveries | 3,935 | — |
| Live births | 3,942 | 44,671.8 |
| Age (years), Mean (SD) | 32.1 (8.9) | 32 (8.9) |
| Maternal deaths | 23 | 236.6 |
| MMR per 100,000 live births | 583.5 | 529.7 |
Interpretation: A total of 3,935 deliveries resulting in 3,942 live births were recorded in the prospective phase 1 survey (study period August 1st 2024 to July 31st 2025). The observed maternal mortality ratio (MMR) was 583.5 per 100,000 live births, while the survey-weighted MMR was 529.7 per 100,000 live births, indicating a high burden of maternal mortality in the study population after accounting for population structure.
Weighting note Post-stratification weighting adjusted the analytic sample by using Local Government Areas (LGAs) to align the cohort with the baseline population distribution. Specific weights were calculated based on the ratio of baseline census deliveries to observed sample deliveries within each LGA.
Table 2: Maternal Mortality Ratio
| Characteristic | Observed | Weighted |
|---|
| Maternal deaths | 23 | 236.6 |
| Live births | 3,942 | 44,671.8 |
| MMR per 100,000 live births | 583.5 (369.9–875.5) | 529.7 (301.7–757.7) |
Interpretation: Table 2 shows that 23 maternal deaths occurred among 3,942 live births, resulting in an observed maternal mortality ratio (MMR) of 583.5 per 100,000 live births (95% CI: 369.9–875.5). The relatively wide confidence interval reflects the small number of events but remains consistent with a high-risk setting. However, the weighted MMR was slightly lower than the observed estimate, suggesting that the sampled population somewhat overrepresented areas with higher maternal mortality. The overlapping confidence intervals indicate that the observed and weighted estimates are broadly consistent.
Table 3: Maternal Mortality by Age Group (Observed and Weighted)
| Age Group | Observed Live Births | Observed Maternal Deaths | Observed MMR | Weighted Live Births | Weighted Maternal Deaths | Weighted MMR |
|---|
| 15–19 | 382 | 1 | 261.8 | 4,391.4 | 12.9 | 293.8 |
| 20–24 | 625 | 4 | 640.0 | 7,131.9 | 33.7 | 472.5 |
| 25–29 | 591 | 5 | 846.0 | 6,693.9 | 52.9 | 790.3 |
| 30–34 | 715 | 3 | 419.6 | 8,193.2 | 30.4 | 371.0 |
| 35–39 | 580 | 5 | 862.1 | 6,383.1 | 51.5 | 806.8 |
| 40–44 | 674 | 3 | 445.1 | 7,624.6 | 33.5 | 439.4 |
| 45–49 | 375 | 2 | 533.3 | 4,253.7 | 21.7 | 510.1 |
| Total | 3,942 | 23 | 583.5 | 44,671.8 | 236.6 | 529.7 |
Figure 1: Deliveries & Maternal Deaths by Age Group
Figure 2: MMR by Age Group (Observed)
Interpretation: Table 3 shows variation in maternal mortality across maternal age groups. The highest observed MMRs were recorded among women aged 35–39 years (862.1 per 100,000 live births) and 25–29 years (846.0 per 100,000 live births), while the lowest MMR was observed among adolescents aged 15–19 years (261.8 per 100,000 live births). The weighted MMRs were generally slightly lower than the observed estimates across most age groups.
M-shaped pattern: Maternal mortality shows an M-shaped pattern (Figure 2), with the highest MMR among women aged 25–39 years rather than at the extremes. This differs from the retrospective analysis which showed a U-shaped pattern. The observed M-shape is likely influenced by the small number of deaths (n=23), which limits stable estimates across age groups.
Table 4: Maternal Mortality Ratio by Broad Age Categories
| Age Category | Observed Live Births | Observed Maternal Deaths | Observed MMR | Weighted Live Births | Weighted Maternal Deaths | Weighted MMR |
|---|
| <25 years | 1,007 | 5 | 496.5 | 11,523.3 | 46.6 | 404.4 |
| 25–39 years | 1,886 | 13 | 689.3 | 21,270.3 | 134.8 | 633.7 |
| ≥40 years | 1,049 | 5 | 476.6 | 11,878.3 | 55.2 | 464.7 |
| Total | 3,942 | 23 | 583.5 | 44,671.8 | 236.6 | 529.7 |
Interpretation: Maternal mortality in the prospective data shows an M-shaped pattern, with the highest MMR among women aged 25–39 years. This differs from the retrospective statistical analysis report which showed a U-shaped pattern. The observed M-shape is likely influenced by the small number of deaths (n=23), which limits stable estimates across age groups.
