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Abstract

Background:

Severe maternal outcomes (SMOs), including maternal deaths and life-threatening complications during pregnancy, childbirth, or within 42 days postpartum, reflect the quality of maternal healthcare services and highlight gaps in timely and effective interventions. Monitoring SMOs is crucial for improving maternal health systems, as it helps identify preventable factors, strengthen clinical practices, and inform policy decisions to reduce maternal morbidity and mortality. This study synthesizes existing evidence on the pooled incidence proportion of SMOs in Ethiopia and examines their underlying causes.

Objective:

To estimate the pooled incidence proportion of SMOs and their underlying causes in Ethiopia.

Design:

Systematic review and meta-analysis.

Data sources and methods:

The review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. A comprehensive search was conducted in PubMed, Cochrane Library, Google Scholar, Scopus, and Hinari using the CoCoPop strategy. Study quality was assessed using the Newcastle–Ottawa Scale. Heterogeneity was evaluated with the I² statistic, and publication bias was assessed using funnel plots and Egger’s test. A random-effects model was applied to calculate the pooled incidence proportion with 95% confidence intervals (CIs).

Results:

Thirteen studies, including 2451 SMO cases among 67,954 live births, were analyzed. The pooled incidence of SMOs was 41.74 per 1000 live births (95% CI: 29.58–53.89). The maternal mortality index was 10.53% (95% CI: 7.71–13.36). The leading causes of SMO were pregnancy-induced hypertension (PIH; 40.8%), obstetric hemorrhage (24.94%), uterine rupture (19.61%), severe systemic infection (11.65%), and early pregnancy complications (7.74%).

Conclusion:

The incidence of SMOs in Ethiopia is higher than in many other countries. PIH, obstetric hemorrhage, uterine rupture, severe systemic infection, and early pregnancy complications are the main contributing causes. Targeted, context-specific interventions that emphasize early detection, effective management, and prevention of these conditions could significantly reduce maternal morbidity and mortality. Strengthening healthcare infrastructure, improving access to quality emergency obstetric care, and enhancing community awareness and timely health-seeking behaviors are essential. Policymakers and program planners should prioritize resource allocation and capacity-building efforts tailored to these high-burden conditions to accelerate progress toward national and global maternal health goals.

PROSPERO registration number:

CRD42024629544.

Keywords

severe maternal outcomes maternal mortality index pregnancy-induced hypertension uterine rupture Ethiopia

Introduction

Maternal mortality is a key global indicator for monitoring maternal health, assessing the quality of reproductive healthcare, and evaluating progress toward the Sustainable Development Goals (SDGs).¹ SDG 3.1 sets a target to reduce the global maternal mortality ratio (MMR) to fewer than 70 deaths per 100,000 live births by 2030, with no country exceeding twice that level (140 per 100,000 live births).^2,3 Ethiopia has demonstrated a strong commitment to achieving this goal and has made notable progress in reducing maternal deaths. However, the country’s MMR remains above the SDG target.^4,5 Severe maternal outcomes (SMOs), which include both maternal deaths and life-threatening complications, are largely preventable, underscoring the urgent need to strengthen healthcare interventions and ensure timely access to quality maternal care.⁶

The World Health Organization (WHO) Working Group on Maternal Mortality and Morbidity Classifications has established clear standards for identifying SMOs to support timely recognition and intervention, ultimately saving mothers’ lives.⁷ SMOs occur when a woman experiences life-threatening complications during pregnancy, childbirth, or the postpartum period. They include both maternal deaths and situations where a woman nearly dies but survives, commonly referred to as “maternal near-miss” (MNM) events.^6,7 SMOs have profound consequences not only for the immediate health of the mother and newborn but also for their long-term physical, emotional, and financial well-being.^8,9 These outcomes may result in chronic health problems for the mother, increased risk of psychological distress, and significant financial strain on families.^10–12 SMOs are a major concern in both high- and low- to middle-income countries, although the burden varies widely. A global review reported that SMO rates average fewer than 8 per 1000 live births in high-income countries, 27 per 1000 in Asia, 7.7 in North Africa and the Middle East, 15.3 in Latin America, and substantially higher rates in Sub-Saharan Africa.¹³ In South Korea, about 2.4% of women experience an SMO.¹⁴ In Rwanda, the incidence is 38.4 per 1000 live births.¹⁵ In Ethiopia, estimates vary considerably, ranging from 37.5 to 84 cases per 1000 live births.^16–18 This wide variation underscores the diverse healthcare challenges and disparities across different regions of the country.

Previous studies have identified obstetric hemorrhage, particularly postpartum hemorrhage, along with preeclampsia-eclampsia syndrome, severe systemic infection, anemia, obstructed labor, complications of abortion, and other indirect obstetric conditions as the leading causes of SMOs.^17,19–24 Research conducted in Ethiopia on SMOs and their underlying causes reveals significant regional variation and a lack of comprehensive national evidence. To address this gap and generate reliable data for guiding best practices, this systematic review and meta-analysis were undertaken. It aims to consolidate existing evidence to estimate the pooled incidence proportion of SMOs in Ethiopia and to identify their major underlying causes.

Method and materials

This systematic review was conducted to estimate the pooled incidence proportion of SMOs among Ethiopian women. The protocol was registered in the International Prospective Register of Systematic Reviews under the registration number CRD42024629544, available at: https://www.crd.york.ac.uk/prospero/#recordDetails. A comprehensive literature search was carried out in major international databases, including PubMed, Cochrane Library, Google Scholar, Scopus, and Hinari Research4Life. In addition, the reference lists of eligible studies were reviewed to identify any further relevant articles.

