Severe maternal outcomes and their underlying causes in Ethiopia. Systematic review and meta-analysis

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 I 2 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.