Determinants of Maternal Mortality among Reproductive-Age Women in a Low-Income Country: A Case–Control Study from Ethiopia

Background: Maternal mortality remains a major global public health problem, with the vast majority of deaths occurring in low- and middle-income countries. Despite substantial reductions in many regions, Ethiopia still records one of the highest maternal mortality ratios globally. Locally generated evidence on the determinants of maternal mortality is essential for designing and implementing effective interventions targeting women at high risk of death. However, studies examining predictors of maternal mortality using primary data are scarce, and most existing evidence relies on secondary data, which may limit the quality and reliability of the findings.

Objective: To identify determinants of maternal death among reproductive-age women attending public health facilities of East Shaw Zone, from January 1st, 2025, to April 30th, 2026.

Methods and materials: An institutional-based matched case–control study was conducted to compare 53 maternal death cases with 212 surviving controls. The study was conducted in 7 government hospitals and 73 health centers in the East Shewa Zone, Oromia Region, Ethiopia. Data were collected using interviewer-administered questionnaires and observational checklists. Conditional logistic regression analysis was used to identify factors associated with maternal mortality. Statistical significance was declared at a p-value < 0.05, and the strength of association was estimated using odds ratios with 95% confidence intervals.

Results: The leading causes of maternal mortality were hypertensive disorders of pregnancy (28.3%), followed by obstetric hemorrhage (22.6%), and sepsis (22.6%). Women residing in rural areas had 3.3 times higher odds of maternal mortality compared with urban residents. An unplanned pregnancy was associated with 4.1-fold higher odds of maternal mortality. Similarly, women who developed obstetric complications had 7.7-fold higher odds of maternal mortality. Delayed care-seeking was associated with 5.6 times increased odds of maternal mortality compared with prompt care-seeking. Travel time greater than two hours to reach a health facility was associated with 4.5-fold higher odds of maternal mortality. In addition, delays in receiving care after arrival at a health facility increased the odds of maternal mortality by 4.5-fold compared with timely care.

Conclusion: In general, the study found that place of residence, unplanned pregnancy, presence of obstetric complications, delay in deciding to seek care, longer travel time to a health facility, and delays in receiving care at health facilities were major determinants of maternal mortality.

Maternal mortality remains a major global public health challenge and a key indicator of health system performance, social development, and equity. Despite substantial global efforts to reduce preventable maternal deaths, maternal mortality remains disproportionately high in low- and middle-income countries, particularly in Sub-Saharan Africa, where the majority of deaths occur (1, 2). Maternal mortality reflects not only the quality of health care services but also broader socioeconomic, cultural, and political determinants, including women’s empowerment and access to essential [1,2].

Maternal mortality is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes [3]. The determinants of maternal mortality are complex and multifactorial, involving interactions among individual-, community-, and health-system-level factors (figure-1). These include socioeconomic characteristics such as maternal education, residence, and income [4-7]; reproductive and clinical factors such as gravidity, antenatal care utilization, obstetric complications, HIV status, and comorbidities (8-14); and health system-related factors such as distance to health facilities, availability of skilled personnel, and access to transportation [6, 9, 15-17]. These determinants are often explained using the “three delays” model, which includes delays in deciding to seek care, delays in reaching care, and delays in receiving adequate care at health facilities.

Maternal mortality is not only a health outcome but also a reflection of national development and health system performance [18]. The loss of a mother has profound consequences for families and communities, including increased risk of illness, malnutrition, disrupted education, early marriage, and long-term economic instability among surviving children (19, 20). At the societal level, maternal deaths contribute to reduced productivity and economic loss, as women represent a key segment of the working population [11,21].

Ethiopia has implemented various strategies to reduce maternal mortality, including expansion of maternal health services such as antenatal care, skilled birth attendance, emergency obstetric care, and family planning services. Despite these efforts, the maternal mortality ratio remains unacceptably high. According to the World Health Organization (WHO) 2020 estimate, Ethiopia accounted for approximately 3.6% of global maternal deaths, with a maternal mortality ratio of 267 per 100,000 live births [5]. Achieving the Sustainable Development Goal target of reducing global maternal mortality to fewer than 70 per 100,000 live births by 2030 requires strengthened evidence-based interventions and improved understanding of context-specific determinants.

