Two of the eight Millennium Development Goals (MDGs)

embraced by UN members in 2000 target the health of

mothers and children, testifying to the vast inequities in

maternal and child health within and between countries.

In 2001, maternal and perinatal conditions represented

the single largest contributor to the global burden of

disease, at nearly 6 percent of total Disability Adjusted Life

Years (DALYs).* About 500,000 women die as a result of

pregnancy or childbirth, nearly all in developing countries.

Maternal and newborn mortality are regarded as sensitive

indicators of the entire health system, and can be used to

monitor general health gains. However, these deaths also

represent the most serious challenges to achieving the MDGs,

particularly in South Asia and sub-Saharan Africa.

Experts agree that nearly all maternal deaths could be

prevented with proper prenatal and postnatal care, along

with skilled attendance at childbirth and the availability

of emergency care for serious complications. The clinical

interventions needed to avert much of the disease burden

from maternal deaths require a reasonably well-functioning

health system.

This fact sheet focuses on causes and management of

conditions that arise during pregnancy and delivery resulting

in the death of the mother. Maternal health is intricately

linked with newborn health, which is discussed in detail in

the “Newborn Health” fact sheet.

Causes of Maternal Deaths

Maternal conditions encompass events occurring from

conception to 42 days postpartum. Within this period,

women’s health can be compromised by conditions that

arise specifi cally from pregnancy, known as direct obstetric

conditions, or that are aggravated by or threaten pregnancy,

known as indirect obstetric conditions. Direct causes account

for 80 percent of all deaths, with indirect causes accounting

for the remainder. Of direct causes, hemorrhage is the most

common. Indirect causes include diseases such as HIV/AIDS

and malaria.

International experts, writing in the comprehensive report,

Disease Control Priorities in Developing Countries, 2nd

edition (DCP2), focus on fi ve major maternal conditions that

account for an estimated 75 percent of maternal deaths—

hemorrhage, sepsis, hypertensive disorders of pregnancy,

obstructed labor, and unsafe abortion.

Although pregnancy and childbirth are natural processes,

maintaining a balance between handling normal deliveries

and readiness to deal with complications represents a

challenge to health systems and a tension in safe

motherhood programs. Assessments of the features of

maternal conditions must be complemented by attention to

the following characteristics of maternal health:

• Many preventive practices related to pregnancy and

childbirth can be harmful in unskilled hands;

• The lives of at least two individuals are at stake if

complications arise;

• Conditions present clinically not as single entities but

as complexes;

• Death is highly concentrated around the time of

delivery. About two-thirds of maternal deaths occur

between the onset of labor or abortion and 48 hours

postpartum or postabortion.

• The initial clinical presentation of some conditions

can be sudden, with rapid escalation to a life-

threatening state; and

• Maternal conditions are often unpredictable.

Maternal Deaths

An Unacceptable Lack of Progress

Fogarty International Center of the U.S. National Institutes of Health The World Bank World Health Organization Population Reference Bureau | Bill & Melinda Gates Foundation

www.dcp2.org

March 2007

Almost all maternal deaths are avoidable with competent

care, but interventions must address a broad set of issues.

Risk factors for both serious maternal health problems and

potential death can be social, economic, or cultural; and

they can be related to the health system or to the health

condition of the mother. To reduce the risk factors, health

system improvements must be complemented by attention

to wider social, economic, and cultural factors as well as to

reproductive rights.

Almost all maternal deaths occur in the developing world.

This differential in maternal mortality between the developing

and developed worlds is often cited as the largest discrepancy

of all public health statistics. Just 13 countries account for

70 percent of all maternal deaths. Two regions — South

Asia and sub-Saharan Africa — account for 74 percent of

the global burden of maternal conditions (see table). There

are also wide disparities across socioeconomic status within

countries, with large gaps between rich and poor.

Globally, little progress has been made in reducing maternal

mortality over the past 20 years, although there is some

evidence of decline in countries where maternal mortality

ratios were already low (fewer than 100 maternal deaths

per 100,000 live births). Recent World Health Organization

(WHO) statistics on unsafe abortion — a major cause

of maternal mortality — show an apparent decrease in

incidence globally, although the risk of death remains high at

50 maternal deaths per 100,000 live births (and as high as 140

per 100,000 live births in Sub-Saharan Africa).

