Variability in the Causes and Delay Factors Contributing to Maternal Mortality: Evidence From Maternal Death Surveillance Reports of 22 African Countries

Objective
To examine the variability in causes of maternal deaths in African countries using the World Health Organization (WHO) International Classification of Diseases Maternal Mortality (ICD-MM) framework and the contributing factors using the three delays framework.

Design
Secondary data analysis.

Setting
African countries.

Sample
National maternal death review reports.

Methods
A framework analysis of data extracted from maternal death review reports utilising the ICD-MM and three delays analytical frameworks.

Main Outcome Measures
Proportions of the causes of maternal death and contributing factors.

Results
Twenty-two reports published between 2009 and 2022 were included, comprising 18,321 maternal deaths. The mean proportions were: 73% direct, 20% indirect, 8% unspecified, and 1% coincidental. The causes of death consisted of: 6% abortion-related; 16% hypertensive disorders; 33% obstetric haemorrhage; 9% infection; 10% other direct complications; 3% complications of management; 20% non-obstetric complications; 8% unknown; and 1% coincidental. All three delays contributed to maternal deaths. The third delay: receiving adequate care, was the most common in all countries except Ethiopia, where the first delay: deciding to seek care, dominated. On average, the first, second, and third delays contributed to 26%, 15%, and 61% of deaths, respectively.

Conclusion
A renewed focus on the quality of care within health facilities, alongside addressing pre-facility contributing factors, could re-ignite progress in reducing the burden of preventable maternal deaths.