The search strategy was guided by the Condition, Context, and Population (CoCoPop) framework. The condition was SMO, the population was pregnant or postpartum women, and the context was Ethiopia. The primary outcome of interest was SMOs among pregnant women in Ethiopia. For each CoCoPop component, electronic databases were searched using keywords and Medical Subject Headings. The search terms included combinations of the following: “SMO,” “maternal mortality,” “severe maternal morbidity,” “maternal near miss,” “life-threatening condition,” and “potentially life-threatening complication,” combined with “Ethiopia.” Boolean operators “OR” and “AND” were applied to structure the search effectively (S1).

Outcome measurement

The primary outcome of interest was SMOs, assessed using the WHO MNM criteria. This standardized tool identifies near-miss cases based on 25 indicators of organ or system dysfunction, including cardiovascular, respiratory, renal, coagulation, hepatic, neurologic, and uterine complications, measured through clinical, laboratory, and management-based parameters.⁷ Severe maternal morbidity, in contrast, is identified from a list of potentially life-threatening conditions from which near-miss cases may arise. The primary outcome for this review was the incidence proportion of SMOs in Ethiopia, while secondary outcomes focused on the immediate underlying causes of SMOs, such as hypertensive disorders of pregnancy, obstetric hemorrhage, uterine rupture, severe systemic infection, and early pregnancy complications. Accordingly, the review aimed to answer two key questions: (1) what is the incidence proportion of SMOs in Ethiopia? and (2) what are the immediate underlying causes of SMOs in the country?

Eligibility criteria and study selection

This systematic review and meta-analysis included studies conducted in Ethiopia that either reported the prevalence, magnitude, or incidence proportion of SMOs based on the WHO MNM criteria or examined predictors, associated factors, or determinants of SMOs. Only studies published in English between January 2016 and January 1, 2025, were considered. We excluded studies that did not meet the inclusion criteria, including case reports, case series, surveillance data (e.g., demographic and health surveys), conference abstracts, editorials, and commentaries. Studies without full-text access despite at least two attempts to contact the corresponding authors, as well as those that did not clearly define SMOs using WHO MNM criteria or lacked relevant primary data, were also excluded. All identified articles were imported into EndNote 20 for citation management. Duplicate records were automatically removed before screening through EndNote 20 management. Study selection was carried out in two stages: an initial screening of titles and abstracts, followed by a full-text review of potentially eligible articles. Three independent reviewers (TNK, KAA, and TM) performed the screening to ensure accuracy and minimize bias. Any disagreements were resolved through discussion and, when necessary, with the involvement of a third reviewer. Studies that fulfilled the eligibility criteria were included in the final review.

Quality assessment and data abstraction

This systematic review and meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 checklist (S2).²⁵ The Newcastle–Ottawa Scale (NOS) quality assessment tool was used to assess the quality of the included studies. The tool contains three components: selection of the study groups, comparability of the study groups, and ascertainment of exposure or outcome.²⁶ The tool’s core component, which was rated on a five-star scale, focused mostly on each primary study’s methodological quality. The tool’s other component, which was rated between two stars, focused mostly on how comparable each study was. The tool’s final component, which was rated from three stars, was used to assess each original study’s statistical analysis and findings. Three category criteria totaling a maximum of nine points were included in the NOS. Each study’s quality was evaluated using one of the following scoring algorithms: studies with a score of greater than or equal to seven were deemed “good,” those with a score of five to six were deemed “satisfactory,” and those with a score of less than or equal to four were deemed “poor.” This systematic review result is more valid now because only primary studies of medium to good quality have been included. Then, the two reviewers (TNK and KAA) independently extracted the pertinent data from the selected articles using a standardized data extraction format prepared in Microsoft Excel. The data extraction format included primary author, publication year, study region (area), total live birth, number of SMO cases, maternal mortality index (MMI), prevalence or incidence of SMO, and the leading immediate causes of SMO were all included in the data extraction format. Were taken based on the available articles (S3). Then it was exported to STATA version 17 (StataCorp LLC, College Station, Texas, USA) for analysis.

Publication bias and statistical analysis

Publication bias was assessed through visual inspection of funnel plots and Egger’s test, with a p-value of less than 0.05 considered indicative of bias.^27,28 Heterogeneity among studies was evaluated using the I² statistic, with a p-value < 0.05 indicating significant heterogeneity. The meta-analysis revealed substantial heterogeneity (I² = 99.9%, p < 0.001), suggesting that the variability in effect estimates was not due to chance alone. Given this high heterogeneity, a random-effects model was employed to estimate the pooled effect size. The results of the meta-analysis were presented using forest plots. To investigate potential sources of heterogeneity, subgroup analyses were conducted based on relevant study-level characteristics. Additionally, sensitivity analyses were performed to determine whether the pooled prevalence estimates were influenced by individual studies.

Result

Study identification and characteristics of included studies

This systematic review and meta-analysis examined published studies on SMOs in Ethiopia using international electronic databases. A total of 1488 articles were initially identified. After removing 129 duplicates, 1296 articles were excluded during the title and abstract screening process. Subsequently, 63 full-text articles were assessed for eligibility based on predefined inclusion and exclusion criteria. Of these, 50 studies were excluded because they did not address the primary outcomes of interest, focusing solely on MNM cases without including maternal mortality. Ultimately, 13 studies met the inclusion criteria and were included in the final quantitative meta-analysis (Figure 1).

Figure 1.

PRISMA flow diagram showing the study selection process for the systematic review and meta-analysis on severe maternal outcomes and their underlying causes in Ethiopia.

Characteristics of the included studies

Among the included studies, 12 employed a cross-sectional design, and one was a prospective follow-up study. All studies reported the incidence proportion, MMI, and underlying causes of SMOs. Collectively, the review included 2451 women with SMOs and 67,954 live births in Ethiopia. The highest incidence proportion of SMOs (94.6 per 1000 live births) was reported in a study conducted in Eastern Ethiopia,²⁹ followed by Oromia (73.5 per 1000 live birth),³⁰ while the lowest incidence proportion (20.8 per 1000 live births) was reported in the Oromia region.³¹ The 13 studies were conducted across 5 regions of Ethiopia: four studies in Oromia,^16,30,32,33 one from the Tigray region,³⁴ four from the Southern Nations, Nationalities, and Peoples’ Region (SNNPR),^17,23,35,36 two from Eastern Ethiopia (Dire Dawa),^29,31 and two from the Amhara region^20,24 (Table 1).

