Why Is Ethiopia an Exemplar?

Exemplar countries for neonatal and maternal mortality are defined as those that have demonstrated exceptional progress at reducing neonatal and maternal mortality —beyond what could be attributable to their socioeconomic progress alone. Figure 2 shows the association between gross national income (GNI) per capita increases and NMR/MMR declines across low- and middle-income countries with populations of at least 2 million that have not yet reached the NMR/MMR Sustainable Development Goals targets. A fitted linear regression line is overlaid, indicating the expected relationship between GNI per capita change and mortality change. Countries falling below the fitted line are those that have experienced faster declines in mortality than what would be expected based on their GNI per capita increases alone.

Overall, Ethiopia stands out as a country that has made particularly rapid progress in reducing maternal mortality. Estimates of maternal mortality in Ethiopia indicate an average annual reduction rate (AARR) of 6.17% from 2000 to 2020, reflecting a decrease from 953 to 267 maternal deaths per 100,000 live births over that time span.¹ Neonatal mortality rate in Ethiopia experienced an AARR of 2.89% from 2000 to 2020, as NMR declined from 48 to 26 neonatal deaths per 1,000 live births.² The decline in neonatal mortality is substantial, but the country’s progress in improving maternal mortality is particularly central to its status as an Exemplar.

Maternal Mortality

Ethiopia has made substantial reductions in maternal mortality, though estimates vary by source. Here, Figure 3 includes estimates from both the Institute for Health Metrics and Evaluation (IHME) and United Nations Maternal Mortality Estimation Inter-Agency Group (UN MMEIG), with the UN MMEIG estimates predominantly used in analyses throughout this narrative.^1,3 Estimates from UN MMEIG indicate that MMR decreased from 953 to 267 maternal deaths per 100,000 live births from 2000 to 2020, constituting a 72% decrease.¹ MMR in Ethiopia has experienced an AARR of 6.17% over this span, which exceeds the trajectory of progress for Eastern and Southern Africa regionally at 3.89% and more broadly for sub-Saharan Africa at 1.99%.¹

Despite this remarkable progress, Ethiopia’s high historical baseline for MMR puts the country’s SDG target of 140 maternal deaths per 100,000 live births by 2030 out of reach of the current trajectory. More detailed information about Ethiopia’s progression towards SDG targets can be found in the section titled Benchmarking progress in Ethiopia.

IHME estimates indicate that abortion/miscarriage, hemorrhage, and sepsis/infection represented the largest contributors to maternal mortality in Ethiopia in 2019, respectively accounting for 22.5%, 19.6%, and 15.4% of all maternal deaths.³ While abortion/miscarriage remains the most common cause of maternal death in these estimates, its relative contribution to overall maternal mortality has halved since 1990 when abortion/miscarriage constituted 45.2% of all maternal deaths.³ Evidence from a systematic review also concluded that main direct causes of maternal death from 1990 to 2016 in Ethiopia were hemorrhage, sepsis, and unsafe abortion – respectively accounting for 30%, 15%, and 9% of maternal deaths over this period.⁴ Additional recent evidence from Ethiopia’s maternal death surveillance and response system echoed that hemorrhage was the most common cause of maternal death, accounting for 41% of maternal deaths in 2018.⁵

The subnational variation in maternal mortality within Ethiopia is notable, as the regions of Afar and Benishangul-Gumuz are estimated to have an MMR more than twice as high as other regions such as Gambela and Amhara.³ Although Afar and Benishangul-Gumuz have the highest MMR values of regions in Ethiopia, they have also seen among the fastest progress in recent decades. For example, Afar experienced a 74.7% reduction in MMR from 2173 to 550 maternal deaths per 100,000 live births from 2000 to 2019.³ This has contributed to the overall narrowing of equity gaps across regions in Ethiopia with regards to MMR. Certain regions, such as Tigray, have experienced conflict and other challenges in recent years – making a subnational lens crucial to understanding mortality in Ethiopia. These challenges often make data landscapes scarce in the regions that would be considered most vulnerable to setbacks.