Interventions

No single health intervention can by itself significantly

reduce maternal mortality. The scope and nature of maternal

conditions call for clusters, or packages, of interventions. Three

main pathways can avert adverse outcomes — preventing

pregnancy, preventing complications, and preventing death

from complications of pregnancy and childbirth. The first

pathway is the only true primary prevention strategy and is

the focus of a forthcoming fact sheet that summarizes the

DCP2 chapter on contraception.

Preventing complications involves maintaining a normal

pregnancy and managing mild complications — in essence,

good quality of care. If complications occur, maternal death

can be avoided by effective, timely, and appropriate clinical

interventions, often referred to as emergency obstetric care.

DCP2 clusters intervention strategies on the basis of:

• Strategic approach — population-based versus

personal interventions;

• Level of care — home, primary, and secondary care;

and

• Time period — pregnancy, labor and delivery,

and postpartum.

The most effective and promising interventions are highlighted below:

Population-Based Interventions

Planning Pregnancies

Research has shown that women face a greater risk of

pregnancy-related death or disability depending on

the frequency of pregnancies (number and spacing),

mother’s age, and desire for the child. Women can better

plan their pregnancies if they are exposed to family

planning information, education, and communication

(IEC) programs, and client-friendly services to increase

access to contraception. These interventions have been

credited with a substantial increase in contraceptive use

and fertility decline in developing countries over the past

40 years. But a significant unmet need for contraceptives

still persists. Experts estimate that avoiding unintended

pregnancies would reduce maternal deaths by 20 percent in

developing countries.

imProving nutrition

Many women in developing countries suffer problems

in pregnancy because of a lack of vital nutrients —

especially iron, iodine, folate, and vitamin A. Limited

evidence supports interventions such as multivitamins,

minerals, or macronutrient interventions, including

protein-energy supplements, as well as iron and folic acid

to combat anemia.

Personal Interventions

Interventions directed at individuals must involve a

continuum of care for mother and baby in terms of time

(before and after delivery), place (linking home and health

services through an effective referral chain), and skilled

personnel (the care provider). Care can be provided in the

home, at the primary level (clinic or health center), and at

the secondary level (district hospital).

PAGE 2 | Maternal Mortality | Disease Control Priorities Project

Home-Based care

Birth preparedness includes planning for the place of and the

attendant at delivery, as well as arranging for rapid transport

to a health center or hospital if needed, and sometimes

identifying a compatible blood donor in case of hemorrhage.

The expectant mother, relatives, and other community

members, including traditional birth attendants (TBAs)

should learn to recognize signs of dangerous complications

and to take the appropriate steps.

Primary-level care

Primary-level care is widely regarded as the crucial entry point

to maternity services, and to care before and after pregnancy.

Primary-care level health centers should provide prenatal,

delivery (including managing abortion complications), and

postpartum care (including family planning and postabortion

counseling), as well as care of the newborn.

Management of complications usually occurs at two

levels — basic emergency obstetric care (BEmOC) and

comprehensive emergency obstetric care (CEmOC).

CEmOC includes surgical interventions and blood

transfusion. The capacity of health centers to provide

BEmOC depends on the availability of supplies, drugs,

infrastructure, and skilled providers.

Routine Prenatal Care. Essential elements of routine

prenatal care include: screening and treatment for syphilis,

immunization with tetanus toxoid, prevention and treatment

of anemia, and prevention and treatment of malaria with

prophylaxis or bed nets. Strong evidence supports the cost-

effectiveness of a four-visit prenatal schedule that includes

educating women and birth attendants about danger signs

and the need for skilled attendance at delivery.

Delivery Care. The risks of adverse outcomes for mother

and baby are highest during childbirth. To reduce these

risks, experts recommend that delivery services be provided

by professionals with obstetric skills, whether the birth

occurs at home or in a health facility. A major strategy for

reducing the maternal health burden involves increasing

the use of skilled providers for the vast majority of normal

deliveries and managing mild complications at the primary

level with referral to CEmOC if necessary. Globally, there

are wide variations in skilled attendance at childbirth,

with the lowest being in sub-Saharan Africa at 48 percent

of deliveries. Variation also exists across socioeconomic

groups within countries. The proportion of deliveries with

a health professional (doctor, midwife, or nurse) present is

an indicator used to assess progress in improving maternal

health care.