Table 5: Maternal Mortality by Parity
| Parity Group | Observed Deliveries | Observed Maternal Deaths | Observed Death (%) |
|---|
| Nulliparous | 481 | 0 | 0.0 |
| Primiparous | 880 | 1 | 4.3 |
| Multiparous | 2,564 | 12 | 52.2 |
| Grand multiparous | 10 | 10 | 43.5 |
| Total | 3,935 | 23 | 100.0 |
Figure: Maternal Deaths by Parity Group (%)
Interpretation: Maternal deaths were concentrated among multiparous and grand multiparous women, but these findings must be interpreted with strict caution due to the small overall number of observed maternal deaths (n = 23) and heavily skewed group distributions. While the concentration of deaths among multiparous women reflects group size imbalances and cumulative risks across sequential pregnancies, the recording of 10 deaths out of 10 grand multiparous deliveries is a distinct statistical anomaly driven by extreme data sparsity.
Table 6: Maternal Mortality by ANC Adequacy
| ANC Adequacy | Observed Live Births | Observed Maternal Deaths | Observed MMR | Weighted Live Births | Weighted Maternal Deaths | Weighted MMR |
|---|
| Inadequate (<4 visits) | 1,318 | 19 | 1,441.6 | 14,800.7 | 194.8 | 1,316.2 |
| Adequate (≥4 visits) | 2,624 | 4 | 152.4 | 29,871.1 | 41.8 | 139.9 |
| Total | 3,942 | 23 | 583.5 | 44,671.8 | 236.6 | 529.7 |
MMR by ANC Adequacy (Weighted)
ANC Coverage & Death Distribution
Interpretation: Maternal mortality was substantially higher among women with fewer than four antenatal care visits, with an MMR (weighted) of 1,316.2 per 100,000 live births, compared with an MMR (weighted) of 139.9 per 100,000 live births among women who had four or more ANC visits. Approximately 67% of the cohort attended four or more ANC visits, and this group experienced markedly fewer maternal deaths. This suggests a strong protective effect of higher ANC utilisation.
Table 7: Place of Delivery and Maternal Mortality Ratio
| Place of Delivery | Observed Live Births | Observed Maternal Deaths | Observed MMR | Weighted Live Births | Weighted Maternal Deaths | Weighted MMR |
|---|
| Health facility | 1,950 | 15 | 769.2 | 22,321.2 | 155.7 | 697.5 |
| Outside health facility | 1,992 | 8 | 401.6 | 22,350.7 | 81.0 | 362.4 |
| Total | 3,942 | 23 | 583.5 | 44,671.8 | 236.6 | 529.7 |
MMR by Place of Delivery (Weighted)
Delivery Distribution & Deaths
Interpretation: Maternal mortality was higher among women delivering in health facilities, with an MMR (weighted) of 697.5 per 100,000 live births, compared with 362.4 per 100,000 among deliveries occurring outside health facilities. This pattern is likely influenced by referral dynamics, where women with high-risk pregnancies or severe obstetric complications are more likely to present to health facilities, thereby concentrating mortality in these settings.
Table 8: Maternal Mortality by Settlement Type
| Place of Residence | Observed Live Births | Observed Maternal Deaths | Observed MMR | Weighted Live Births | Weighted Maternal Deaths | Weighted MMR |
|---|
| Rural | 1,544 | 9 | 582.9 | 16,328.3 | 105.5 | 646.3 |
| Peri-urban | 1,640 | 12 | 731.7 | 15,626.5 | 103.7 | 663.9 |
| Urban | 758 | 2 | 263.9 | 12,717.0 | 27.3 | 215.0 |
| Total | 3,942 | 23 | 583.5 | 44,671.8 | 236.6 | 529.7 |
MMR by Settlement Type (Weighted)
Deaths by Settlement Type
Interpretation: The maternal mortality ratio was highest in peri-urban settlements (663.9 per 100,000 live births), followed by rural areas (646.3 per 100,000), while urban areas recorded the lowest MMR (263.9 per 100,000). The higher MMR in peri-urban areas may reflect context-specific challenges in Kano State, where these areas may still have limited proximity to well-equipped health facilities despite being outside fully rural settings.
