Maternal death surveillance in Addis Ababa, Ethiopia, 2017-2021: Causes and contributing factors.

Background: Despite national efforts, maternal mortality remains a major public health challenge in Ethiopia. Identifying context-specific causes and delays in receiving appropriate and timely healthcare is essential to guide targeted interventions. This study analysed maternal mortality in Addis Ababa over a 5-year period to identify the causes and contributing factors. Methods: A retrospective analysis was conducted using maternal death surveillance data collected from 2017 and 2021 in Addis Ababa. The data were extracted from health facility-based maternal death case-based reports and the verbal autopsy tool utilized for community-based maternal death investigations. The data are part of the national surveillance system owned by the Public Health Emergency Management Center of the Ethiopian Public Health Institute. Information included in the dataset included socio-demographic characteristics, the underlying causes of death, the timing of death, and type of delays in receiving healthcare. Results: A total of 309 maternal deaths were recorded in Addis Ababa. The maternal mortality ratio was 74 maternal deaths per 100,000 live births. The majority of deaths (86.4 %) occurred after delivery. Direct obstetric causes were responsible for 94.2 % of deaths, with obstetric haemorrhage identified as the leading cause (41.1 %). Other direct causes included hypertensive disorders (23.0 %) and puerperal sepsis (12.6 %). An additional 5.8 % of deaths were resulting from indirect causes. Among the deaths resulting from direct obstetric causes, 62.2 % were due to delays in receiving appropriate and timely care after reaching health facilities. Common reasons for the delays in receiving care were delayed facility referrals (46.0 %), case management challenges (43.1 %), and lack of supplies and equipment (28.7 %). Furthermore, 37.5 % of deaths were resulting from delays in deciding to seek health care, primarily contributed by a failure to recognize the problem. About a quarter of deaths (24.7 %), were contributed by delays in reaching health facility, predominantly due to delayed arrival at referral receiving health facilities. Conclusion: Although the maternal mortality ratio in Addis Ababa is lower than the national rate, it is still above the WHO target. Almost all maternal deaths were results of the direct obstetric causes. Delays in receiving appropriate and timely care remain the leading contributing factor to maternal deaths. Strengthening emergency referral systems, enhancing facility-based management capacity through health worker training, and increasing community awareness could address key gaps in reducing preventable maternal mortality. Enhanced surveillance can be used to monitor the impact of interventions over time.