Table 1.

The characteristics of the included studies on late request for safe abortion and its determinants among reproductive age women in Ethiopia.

Author	Year of publication	Study setting	Study design	No. SMO	Incidence proportion of SMO per 1000 live births
Kamangira B et al	2024	Oromia	Cross-sectional	61	42.9
Tura AK et al.	2018	Eastern Ethiopia	Cross-sectional	154	20.8
Wakgar N et al.	2019	SNNPR	Cross-sectional	591	39.2
Beyene T et al.	2022	SNNPR	Cross-sectional	108	37.5
Kebede TN et al.	2025	Amhara	Prospective follow up	84	26.5
Ayele B et al.	2016	SNNPR	Cross-sectional	229	26.9%
Regassa WM et al.	2024	Oromia	Cross-sectional	116	35.6
Woldeyes WS et al.	2018	Oromia	Cross-sectional	162	59.2
Tenaw SG et al.	2021	Eastern Ethiopia	Cross-sectional	111	94.6
Abdulrazaq B et al.	2020	Oromia	Cross-sectional	352	73.5
Teka H et al.	2019	Tigray	Cross-sectional	170	33.2
Yemane Y et al.	2020	SNNPR	Cross-sectional	227	41
Mekonnin AW et al.	2019	Amhara	Cross-sectional	86	31.9

SMO: severe maternal outcome; SNNPR: southern nations, nationalities, and peoples’ region.

Incidence proportion of SMO

The meta-analysis of thirteen studies estimated the pooled incidence proportion of SMOs in Ethiopia to be 41.74 per 1000 live births (95% CI: 29.58–53.89). A random-effects model was used due to substantial heterogeneity among the studies (I² = 99.9%, p < 0.001), indicating that SMO incidence varies considerably across different settings within the country. Despite this variation, no significant differences were noted in study methodologies or data collection tools, as all studies applied the WHO MNM criteria. Regionally, the highest pooled incidence was observed in Eastern Ethiopia (57.70%), whereas the lowest was reported in the Amhara region (29.18%), which also exhibited the lowest within-group heterogeneity (Figure 2).

Figure 2.

Forest plot showing the pooled incidence proportion of severe maternal outcomes in Ethiopia, based on a meta-analysis of eligible studies.

Subgroup analysis

A subgroup analysis was performed to explore potential sources of heterogeneity in the incidence proportion of SMOs based on study settings. This analysis, however, did not substantially reduce heterogeneity. Extremely high variation was observed in the Oromia region and Eastern Ethiopia (I² = 100%). In the SNNPR, heterogeneity remained high but was slightly lower than in Oromia and Eastern Ethiopia (I² = 99.4%). The Amhara region exhibited the lowest heterogeneity among subgroups, though it was still considerable (I² = 95.1%). Despite these variations within regions, differences between regions were not statistically significant (p = 0.398). A detailed review of the included studies revealed no major methodological differences that could account for the high heterogeneity (Figure 3).

Figure 3.

Subgroup analysis comparing the incidence proportion of SMO across different regions in Ethiopia.

Sensitivity analysis

The sensitivity analysis showed that individual study estimates ranged from 37.33 per 1000 live births (Tenaw SG et al., 2021) to 43.92 per 1000 live births (Regassa WM et al., 2024), with overlapping confidence intervals. This indicates consistency across studies despite some variability. The overall pooled estimate of SMOs was 41.74 per 1000 live births (95% CI: 29.58–53.89), suggesting that, on average, the incidence falls within this range. The analysis confirmed the robustness of the meta-analysis, as the pooled estimate remained stable even when individual studies were omitted, indicating that no single study disproportionately influenced the overall result. The narrow range of estimates (37.33–43.92) further supports the reliability of the findings. This stability reinforces the validity and generalizability of the meta-analysis conclusions (Table 2 and Figure 4).

Table 2.

The sensitivity analysis report of incidence proportion of SMO in Ethiopia.

Study omitted	Estimate	95% confidence interval
Kamangira B et al. (2024)	41.639381	28.871498–54.407265
Tura AK et al. (2018)	43.482132	30.452465–56.511795
Wakgar N et al. (2019)	41.948044	27.987038–55.909046
Beyene T et al. (2022)	42.08902	29.170261–55.007778
Kebede TN et al. (2025)	43.005741	30.077188–55.934292
Ayele B et al. (2016)	42.973499	29.605442–56.341557
Regassa WM et al. (2024)	43.924248	31.501398–56.347099
Woldeyes WS et al. (2018)	40.2901	27.62244–52.95776
Tenaw SG et al. (2021)	37.326218	28.080549–46.571888
Abdulrazaq B et al. (2020)	39.087578	27.427208–50.747944
Teka H et al. (2019)	42.447803	29.30831–55.587299
Yemane Y et al. (2020)	41.79763	28.662882–54.932381
Mekonnin AW et al. (2019)	42.55545	29.647982–55.462925
Combined	41.736089	29.582482–53.889696

SMO: severe maternal outcome.

Figure 4.

Leave-one-out sensitivity analysis plot for the pooled incidence proportion of severe maternal outcomes in Ethiopia.

Publication bias

Publication bias was assessed using a funnel plot and Egger’s test. The funnel plot appeared symmetrical, and the results of Egger’s test supported this observation. The slope coefficient was 14.13 (p = 0.471), and the bias coefficient was 40.22 (p = 0.228), indicating no significant asymmetry. These non-significant p-values suggest that publication bias is unlikely, and the findings of this meta-analysis are robust and not substantially affected by it (Figure 5).

Figure 5.

Funnel plot assessing potential publication bias in the meta-analysis of the incidence proportion of severe maternal outcomes in Ethiopia.

