Maternal mortality

WHO / MPS

Every day, 1500 women die from pregnancy- or childbirth-related complications. In 2005, there were an estimated 536 000 maternal deaths worldwide. Most of these deaths occurred in developing countries, and most were avoidable. (1) Improving maternal health is one of the eight Millennium Development Goals adopted by the international community at the United Nations Millennium Summit in 2000. In Millennium Development Goal 5 (MDG5), countries have committed to reducing the maternal mortality ratio by three quarters between 1990 and 2015. However, between 1990 and 2005 the maternal mortality ratio declined by only 5%. Achieving Millennium Development Goal 5 requires accelerating progress.

^{(1) Maternal mortality in 2005: estimates developed by WHO, UNICEF, UNFPA and the World Bank. Geneva, World Health Organization, 2007 (http://www. who.int/reproductive-health/publications/maternal_mortality_2005/index.html, accessed 14 August 2008).}

Where do maternal deaths occur?

The high incidence of maternal death is one of the signs of major inequity spread throughout the world, reflecting the gap between rich and poor.

The designation employed and the presentation of the material on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dashed lines represent approximate border lines for which there may not be yet full agreement.

A total of 99% of all maternal deaths occur in developing countries, where 85% of the population lives. More than half of these deaths occur in sub-Saharan Africa and one third in South Asia. The maternal mortality ratio in developing countries is 450 maternal deaths per 100 000 live births versus 9 in developed countries. Fourteen countries have maternal mortality ratios of at least 1000 per 100 000 live births, of which all but Afghanistan are in sub-Saharan Africa: Afghanistan, Angola, Burundi, Cameroon, Chad, the Democratic Republic of the Congo, Guinea-Bissau, Liberia, Malawi, Niger, Nigeria, Rwanda, Sierra Leone and Somalia.(1)

Because women in developing countries have many pregnancies on average, their lifetime risk more accurately reflects the overall burden of these women. A woman’s lifetime risk of maternal death is 1 in 7300 in developed countries versus 1 in 75 in developing countries. But the difference is more striking in Niger, where women’s lifetime risk of dying from pregnancy-related complications is 1 in 7 versus 1 in 48 000 in Ireland.(1)

In addition to the differences between countries, there are also large disparities within countries between people with high and low income and between rural and urban populations.

^{(1) Maternal mortality in 2005: estimates developed by WHO, UNICEF, UNFPA and the World Bank. Geneva, World Health Organization, 2007 (http://www. who.int/reproductive-health/publications/maternal_mortality_2005/index.html, accessed 14 August 2008).}

Why do mothers die?

Women die from a wide range of complications in pregnancy, childbirth or the postpartum period. Most of these complications develop because of their pregnant status and some because pregnancy aggravated an existing disease. The four major killers are: severe bleeding (mostly bleeding postpartum), infections (also mostly soon after delivery), hypertensive disorders in pregnancy (eclampsia) and obstructed labour. Complications after unsafe abortion cause 13% of maternal deaths. Globally, about 80% of maternal deaths are due to these causes. Among the indirect causes (20%) of maternal death are diseases that complicate pregnancy or are aggravated by pregnancy, such as malaria, anaemia and HIV.(2) Women also die because of poor health at conception and a lack of adequate care needed for the healthy outcome of the pregnancy for themselves and their babies.

^{(2) The world health report 2005 – Make every mother and child count. Geneva, World Health Organization, 2005 (http://www.who.int/whr/2005/en, accessed 14 August 2008).}

How can the mothers' lives be saved?

WHO / Marie-Agnes Heine

The first step for avoiding maternal deaths is to ensure that women have access to family planning and safe abortion. This will reduce unwanted pregnancies and unsafe abortions.

The women who continue pregnancies need care during this critical period for their health and for the health of the babies they are bearing. Most maternal deaths are avoidable, as the health care solutions to prevent or manage the complications are well known. Since complications are not predictable, all women need care from skilled health professionals, especially at birth, when rapid treatment can make the difference between life and death. For instance, severe bleeding after birth can kill even a healthy woman within two hours if she is unattended. Injecting the drug oxytocin immediately after childbirth reduces the risk of bleeding very effectively.

Sepsis – a very severe infection – is the second most frequent cause of maternal death. It can be eliminated if aseptic techniques are respected and if early signs of infection are recognized and treated in a timely manner. The third cause, eclampsia, emerges as pre-eclampsia, a common hypertensive disorder, which can be detected during pregnancy. Although pre-eclampsia cannot be completely cured before the delivery, administering drugs such as magnesium sulfate can lower a woman’s risk of developing convulsions (eclampsia), which can be fatal. Another frequent cause of maternal death is obstructed labour, which occurs when the fetus’ head is too big compared with the mother’s pelvis or if the baby is abnormally positioned. A simple tool for identifying problems early in labour is the partograph, a graph of progress of labour and the maternal and fetal condition. Skilled practitioners can use the partograph to recognize and deal with slow progress before labour becomes obstructed, and, if necessary, ensure that Caesarean section is performed on time to save the mother and the baby. For women to benefit from those cost-effective interventions they must have antenatal care in pregnancy, in childbirth they must be attended by skilled health providers and they need support in the weeks after the delivery.

