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BackgroundFew studies assess the magnitude, variations, and reduction of maternal mortality at a lower administrative level. This study was conducted to estimate the life time risk (LTR) of maternal death and the maternal mortality ratio (MMR) and assess the reduction in MMR.MethodsThis is a population-based cross-sectional study conducted in six districts of Sidama National Regional State, southern Ethiopia, from July 2019 to May 2020. The study was conducted with men and women aged 15–49 years. By creating a retrospective cohort of women of reproductive age, we calculated the LTR of maternal mortality and approximated the MMR using the total fertility of the rural Ethiopian population. Variations in maternal mortality was assessed based on characteristics of the respondents, like age, sex, and the districts where they lived. Reduction in MMR was examined using the estimates of the sisterhood method and the 5-year recall of pregnancy and birth outcome household survey.ResultsWe analysed 17374 (99.6%) respondents: 8884 (51.1%) men and 8490 (48.9%) women. The 17,374 respondents reported 64,387 maternal sisters. 2,402 (3.7%) sisters had died; 776 (32.3%) were pregnancy-related deaths. The LTR of maternal death was 3.2%, and the MMR was 623 (95% CI: 573–658) per 100,000 live births (LB). The remote district (Aroresa) had a MMR of 1210 (95% CI: 1027–1318) per 100,000 LB. The estimates from male and female respondents were not different. A significant reduction in MMR was observed in districts located near the regional centre. However, no reduction was observed in districts located far from the regional centre.ConclusionsThe high MMR with district-level variations and the lack of mortality reduction in districts located far from the centre highlight the need for instituting interventions tailored to the local context to save mothers and accelerate reductions in MMR.