Background: Even though Ethiopia has achieved the Millennium Development Goal targets for child health set for 2015 by the international community, it has failed to do so with regard to maternal health. Maternal deaths are still high, with an estimated maternal mortality ratio of 412 maternal deaths per 100,000 live births in 2016.The causes of maternal death and individual, environmental and health systems related gaps contributing to maternal death in Ethiopia remain unclear.

Objectives: The main aim of this study was to document the causes of maternal deaths and risk factors contributing to deaths aggravated by pregnancy and its management in Ethiopia over the period 1990 to 2016, using a systematic review with meta-analysis.

Methods: Manuscripts were reviewed on causes of maternal death that were published in scientific journals and grey literature, including the compendium of abstracts presented in the series of annual conferences of the Ethiopian Public Health Association, masters’ theses in public health from different public universities in Ethiopia, and periodic reports of the Federal Ministry of Health of Ethiopia. A comprehensive and reproducible literature search was used, employing the Cochrane systematic literature review technique. Medical subject heading terms – including maternal deaths, maternal mortality, causes of maternal mortality/death, maternal mortality/death in Ethiopia and etiology of maternal mortality/death in Ethiopia – were used to search the required articles. A total of 146 articles (134 from online sources and 12 hard copies) were identified on the basis of their titles and abstracts. Of these, 24 were found to be suitable for further analysis by applying the review criteria, which were then synthesized to identify the main causes of maternal death, as well as the risk factors affecting the patterns of deaths.

Results: The main direct causes of maternal death in Ethiopia include obstetric complications such as hemorrhage (29.9%; 95% CI: 20.28%-39.56%), obstructed labor/ruptured uterus (22.34%; 95% CI: 15.26%-29.42%), pregnancy-induced hypertension (16.9%; 95% CI:11.2%-22.6%), puerperal sepsis (14.68%; 95% CI: 10.56%-18.8%), and unsafe abortion (8.6%; 95% CI: 5.0%-12.18%). In recent years, hemorrhage has been the leading cause of mortality, followed by hypertensive disorders of pregnancy and sepsis, while the contributions of obstructed labor and abortion have decreased over the period. The most reported indirect causes of maternal death were anemia (10.39%; 95% CI: 4.79%-15.98%) and malaria (3.55%; 95% CI: 1.50%-3.30%).

Conclusions: The nationwide registration of causes of maternal death should be strengthened to understand the causes in detail, their attributes, as well as the patterns of causes of death. The health sector should sustain its current effort to tackle the diverse causes of maternal death in Ethiopia. [ Ethiop. J. Health Dev. 2018;32(4):225-242]