Why do mothers not get the care they need?

WHO / Jim Holmes

Data show that less than two thirds (62%) of women in developing countries receive assistance from a skilled health worker when giving birth.(5) This means that 45 million home deliveries each year are not assisted by skilled health personnel.

In high-income countries, virtually all women have at least four antenatal care visits, are attended by a midwife and/or a doctor for childbirth and receive postnatal care. In low- and middle-income countries, just above two thirds of women get at least one antenatal care visit, but in some countries less than one third have this or, as in Ethiopia, just 12%.(4)

Even fewer women have the birth attended by a skilled health worker. The 63% average for low- and middle-income countries covers large differences: from 34% in eastern Africa to 93% in South America. (3)

There are many reasons why women do not receive the care they need before, during and after childbirth. Many pregnant women do not get it because there are no services where they live, they cannot afford the services because they are too expensive or reaching them is too costly. Some women do not use services because they do not like how care is provided or because the health services are not delivering high-quality care.

Further, cultural beliefs or a woman’s low status in society can prevent a pregnant woman from getting the care she needs. To improve maternal health, gaps in the capacity and quality of health systems and barriers to accessing health services must be identified and tackled at all levels, down to the community.

^{(3) Proportion of births attended by a skilled health worker – 2008 updates. Geneva, World Health Organization, 2008 (http://www.who.int/reproductive_health/ global_monitoring/data.html, accessed 14 August 2008).
(4) WHO and UNICEF. Antenatal care in developing countries: promises, achievements and missed opportunities. WHO/UNICEF 2003 (http://www.who.int/reproductive_ health/global_monitoring/data.html. Countdown to 2015. Tracking progress in maternal, newborn & child survival: the 2008 report. New York, United Nations Children’s Fund, 2008 (http://www. countdown2015mnch.org/index.php?option=com_content&view=article&id=68&itemid=61, accessed 14 August 2008).}

What does MPS do to reduce maternal mortality?

Maternal health is one of WHO’s priority areas. In 2007, we celebrated – together with partners – the 20th anniversary of Safe Motherhood, an initiative that placed maternal mortality on the global agenda.

Through the Department of Making Pregnancy Safer, WHO is providing guidance to countries for improving maternal health. We assist countries in collaboration with other parts of the Organization and experts in WHO regional and country offices. We aim to reduce maternal mortality by providing and promoting evidence-based clinical and programmatic guidance. In addition, WHO advocates for a social, political and economic environment conducive to action in countries.

A cornerstone of the WHO guidance is guidelines on effective, efficient, safe and culturally appropriate services. A set of guidelines under a common title Integrated Management of Pregnancy and Childbirth (IMPAC) assists countries in addressing the main problems facing pregnant women and their newborn infants. The guidelines are supported by other tools that help countries’ implementation according to their needs and capacity, such as how to set policies that address country needs, tools for costing programmes that will increase women’s access to the care they need and methods and instruments for monitoring what they are doing and for measuring progress in reducing maternal mortality. We guide critical actions that are necessary in countries to ensure that enough well-trained midwives and doctors become available.

WHO also promotes the involvement of individuals, families and communities in increasing access to high-quality care. To advance these approaches, staff of the WHO Department of Making Pregnancy Safer and WHO staff in the regions organize workshops to orient health programme managers and provide ongoing technical support to countries.

What about babies

Every year more than 133 million babies are born, 90% in low- and middle-income countries. When their mother dies, the chance of their surviving is meagre. Lack of maternal care is causing a large burden of babies’ deaths and disability among infants.

Every year 3 million babies are stillborn. Almost one quarter of these die during birth. The causes of these deaths are similar to the causes of maternal deaths: obstructed or very long labour, eclampsia and infection such as syphilis. Poor maternal health and diseases that have not been adequately treated before or during pregnancy contribute to intrapartum death but also contribute to many babies born preterm and with low birth weight. About 20 million (17%) are born with low birth weight. The exact number is not known since only one third of babies are weighed at birth.

Among the 133 million babies who are born alive each year, 2.8 million die in the first week of life and slightly less than 1 million in the following three weeks. Neonatal tetanus is still killing 100 000 babies a year.

The patterns of babies’ deaths are similar to the patterns of maternal deaths: large numbers in Africa and Asia and very low numbers in high-income countries. The rates vary from 7 per 1000 births in high-income countries to 74 per 1000 births in central Africa.

Interventions for saving babies’ lives are very similar to those that save maternal lives. Although the underlying causes differ, poor maternal health and lack of services are the most important factors. Infants who survive either maternal or neonatal complications have high morbidity and resulting disability. At present it is too difficult to measure how many disabled infants – infants with cerebral palsy, mental retardation or visual or auditory impairment – are among the survivors. Many are among the babies who die later in infancy and childhood.

Maternal and perinatal deaths (stillbirths and firstweek deaths) together add up to 6.3 million lives lost every year. Further, many women must live with an obstetric fistula because of childbirth complications, and many babies are disabled. This combined toll that mother and babies are paying for inadequate services should be considered when maternal mortality is being discussed.

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