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Changes in causes of pregnancy-related and maternal mortality in Zimbabwe 2007-08 to 2018-19: findings from two reproductive age mortality surveys



Reducing maternal mortality is a priority of Sustainable Development Goal 3.1 which requires frequent epidemiological analysis of trends and patterns of the causes of maternal deaths. We conducted two reproductive age mortality surveys to analyse the epidemiology of maternal mortality in Zimbabwe and analysed the changes in the causes of deaths between 2007-08 and 2018-19.


We performed a before and after analysis of the causes of death among women of reproductive ages (WRAs) (12-49 years), and pregnant women from the two surveys implemented in 11 districts, selected using multi-stage cluster sampling from each province of Zimbabwe (n=10); an additional district selected from Harare. We calculated mortality incidence rates and incidence rate ratios per 10000 WRAs and pregnant women (with 95% confidence intervals), in international classification of disease groups, using negative binomial models, and compared them between the two surveys. We also calculated maternal mortality ratios, per 100 000 live births, for selected causes of pregnancy-related deaths.


We identified 6188 deaths among WRAs and 325 PRDs in 2007-08, and 1856 and 137 respectively in 2018-19. Mortality in the WRAs decreased by 82% in diseases of the respiratory system and 81% in certain infectious or parasitic diseases' groups, which include HIV/AIDS and malaria. Pregnancy-related deaths decreased by 84% in the indirect causes group and by 61% in the direct causes group, and HIV/AIDS-related deaths decreased by 91% in pregnant women. Direct causes of death still had a three-fold MMR than indirect causes (151 vs. 51 deaths per 100 000) in 2018-19.


Zimbabwe experienced a decline in both direct and indirect causes of pregnancy-related deaths. Deaths from indirect causes declined mainly due to a reduction in HIV/AIDS-related and malaria mortality, while deaths from direct causes declined because of a reduction in obstetric haemorrhage and pregnancy-related infections. Ongoing interventions ought to improve the coverage and quality of maternal care in Zimbabwe, to further reduce deaths from direct causes.

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Reducing maternal mortality is a priority of Sustainable Development Goal (SDG) 3.1 and the target is to reduce the global maternal mortality ratio (MMR) to 70 maternal deaths per 100 000 live births by 2030 and to leave no country with an MMR greater than double the global average [1]. To achieve these targets,  systematic epidemiologic analysis of the levels, trends and causes of maternal deaths is required to periodically assess progress towards this goal [2,3,4]. Analysis of the MMR evaluates efforts to reduce the levels, while analysis of the causes of death identifies the aetiologies to target with ongoing interventions to reduce maternal mortality.

The World Health Organisation (WHO) developed the international classification of diseases (ICD), which groups diseases and causes of death into standard categories to aid their analysis. Currently, the 10thEdition of the ICD (ICD-10) is used to classify diseases and causes of death in the general population, including women of reproductive ages (WRAs) [5]. The 1stedition of the manual for classifying deaths during pregnancy, childbirth and the puerperium (ICD-MM) is currently used to classify pregnancy-related deaths [6, 7]. The ICD manuals enable standardised coding and description of diseases and causes of death globally.

Zimbabwe is among Sub-Saharan Africa (SSA) countries with high maternal mortality ratios (MMR), though the country's MMR has been gradually declining over the years. The Zimbabwe Demographic and Health Survey (ZDHS) reported an MMR of 960 in 2011 and 651 in 2015 [8, 9], the Multiple Indicator Cluster Surveys (MICS) in 2014 and 2019 estimated the MMR at 614 and 462 respectively [10, 11], while the United Nations Maternal Mortality Estimation Inter-agency Group (MMEIG) in 2017 estimated the MMR at 458 [12]. In 2017 the MMEIG estimated the MMR in SSA at 542, (917 in Nigeria, 524 in Tanzania, 401 in Ethiopia and 119 in South Africa). These high MMRs raise the need for studies that will identify the causes of maternal deaths to prioritise interventions regionally and globally.


We conducted two reproductive age mortality surveys (RAMOS) to analyse the changes in Zimbabwe’s MMR and causes of death between 2007-08 and 2018-19. The study protocol has been published elsewhere [13]. This paper describes the important changes that occurred in the causes of reproductive age and maternal mortality in Zimbabwe during the review period. Another paper will report changes in the MMR. The RAMOS method was used because it provided data on the causes of death and applies to the use of secondary data sources.

