Where do maternal deaths occur?
The high number of maternal deaths in some areas of the world reflects inequalities in access to quality health services and highlights the gap between rich and poor. The MMR in low-income countries in 2020 was 430 per 100 000 live births compared to 12 per 100 000 live births in high-income countries.
Humanitarian, conflict, and post-conflict settings hinder progress in reducing the burden of maternal mortality. The average MMR for very high and high alert fragile states in 2020 was 551 per 100 000, more than double the world average.
Women in less developed countries have, on average, many more pregnancies than women in developed countries, and their lifetime risk of death due to pregnancy is higher. A woman’s lifetime risk of maternal death is the probability that a 15-year-old woman will eventually die from a maternal cause. In high-income countries, this is 1 in 5300, compared to 1 in 49 in low-income countries.
Why do women die?
Women die from complications during and following pregnancy and childbirth. Most of these complications develop during pregnancy and most are preventable or treatable. Other complications may exist before pregnancy but are worsened during pregnancy, especially if not managed as part of the woman’s care. The major complications that account for nearly 75% of all maternal deaths are:
- severe bleeding (mostly bleeding after childbirth)
- infections (usually after childbirth)
- high blood pressure during pregnancy (pre-eclampsia and eclampsia)
- complications from delivery
- unsafe abortion.
How can women’s lives be saved?
Most maternal deaths are preventable, as the health-care solutions to prevent or manage complications are well known. All women need access to high-quality care in pregnancy, and during and after childbirth. Maternal health and newborn health are closely linked. It is particularly important that all births are attended by skilled health professionals, as timely management and treatment can make the difference between life and death for the woman and for the newborn.
Severe bleeding after birth can kill a healthy woman within hours if she is unattended. Injecting oxytocics immediately after childbirth effectively reduces the risk of bleeding.
Infection after childbirth can be eliminated if good hygiene is practiced and if early signs of infection are recognized and treated in a timely manner.
Pre-eclampsia should be detected and appropriately managed before the onset of convulsions (eclampsia) and other life-threatening complications. Administering drugs such as magnesium sulfate for pre-eclampsia can lower a woman’s risk of developing eclampsia.
To avoid maternal deaths, it is also vital to prevent unintended pregnancies. All women, including adolescents, need access to contraception, safe abortion services to the full extent of the law, and quality post-abortion care.
Why do women not receive the care they need?
Poor women in remote areas are the least likely to receive adequate health care. The latest available data suggest that in most high-income and upper middle-income countries, approximately 99% of all births benefit from the presence of a trained midwife, doctor or nurse. However, only 68% in low-income and 78% in lower middle-income countries are assisted by such skilled health personnel.
Factors that prevent women from receiving or seeking care during pregnancy and childbirth are:
- health system failures that translate to (i) poor quality of care, including disrespect, mistreatment and abuse, (ii); insufficient numbers of and inadequately trained health workers, (iii); shortages of essential medical supplies; and (iv) poor accountability of health systems;
- social determinants, including income, access to education, race and ethnicity, that put some subpopulations at greater risk;
- harmful gender norms and/or inequalities that result in low prioritization of the rights of women and girls, including their right to safe, quality and affordable sexual and reproductive health services; and
- external factors contributing to instability and health system fragility, such as conflicts and humanitarian crises.
To improve maternal health, barriers that limit access to quality maternal health services must be identified and addressed at both health system and societal levels.
What was the impact of the COVID-19 pandemic on maternal mortality?
It is clear from the data that the stagnation in maternal mortality reductions pre-dates the start of the COVID-19 pandemic in 2020. The COVID-19 pandemic may have contributed to the lack of progress but does not represent the full explanation.
The level of maternal mortality during the COVID-19 pandemic may have been impacted by 2 mechanisms: deaths due to the interaction between the woman’s pregnant state and COVID-19 (known as indirect obstetric deaths), or deaths where pregnancy complications were not prevented or managed due to disruption of health services.
A robust global assessment of the impact of COVID-19 on maternal mortality is not possible based on the data currently available: only around 20% of the countries and territories have thus far reported empirical data on their maternal mortality levels in 2020, and high-income and/or relatively smaller populations are overrepresented in this group – with implications for the generalizability of findings.
The current estimates only extend to include the year 2020. Given the limited data, we expect the estimates to be revised in future updates.
WHO/Europe response
Improving maternal health is one of WHO’s key priorities and part of the third core priority of WHO/Europe’s European Programme of Work, 2020–2025 – “United Action for Better Health”.
WHO/Europe works to contribute to the reduction of maternal mortality by increasing research evidence, providing evidence-based clinical and programmatic guidance, setting global standards, and providing technical support to Member States on developing and implementing effective policy and programmes.
As defined in the Action plan for sexual and reproductive health: towards achieving the 2030 Agenda for Sustainable Development in Europe – leaving no one behind, WHO is working with partners in supporting countries towards:
- addressing inequalities in access to and quality of reproductive, maternal and newborn health-care services;
- ensuring universal health coverage for comprehensive reproductive, maternal and newborn health care;
- addressing all causes of maternal mortality, reproductive and maternal morbidities, and related disabilities;
- strengthening health systems to collect high-quality data in order to respond to the needs and priorities of women and girls; and
- ensuring accountability to improve quality of care and equity.
References
- Fragile States. https://fragilestatesindex.org/data/.
- Say L, Chou D, Gemmill A, Tunçalp Ö, Moller A-B, Daniels J et al. Global Causes of Maternal Death: A WHO Systematic Analysis. Lancet Global Health. 2014;2(6): e323-e333.
- Samuel O, Zewotir T, North D. Decomposing the urban–rural inequalities in the utilisation of maternal health care services: evidence from 27 selected countries in Sub-Saharan Africa. Reprod Health 18, 216 (2021).
- World Health Organization and United Nations Children’s Fund. WHO/UNICEF joint database on SDG 3.1.2 Skilled Attendance at Birth. https://unstats.un.org/sdgs/indicators/database/.