Although several studies have assessed factors associated with maternal mortality, most available evidence in Ethiopia is derived from secondary data sources such as national surveys (e.g., DHS). These data often lack detailed clinical and facility-level variables, limiting their ability to fully capture the complexity of determinants of maternal mortality. In addition, primary data-based studies using robust designs such as matched case–control approaches remain limited, despite their importance in generating more detailed and context-specific evidence. Furthermore, existing studies often assess determinants in isolation, without adequately integrating individual, clinical, and health system factors within a comprehensive framework. This limits policymakers' and health planners' ability to design targeted and effective interventions.

Therefore, locally generated primary evidence is essential to better understand the determinants of maternal mortality and to guide effective interventions. This study aimed to identify determinants of maternal mortality among reproductive-age women attending public health facilities in East Shewa Zone, Oromia Region, Ethiopia, using a matched case–control study design.

Conceptual Framework

Figure 1: A conceptual framework adopted from McCarthy J and Maine D, a framework for analyzing the determinants of maternal mortality [22,23].

Study setting and period

The study was conducted in seven public hospitals and 73 health centers in East Shewa Zone, Oromia Region, Ethiopia, from January 1, 2025, to April 30, 2026. East Shewa Zone is one of the largest and most populous zones in the region, with a total population of 1,513,063, of whom 748,966 are males, and 764,097 are females. Of the total population, approximately 334,841 are women of reproductive age, and 52,503 are pregnant women, according to the East Shewa Zone Health Office 2017 E.C report.

Study design

An institutional-based matched case–control study was conducted. Cases (maternal deaths) were compared with matched controls (women who survived pregnancy and childbirth) to identify determinants of maternal mortality. A matching procedure was applied to ensure comparability between cases and controls based on selected characteristics.

Study Populations 

Cases

All reproductive-age women (15–49 years) who died during pregnancy, childbirth, or within 42 days of termination of pregnancy due to causes related to or aggravated by pregnancy or its management in public health facilities of East Shewa Zone during the study period were included as cases. Maternal deaths were identified using health facility death registers and Maternal Death Surveillance and Response (MDSR) records. Women who died from accidental or incidental causes and those who died after 42 days postpartum were excluded.

Controls

Controls were reproductive-age women (15–49 years) who were pregnant, in childbirth, or within 42 days postpartum or post-abortion and who survived the same pregnancy episode in the same health facilities during the study period. Controls were selected from the same health facilities as cases and were matched based on gestational age and time of event occurrence. When a matched control was not available on the same day, selection was extended to subsequent days until an appropriate match was identified. Women who refuse to give consent or not willing to participate in the study were also excluded from the controls. 

Sample size determination and Sampling procedure

The sample size for the case–control study was calculated using Epi Info version 7.2 based on the following assumptions: 80% power, 95% confidence level, and a 4:1 control-to-case ratio. The calculation considered inadequate antenatal care (ANC) follow-up as a key exposure variable, with proportions of 10.7% among controls and 25.8% among cases, based on a previous study conducted in northern Cameroon. After adding a 10% non-response rate, the final sample size was 280 participants, including 56 cases and 224 controls. Sample size estimates for other variables were also computed, and the largest sample size was used for the study.

All eligible maternal death cases occurring in public health facilities of East Shewa Zone during the study period were included consecutively until the required sample size was reached. Controls were selected using simple random sampling from surviving women who were matched to cases based on time of pregnancy/gestational age and managed in the same health facility.