Interventions implemented

After the 2007-08 survey, Zimbabwe implemented several health interventions that could impact the country’s pregnancy-related and maternal deaths. Among these were HIV interventions, where the roll-out of antiretroviral therapy (ART) began in 2004 [14], and was scaled up with the number of health facilities providing ART increasing from 17% (282/1643) in December 2007 to 91% (166/1722) in December 2017 [15]. By 2019, 97% of adults (15-49 years), out of those who tested HIV-positive over time, were on ART [16]. For pregnant women, comprehensive HIV testing and treatment services were widely availed antenatally [17,18,19,20]. The "Option A" regimen was introduced in 2011 for the prevention of mother-to-child transmission (PMTCT) of HIV, in which pregnant and breastfeeding women in WHO clinical stage 3 or 4 or with a CD4 count \(\le\)350 cells/µl of blood were initiated on ART. In 2013, "Option B+" was introduced, where HIV-positive pregnant and breastfeeding women were initiated on life-long ART [17, 16]. As a result, more than 50% of HIV-positive pregnant women were already on ART at their first ANC visit in 2017 [21].

The government and its partners also implemented interventions to reduce the direct causes of maternal mortality. A maternal and neonatal health roadmap was developed to guide the prioritized interventions [22]. Doctors and nurses were trained throughout the country on basic and comprehensive emergency obstetric and newborn care (BEmONC and CEmONC) [23, 24]. BEmONC was introduced in primary healthcare clinics and CEmONC in district, provincial and central hospitals [23, 25, 26]. The training in emergency obstetric care supported the nurses, midwives and doctors to identify and manage signs and symptoms of the direct causes of maternal deaths such as obstetric haemorrhage, hypertensive disorders of pregnancy, obstetric trauma and others posing a danger to the mother and/or foetus, and hence institute timely life-saving interventions.

Guidelines for a maternal and perinatal death surveillance and response (MPDSR) system were developed [27]. Under these guidelines, the country started auditing maternal and perinatal deaths occurring in all health institutions [27]. The deaths were documented and reported on standard forms that health institutions submitted to the Ministry of Health and Child Care (MoHCC)’s head office where a national database was created to collect the data for all deaths reported [25]. MPDSR committees were established in hospitals and at district, provincial and national levels. The national MPDSR committee audited selected deaths and used the findings to develop and implement supervisory support and mentorship plans for the provinces and districts [27]. Maternity waiting homes which started in the 1980s were expanded to allow women to stay at maternity institutions from the third trimester until they delivered, so as to increase access to skilled delivery and emergency obstetric care when needed while reducing unsafe home deliveries [28,29,30,31]. The government removed user fees for maternity care in government-funded health institutions with the support of a multi-donor fund named the “health transition fund (HTF)” from 2012 to 2015 and the “health development fund (HDF)” from 2016 to 2020 [32,33,34,35]. The HTF and HDF supported the MPDSR activities, minor renovations in maternity institutions, procurement of basic commodities, medicines and equipment, and provided retention allowances for critical maternal health staff. Consequently, the use of maternity health care and institutional deliveries increased, as the ZDHS reported an increase in institutional deliveries from 65% in 2007-11 to 72% in 2012-16 [8, 9], while MICS reported 86% in 2015-19 [10]. Caesarean section deliveries also increased [36,37,38].

Study design

A before and after analysis was performed using data from the two cross-sectional RAMOS conducted in 11 districts of the country to evaluate the impact on the causes of maternal mortality of the interventions implemented. The two surveys used multi-stage cluster sampling, first stratifying the population into provinces (n=10), and selecting one district from each province using simple random sampling. An additional district was selected in Harare, because of the presence of two referral hospitals in the capital city province, to which complicated maternal cases were referred from other provinces. The surveys collected data for births and deaths among WRAs, including maternal deaths. The surveys were designed to produce representative samples of births (45000 and 46000 respectively), needed to calculate the MMR. The study protocol describes in detail the sampling procedures and sample size calculations [13].

Study setting

The 11 study districts (provinces) were: Mutare (Manicaland), Mutoko (Mashonaland East), Bindura (Mashonaland Central), Zvimba (Mashonaland West), Chivi (Masvingo), Kwekwe (Midlands), Tsholotsho (Matabeleland North), Matobo (Matabeleland South), Nkulumane (Bulawayo), and South-Eastern and Western (Harare). Mutare, Bindura and Kwekwe are partly urban districts. Nkulumane, Harare South Eastern, and Harare Western are urban districts (See Figure 1).

Fig. 1
figure 1

Map of Zimbabwe maternal and perinatal mortality study sites

Data collected

Data were collected for deaths among WRAs on location (province, district and place of residence – rural/urban), age (completed years), pregnancy status (pregnant or not), and causes of death (as stated on medical and death certificates). For pregnancy-related deaths, we collected data on complications suffered and birth outcomes, institutions where the patient was referred to (level of the facility – district, provincial or tertiary hospital, and reasons for referral), causes of death (as above) and place of death (home or institutional).