Table 9A: Maternal Mortality by LGA (with recorded Maternal deaths ONLY)
| LGA | Observed Deliveries | Observed Live Births | Observed Maternal Deaths | Observed MMR (95% CI) | Weighted Live Births | Weighted Maternal Deaths | Weighted MMR |
|---|
| MAKODA | 46 | 46 | 3 | 6,521.7 (1,344.9–19,059.3) | 703.0 | 45.8 | 6,521.7 |
| ROGO | 105 | 105 | 4 | 3,809.5 (1,038–9,753.9) | 675.0 | 25.7 | 3,809.5 |
| TUDUN WADA | 145 | 145 | 5 | 3,448.3 (1,119.6–8,047.1) | 1,534.0 | 52.9 | 3,448.3 |
| BAGWAI | 76 | 76 | 2 | 2,631.6 (318.7–9,506.2) | 1,015.0 | 26.7 | 2,631.6 |
| MADOBI | 125 | 125 | 2 | 1,600 (193.8–5,779.8) | 1,084.0 | 17.3 | 1,600.0 |
| TAKAI | 78 | 78 | 1 | 1,282.1 (32.5–7,143.1) | 608.0 | 7.8 | 1,282.1 |
| RIMIN GADO | 161 | 161 | 2 | 1,242.2 (150.4–4,487.4) | 938.0 | 11.7 | 1,242.2 |
| DALA | 82 | 82 | 1 | 1,219.5 (30.9–6,794.7) | 1,180.0 | 14.4 | 1,219.5 |
| TOFA | 82 | 82 | 1 | 1,219.5 (30.9–6,794.7) | 1,280.0 | 15.6 | 1,219.5 |
| BICHI | 144 | 144 | 1 | 694.4 (17.6–3,869.2) | 823.0 | 5.7 | 694.4 |
| GWALE | 150 | 150 | 1 | 666.7 (16.9–3,714.4) | 1,942.0 | 12.9 | 666.7 |
| TOTAL | 3,935 | 3,942 | 23 | 583.5 (370.5–877.0) | 44,671.8 | 236.6 | 529.7 |
Figure 3: Maternal Deaths by LGA (Observed Prospective Data)
Interpretation: The plot shows noticeable rural–urban differences in maternal mortality across Kano State, with a high burden in rural and peri-urban LGAs such as Tudun Wada, Rogo, and Makoda. Peri-urban areas may experience high deaths due to population pressure and gaps in access to timely, quality care. Rural areas also face challenges such as limited healthcare facilities and fewer skilled providers, increasing the risk of delayed treatment. In contrast, metropolitan LGAs like Gwale and Dala recorded fewer deaths, likely reflecting better access to services.
Table 9B: Maternal Mortality by LGA (all LGAs)
| LGA | Observed Deliveries | Observed Live Births | Observed Maternal Deaths | Observed MMR (95% CI) | Weighted MMR |
|---|
| MAKODA | 46 | 46 | 3 | 6,521.7 (1,344.9–19,059.3) | 6,521.7 |
| ROGO | 105 | 105 | 4 | 3,809.5 (1,038–9,753.9) | 3,809.5 |
| TUDUN WADA | 145 | 145 | 5 | 3,448.3 (1,119.6–8,047.1) | 3,448.3 |
| BAGWAI | 76 | 76 | 2 | 2,631.6 (318.7–9,506.2) | 2,631.6 |
| MADOBI | 125 | 125 | 2 | 1,600 (193.8–5,779.8) | 1,600.0 |
| TAKAI | 78 | 78 | 1 | 1,282.1 (32.5–7,143.1) | 1,282.1 |
| RIMIN GADO | 161 | 161 | 2 | 1,242.2 (150.4–4,487.4) | 1,242.2 |
| DALA | 82 | 82 | 1 | 1,219.5 (30.9–6,794.7) | 1,219.5 |
| TOFA | 82 | 82 | 1 | 1,219.5 (30.9–6,794.7) | 1,219.5 |
| BICHI | 144 | 144 | 1 | 694.4 (17.6–3,869.2) | 694.4 |
| GWALE | 150 | 150 | 1 | 666.7 (16.9–3,714.4) | 666.7 |
| AJINGI | 93 | 93 | 0 | 0 (0–3,966.5) | 0.0 |
| ALBASU | 121 | 121 | 0 | 0 (0–3,048.7) | 0.0 |
| BEBEJI | 51 | 51 | 0 | 0 (0–7,233.1) | 0.0 |
| BUNKURE | 100 | 101 | 0 | 0 (0–3,652.4) | 0.0 |
| DAMBATTA | 128 | 128 | 0 | 0 (0–2,881.9) | 0.0 |