Data collection tools, procedures, and Data quality control

Data were collected using interviewer-administered semi-structured questionnaires and observational checklists extracted from medical records and health facility inspections. The data collection tools were developed after reviewing relevant literature. The questionnaire was initially prepared in English, translated into Afan Oromo and Amharic (the commonly spoken languages in the study area), and then back-translated into English to ensure consistency. The tools included variables related to socioeconomic and demographic factors, reproductive and clinical characteristics, and health system-related determinants of maternal mortality.

A pretest was conducted on 5% of the total sample size at Asella Teaching Hospital to assess the clarity and validity of the instruments, and necessary modifications were made based on the findings. Data were collected by BSc nurses working in departments other than obstetrics and gynecology at each health facility. The data collectors received two days of training on the study tools and procedures prior to data collection.

Data collection involved interviews with adult caregivers or next-of-kin of deceased women, as well as review of medical records, death registers, and Maternal Death Surveillance and Response (MDSR) reports. Obstetrics and gynecology departments were instructed to notify data collectors immediately when a maternal death occurred. Supervisors closely monitored the data collection process, and all completed questionnaires were checked for completeness, accuracy, and consistency by the investigators. 

Data Processing and Analysis

The collected data were coded, entered into Epi Info version 7.2, and exported to SPSS version 22 for analysis. Data cleaning, coding, categorization, and transformation were performed prior to analysis. Descriptive statistics, including means with standard deviations, frequencies, and cross-tabulations, were used to summarize the characteristics of cases and controls across socioeconomic, reproductive, clinical, and health system-related variables. Conditional logistic regression analysis was used to identify determinants of maternal mortality while accounting for the matched study design.

Bivariable conditional logistic regression analysis was first conducted to identify candidate variables with a p-value < 0>

Operational Definitions

Unplanned Pregnancy - A pregnancy that was reported by the woman (or documented in her medical record) as either unwanted at the time of conception or occurring earlier than desired (mistimed).

Obstetric Complications- The occurrence of one or more pregnancy, childbirth, or postpartum-related medical conditions that may adversely affect the health of the mother as documented in the medical record.

Delayed Care Seeking – A delay in deciding to seek care after the onset of danger signs or symptoms related to pregnancy, childbirth, or the postpartum period.

Travel Time to Reach a Health Facility - The time required to travel from the woman's residence to the first health facility where care was sought.

Delay in Receiving Care - Any delay occurring after arrival at a health facility that prevents her from receive appropriate assessment, treatment, or referral within one hour.

During the study period, 56 maternal deaths were recorded. Three cases were excluded due to refusal of consent by the primary caregiver, leaving 53 cases for analysis. Accordingly, 53 cases of maternal mortality were compared with 212 surviving controls. The leading causes of maternal mortality were hypertensive disorders of pregnancy, accounting for 15 (28.3%) cases, followed by obstetric hemorrhage, 12 (22.6%), and sepsis or infection, 12 (22.6%). Indirect causes accounted for 3 (5.7%) of deaths. Other reported causes included embolism, obstructed labor complicated by uterine rupture, and anesthesia-related complications (Table-1).

Table 1: Causes of maternal death among reproductive age women attending public health facilities of East Shaw Zone, Oromia, Ethiopia from January 2025 to April 2026 (n=53)

Socio-Demographic Characteristics of the Study Participants

The majority of maternal deaths (69.8%) occurred among women from rural areas. More than 80% of both cases and controls were aged 20–34 years. Women with no formal education were more common among cases (39.6%) compared with controls (10.4%). More than 90% of participants in both groups were married. Housewives constituted the largest occupational group among both cases (79.2%) and controls (71.3%). Coverage of improved sanitation services was lower among cases (43.4%) compared with controls (74.3%) (Table 2).