Data collection procedures

Secondary data were collected from civil registration and vital statistics (CRVS) records at the government’s Registrar General’s (RG’s) offices and health facility records. The health records included patient registers and charts at the following sites: maternity units, theatres, high dependency and intensive care units, gynaecological, medical and surgical wards, mortuaries, hospital police posts, and casualty departments. In addition, village health workers and village heads recorded home deaths in community registers in 2007-08, and trained research nurse-midwives interviewed the deceased women's close relative present at the time of death (husband, mother, sister or other) using verbal autopsy forms adapted from the WHO [39]. In 2018-19, additional deaths were identified in maternal death notification forms from the Ministry of Health and Child Care's district, provincial and national reproductive health offices.

Civil registration and vital statistics (CRVS) policy and procedures

The CRVS and health system data are regulated by government legislation in Zimbabwe. The law enforces registration and issuance of certificates for all deaths [40], and requires health institutions and relatives or village heads of persons who die at home to notify the death at the RG's office to create a death record and issue a death certificate. Medical officers or nurses who attend a death in a health institution complete and sign a medical death certificate. Family members report home deaths to the police, which takes the bodies to hospitals, where medical officers perform post-mortems and issue medical death certificates with causes of death. Health institutions submit the medical death certificates to RG's district offices, where death records are created. The RG's officers file the death records by year and date and store them in secure record rooms.

Data collection period

Data collection for the first survey was conducted prospectively between 1st May 2007 and 15th June 2008 and repeated retrospectively between 1st May and 31st July 2020. For the second survey covering the period 1 May 2018 to 15 June 2019, data collection was done retrospectively between 1st May and 31st July 2020 and repeated between 3rd May and 20th July 2021.


WRAs were women aged 15 to 49 years. Pregnancy-related deaths were deaths during pregnancy or within 42-days of termination of pregnancy or delivery, irrespective of the cause of the termination of pregnancy and death [12]. Maternal deaths were deaths of women during pregnancy or within 42-days of termination of pregnancy or delivery, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes [6, 12].

Eligibility criteria and participant selection

Deaths among WRAs resident in the study districts who died from any cause, in health institutions or home, with their death records filed in the district RG's office were eligible for the study, including those who died in referral hospitals in other districts. Similarly, pregnancy-related deaths of district residents, which occurred in the local or referral hospitals, at home or in transit, were eligible for the study.

Data analysis

A before-and-after analysis of the changes in causes of reproductive age and maternal mortality was performed. Mortality incidence rates (IR) and incidence rate ratios (IRR) (per 10 000 WRA) with 95% confidence intervals (CIs) were calculated in ICD-10 groups, and IR and IRR (per 10 000 deliveries) were calculated with 95% CIs for pregnancy-related deaths in ICD-MM groups and specific causes. Cause-specific MMRs were also calculated with 95% CIs for the leading causes of pregnancy-related deaths. We used negative binomial models in the analysis, which treated the two surveys as cohorts because of the before-and-after design and used mortality incidence rate ratios to quantify changes in mortality levels of each cause of death between the two surveys. We used STATA version 17.0’s immediate commands [41], to perform the analysis because the denominators of the ratios were aggregate data. The 95% CIs for IRRs that contained “1” were considered not statistically significant. Percentages of maternal deaths in ICD-MM groups (out of total maternal deaths) were calculated. The leading causes of maternal deaths were ranked according to the calculated percentage and compared with Southern Africa (SA), and Sub-Saharan Africa (SSA) estimates using data from a recent systematic review [42].

Strengths of the study

The study has the strength that it collected data to estimate changes in the MMR together with changes in the causes of death, to provide comprehensive recommendations for reducing the mortality. The two surveys triangulated data from various sources (civil registration records, patient health records, and maternal death notification forms and databases), which enhanced the identification of the deaths and their causes. The study used ICD-10 and ICD-MM manuals to classify and code the causes of death and the classification was done by trained obstetricians using the ICD manuals. This minimized misclassification of the deaths and their causes, and the ICD coding makes the findings interpretable within global trends.


Deaths among women of reproductive ages (WRAs)

We identified 6 188 WRAs in 2007-08 and 1 856 in 2018-19 (Table 1). Majority of the deaths of WRAs were in 12 cause groups in both years; 96% in 2007-08 and 89% in 2018-19. The ICD-10 group “certain infectious or parasitic diseases” constituted 60% of all deaths in 2007-08 and 44% in 2018-19. HIV/AIDS constituted 96% of deaths in this group (3568/3728 and 790/823 respectively) and was the leading cause of death in both study periods; causing 58% (3568/6188) of deaths in 2007-08 and 43% (790/1856) of deaths in 2018-19.

Table 1 Causes of death among women of reproductive age (15-49 years) in Zimbabwe, 2007-08 and 2018-19

Mortality declined significantly in six groups: certain infectious or parasitic diseases (81%), diseases of the respiratory system (82%), diseases of the nervous system (70%), diseases of the circulatory system (69%), diseases of the digestive system (79%) and pregnancy and childbirth (64%).

