Background: Reducing maternal deaths is one of the key goals of Millennium DevelopmentrnGoals (NDGs). Programs and policies aiming to reduce maternal deaths need reliable and validrninformation. Maternal Death Surveillance and Response (MDSR) system is a method ofrncollecting information on the level and causes of maternal death in order to provide accuraterninformation to improve quality of maternal health care.rnObjective: The study aims to assess causes of maternal deaths and factors affecting MDSRrnsystem in public health facilities in Dire DawarnMethods: A cross sectional facility based study design including quantitative and qualitativernmethods was conducted in nine health facilities of Dire Dawa where an MDSR system wasrnintroduced. The quantitative method assessed maternal deaths and complications for causes andrnavoidable factors before the introduction of MDSR from 8 June 2013 to 7 June 2014 and afterrnthe introduction of MDSR from 8 June 2014 to 9 March 2015 by reviewing patient and facilityrnrecords and interviewing with health care providers. Factors which affect the implementation ofrnMDSR assessed qualitatively through in-depth interview with 24 purposively selected healthrncare providers working in the nine public health facilities.rnResults: A total of 45 maternal deaths, 247 maternal complications and 8,857 deliveries werernrecorded during the two study periods. Maternal mortality ratios for the two periods were 511rnand 505 per 100,000 live births in the baseline and implementation period respectively. Of therntotal maternal deaths 33 (73.3%) were avoidable. The direct obstetric causes were responsiblernfor 41 (91%) of the deaths, of which hemorrhage 27%, hypertension during pregnancy 22% andrnobstructed labour 18% are the leading causes. MDSR is implementing in the nine public healthrnfacilities. Knowledge, attitude, support and supervision, training, staff turnover, and communityrnparticipation are the main factors which affect the program implementation.rnConclusions and recommendations: The identified maternal death is very high and most ofrnthem are avoidable and caused by direct obstetric causes of maternal death. MDSR system isrnimplementing and accepted by most of the care providers. Improving care, capacity building,rnsupport and supervision and community awareness is crucial to reduce the number of maternalrndeath and to strengthen and sustain the program implementations