Neonatal Mortality

Although not as rapid as its MMR reductions, Ethiopia has also made substantial progress in improving NMR over recent decades. Estimates from the United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) indicate that NMR decreased from 48 to 26 neonatal deaths per 1,000 live births from 2000 to 2021, a 46% decrease.² During this period, NMR in Ethiopia experienced an AARR of 2.89%, which outpaces the AARR regionally for Eastern and Southern Africa at 2.36% and 1.85% more broadly for sub-Saharan Africa.² Ethiopia has seen accelerated progress in improving NMR, as the AARR has improved each of the last four decades.² Despite this progress, Ethiopia will need to make additional advancements to achieve the Sustainable Development Goals target of 12 neonatal deaths per 1,000 live births. More details about Ethiopia’s progression towards the SDG targets are available in the section titled Benchmarking progress in Ethiopia.

The most common causes of neonatal mortality in Ethiopia in 2017 were birth asphyxia or trauma, prematurity, as well as sepsis and other infections according to the World Health Organization Maternal and Child Epidemiology Estimation (MCEE) Group.⁶ These causes of death accounted for about three-quarters of all neonatal deaths in Ethiopia in 2017.⁴ The cause of death that saw the largest reduction from 2000 to 2017 was tetanus, which made up 9.5% of neonatal deaths in 2000 but only 1.6% of neonatal deaths in 2017.⁴ In contrast, sepsis and other infections saw the smallest decline during this period, declining from 5.82 to 4.86 neonatal deaths per 1,000 live births for reduction of 16.5%.⁴ While most causes of death saw overall reductions during this period, congenital abnormalities stand out as one cause that did not, leading them to proportionally contribute more deaths over time.⁴

Although Ethiopia has seen progress in improving neonatal mortality nationally, disparities across key dimensions indicate that equity gaps have generally widened in recent years. The urban center of Addis Ababa has experienced particularly remarkable progress as NMR decreased 61% between 2000 to 2019 from 43 to 17 neonatal deaths per 1,000 live births.⁷ Other regions generally saw less progress, with Benishangul-Gumuz, Amhara, and Somali respectively experiencing 15%, 23%, and 25% declines in NMR from 2000 to 2019.⁵ Tigray also saw notable reductions from 68 to 28 neonatal deaths per 1,000 live births from 2000 to 2019 – representing a 59% decline.⁵ Importantly, progress in Tigray is suspected to have been affected by recent conflict, exemplifying the importance of a subnational lens in Ethiopia.

Widening equity gaps are particularly stark when the population is disaggregated by residence, with urban communities seeing substantially lower NMR and accelerated NMR declines.⁵ From 2000 to 2019, NMR declined 52% in urban areas, while it declined 32% in rural areas.⁵ The NMR among urban communities was 22 neonatal deaths per 1,000 live births in 2019, while among rural communities the NMR was 40 neonatal deaths per 1,000 live births. ⁵

NMR is also generally lowest for the wealthiest in Ethiopia, with the richest quintile seeing a nearly 50% decline in NMR from 2000 to 2019, contributing to a widening margin across wealth quintiles.⁵ In contrast, the poorest quintile saw a more modest 17% reduction in NMR across this time span.⁵

Stillbirths

Estimates from UN IGME indicate that the stillbirth rate in Ethiopia has declined from 32.6 to 20.6 stillbirths per 1,000 total births from 2000 to 2021, a decrease of 36.9%.⁸ This reflects a stillbirth rate that is slightly higher than that of the Eastern and Southern Africa region, which was 18.9 stillbirths per 1,000 total births in 2021.⁶ However, from 2000 to 2021, the AARR for stillbirths has indicated faster progress in Ethiopia relative to the region, estimated at 2.2% compared to 1.5%.⁶ Although Ethiopia has made steady progress since 2000, the country still has further progress to make to reach Every Newborn Action Plan target of 12 stillbirths per 1,000 total births.

Insight from DHS surveys in Ethiopia suggest that there are not substantial disparities in stillbirth rate across wealth quintiles or residence, but that some regions experience elevated levels of stillbirth compared to others.⁵ Ethiopia’s second most populous region, Amhara, in particular has a stillbirth rate that stands out among other regions as the highest.⁵