Pregnancy-related deaths

We identified 325 pregnancy-related deaths in 2007-08 and 137 in 2018-19 (Table 2). Direct causes accounted for 55% (180/325) of the deaths in 2007-08 and 75% (103/137) in 2018-19. Deaths due to direct causes decreased by 61%. Within this category, deaths more than halved in three groups– hypertensive disease in pregnancy (50%), obstetric haemorrhage (64%), pregnancy-related infections (86%), and the largest decline occurred in puerperal sepsis (91%).

Table 2 Causes of pregnancy-related deaths in Zimbabwe, 2007-08 and 2018-19; Incidence rate (IR) and Incidence rate ratio (IRR) per 10 000 and 95% confidence intervals (CI)

Deaths due to indirect causes decreased by 84%, with deaths due to non-obstetric complications decreasing by 82%. The largest declines occurred in HIV/AIDS (91%), and malaria (94%). HIV/AIDS dropped from being the top cause of death in 2007-08 (16 deaths per 10 000) to fourth cause (2 deaths per 10 000) in 2018-19, behind the direct causes of eclampsia (3 deaths per 10 000), abortion-related complications (4 deaths per 10 000) and postpartum haemorrhage (3 deaths per 10 000).

Direct causes of death had a three-fold MMR (151 maternal deaths per 100 000) than indirect causes (51 maternal deaths per 100 000) in 2018-19. Obstetric haemorrhage alone had the same MMR as all indirect causes of death (Table 3).

Table 3 Cause-specific maternal mortality ratio (MMR) for the selected cause of death groups in Zimbabwe, 2018-19


Analysing the causes of pregnancy-related and reproductive age mortality together provides important insights into the reasons for the decline. Sometimes declines in pregnancy-related mortality are associated with declines in WRAs because the interventions for non-obstetric diseases and causes of death in the general population benefits pregnant women as well [2,3,4].

This study found significant declines in deaths due to different causes in WRAs and pregnant women in Zimbabwe from 2007-08 to 2018-19. Mortality among WRAs significantly declined in six out of twelve ICD-10 groups; mainly among groups associated with HIV/AIDS, such as certain infectious and parasitic diseases, respiratory system, and digestive system diseases. HIV and malaria are the main infectious and parasitic diseases in Zimbabwe [5]. Respiratory diseases such as pulmonary tuberculosis and bacterial pneumonia and digestive system diseases such as acute gastroenteritis are AIDS-related in high HIV burden countries [43, 44]. Zimbabwe has achieved significant reductions in HIV-related [45,46,47] and malaria deaths [48]. Improvement in the provision of antiretroviral therapy (ART) has reduced HIV-related mortality significantly. On the contrary, mortality among WRAs from non-infectious diseases remained stable, consistent with observed trends of non-communicable diseases (NCDs) in Africa [49, 50].

Pregnancy-related deaths from indirect causes decreased by more than four-fifths (84%), of which HIV/AIDS was the leading cause in 2007-08, before the widespread availability of antiretroviral therapy (ART) [14]. A that time, significant proportions of pregnant women went through their antenatal period not knowing their HIV status [46, 47]. By 2018-19, the situation had changed significantly. HIV/AIDS dropped to the fourth cause of death, after the direct causes of abortion, eclampsia, and postpartum haemorrhage.

In 2018-19, the leading causes of maternal deaths in Zimbabwe (obstetric haemorrhage, hypertensive disease in pregnancy and non-obstetric causes) were the same as in the Southern Africa (SA) and Sub-Saharan Africa (SSA) regions (Table 4) [42]. Abortion-related deaths were higher in Zimbabwe than SA and SSA (18% vs. 8% and 7%), despite the known challenges of identifying them because of prohibitive legislation and religious objections [51,52,53]. Unanticipated complications of management deaths were possibly poorly reported because medical staff fear blame and litigation [54, 55].

Table 4 Comparison of the leading causes of pregnancy-related deaths in ICD-MM groups in Zimbabwe, Southern Africa and Sub-Saharan Africa, 2018-2019

Zimbabwe halved deaths due to direct causes of maternal deaths (hypertension, haemorrhage, pregnancy-related infections) and the indirect causes of HIV/AIDS and malaria. Interventions implemented at various levels of the health system: policy development (roadmap), training (EmONC), providing access (maternity waiting homes, removal of user fees), monitoring and evaluation (MPDSR) achieved this impact. The achievements demonstrated how concerted multipronged interventions can reduce maternal mortality.