Mortality index

The meta-analysis of 12 studies estimated the pooled MMI in Ethiopia to be 10.53%. The MMI is an important indicator of the quality of maternal healthcare, with lower values suggesting that a higher proportion of women with life-threatening conditions survive, reflecting better quality of care. An MMI of 10.53% indicates that, on average, for every 100 women who experience a MNM event, approximately 10.53 women die from maternal causes in Ethiopia (Figure 6).

Figure 6.

Forest plot showing the pooled incidence ratio of the Maternal Mortality Index (MMI) in Ethiopia, based on a meta-analysis of eligible studies.

The underlining causes of SMO in Ethiopia

The meta-analysis identified the main underlying causes of SMO in Ethiopia. These include PIH specifically preeclampsia with severe features and eclampsia obstetric hemorrhage, which encompasses both antepartum and postpartum bleeding, uterine rupture, severe systemic infections such as sepsis, and complications arising from early pregnancy bleeding, including unsafe abortion and ectopic pregnancy.

Pregnancy-induced hypertension

PIH, including preeclampsia with severe features and eclampsia, accounts for a substantial proportion (40.8%) of SMO in Ethiopia. This finding identifies PIH as the leading direct cause of SMO nationally. Given its significant contribution, addressing PIH should be a top priority in maternal health interventions. Targeted efforts to improve early detection, timely management, and effective referral systems for hypertensive disorders during pregnancy are critical to reducing maternal morbidity and mortality and enhancing overall maternal outcomes throughout pregnancy, childbirth, and the postpartum period (Figure 7).

Figure 7.

Forest plot illustrating the pooled incidence proportion of pregnancy-induced hypertension as an underlying cause of severe maternal outcomes in Ethiopia.

Obstetrical hemorrhage

Obstetric hemorrhage, primarily postpartum hemorrhage (PPH) followed by antepartum hemorrhage, was identified as the second leading cause of SMO in Ethiopia, contributing 24.94% according to this meta-analysis. The high burden of PPH highlights the urgent need for strengthened prevention, early recognition, and prompt management strategies within maternal health services. Prioritizing clinical training, ensuring access to essential supplies such as uterotonics and blood products, and implementing timely referral systems are essential to mitigate the life-threatening impact of hemorrhage during childbirth and significantly improve maternal survival (Figure 8).

Figure 8.

Forest plot showing the pooled incidence proportion of obstetrical hemorrhage as an underlying cause of severe maternal outcomes (SMO) in Ethiopia.

Uterine rupture

This meta-analysis revealed that uterine rupture was identified as the third leading underlying cause of SMO in Ethiopia, contributing 19.61%. This finding is particularly concerning, as uterine rupture remains a major contributor to maternal morbidity and mortality despite being largely preventable with timely and appropriate obstetric care. The persistence of this condition as a leading cause of SMO decades after it was prevalent in the 20th century underscores critical gaps in access to quality intrapartum care, particularly in rural and resource-limited settings. These results highlight an urgent need to strengthen emergency obstetric care, ensure skilled birth attendance, and promote timely referrals to prevent avoidable maternal complications and deaths (Figure 9).

Figure 9.

Forest plot depicting the pooled incidence proportion of uterine rupture as an underlying cause of severe maternal outcomes in Ethiopia.

Severe systemic infection

This meta-analysis identified severe systemic infection as the fourth leading underlying cause of SMO in Ethiopia, accounting for 11.65% of cases. With over 1 in 10 SMO cases resulting from infections, infection-related complications represent a critical area of concern in maternal health. These findings underscore the urgent need to strengthen infection prevention and management strategies within maternal health services. Key areas for improvement include enhancing hygiene practices during childbirth, ensuring timely and appropriate medical interventions, and expanding access to quality healthcare services to reduce infection-related complications (Figure 10).

Figure 10.

Forest plot showing the pooled incidence proportion of severe systemic infection as an underlying cause of severe maternal outcomes in Ethiopia.

Early trimester pregnancy complication

Early trimester pregnancy complications, such as abortion and ectopic pregnancy, were identified as the fifth leading underlying cause of SMO in Ethiopia, accounting for 7.74%. With nearly 8% of SMOs resulting from early pregnancy complications, these conditions represent a notable cause of life-threatening maternal events and require focused attention within maternal health strategies. This underscores the importance of improving early pregnancy care, access to timely diagnosis, and appropriate interventions to reduce the risks associated with these complications and prevent adverse maternal outcomes (Figure 11).

Figure 11.

Forest plot illustrating the pooled incidence proportion of early trimester pregnancy complications including abortion and ectopic pregnancy as underlying causes of severe maternal outcomes in Ethiopia.

Discussion

This systematic review and meta-analysis found that the pooled incidence proportion of SMO in Ethiopia is 41.74 per 1000 live births (95% CI: 29.58–53.89). This finding aligns with several studies conducted in other countries, including Tanzania (40.23 per 1000 live birth),³⁷ Uganda (31.9 per 1000 live birth),³⁸ Rwanda (38.4 per 1000 live births),¹⁵ and India (30.29 per 1000 live births).³⁹ The persistently high incidence of SMO across these settings indicates systemic challenges in maternal healthcare delivery, including delays in recognizing complications, limited access to timely and quality obstetric care, and insufficient implementation of evidence-based interventions.^40,41 These findings underscore the urgent need for targeted strategies to reduce SMO, such as strengthening early detection and management of obstetric complications, improving referral systems, ensuring the availability of essential medications and blood products, and providing continuous training for healthcare providers. Addressing these gaps could significantly improve maternal survival and contribute toward achieving national and global maternal health targets.^42–45