| DAWAKIN KUDU | 187 | 188 | 0 | 0 (0–1,962.2) | 0.0 |
| DAWAKIN TOFA | 77 | 77 | 0 | 0 (0–4,790.8) | 0.0 |
| DOGUWA | 43 | 43 | 0 | 0 (0–8,578.8) | 0.0 |
| FAGGE | 19 | 19 | 0 | 0 (0–19,415.2) | 0.0 |
| GABASAWA | 108 | 108 | 0 | 0 (0–3,415.6) | 0.0 |
| GARKO | 78 | 78 | 0 | 0 (0–4,729.3) | 0.0 |
| GARUM MALLAM | 86 | 86 | 0 | 0 (0–4,289.4) | 0.0 |
| GAYA | 59 | 59 | 0 | 0 (0–6,252.3) | 0.0 |
| GEZAWA | 61 | 61 | 0 | 0 (0–6,047.3) | 0.0 |
| GWARZO | 67 | 67 | 0 | 0 (0–5,505.8) | 0.0 |
| KABO | 71 | 71 | 0 | 0 (0–5,195.6) | 0.0 |
| KANO MUNICIPAL | 51 | 51 | 0 | 0 (0–7,233.1) | 0.0 |
| KARAYE | 86 | 87 | 0 | 0 (0–4,240.1) | 0.0 |
| KIBIYA | 57 | 57 | 0 | 0 (0–6,471.7) | 0.0 |
| KIRU | 77 | 77 | 0 | 0 (0–4,790.8) | 0.0 |
| KUMBOTSO | 112 | 112 | 0 | 0 (0–3,293.6) | 0.0 |
| KUNCHI | 60 | 60 | 0 | 0 (0–6,148.1) | 0.0 |
| KURA | 42 | 42 | 0 | 0 (0–8,783) | 0.0 |
| MINJIBIR | 124 | 124 | 0 | 0 (0–2,974.9) | 0.0 |
| NASARAWA | 157 | 157 | 0 | 0 (0–2,349.6) | 0.0 |
| RANO | 66 | 67 | 0 | 0 (0–5,505.8) | 0.0 |
| SHANONO | 36 | 36 | 0 | 0 (0–10,246.9) | 0.0 |
| SUMAILA | 97 | 99 | 0 | 0 (0–3,726.1) | 0.0 |
| TARAUNI | 62 | 62 | 0 | 0 (0–5,949.8) | 0.0 |
| TSANYAWA | 138 | 139 | 0 | 0 (0–2,653.9) | 0.0 |
| UNGOGGO | 125 | 125 | 0 | 0 (0–2,951.1) | 0.0 |
| WARAWA | 43 | 43 | 0 | 0 (0–8,578.8) | 0.0 |
| WUDIL | 59 | 59 | 0 | 0 (0–6,252.3) | 0.0 |
| TOTAL | 3,935 | 3,942 | 23 | 583.5 (370.5–877.0) | 529.7 |
Interpretation: While the data shows wide geographic variation with extreme MMR peaks in Makoda, Rogo, and Tudun Wada, these localized estimates must be interpreted with extreme caution due to severe data sparsity and wide confidence intervals. Similarly, the zero recorded deaths across 33 LGAs reflect small sample sizes rather than a true clinical absence of risk. Adjusting for these geographic imbalances via post-stratification weighting provides a more reliable, slightly lower statewide MMR of 529.7 per 100,000 live births.
Inferential Analysis
Table 1: Interaction between Antenatal Care and Place of Delivery on Maternal Mortality
| Variable | Comparison | Odds Ratio (95% CI) | P value | Significance |
|---|
| Antenatal care | ≥4 visits vs <4 visits | 0.21 (0.05–0.68) | 0.009 | Significant |
| Place of delivery | Facility vs Non-facility | 1.38 (0.57–3.48) | 0.480 | Not Significant |
| Interaction effect | ≥4 ANC visits + Facility delivery | 0.31 (0.03–2.29) | 0.253 | Not Significant |
Interpretation: Women with ≥4 ANC visits had significantly lower odds of maternal death, showing a protective effect. Place of delivery was not significantly associated with mortality (OR=1.38, p=0.480), meaning no clear difference was observed between facility and non-facility deliveries; this may be due to the small number of maternal deaths (n=23), which limits reliable comparisons. The combined effect of ANC and facility delivery was also not significant (OR=0.31, p=0.253).
