Changes in Causes of Maternal Mortality in Zimbabwe 2007-08 to 2018-19: Findings From Two Reproductive Age Mortality Surveys

Background: Reducing maternal mortality is a priority of Sustainable Development Goal (SDG) 3.1 which requires frequent epidemiological analysis of trends, patterns and causes of maternal deaths. We conducted two reproductive age mortality surveys (RAMOS) to analyse the epidemiology of maternal mortality in Zimbabwe; assessing changes in the causes of death between 2007-08 and 2018-19. Methods: : We collected data for deaths among women of reproductive ages (WRAs), and pregnancy-related deaths (PRDs) in 11 districts using multi-stage cluster and simple random sampling. We calculated mortality incidence rates (IR) and incidence rate ratios (IRR) per 10000 WRA with 95% confidence intervals (CIs) in ICD-10 groups. We calculated IR and IRR (per 10000 births) for PRDs with 95% CIs in ICD-MM groups. We also calculated maternal mortality ratios (MMR), per 100 000 live births, for selected causes of PRDs. Results: We identified 6188 deaths among WRAs and 325 PRDs in 2007-08, and 1856 and 137 respectively in 2018-19. Mortality in WRAs decreased by 81% in certain infectious or parasitic diseases, by 82% in diseases of the respiratory system, and by 79% in diseases of the digestive system. Pregnancy-related deaths from direct causes decreased by 61% and deaths from indirect causes by 84%. HIV/AIDS-related deaths decreased by 81% in WRAs and by 91% in pregnant women. However, direct causes of death still had a three-fold MMR (151 deaths) than indirect causes (51 deaths per 100 000), and obstetric haemorrhage alone had equal MMR as all indirect causes in 2018-19. Conclusion: HIV-related mortality has declined significantly in Zimbabwe in WRAs and pregnant women, though it is still an important cause of death. Zimbabwe has also reduced pregnancy-related deaths from direct causes significantly, through multipronged interventions. The focus is to improve coverage and quality of antenatal care to reduce deaths from indirect causes, and increase access to emergency obstetric care to further reduce deaths from the direct causes.