The findings of this systematic review and meta-analysis indicate a significantly higher incidence of SMO in Ethiopia compared to studies conducted in other countries. Like, the reported incidence of SMO is lower in Somaliland (17.69 per 1000 live birth),⁴⁶ referral hospitals in Northern Tanzania (27.2 per 1000 live birth),⁴⁷ South west Uganda (23.46 per 1000 live birth),⁴⁸ Kenya (10.42 per 1000 live birth),⁴⁹ tertiary care hospital in Rwanda (11 per 1000 live births),⁵⁰ Pretoria south Africa (5.8 per 1000 live birth),⁵¹ Egypt (6.5 per 1000 live births),⁵² four regions (Egypt, Lebanon, Palestine, and Syria; 8.5 per 1000 live births).⁵³ Several factors may explain these discrepancies. First, geographical, population, economic, and health system differences, as well as variations in healthcare infrastructure, may be contributed to the burden of SMO across different countries. Second, Ethiopia has experienced political instability since 2016, with severe and prolonged conflicts intensifying from 2021 onward.^54–56 This instability has likely weakened the country’s healthcare system, may be contributing to higher SMO rates in this study compared to other nations. Third, Ethiopia is home to more than 80 ethnic groups with diverse cultures, traditions, and lifestyles.^57,58 These variations in socio-cultural and economic factors may influence health-seeking behaviors, which in turn may affect maternal health outcomes. In low-income countries like Ethiopia, disparities in education, income, cultural beliefs, and access to healthcare may be related to differences in how and when women seek maternal health services. Such variations may contribute to the observed differences in maternal morbidity and mortality rates across different population groups.^59–61 Lastly, regional disparities in the distribution, accessibility, and readiness of healthcare infrastructure including the availability of Comprehensive Emergency Obstetric and Newborn Care (CEmONC) services, access to skilled birth attendants, and effective referral systems are likely major contributors to the high incidence of SMO in Ethiopia.^62–64

Addressing the structural and systemic challenges that contribute to the high incidence of SMO in Ethiopia is essential for improving maternal health and reducing preventable morbidity and mortality. Evidence suggests that delays in recognizing obstetric complications, limited access to timely and quality care, and insufficient implementation of evidence-based practices are major determinants of SMO.^65–69 To mitigate these risks, implementing evidence-based interventions such as standardized protocols for managing obstetric emergencies, active monitoring of high-risk pregnancies, adherence to infection prevention practices and ensuring timely access to appropriate and high-quality obstetric care are vital; it can significantly improve maternal survival.^69–71 Strengthening healthcare infrastructure, including expanding access to skilled birth attendants, ensuring the availability of essential medications and blood products, and improving referral systems, addresses critical gaps in emergency obstetric care,^71,72 Additionally, tackling socio-cultural barriers, such as low health literacy, traditional beliefs, and gender inequities, can enhance timely care-seeking behaviors and utilization of maternal health services. Collectively, these targeted strategies provide a comprehensive approach to reducing SMO, promoting equity in maternal health, and achieving sustainable improvements aligned with national and global maternal health goals.^61,73–76

In contrast, the findings of this systematic review and meta-analysis on SMO are lower than those reported in South Sudan (104.63 per 1000 live births),⁷⁷ and Nigeria (83.53 per 1000 live births).²² This difference may be attributed to variations in geography, population characteristics, and healthcare system factors. In particular, South Sudan faces significant challenges in maternal healthcare, contributing to its high SMO rates. The country has one of the weakest healthcare systems globally, with poor access to health services due to an acute health workforce shortage, inadequate health infrastructure, and poor health service utilization. These factors result in poor health indicators, including some of the highest maternal, infant, and child mortality rates in the world.^78,79 In addition, the ongoing military conflict in Sudan has worsened healthcare challenges by destroying vital infrastructure, including clinics and hospitals, and displacing healthcare workers. These systemic difficulties, such as limited access to healthcare facilities, inadequate transportation infrastructure, and a lack of awareness about the significance of prompt and expert maternity care, frequently cause delays in seeking and receiving maternal healthcare.⁸⁰ These findings underscore the importance for Ethiopia and similar settings to learn from such contexts by safeguarding healthcare infrastructure, retaining skilled birth attendants, and strengthening health system resilience to ensure timely and quality maternal care. In Nigeria, despite being Africa’s most populous country, it also faces critical challenges in maternal healthcare. The healthcare sector consistently receives a lower budget allocation than the 15% benchmark set by the Abuja Declaration of 2001, leading to underfunded health facilities lacking necessary resources and medical equipment.^81,82 Moreover, the country experiences a severe brain drain in the medical sector, with a high number of healthcare professionals emigrating in search of better opportunities. This shortage results in overworked healthcare personnel, longer patient wait times, and reduced quality of care. The lack of trust in the underfunded and inadequately staffed healthcare system exacerbates the issue, contributing to delays in seeking care and increased maternal mortality.⁸¹ Ethiopia could learn from Nigeria’s challenges by proactively addressing healthcare financing and workforce retention. Allocating at least 15% of the national budget to the health sector, as recommended by the Abuja Declaration, would strengthen health infrastructure, ensure the availability of essential medical equipment, and improve service delivery.

This meta-analysis revealed that the pooled incidence ratio of the MMI in Ethiopia is 10.53% (95% CI: 7.71–13.36), which is consistent with studies conducted in Tanzania (11.43% and 12.9%),^37,47 south Sudan (9.6%),⁷⁷ south Africa (12.25%),⁵¹ Egypt (7.5%),⁵² and India (12.53%).³⁹ These comparable rates suggest that, despite variations in maternal mortality across countries, the quality of care aimed at preventing maternal deaths in Ethiopia is relatively similar to other low- and middle-income countries facing comparable health system challenges. To address these challenges, evidence-based strategies have been shown to be effective. Implementing standardized protocols for managing obstetric emergencies, enhancing referral systems, and actively monitoring high-risk pregnancies can significantly reduce maternal mortality.^43,69 Furthermore, addressing socio-cultural barriers, such as low health literacy, traditional beliefs, and gender inequities, is crucial to improve care-seeking behaviors and utilization of maternal health services.^61,73,83,84 Collectively, these interventions can contribute to reducing SMOs, improving equity in maternal health, and achieving sustainable progress toward national and global maternal health targets.