Notwithstanding, direct causes continued to cause maternal deaths more than indirect, with a three-fold cause-specific MMR. Direct causes are continuing to contribute significantly to maternal deaths because of the ever-present threat of brain drain where skilled healthcare workers migrate to better-remunerating countries [56]. Zimbabwe has also seen intermittent supplies of life-saving resources, such as blood products for obstetric haemorrhage, oxytocin – the standard uterotonic drug for managing the active third stage of labour and treating patients with post-partum haemorrhage. Similarly, stock ruptures of magnesium sulphate for eclampsia and anti-hypertensive medicines have been reported from time to time [57, 58]. Sustained investment in the supply of these life-saving drugs and resources is required to reduce deaths from direct causes.

Addressing obstetric haemorrhage would reduce deaths from direct causes by a third while addressing obstetric haemorrhage, abortion and hypertensive diseases would reduce deaths due to direct-causes by four-fifths. Thus, improving the coverage and quality of maternity care targeting these three causes remains a priority. Despite the presence of maternal waiting shelters in health facilities, women continue to experience significant first, second and third delays from various controllable factors, such as long distances to the nearest health facility and significant delays in getting transport to referral centres, coupled with human resource and commodity challenges at the referral centres. Efforts to reduce unskilled deliveries at home and ill-equipped primary-care facilities, improve emergency transport and increase access to the right care should continue [59,60,61,62,63]. Diagnosis and treatment of hypertensive diseases in pregnancy must also be prioritised as NCDs increase in SSA [49, 50, 64, 65].

Study limitations

The limitation of this study is the possible under-representation of community deaths in 2018-19 data. The 2007-08 survey collected home deaths in the community, while the 2018-19 survey only included community deaths that were recorded in maternal death notification and CRVS records. Missing information for some deaths was addressed by triangulating the deaths across data sources. Deaths identified in CRVS records with incomplete information and not found in health records were classified as deaths of unknown causes, but these were few. Despite these limitations, the study identified sufficient deaths that were thoroughly reviewed by obstetricians to produce these findings.


Mortality due to HIV and malaria has declined significantly in Zimbabwe in WRAs and pregnant women, though the two remain important causes of death. Zimbabwe has also significantly reduced pregnancy-related deaths from direct causes (pregnancy-related infections, obstetric haemorrhage and hypertensive disease in pregnancy) through concerted multipronged interventions. Sustained investment into the health system focusing on improving coverage and quality of antenatal care and access to emergency obstetric care will further reduce deaths from direct causes (haemorrhage, eclampsia and abortion). Efforts to contain the indirect causes of HIV and malaria should continue whilst increasing efforts to manage NCDs in pregnancy. The RAMOS should be repeated in the same districts before 2030, to assess progress towards the SDG target.

Availability of data and materials

The dataset supporting the conclusions of this article will be available to the public via this link:



Antiretroviral therapy


Birth and death


Confidence interval


Civil registration and vital statistics


Demographic and health survey


District health information system


International classification of diseases


Maternal and perinatal death surveillance and response


Millennium development goal


Multiple indicator cluster survey


Maternal mortality ratio


Pregnancy-related death


Reproductive age mortality survey 


Registrar general


Sub-Saharan Africa


Sustainable development goal


Total fertility rate


Verbal autopsy


Women of reproductive age


  1. UN. SDG 3: Ensure healthy lives and promote well-being for all at all ages. 2020. Accessed 14 Nov 2020.

  2. Lili X, Jian H, Mengjun Z, et al. Epidemiological analysis of maternal deaths in Hunan province in China between 2009 and 2014. PLoS One. 2018;13(11): e0207920.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  3. Bhadra B, Choudhury RR, Sarkar D, Sarkar S. An epidemiological study of mortality among mothers admitted in a rural tertiary hospital of West Bengal. J Family Med Prim Care. 2017;6(2):270–3.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Geubbels E. Epidemiology of Maternal Mortality in Malawi. Malawi Med J. 2006;18(4):206–25.

    PubMed  PubMed Central  Google Scholar 

  5. WHO. International Classification of Diseases, 11th Edition. 2011. Accessed 11 October 2021.

  6. WHO. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD-MM. World Health Organization; Geneva. 2011. Accessed 12 October 2021.

  7. Ameh CA, Adegoke A, Pattinson RC, van den Broek N. Using the new ICD-MM classification system for attribution of cause of maternal death–a pilot study. BJOG. 2014;121(Suppl 4):32–40.

    Article  PubMed  Google Scholar 

  8. ZimStat and ICF International. Zimbabwe Demographic and Health Survey 2015: Final Report. Zimbabwe National Statistics Agency (ZIMSTAT), Harare, Zimbabwe and ICF International Rockville, Maryland, USA.

  9. ZimStat and ICF International. Zimbabwe Demographic and Health Survey 2011/12. Final Report. Zimbabwe National Statistics Agency (ZIMSTAT) and ICF International Rockville. USA: Maryland; 2012.

