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

## TL;DR

A confidential enquiry into maternal deaths was introduced in Ethiopia to identify causes and prevent future deaths.

## Contribution

The introduction of a confidential enquiry system in Ethiopia to assess and learn from maternal deaths.

## Key findings

- 46% of reviewed maternal deaths were caused by obstetric haemorrhage and 25% by hypertensive disorders of pregnancy.
- 81-92% of cases had at least one delay in care, indicating preventable deaths with better care.
- Recommendations included training providers, improving supplies, and strengthening referrals to reduce maternal deaths.

## Abstract

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.

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.

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.

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.

Maternal death is a tragedy that comes with pregnancy and childbirth complications. The consequences of death of a woman goes beyond her life and the family, and extends to the wider community and nation at large. We intended to identify common causes of maternal deaths at maternity units in eastern Ethiopia, and factors behind the medical cause of death through a confidential enquiry approach to learning from and prevent maternal deaths from similar causes.

The Ethiopian Obstetric Surveillance System (EthOSS) collected data on maternal deaths from 13 hospitals having maternity units and anonymised them before a review by the EthOSS committee for confidential enquiry in to maternal deaths (CEMD) on a quarterly meetings. The EthOSS study was approved by the Institutional Health Research Ethics Review Committee of the College of Health and Medical Sciences of Haramaya University in Ethiopia and the University of Oxford’s Oxford Tropical Research Ethics Committee. The reviews identified that majority of deaths were caused by direct obstetric causes; 27/59 (46%) by haemorrhage and 15/59 (25%) hypertensive disorders of pregnancy. Delay one (delay in seeking care), delay two (delay in reaching an appropriate health facility) and delay three (delay in receiving adequate care at health facility) were identified in 48 (81%), 52 (88%), and 54 (92%) cases reviewed. The reviews indicated that almost all maternal deaths were potentially preventable by appropriate care.

Based on the study findings, improving maternity care providers’ clinical skills through skill trainings, enhancing availability of blood and basic supplies, strengthening postpartum maternal monitoring, and strengthening inter- and intra-facility referrals were recommended for reducing preventable maternal deaths.