However, the MMI in Ethiopia is significantly higher than the rates reported in Rwanda (6%),¹⁵ Kenya (4.5%),⁴⁹ and Egypt (7.6%).⁵² This discrepancy may be due to differences in population characteristics, geographical regions, and healthcare systems.⁸⁵ Specifically, in Egypt, data were retrospectively collected through chart reviews. In such cases, some findings may not be recorded in patient charts, either intentionally or unintentionally, leading to the omission of important data related to maternal outcomes. In contrast, nearly all studies included in this review were prospective cross-sectional or prospective follow-up studies.⁵² In Rwanda, the study was conducted in four rural district hospitals, which may have made it difficult to capture the outcomes of all mothers diagnosed with SMO. If district hospitals were not equipped to manage severe cases, women were often referred to tertiary hospitals, a routine practice in Ethiopia as well. This referral system may reduce the number of maternal deaths recorded in district hospitals, compared to the reported incidence of SMO.¹⁵ These findings underscore the importance of strengthening data collection systems and ensuring accurate reporting of maternal deaths. Implementing standardized protocols for maternal death reviews and enhancing the capacity of healthcare facilities to manage obstetric emergencies can contribute to more accurate data and improved maternal health outcomes.⁸⁶

In contrast, the MMI reported in this systematic review and meta-analysis is lower than the rates reported in Somaliland (26.2%),⁴⁶ Uganda (15.8% and 16%),^38,48 and tertiary care hospital in Rwanda (20%).⁵⁰ This variation may be attributed to differences in population characteristics, geography, healthcare systems, and infrastructure. Specifically, the study conducted in the tertiary care hospital in Rwanda took place between 2011 and 2012, whereas this meta-analysis includes studies conducted from 2016 to 2025,⁵⁰ with most studies conducted after 2018. This time gap may significantly contribute to the observed differences. Healthcare systems and infrastructure have improved between 2011 and 2018 and continue to evolve up to 2025. During this period, there has likely been increased access to healthcare facilities, a higher number of healthcare providers, and improved access to comprehensive obstetric care compared to the earlier years.^64,87,88 These advancements may explain why MMI was higher in Rwanda in the past. Regarding Somaliland, the region has been striving for independence from Somalia, and its healthcare infrastructure and related parameters are not equivalent to those in Ethiopia. This disparity may explain why SMO is relatively low, while MMI remains high in Somaliland.⁸⁹ These observations underscore the importance for Ethiopia to sustain and further strengthen its maternal health system. Specifically, Ethiopia should continue expanding access to comprehensive obstetric care, maintain and scale up the training of skilled birth attendants, reinforce referral networks, and ensure the availability of essential medical equipment and supplies.^90,91 Additionally, ongoing monitoring and evaluation of maternal health indicators can guide targeted interventions, addressing persistent gaps and preventing increases in MMI.^92,93 By sustaining these efforts, Ethiopia can further reduce SMOs, improve equity in maternal health, and progress toward national and global maternal mortality reduction targets.

This meta-analysis identified the primary underlying causes of SMO in Ethiopia as PIH (including preeclampsia with severe features and eclampsia), obstetric hemorrhage (antepartum and postpartum), uterine rupture, severe systemic infections, and early pregnancy complications such as abortion-related and ectopic pregnancy-related bleeding, listed in order of their relative contribution.