    Google Scholar 

  10. ZimStat and UNICEF. Multiple Indicator Cluster Survey 2017: Final Report. Accessed 20 September 2020.

  11. ZimStat and UNICEF. Multiple Indicator Cluster Survey 2014. Final Report. Accessed 20 Sept 2020.

  12. WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Trends in maternal mortality 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: World Health Organization; , 2019. Accessed 20 Sept 2020.

  13. Musarandega R, Machekano R, Pattinson R, Munjanja SP, Zimbabwe Maternal and Perinatal Mortality Study Group. Protocol for analysing the epidemiology of maternal mortality in Zimbabwe: A civil registration and vital statistics trend study. Plos One. 2021;16(6):e0252106.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Apollo T, Takarinda K, Mugurungi O, Chakanyuka C, Simbini T, Harries AD. A report on the Zimbabwe Antiretroviral Therapy (ART) programme progress towards achieving MGD6 target 6B: achievement and challenges. Cent Afr J Med. 2010;56(1–4):12–4.

    CAS  PubMed  Google Scholar 

  15. ICAP. Zimbabwe Population-based HIV Impact Assessment (ZIMPHIA) 2015–2016. New York: ICAP at Columbia University; 2018.

    Google Scholar 

  16. ICAP. Zimbabwe Population-based HIV Impact Assessment (ZIMPHIA) 2020. New York: ICAP at Columbia University; 2020.

    Google Scholar 

  17. Musarandega R, Robinson J, Sen PD, et al. Using the critical path method to rollout and optimise new PMTCT guidelines to eliminate mother-to-child transmission of HIV in Zimbabwe: a descriptive analysis. BMC Health Serv Res. 2020;20(1):1042.

    Article  PubMed  PubMed Central  Google Scholar 

  18. McCoy SI, Fahey C, Buzdugan R, et al. Targeting elimination of mother-to-child HIV transmission efforts using geospatial analysis of mother-to-child HIV transmission in Zimbabwe. AIDS. 2016;30(11):1829–37.

    Article  PubMed  Google Scholar 

  19. Buzdugan R, McCoy SI, Webb K, et al. Facility-based delivery in the context of Zimbabwe’s HIV epidemic–missed opportunities for improving engagement with care: a community-based serosurvey. BMC Pregnancy Childbirth. 2015;15:338.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  20. Buzdugan R, McCoy SI, Watadzaushe C, et al. Evaluating the Impact of Zimbabwe’s Prevention of Mother-to-Child HIV Transmission Program: Population-Level Estimates of HIV-Free Infant Survival Pre-Option A. PLoS One. 2015;10(8): e0134571.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  21. MOHCC. Global AIDS response progress report,. Zimbabwe country progress report for reporting period January - December 2017. Harare: Zimbabwe Ministry of Health and Child Care; 2018. p. 2018.

    Google Scholar 

  22. MOHCC. Zimbabwe Maternal and Neonatal Health Roadmap. Harare: Zimbabwe Ministry of Health and Child Care; 2007.

    Google Scholar 

  23. RCOG. Life Saving Skills Manual: Essential Obstetric and Newborn Care. 2nd ed. Glasgow: The Royal College of Obstetricians and Gynaecologist; 2007.

    Google Scholar 

  24. Crofts JF, Mukuli T, Murove BT, et al. Onsite training of doctors, midwives and nurses in obstetric emergencies. Zimbabwe Bull World Health Organ. 2015;93(5):347–51.

    Article  PubMed  Google Scholar 

  25. MOHCC. Guidelines for Maternal and Perinatal Death Audits in Zimbabwe. Harare: Zimbabwe Ministry of Health and Child Care; 2013.

    Google Scholar 

  26. MOHCC. Analysis of Notified Institutional Maternal Deaths,. – December 2011. Ministry of Health and Child Care Zimbabwe: Harare; 2010. p. 2011.

    Google Scholar 

  27. MOHCC. Maternal and Perinatal Death Surveillance and Response Report. Harare: Ministry of Health and Child Care Zimbabwe; 2018.

    Google Scholar 

  28. Tumwine JK, Dungare PS. Maternity waiting shelters and pregnancy outcome: experience from a rural area in Zimbabwe. Ann Trop Paediatr. 1996;16(1):55–9.

    Article  CAS  PubMed  Google Scholar 

  29. UNICEF. A ‘Sheltering’ Grace: The maternity waiting home giving hope to mothers in rural Zimbabwe. 10 May 2021 2021. Accessed 19 July 2021 2021.

  30. UNFPA. MATERNITY WAITING HOMES: Promoting Institutional Delivery and Pregnant Women’s Access to Skilled Care2012. Accessed 19 July 2021.

