Introduction of confidential enquiry into maternal deaths in Ethiopia: Implementation and methodological considerations

Background: Despite having high maternal mortality, no recent confidential enquiry into maternal deaths (CEMD) has been implemented in Ethiopia. This paper outlines the introduction of the CEMD, major findings, and key methodological considerations. 

Methods: We embedded this CEMD in the ongoing Ethiopian Obstetric Surveillance System (EthOSS), a regional system that monitors a range of major obstetric conditions in eastern Ethiopia. Multiple methods (both qualitative and quantitative) were used to collect, analyse and report the data. A multidisciplinary committee was established and trained on principles and methodology of CEMD by international experts. The CEMD committee conducted two plenary CEMD sessions to review maternal deaths reported from April 1, 2021, to March 31, 2022, from 13 hospitals in the EthOSS consortium. Each case was assessed for causes, contributing factors, delays in care using the three-delays model, preventability, and recommendations for improving care. Results: Out of 70 maternal deaths, in 59 there was enough information to enable a review by the committee; 27/59 (46%) and 15/59 (25%) were caused by obstetric haemorrhage and hypertensive disorders of pregnancy respectively. In 55/59 (93%), at least one of the three delays was identified: delay one (seeking care) in 48 (81%), delay two (reaching an appropriate facility) in 52 (88%), and delay three (receiving adequate care) in 54 (92%). The review indicated that almost all reported deaths could have been prevented with better care. 

Conclusions: Almost all the maternal deaths in the region were considered preventable. Training for improving providers’ clinical skills, improving availability of blood and basic supplies, strengthening postpartum monitoring, and referrals were recommended for saving lives through reducing preventable maternal deaths.