This meta-analysis showed that PIH (40.9%, 95% CI: 30.26–51.35) and obstetrical hemorrhage (24.96%, 95% CI: 20.7–29.19) are the primary leading causes of SMO in Ethiopia. This finding is consistent with studies from Kenya,⁴⁹ Uganda,^38,48 Egypt,⁵² Somaliland,⁴⁶ and Tanzania³⁷ where PIH and obstetric hemorrhage are also the primary causes of SMO. This highlights the high prevalence of these two obstetric complications and their significant contribution to maternal morbidity and mortality in many countries. Therefore, special attention is needed to focus on prevention, early detection, and timely management to reduce severe morbidity and maternal deaths. However, in Nigeria, the leading causes of SMO are sepsis (40%), PIH (11.1%), and obstructed labor (8.8%).²² These inter-country differences may stem from geographic, demographic, and systemic variations in healthcare delivery. Differences in access to emergency obstetric services, referral efficiency, staffing levels, and quality of care may further explain why sepsis plays a larger role in Nigeria than in Ethiopia.^94–96 PIH remains a leading cause of SMO in Ethiopia, contributing significantly to maternal morbidity and mortality. The prevalence of PIH in Ethiopia ranges from 2.2% to 18.3%, with approximately 10% of maternal deaths attributed to this condition.^97,98 This underscores the urgent need for targeted interventions to mitigate its impact. Strengthening antenatal care (ANC) services is crucial for early detection and management of PIH. Routine blood pressure monitoring during ANC visits enables the timely identification of hypertensive disorders, allowing for prompt intervention. Ensuring that all pregnant women have access to regular ANC visits can significantly reduce the progression to severe disease.^99,100 Furthermore, integrating remote blood pressure monitoring into ANC services has shown promise in improving the management of hypertensive disorders.¹⁰¹ Training and capacity building of healthcare providers are essential to improve the management of PIH and obstetrical hemorrhage. Equipping healthcare workers with the necessary skills and knowledge to identify and manage hypertensive disorders can enhance the quality of care and reduce maternal and perinatal complications.^102,103 Improving health literacy among pregnant women is vital for early detection and management of PIH. Educating women about the risks and signs of hypertensive disorders can empower them to seek timely care, thereby reducing delays in treatment and improving maternal outcomes.¹⁰⁴ Strengthening referral systems is also critical to ensure that women with severe PIH receive appropriate care. Establishing efficient referral pathways between primary, secondary, and tertiary healthcare facilities can facilitate the timely management of hypertensive disorders and prevent adverse outcomes.^105,106 Implementing these evidence-based interventions can significantly reduce the burden of PIH in Ethiopia and similar settings. By enhancing ANC services, training healthcare providers, improving health literacy, and strengthening referral systems, Ethiopia can make substantial progress toward reducing maternal morbidity and mortality associated with hypertensive disorders. Reducing SMO related to obstetric hemorrhage requires the systematic implementation of evidence-based strategies that span prevention, early detection, and timely, effective management. This is particularly crucial in low-resource settings such as Ethiopia, where limitations in healthcare infrastructure can exacerbate maternal risks.¹⁰⁷ Strengthening the capacity of healthcare providers through targeted training in the recognition and management of postpartum hemorrhage, including the appropriate use of uterotonic agents, timely surgical interventions, and other life-saving measures, has been shown to significantly improve maternal outcomes.¹⁰⁸ Furthermore, integrating the latest evidence-based guidelines into routine practice, coupled with continuous professional development to update providers on emerging best practices, is essential to ensure high-quality care and minimize preventable maternal morbidity and mortality.^109,110 Based on this meta-analysis, the third leading cause of SMO in Ethiopia is uterine rupture, accounting for 19.61% (95% CI: 6.14–33.07). This finding is consistent with studies from Rwanda, where uterine rupture accounts for 22.9%, following obstetric hemorrhage (23.4%),¹⁵ South Sudan, where it accounts for 25%, second to obstetric hemorrhage (33.7%),⁷⁷ and Uganda uterine rupture contributes 5.5% of SMO.⁴⁸ This finding highlights that uterine rupture is a major public health concern, significantly contributing to maternal morbidity and mortality. Targeted interventions are essential to address this burden and safeguard the health of childbearing women, especially in low- and middle-income countries. Significance of uterine rupture, particularly in sub-Saharan Africa. Its high contribution to SMO indicates systemic gaps in timely access to skilled obstetric care, delays in referral, and the inadequacy of emergency obstetric services, especially in rural and underserved areas.⁶⁶ The primary causes of uterine rupture, obstructed labor, lack of timely cesarean delivery, and previous uterine surgery are largely preventable with appropriate ANC and emergency obstetric services. Studies have shown that careful birth preparation, early recognition of obstructed labor, close monitoring, and timely intervention are critical in preventing maternal deaths due to uterine rupture.^111–113 Addressing uterine rupture requires a multifaceted approach. Strengthening EmONC by ensuring that all health facilities are equipped to manage obstetric emergencies, including timely cesarean sections, is crucial.¹¹⁴ Improving referral systems through efficient pathways between primary, secondary, and tertiary healthcare facilities facilitates prompt management of obstetric complications and prevents adverse outcomes.¹¹³ Enhancing ANC allows for the early detection of risk factors such as obstructed labor and previous uterine surgeries, enabling timely interventions.^112,115 Training mid-level healthcare providers in EmONC is crucial for preventing uterine rupture, particularly in remote areas where access to specialized care is limited.^116,117

This meta-analysis also reports that severe systemic infection (11.65%, 95% CI: 7.73–15.57) and early pregnancy complications, mainly abortion and ectopic pregnancy (7.7%, 95% CI: 4.97–10.5), contribute to SMO. This finding aligns with studies from Rwanda, where first-trimester pregnancy complications account for 16.8% of SMO,¹⁵ South Sudan, where severe systemic infection and early pregnancy complications contribute to 11.5% and 12.6% of SMO, respectively,⁷⁷ and Tanzania, where they account for 8.57% and 7.3%, respectively.³⁷ The convergence of data from multiple settings highlights that severe infections and early pregnancy complications remain significant and preventable causes of maternal morbidity and mortality across the region. This underscores the urgent need for targeted interventions focusing on prevention strategies, timely diagnosis, and prompt management. Strengthening access to quality ANC, improving post-abortion care services, and enhancing infection control protocols are essential measures to reduce the burden of SMO linked to these conditions, particularly in resource-limited settings.^118–121 Early pregnancy complications, including ectopic pregnancies, spontaneous abortions, and severe infections, are significant contributors to SMO. Addressing these complications is crucial, especially in resource-limited settings like Ethiopia, where healthcare infrastructure may be limited. Implementing evidence-based prevention strategies can substantially reduce maternal morbidity and mortality associated with these conditions. Early initiation of ANC is vital for early detection and management of high-risk pregnancies. The WHO emphasizes that ANC reduces maternal and perinatal morbidity and mortality by facilitating the identification and management of complications during pregnancy.¹⁰⁰ Improving post-abortion care services, including safe and timely management of incomplete abortion and ectopic pregnancy, is essential to reduce preventable maternal complications.¹²² Infection-related complications are a leading cause of SMO. Strengthening infection prevention and control (IPC) protocols within healthcare facilities, alongside provider training on early recognition and management of sepsis, is critical.¹²³ Implementing robust IPC protocols in healthcare facilities is essential to reduce infection-related maternal and neonatal morbidity and mortality. The WHO underscores the importance of standard precautions, which include hand hygiene, sterilization of instruments, and maintaining a clean environment, to prevent healthcare-associated infections.¹²⁴ These protocols are critical in maternity and neonatal care settings, where the risk of infection is heightened due to invasive procedures and the vulnerability of patients.

Limitations of the review

The primary limitation of this systematic review on SMO is that it includes only 13 studies conducted across 5 regions of the country. The lack of data from other regions limits the ability to fully capture regional variations in SMO. This restricted geographical coverage may reduce the representativeness of the findings and limit the generalizability of the conclusions at the national level. Additionally, the results exhibit significant heterogeneity, indicating variability among findings from different regions. Consequently, these findings should be interpreted with caution, considering potential regional differences and the lack of representation from all areas of the country.