  31. Agents C. Waiting homes – the initiative helping more mothers give birth safely in Zimbabwe. 7th April 2021 2021. Accessed 19 July 2021.

  32. World Bank Group. Health Public Expenditure Review- Zimbabwe. Harare: World Bank Group; 2015.

    Google Scholar 

  33. JICA. Data Collection Survey on Health Sector: Country Report Republic of Zimbabw. Harare: Japan International Cooperation Agency (JICA); 2012.

    Google Scholar 

  34. USAID. Zimbabwe Health System Assessment 2010. Harare: United States Agency for International Development; 2010.

    Google Scholar 

  35. UNICEF. Comparing facility and community level evidence on health services performance 2009 and 2010, Zimbabwe. Harare: Training and Research Support Centre (TARSC) and UNICEF Collaborating Centre for Operational Research and Evaluation (CCORE); 2011.

    Google Scholar 

  36. Betran AP, Ye J, Moller AB, Souza JP, Zhang J. Trends and projections of caesarean section rates: global and regional estimates. BMJ Glob Health. 2021;6(6): e005671.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Ngwenya S. Factors associated with maternal mortality from sepsis in a low-resource setting: a five-year review at Mpilo Central Hospital, Bulawayo. Zimbabwe Trop Doct. 2020;50(1):12–5.

    Article  PubMed  Google Scholar 

  38. Pattinson R, Moodley J, Fawcus S. Improvements in maternal mortality in South Africa. South Afri Med J. 2018;108(3 Supplement 1):S4–8.

    Google Scholar 

  39. WHO. The 2007 WHO Verbal Autopsy Instrument. 2021 2007. Accessed 9 December 2021 2021.

  40. Zimbabwe Government. Birth and Death Registration Legislation of Zimbabwe. Harare: Government of Zimbabwe; 2001.

    Google Scholar 

  41. STATA. Statistical Software for Data Science. 2022. Accessed 21 Jan 2022 2022.

  42. Musarandega R, Machekano R, Pattinson R, Munjanja SP, Causes of maternal mortality in Sub-Saharan Africa: a systematic review of studies published from,. to 2020. J Global Health. 2015;2021:11.

    Google Scholar 

  43. Huang L, Crothers K. HIV-associated opportunistic pneumonias. Respirology. 2009;14(4):474–85.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Head BM, Trajtman A, Rueda ZV, Vélez L, Keynan Y. Atypical bacterial pneumonia in the HIV-infected population. Pneumonia. 2017;9(1):12.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Halperin DT, Mugurungi O, Hallett TB, et al. A surprising prevention success: why did the HIV epidemic decline in Zimbabwe? PLoS Med. 2011;8(2): e1000414.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Hargrove JW, Humphrey JH, Mahomva A, et al. Declining HIV prevalence and incidence in perinatal women in Harare. Zimbabwe Epidemics. 2011;3(2):88–94.

    Article  PubMed  Google Scholar 

  47. Mahomva A, Greby S, Dube S, et al. HIV prevalence and trends from data in Zimbabwe, 1997–2004. Sex Transm Infect. 2006;82(Suppl 1):i42-7.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Sande S, Zimba M, Mberikunashe J, Tangwena A, Chimusoro A. Progress towards malaria elimination in Zimbabwe with special reference to the period 2003–2015. Malar J. 2017;16(1):295.

    Article  PubMed  PubMed Central  Google Scholar 

  49. de-Graft Aikins A, Unwin N, Agyemang C, Allotey P, Campbell C, Arhinful D. Tackling Africa’s chronic disease burden: from the local to the global. Globalization and Health. 2010;6(1):5.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Gouda HN, Charlson F, Sorsdahl K, et al. Burden of non-communicable diseases in sub-Saharan Africa, 1990–2017: results from the Global Burden of Disease Study 2017. Lancet Global Health. 2019;7(10):e1375–87.

    Article  PubMed  Google Scholar 

  51. Say L, Chou D, Gemmill A, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2(6):e323-33.

    Article  PubMed  Google Scholar 

  52. Kassebaum NJ, Barber RM, Bhutta ZA, et al. Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388(10053):1775–812.

    Article  Google Scholar 

  53. Gebremedhin M, Semahegn A, Usmael T, Tesfaye G. Unsafe abortion and associated factors among reproductive aged women in Sub-Saharan Africa: a protocol for a systematic review and meta-analysis. Syst Rev. 2018;7(1):130.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Partners Ka. LIABILITY OF MEDICAL NEGLIGENCE (MEDICAL & DENTAL PRACTITIONER). 15-May-2020 2020. Accessed 13 October 2021.

