Maternal and perinatal death surveillance and response system in post-conflict hospitals of tigray region, Ethiopia: a facility-based cross-sectional study

Abstract

Since 2020, conflict in Ethiopia’s Tigray region has disrupted the health system, leading to a collapse in services and a rise in preventable maternal and prenatal deaths. The Maternal and Perinatal Death Surveillance and Response (MPDSR) system—designed to identify and address avoidable deaths – may have been severely affected aftermath of the conflict. However, little is known about its functionality in the post-conflict period (two years after the signing of Pretoria’s cessation of hostility agreement). Thus, this study aimed to address this gap by assessing the status of MPDSR in conflict-affected hospitals, the current extent of maternal and perinatal deaths, and the application of review and response mechanisms. Hospital-based cross-sectional study was conducted between December 20, 2024, and January 30, 2025, in 29 selected public hospitals of conflict-affected Tigray region, Ethiopia. Data were collected by three multidisciplinary teams composed of public health researchers, Obstetricians and Gynecologists, and pediatricians using standardized study tool. Descriptive statistics was used to summarize MPDSR system performance, causes and contributing factors of deaths, and facility-level practices. Furthermore, mean difference, correlation coefficients, and concordance correlation coefficients (CCC)—with their 95%Confidence Intervals (CIs), were reported to compare discrepancy/agreement level of regional Public Health Emergency Management (PHEM) and District Health Information System (DHIS2) reports against this study’s findings on number of maternal and perinatal deaths. Among the health facilities included in this study, though 62% of them had MPDSR committees, only 41% of them had trained focal persons. MPDSR guidelines and formats were available in only 38% of the hospitals. Marked discrepancies were observed between maternal and perinatal deaths (MPDs) reported through the PHEM, and DHIS2 systems, and the findings of this study. Of the occurred 38 maternal deaths, 90% of them were deemed preventable, 84% occurred during postpartum, and 87% due to direct causes -primarily hemorrhage, hypertensive disorders, and sepsis. Among the 117 perinatal deaths reviewed, 89% of them died during neonatal period, of whom 31% of them occurred in the first day of life and 12% of the deceased perinates were delivered at home. The leading causes for perinatal mortality were birth asphyxia (42.7%), prematurity (26.5%), and neonatal sepsis (14.5%), with over half of the deaths occurring in primary hospitals. Three-delay analysis showed that the third delay-failure to receive timely and quality care caused 34.3% of maternal and 44.5% of perinatal deaths. This study highlights critical gaps in the implementation and functionality of the MPDSR system in conflict-affected hospitals of Tigray. Widespread underreporting, limited death reviews, and weak response mechanisms reflect not only missed opportunities to learn from preventable deaths but also a broader collapse of the region’s health system. Key structural and operational components—such as trained focal persons, functional MPDSR committees, timely notifications, and systematic reviews—remain suboptimal or absent in the hospitals. Urgent, context-specific action is needed to revitalize MPDSR systems and improve quality of care. Promoting a culture of transparency and continuous learning is critical. Additionally, research on community-based MPDSR is recommended to enhance detection and response beyond health facilities.