Conclusion

The pooled incidence proportion of SMO and MMI in Ethiopia is higher compared to reports from most other countries. PIH, obstetric hemorrhage, uterine rupture, severe systemic infection, and early pregnancy complications have been identified as the primary underlying causes of SMO in the country. Reflect preventable or manageable conditions when timely and effective care is provided. These findings carry important implications for programmatic and policy interventions. At the national level, the Ethiopian government and the Ministry of Health should give special attention to reducing maternal mortality and morbidity by targeting these leading causes. This requires strengthening EmONC services, ensuring the establishment and regular monitoring of fully equipped maternity units, and guaranteeing the continuous availability of essential medicines, blood products, and medical equipment. Policymakers should also integrate these evidence-based strategies into national and regional maternal health plans to ensure coordinated, multisectoral action.

At the health facility level, managers and professional associations should ensure ongoing training and competency-based certification of healthcare providers in the recognition, prevention, and management of high-risk pregnancies, postpartum hemorrhage, sepsis, and early pregnancy complications. In parallel, healthcare providers themselves are expected to play a central role in early detection, timely implementation of prevention strategies, and provision of evidence-based clinical management to safeguard the lives of women and newborns. Higher education institutions that train midwives and other healthcare providers must ensure that their graduates are equipped with the necessary knowledge, competencies, and clinical skills to manage obstetric emergencies effectively and provide evidence-based, quality maternal health services across the continuum of care.

Non-governmental organizations (NGOs) working in maternal and child health should focus on strengthening the capacity of maternal healthcare providers through training, mentorship, and dissemination of the latest evidence-based interventions. By supporting health facilities with technical and material resources, NGOs can play a vital role in filling service gaps and improving the quality of care. At the community level, health extension workers and local organizations should expand maternal health education programs to raise awareness on danger signs of pregnancy, promote timely care-seeking behaviors, and emphasize the importance of skilled birth attendance. Strengthening community-facility linkages is critical for ensuring that women receive care promptly when complications arise. If implemented collaboratively, these targeted interventions will not only reduce preventable maternal morbidity and mortality but also improve neonatal outcomes and generate broader social and economic benefits for women, families, and the country as a whole.

Supplemental Material

sj-docx-1-whe-10.1177_17455057251387475 – Supplemental material for Severe maternal outcomes and their underlying causes in Ethiopia. Systematic review and meta-analysis

Supplemental material, sj-docx-1-whe-10.1177_17455057251387475 for Severe maternal outcomes and their underlying causes in Ethiopia. Systematic review and meta-analysis by Tirusew Nigussie Kebede, Kidist Ayalew Abebe, Worku Taye Getahun, Birhan Tsegaw Taye, Temesgen Dessie Mengistu, Bezawit Melak Fente, Moges Sisay Chekole and Tebabere Moltot in Women's Health

Supplemental Material

sj-docx-2-whe-10.1177_17455057251387475 – Supplemental material for Severe maternal outcomes and their underlying causes in Ethiopia. Systematic review and meta-analysis

Supplemental material, sj-docx-2-whe-10.1177_17455057251387475 for Severe maternal outcomes and their underlying causes in Ethiopia. Systematic review and meta-analysis by Tirusew Nigussie Kebede, Kidist Ayalew Abebe, Worku Taye Getahun, Birhan Tsegaw Taye, Temesgen Dessie Mengistu, Bezawit Melak Fente, Moges Sisay Chekole and Tebabere Moltot in Women's Health

Supplemental Material

sj-xlsx-3-whe-10.1177_17455057251387475 – Supplemental material for Severe maternal outcomes and their underlying causes in Ethiopia. Systematic review and meta-analysis

Supplemental material, sj-xlsx-3-whe-10.1177_17455057251387475 for Severe maternal outcomes and their underlying causes in Ethiopia. Systematic review and meta-analysis by Tirusew Nigussie Kebede, Kidist Ayalew Abebe, Worku Taye Getahun, Birhan Tsegaw Taye, Temesgen Dessie Mengistu, Bezawit Melak Fente, Moges Sisay Chekole and Tebabere Moltot in Women's Health

Footnotes

Acknowledgements

We would like to extend our heartfelt gratitude to Debre Berhan University, Asrat Woldeyes Health Science Campus, and the Midwifery Department for generously providing us with the time needed to conduct this systematic review and meta-analysis.

ORCID iDs

Tirusew Nigussie Kebede

Moges Sisay Chekole

Ethical consideration

Not applicable.

Consent for publication

Not applicable.

Author contributions

Tirusew Nigussie Kebede: Conceptualization; Investigation; Funding acquisition; Writing – original draft; Writing – review & editing; Visualization; Validation; Methodology; Software; Formal analysis; Supervision; Data curation.

Kidist Ayalew Abebe: Funding acquisition; Investigation; Writing – review & editing; Visualization; Validation; Methodology; Software; Formal analysis; Resources; Supervision; Data curation.

Worku Taye Getahun: Conceptualization; Investigation; Writing – review & editing; Visualization; Methodology; Formal analysis; Software.

Birhan Tsegaw Taye: Investigation; Writing – original draft; Writing – review & editing; Visualization; Validation; Methodology; Formal analysis; Software; Supervision.

Temesgen Dessie Mengistu: Investigation; Visualization; Validation; Methodology; Software; Formal analysis; Resources; Supervision; Data curation; Writing – review & editing.

Bezawit Melak Fente: Writing – original draft; Writing – review & editing; Visualization; Validation; Methodology; Software; Formal analysis; Supervision.

Moges Sisay Chekole: Investigation; Writing – original draft; Writing – review & editing; Visualization; Validation; Methodology; Formal analysis; Software; Supervision.

Tebabere Moltot: Investigation; Conceptualization; Writing – original draft; Writing – review & editing; Visualization; Validation; Methodology; Software; Formal analysis; Supervision.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

All data generated or analyzed during this systematic review and meta-analysis are fully included within the manuscript and supplementary file.

Supplemental material

Supplemental material for this article is available online.

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