Table 2: Socio-demographic Characteristics of Reproductive Age Women Attending Public Health Facilities of East Shaw Zone, Oromia, Ethiopia from January 2025 to April 2026 (n=265)

Reproductive and Clinical Characteristics of the Study Participants

Regarding reproductive performance, the majority of both cases, 37(69.8%), and controls, 113(56.6%), were multiparous women. More than half of the current pregnancies among cases, 31 (58.5%), were unplanned, whereas the proportion was considerably lower among controls, 40 (18.9%). Obstetric complications were also more commonly reported among cases, 47 (88.7%), than among controls, 104 (49.1%). Delay in making the decision to seek care at a health facility after the onset of clinical symptoms was more frequently reported among cases, 42 (79.2%), compared with controls, 72 (34.0%). The most commonly reported reason for not making an early decision to seek care in both groups was underestimation of the severity of the condition, 72 (63.2%), followed by failure to recognize the problem, 19 (16.7%) (Table-3).

Table 3: Reproductive and Clinical Characteristics of Reproductive Age Women Attending Public Health Facilities of East Shaw Zone, Oromia, Ethiopia from January 2025 to April 2026 (n=265)

Health Services Related Characteristics of the Study Participants

The proportion of women with no antenatal care (ANC) follow-up was higher among cases, 20 (37.7%), compared to controls, 19 (9.0%). Similarly, an inadequate number of ANC contacts (<4>

Table 4: Health Services Related Characteristics of Reproductive Age Women Attending Public Health Facilities of East Shaw Zone, Oromia, Ethiopia from January 2025 to April 2026 (n=265)

Factors Associated with Maternal Death 

The study found that rural residence was significantly associated with maternal death, with rural women having 3.3 times higher odds of maternal death compared to urban residents (AOR = 3.29; 95% CI: 1.10, 9.79). Women with unplanned pregnancies had fourfold higher odds of maternal death compared to those with planned pregnancies (AOR = 4.05; 95% CI: 1.26, 13.08). Similarly, women who developed obstetric complications were 7.7 times more likely to experience maternal death than those without complications (AOR = 7.74; 95% CI: 2.06, 29.14). The findings also indicated that women who delayed seeking health care services had 5.6 times higher odds of maternal death compared with those who sought care promptly (AOR = 5.61; 95% CI: 1.81, 17.35). In addition, women who traveled for more than two hours to reach a health facility had 4.5 times higher odds of maternal death compared to those who traveled less than two hours (AOR = 4.51; 95% CI: 1.39, 14.61). Furthermore, delays in receiving care after arriving at a health facility increased the odds of maternal death by 4.5 times compared with women who received timely care (AOR = 4.49; 95% CI: 1.37, 14.71) (Table-5).

Table 5: Factors associated with Maternal Death Among Reproductive Age Women Attending Public Health Facilities of East Shaw Zone, Oromia, Ethiopia from January 2025 to April 2026 (n=265)

*P < 0.25; **P < 0.05

Most existing studies on the determinants of maternal mortality rely on national or international household surveys originally designed for other purposes. To address the inherent limitations of such secondary data, this study utilizes primary data collected directly from multiple health facilities to identify factors that increase the risk of maternal death.

Women residing in rural areas had 3.3-fold higher odds of maternal death compared with urban residents. This finding is consistent with a systematic review conducted globally on individual and ecological determinants of maternal mortality [6] and an ecological study covering 82 countries [24]. Similar results have been reported in studies conducted in South Africa and Jimma, Ethiopia, where rural residence was associated with increased risk of maternal death [7,25]. However, a systematic review from Iran reported no significant association between place of residence and maternal mortality [26], which may be explained by better access to primary health care services among rural populations in that setting. The higher risk of maternal death among rural women may be attributed to limited access to skilled maternal health services, delayed health-seeking behavior, lower educational status, transportation barriers, weak referral systems, and inadequate emergency obstetric care. In contrast, urban residents generally benefit from better access to health facilities and timely obstetric interventions, which contribute to lower maternal mortality.

