Maternal Mortality: A Global Perspective

Maternal Health and the Burden of Death and Disability

“Many Births Mean Many Burials” —Kenyan Proverb

Every year worldwide, it is estimated that more than 300,000 mothers die from preventable causes during pregnancy, birth, and the postnatal period—approximately 830 women every day. Despite ongoing efforts by the global health community, the death rate has dropped by only 44% overall since 1975, far less than the 75% decline anticipated after the introduction of the United Nation (UN) Millennium Development Goals (MDGs) in 1990. Despite recent initiatives, which in some resource-poor countries have resulted in quite significant declines over the past few years, too little has happened too late. The irrefutable fact is that the main preventive or remediable interventions to reduce maternal deaths have been well known for many years, and nearly all of these tragedies could be avoided at little or no extra cost. Lives would be saved in those countries which carry a significant burden of maternal and newborn deaths if there was stronger political will to improve the lives of women by placing women's health and reproductive rights far higher up the agenda rather than at the tail end of services, as so often happens. As the father of the Safe Motherhood movement, Professor Mahmoud Fathalla famously said “women are not dying of diseases we cannot treat…they are dying because societies have yet to decide that their lives are worth saving.”

Maternal deaths and disabilities are eminently avoidable if women have a choice about becoming pregnant and, once pregnant, if they have access to essential health services that provide evidence-based, technologically appropriate, and affordable interventions even in the poorest countries of the world. For example, a UN report estimated that if all women who wanted to space or avoid pregnancy were able to access and use an effective modern method of contraception, the global number of unintended pregnancies would drop by 70% and the number of unsafe, potentially fatal abortions would drop by 74%. In addition, if all pregnant women and their newborn babies received only the basic standards of maternity care recommended by the World Health Organization (WHO), the number of women dying would fall by two-thirds and those of their babies would decrease by more than three-quarters.

Deaths are merely the tip of the iceberg. Globally it is estimated that more than 300 million women are living with short- or long-term pregnancy-related complications, with approximately 20 million new cases occurring each year. In addition, these figures generally do not include the poorly recognized or accepted burden of mental health. In most countries, postnatal depression, suicide from puerperal psychosis, and other mental health issues are not even acknowledged as pregnancy-related problems, and the stories of legions of women dying or suffering from these debilitating conditions remain untold.

Since maternal and newborn health are a dyad, babies are also affected by their mother's health in pregnancy and birth. It is estimated that 2.7 million newborns die, and another 2.6 million babies are stillborn annually, and many more millions are left motherless and far less able to thrive. The risk of death for preexisting children younger than age 5 is doubled if their mother dies in childbirth and is even more challenging for girls. Every maternal death or long-term complication is not only a tragedy for the mother, her partner, and her surviving children but is also an economic loss to her family, community, and society.

In Chichewa, the national language of Malawi, the word pakati refers to pregnancy. Its literal translation means “ in the middle between life and death. ” In other African countries, it is common to hear women in labor using euphemisms such as “ I am going to the river to fetch water; I may not come back, ” or childbirth is described as “ slipping on a banana skin at the edge of a cliff with no safety net. ” These concerns are all too real for many women, and “ a place between life and death ” is an accurate description of the 9 months of anxiety and fear that accompany pregnancy and delivery.

The World Bank classifies every economy as low, middle, or high income; as an indicator it uses gross national income (GNI) per capita because it is considered to be the single best gauge of economic capacity and progress. For the 11 million mothers who give birth each year in high-income countries, access to quality antenatal, intrapartum, and postnatal care for both mothers and babies is readily available and health outcomes are generally good. Another 34 million women deliver in middle-income countries (MICs), where hospital facilities with variable quality of care or resources such as staff, blood, drugs, or high-dependency units tend to be available. However, for the 90 million mothers in low-income countries (LICs), the situation is usually very different, with little or no access to even basic healthcare, which places the both mother and baby at significantly higher risk, and, of these mothers, approximately 830 will die and 16,000 will suffer severe and long-lasting complications from pregnancy, birth, or postnatal complications every day. In addition, every day, nearly 8000 babies will die around the time of birth, and another 7000 will be stillborn. Overall, this burden of maternal and neonatal mortality, including stillbirths, accounts for approximately 15,800 deaths each day, or 10 lives lost every minute . Most of these will be from preventable or treatable causes of maternal ill health. The film “Why Did Mrs. X Die: Retold” is available online in several languages ( vimeo.com/50848172 ), and it provides a simple introduction.