Prevalence of errors in medical certification of maternal deaths in Zambia using a retrospective analysis of maternal death surveillance and response data from 2018 to 2022

Data on maternal mortality (MM) from many countries in Sub-Saharan Africa, are still not reliable partly due to inappropriate application of World Health Organisation International Statistical Classification of Diseases and Related Health Problems (WHO ICD) - MM. The WHO ICD - MM classification is essential for boosting the quality of MM reporting and increasing international comparability. This process is intended to enhance MM data reporting and make it easier to code the classification of causes of maternal death, leading to improved interventions and policy decisions aimed at improving maternal health outcomes. This study was conducted to ascertain errors in medical certification of the cause of death (MCCD) of maternal deaths by analyzing data from the Maternal Death Surveillance and Response (MDSR) database at the Ministry of Health of Zambia. This retrospective analysis used MDSR data in Zambia from 2018 to 2022. Errors in medical certification were identified using WHO ICD-MM coding guidelines. Multivariable logistic regression was applied to estimate adjusted odds ratios (aOR) for factors associated with classification errors for immediate, underlying and all the three causes (immediate, underlying, and other contributory causes) of maternal deaths. MCCD prevalence errors for immediate, underlying and all the three causes of maternal death during 2018–2022 was 83.4% (95% CI:82.1%-84.6%), 62.5% (95% CI:60.9%-64.2%), and 24.0% (95% CI:22.5%-25.4%), respectively. Northern and Luapula Provinces had higher odds of MCCD errors of all MM causes (aOR = 2.49; 95% CI:1.80–3.44) and (aOR = 2.31; 95% CI:1.55–3.46), respectively) compared with other provinces. The prevalence of error in MCCD of maternal death for the immediate and underlying causes was high in Zambia. However, variations by province suggest diverse experiences and expertise in abilities to correctly classify maternal deaths by their true causes. There is need to strengthen training of medical staff responsible for medical certification of maternal causes of death to adhere to the WHO guidelines.