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‘We identify, discuss, act and promise to prevent similar deaths’: a qualitative study of Ethiopia's Maternal Death Surveillance and Response system
  1. Berhanu Abebe1,
  2. Joanna Busza2,
  3. Azmach Hadush1,
  4. Abdurehman Usmael1,
  5. Amsalu Belew Zeleke1,
  6. Sahle Sita1,
  7. Solomon Hailu1,
  8. Wendy J Graham3
  1. 1MCH Department, WHO Ethiopia Country Office, Addis Ababa, Ethiopia
  2. 2Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
  3. 3IMMPACT, University of Aberdeen, Aberdeen, UK
  1. Correspondence to Joanna Busza; Joanna.busza{at}


Introduction Ethiopia introduced national Maternal Death Surveillance and Response (MDSR) in 2013 and is among the first sub-Saharan African countries to capture data on facility-based and community-based maternal deaths. We interviewed frontline MDSR implementers about their experiences of the first 2 years of MDSR, including perceptions of its introduction and outcomes for health services.

Methods We conducted a qualitative case study in 4 zones in the largest regions, interviewing 69 key informants from regional, zonal, district and facility levels.

Results A defining feature of Ethiopia's MDSR system is its integration within existing disease surveillance, with both benefits and challenges. Facilitators of the system's introduction were strong political support, alignment with broader health strategies and strong links across health system departments. Barriers included confusion around new responsibilities, high staff turnover and fear of legal repercussions. Stakeholders believed MDSR increased confidence in using local data to improve maternal health services and enhanced communication across the health system.

Conclusions MDSR systems take time to establish, encountering challenges in early implementation. Ensuring MDSR has a clear purpose, explicitly defined roles and responsibilities, and adequate supervisory support from the start will ensure it becomes embedded within the health system as routine practice rather than perceived as a stand-alone system. Countries planning to adopt or extend MDSR can learn from Ethiopia's experience, particularly the decision to make maternal mortality a weekly reportable condition within Public Health Emergency Management.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:

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  • Handling editor Valery Ridde.

  • Contributors BA helped design the study, conducted all fieldwork and wrote the Methods section of the paper. JB led design of the study and drafted the manuscript. AH coordinated the research and provided feedback on early drafts. AU, ABZ, SS and SH were responsible for study design, ethical approval and study logistics in the four regional sites. WJG led the technical assistance programme E4A within Ethiopia and helped design the study. All authors have read, commented on and approved the manuscript.

  • Funding Funding was provided by the UK Department for International Development (UKAID) under Evidence for Action (E4A) Programme Number 201512.

  • Competing interests All authors worked for the Evidence for Action (E4A) programme at the time of conducting the study and writing the paper, which was funded through the UK Department for International Development.

  • Ethics approval LSHTM, University of Aberdeen and the IRBs of four regional health bureau in Ethiopia.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.