Table 2: Assessing the Care Cascade Pathway and Maternal Mortality rate %
| Care cascade | Total deliveries (N) | Maternal deaths (n) | Survived (n) | Mortality % (95% CI) |
|---|
| Low ANC | 1,316 | 19 | 1,297 | 1.44 (0.93–2.24) |
| Facility gap | 1,320 | 1 | 1,319 | 0.08 (0.01–0.43) |
| Optimal pathway | 1,299 | 3 | 1,296 | 0.23 (0.08–0.68) |
| Total | 3,935 | 23 | 3,912 | 0.58 (0.39–0.88) |
Figure: Care Cascade Pathway Distribution & Mortality Rates
Interpretation: The care cascade analysis demonstrated significant differences in maternal mortality across the continuum of maternal healthcare (Fisher's Exact Test, p<0.001). Women with inadequate antenatal care (<4 ANC visits) recorded the highest mortality rate, with 19 maternal deaths among 1,316 deliveries (1.44%, 95% CI: 0.93–2.24). Women who achieved adequate ANC but delivered outside health facilities had a markedly lower mortality rate of 0.08% (95% CI: 0.01–0.43), while women who completed both adequate ANC attendance and facility delivery experienced low mortality, with three maternal deaths among 1,299 deliveries (0.23%, 95% CI: 0.08–0.68).
Formula Mortality % = (Maternal deaths / Total deliveries) × 100
Table 3: Univariable Firth Logistic Regression for Maternal Mortality
| Predictor | Category | OR (95% CI) | P value |
|---|
| Age group | <25 | Baseline Category | |
| 25–34 | 1.19 (0.41–3.74) | 0.75 |
| ≥35 | 1.18 (0.43–3.59) | 0.75 |
| ANC visits | <4 visits | Baseline Category | |
| ≥4 visits | 0.11 (0.04–0.29) | <0.001 |
| Place of delivery | Non-facility | Baseline Category | |
| Facility | 1.12 (0.50–2.54) | 0.79 |
Interpretation: Having ≥4 ANC visits was associated with an 89% reduction in the odds of maternal death (OR=0.11, 95% CI: 0.04–0.29, p<0.001), indicating a strong protective effect. The non-significant findings for age group and place of delivery highlight a study limitation, particularly the small number of maternal deaths, which reduces the ability to detect meaningful differences.
Table 4: Multivariable Firth Logistic Regression for Maternal Mortality
| Predictor | Category | Adjusted OR (95% CI) | P value |
|---|
| Age group | <25 | Reference | |
| 25–34 | 1.19 (0.41–3.76) | 0.745 |
| ≥35 | 1.26 (0.46–3.84) | 0.664 |
| ANC visits | <4 visits | Reference | |
| ≥4 visits | 0.11 (0.04–0.29) | <0.001 |
| Place of delivery | Non-facility | Reference | |
| Facility | 1.10 (0.49–2.50) | 0.818 |
Interpretation: Having ≥4 ANC visits remained strongly associated with reduced odds of maternal death after adjustment (AOR=0.11, 95% CI: 0.04–0.29, p<0.001), consistent with the univariable findings and confirming its independent protective effect. The non-significant associations for age group and place of delivery indicate a key study limitation, likely due to the small number of maternal deaths.
Table 5: Sensitivity analysis among facility deliveries only (Firth logistic regression)
| Predictor | Category | Adjusted OR (95% CI) | P value |
|---|
| Age group | <25 | Reference | |
| 25–34 | 1.21 (0.32–5.28) | 0.778 |
| ≥35 | 0.89 (0.21–4.01) | 0.870 |
| ANC visits | <4 visits | Reference | |
| ≥4 visits | 0.06 (0.01–0.27) | <0.001 |
Interpretation: As a sensitivity analysis among facility deliveries, having ≥4 ANC visits remained strongly associated with reduced odds of maternal death (AOR=0.06, 95% CI: 0.01–0.27, p<0.001), confirming the robustness of this protective effect. The non-significant findings for age group highlight a study limitation, likely due to the small number of maternal deaths and reduced sample size in this subgroup.