  55. MDPCZ. MDPCZ Disciplinary BulletinJULY 2014, 2014. Accessed 13 October 2021.

  56. Makoni M. COVID-19 worsens Zimbabwe’s health crisis. Lancet. 2020;396(10249):457.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Murewanhema G, Makurumidze R. Essential health services delivery in Zimbabwe during the COVID-19 pandemic: perspectives and recommendations. Pan African Medical Journal. 2020;35(Suppl 2):143.

    Google Scholar 

  58. Shafiq N, Pandey AK, Malhotra S, et al. Shortage of essential antimicrobials: a major challenge to global health security. BMJ Global Health. 2021;6(11): e006961.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Bwana VM, Rumisha SF, Mremi IR, Lyimo EP, Mboera LEG. Patterns and causes of hospital maternal mortality in Tanzania: A 10-year retrospective analysis. PLoS One. 2019;14(4): e0214807.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  60. Sageer R, Kongnyuy E, Adebimpe WO, Omosehin O, Ogunsola EA, Sanni B. Causes and contributory factors of maternal mortality: evidence from maternal and perinatal death surveillance and response in Ogun state, Southwest Nigeria. BMC Pregnancy Childbirth. 2019;19(1):63.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Diallo A, Michalek IM, Bah IK, et al. Maternal mortality risk indicators: Case-control study at a referral hospital in Guinea. European journal of obstetrics, gynecology, and reproductive biology. 2020;251:254–7.

    Article  PubMed  Google Scholar 

  62. Said A, Malqvist M, Pembe AB, Massawe S, Hanson C. Causes of maternal deaths and delays in care: comparison between routine maternal death surveillance and response system and an obstetrician expert panel in Tanzania. BMC Health Serv Res. 2020;20(1):614.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Taye Makuria A, Gebremichael D, Demoz H, et al. Obstetric hemorrhage and safe blood for transfusion in Ethiopia: the challenges of bridging the gap. Transfusion. 2017;57(10):2526–31.

    Article  PubMed  Google Scholar 

  64. Boateng D, Agyemang C, Beune E, et al. Cardiovascular disease risk prediction in sub-Saharan African populations - Comparative analysis of risk algorithms in the RODAM study. Int J Cardiol. 2018;254:310–5.

    Article  PubMed  Google Scholar 

  65. Adjei DN, Stronks K, Adu D, et al. Chronic kidney disease burden among African migrants in three European countries and in urban and rural Ghana: the RODAM cross-sectional study. Nephrol Dial Transplant. 2018;33(10):1812–22.

    Article  PubMed  Google Scholar 

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We acknowledge the 2007-08 and 2018-19 Zimbabwe Maternal and Perinatal Mortality Study (ZMPMS) group members (See Online Supplementary document) for their contributions to the two surveys. Dr Allison Beattie (FDCO) gave much support to the 2007-08 ZMPMS study. Staff in the Ministry of Health and Child Care’s family health department, reproductive health officers (RHOs), MNCH nurses, and RG's provincial and district office staff are appreciated for facilitating the data collection.


The United Kingdom’s Foreign, Commonwealth and Development Office (FCDO), formerly Department for International Development (DfID), funded the 2007-08 survey. UNFPA, UNICEF and WHO Zimbabwe offices, University of Zimbabwe and Ministry of Health provided technical and financial support to both the 2007-08 and the 2018-19 surveys. WHO-Geneva (through a grant from the Improving Maternal Health Measurement (IMHM) Project at the Women & Health Initiative of the Harvard T.H. Chan School of Public Health, funded by the Bill & Melinda Gates Foundation and Development and Research Training in Human Reproduction (HRP) [Grant Number OPP1169546] and WHO-Zimbabwe funded the 2007-08 and 2018-19 data validation.

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SPM developed and implemented the protocol for the 2007-08 survey with the first ZMPMS group. RM1 developed the 2018-19 survey and combined analysis protocol and implemented it with the 2018-19 ZMPMS group (See additional file 1 ). RM1 conceptualised and developed the manuscript. GM, SPM and others classified the deaths using ICD-11 and ICD-MM. LN, SN, RP and SPM critically reviewed the data and draft manuscripts. All authors reviewed and approved the final manuscript.

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Correspondence to Reuben Musarandega.

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The study protocol received ethical approvals from the Research Ethics Committee of the Faculty of Science of the University of Pretoria (339/2019), WHO Research Ethics Committee (ERC 0003348), Human Reproduction Program Ethics Review (2019-03-19), and Medical Research Council of Zimbabwe (MRCZ/A/2613). All ethics approvals waived informed consent to participate because the study used secondary data. This study was conducted in accordance with the Declarations of Helsinki.

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Musarandega, R., Ngwenya, S., Murewanhema, G. et al. Changes in causes of pregnancy-related and maternal mortality in Zimbabwe 2007-08 to 2018-19: findings from two reproductive age mortality surveys. BMC Public Health 22, 923 (2022).

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