The study found that women with unplanned pregnancies had fourfold higher odds of maternal death compared with women with planned pregnancies. This finding is consistent with studies conducted in different parts of the world that reported an increased risk of maternal mortality among women with unplanned pregnancies [27,28]. A community-based case–control study in the pastoralist areas of Borena Zone, Ethiopia, also identified unplanned pregnancy as a significant determinant of maternal death [29]. The association between unplanned pregnancy and maternal death may be explained by delayed initiation of antenatal care, reduced utilization of skilled delivery services, poor maternal nutrition and self-care, and inadequate birth preparedness and complication readiness among women with unintended pregnancies. In addition, unplanned pregnancies are associated with a higher likelihood of unsafe abortion practices. These factors contribute to delays in recognizing and managing obstetric complications, thereby increasing the risk of maternal mortality.

Obstetric complications that occur during pregnancy, labor, delivery, or the postpartum period are among the leading direct causes of maternal death worldwide. Women who developed obstetric complications had 7.7-fold higher odds of maternal death compared with those without complications. This finding is consistent with evidence from a global systematic review [6] and case–control studies conducted in Indonesia, Kenya, and Mizan-Tepi, Ethiopia, which also reported a strong association between obstetric complications and maternal mortality [12, 14, 30]. The increased risk of maternal death among women with obstetric complications may be attributed to delayed recognition, inadequate emergency obstetric care, and limited access to timely referral and treatment. Major complications such as postpartum hemorrhage, hypertensive disorders, sepsis, obstructed labor, and uterine rupture can rapidly become life-threatening if prompt emergency care is not provided. Delays in diagnosis and inadequate management contribute to rapid progression to shock, organ failure, and death, particularly in low-resource settings.

The decision to delay seeking care is a critical contributor to maternal death, often driven by late recognition of complications, financial barriers, cultural influences, and previous negative experiences with healthcare [31]. Women who experienced a delay in deciding to seek care had 5.6-fold higher odds of maternal death. This finding is consistent with a systematic review conducted in low- and lower-middle-income countries, which reported an increased risk of maternal mortality among women who delayed seeking care [6]. Similar findings have been reported in studies from Indonesia [32] and community-based case–control studies in Ethiopia [29]. The association between delayed decision-making and maternal mortality may be explained by poor recognition of obstetric danger signs and delayed access to emergency obstetric care. Because many obstetric complications progress rapidly, delays in seeking care reduce the likelihood of receiving timely life-saving interventions.

Longer travel time to a health facility is strongly associated with increased maternal mortality. Women who required more than two hours to reach a health facility had 4.5-fold higher odds of maternal death. This finding is consistent with evidence from multiple studies showing that longer travel time to health facilities is associated with increased risk of maternal mortality. A retrospective cohort study conducted in 24 public hospitals in Lagos reported a sevenfold increase in the odds of maternal death among non-referred women traveling directly from home when travel time reached or exceeded two hours (≥120 minutes) [33]. Similar findings have been reported in studies from Indonesia [32], Kenya [34], and a systematic review conducted in low- and lower-middle-income countries [6]. Prolonged travel time may delay access to emergency obstetric care, particularly in settings with poor transportation systems, limited road infrastructure, or geographically distant health facilities. Such delays reduce the likelihood of timely management of life-threatening complications, including hemorrhage, hypertensive disorders, obstructed labor, and sepsis. Consequently, increased travel time remains a major contributor to maternal mortality, especially in rural and hard-to-reach areas.

Even when a woman reaches a health facility on time, survival may still depend on how quickly she is assessed, diagnosed, and treated. Women who experienced delays in receiving care at health facilities had 4.5-fold higher odds of maternal death. This finding is consistent with evidence from a systematic review [6] and studies conducted in Indonesia [32] and Ethiopia [35]. This association may be explained by delayed diagnosis and management of life-threatening obstetric complications such as postpartum hemorrhage, hypertensive disorders, sepsis, and obstructed labor. Inadequate emergency obstetric services, shortages of skilled personnel, delayed surgical intervention, weak referral systems, and limited availability of essential supplies may further contribute to these delays and increase the risk of maternal mortality.

The three leading causes of maternal death were hypertensive disorders of pregnancy, followed by obstetric hemorrhage and sepsis. Overall, key determinants of maternal death included rural residence, unplanned pregnancy, presence of obstetric complications, delay in deciding to seek care, longer travel time to health facilities, and delays in receiving care after arrival at health facilities. 

Strength of the Study

This study has several strengths. First, it used primary data collected specifically to investigate the determinants of maternal mortality, enabling the collection of detailed and relevant information on potential risk factors. Second, the study was conducted across multiple health facilities, which enhanced the diversity of the study population and improved the generalizability of the findings within the study area. Third, the case-control design is particularly appropriate for studying maternal mortality, a relatively rare outcome, as it allows efficient assessment of multiple exposures and determinants within a reasonable timeframe. Additionally, the use of matched controls helped reduce the influence of potential confounding factors, thereby improving the validity of the observed associations. Finally, the inclusion of both socio-demographic, obstetric, and health system related variables provided a comprehensive assessment of factors associated with maternal mortality.

Limitation of the study

This study has some limitations that should be considered when interpreting the findings. As a case–control design was used, the study is subject to recall bias due to the retrospective collection of information on past exposures and obstetric conditions. In addition, information on cases was obtained from caregivers or next of kin, which may have further contributed to recall bias. Although the calculated sample size was 56 cases and 224 controls, the final analysis included 53 cases and 212 controls because consent could not be obtained from the families of three eligible cases. This slight reduction in sample size may have minimally reduced the statistical power of the study. Finally, causes of death were extracted from medical records and Maternal Death Surveillance and Response (MDSR) registration books and were not confirmed by autopsy.

Abbreviations

ANC – Antenatal Care. 

CAC- Comprehensive Abortion Care. 

MDSR- Maternal Death Surveillance and Response. 

MMR - Maternal Mortality Ratio. 

SDG- Sustainable Development Goals. 

WHO – World Health Organization? 

Ethics approval and consent to participate

Ethical clearance was obtained from the Institutional Review Board (IRB) of Adama Hospital Medical College. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Written informed consent was obtained from all study participants after explaining the objectives of the study. For maternal death cases, informed consent was obtained from caregivers or next of kin. Participants were informed that participation was voluntary and that refusal to participate would not affect their current or future care. They were also informed that the interview would take approximately 30 minutes and that they were free to skip any questions they did not wish to answer. Confidentiality was strictly maintained throughout the study. Personal identifiers were not collected, and all data were anonymized during data analysis and interpretation. Participants were also informed that no direct benefit was expected from participation; however, the findings would contribute to identifying determinants of maternal death and improving maternal health services in the study area.

Consent for publication

Not applicable

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Competing interests

All authors declare that they have no competing interests.

Funding

This research project was financed by the Spanish Agency for International Development Cooperation (AECID). In addition to financial support, we received continuous technical support through the training and supervision. The financial support was utilized during the process of the research project from proposal development to final manuscript writing. This information is in accordance with the Spanish Agency for International Development Cooperation (AECID) and is accurate. 

Authors' contributions

The initial research concept was developed by the corresponding author. All authors participated in drafting the study proposal and defining the methodology. A collective effort was made by all authors during data collection, study execution, statistical analysis, and interpretation of the data. Every author contributed to the initial drafting and subsequent critical revision of the manuscript. The final version has been reviewed and approved by all authors, who accept full responsibility and accountability for its contents.

Acknowledgments

The authors sincerely acknowledge the Joint European Initiative to Strengthen Medical Specialization in Ethiopia for inspiring the conception of this research and for providing financial, technical, and institutional support throughout the study. We also thank the data collectors, supervisors, and expert panel members for their dedication and valuable contributions to the successful completion of the study. The authors further acknowledge the Federal Ministry of Health of Ethiopia, Adama Hospital Medical College, and the East Shoa Zone Health Office for their administrative and technical support. We also extend our appreciation to the staff of the East Shoa Zonal and District Health Offices for facilitating the data collection process. Finally, we thank all study participants for their time and cooperation during the study.