Postpartum Care. Primary care services continue to neglect

the postpartum period despite significant problems during

this time. Routine postnatal checks are not widespread,

and most contacts with services after delivery focus on

educational messages aimed at danger signs, breastfeeding,

nutrition, and lifestyle, rather than physical examination of

the postpartum woman. Because unsafe abortion accounts

for a significant proportion of the burden of maternal

conditions, management of complicated abortions should

receive higher priority, but attention to this critical need is

often neglected.

secondary-level care

Hospital-based care, generally at the district level, includes

CEmOC, and must include strong links to the primary-

level through an effective rapid referral communication

chain. District hospitals must be able to provide surgical

interventions with the requisite backup, such as blood banks.

Obstetric experts agree that maternal mortality cannot be

reduced without effective secondary care for complications.

The UN has endorsed a minimum of one CEmOC facility

per 500,000 people.

Cost-Effectiveness

Cost-effectiveness analysis focuses on prenatal care, delivery,

or intrapartum care, and emergency obstetric care. The most

cost-effective intervention package relative to an assumed

routine maternity service, improves the quality of prenatal

and intrapartum care by ensuring the availability of BEmOC

at the primary level and by increasing the adequacy of

CEmOC at the secondary level. In South Asia, moving from a

routine maternity service to this package of enhanced quality

of care costs $142 per additional DALY averted and $5017

per additional death averted; and in sub-Saharan Africa, the

costs were $83 per additional DALY averted and $2,729 per

additional death averted. Small increases in prenatal care

coverage, of even 20 percent more women, boost the number

of women benefiting from the addition of obstetric first aid

and CEmOC.

Maternal Mortality | Disease Control Priorities Project | PAGE 3

Benefits of Intervention

Reducing maternal mortality benefits households

economically by allowing women to remain productive

longer and by averting the costs associated with a health

crisis. Because children’s health and education usually suffer

when mothers die, avoiding maternal deaths also avoids

these extra economic burdens. Thus, preventing maternal

mortality can support broader efforts to reduce poverty.

However, gains in maternal health depend on functioning

health systems and a supportive policy environment. Attaining

basic prenatal and delivery coverage for 50 percent of women

costs only $0.41 per capita in South Asia and $0.60 per capita

in sub-Saharan Africa, yet funding for prenatal and delivery

care services is inadequate. Progress depends on a complex set

of factors, including solving human resource problems (the

“brain drain”), effective referral systems, extending access to

services to the poorest groups, improved surveillance, and

additional research.

*1 DALY (disability-adjusted life year) is a composite measure that com-bines the number of years lived with a disability and the number of years lost to premature death.

References

Wendy J. Graham, John Cairns, Sohinee Bhattacharya, Colin

H.W. Bullough, Zahidul Quayyum, and Khama Rogo. 2006.

“Maternal and Perinatal Conditions.” In Disease Control

Priorities in Development Countries, 2nd ed. D. T. Jamison,

J. G. Breman, A. R. Measham, G. Alleyne, M. Claeson, D. B.

Evans, P. Jha, A. Mills, and P. Musgrove, 591-603. New York

Oxford University Press.

www.dcp2.org

Estimates of Maternal Mortality by Region, 2000-2001

RegionMaternal mortality ratio

(maternal deaths per 100,000 live births), 2000

Number of maternal deaths as modeled by

WHO, 2000

Lifetime risk of maternal death

(1 in number shown)

Central and Eastern Europe, Commonwealth of Independent States, Baltic states, Europe, and

Central Asia64 3,400 770

East Asia and the Pacific 110 37,000 360

Eastern and Southern Africa 980 123,000 15

Latin America and the Caribbean 190 22,000 160

Middle East and North Africa 220 21,000 100

South Asia 560 205,000 43

Sub-Saharan Africa 940 240,000 16

Western and Central Africa 900 118,000 16

High-income countries 13 1,300 4,000

Low- and middle- income countries 440 527,000 61

Low-income countries 890 236,000 17

World 400 529,000 74

Source: Graham, W. L., J. Cairns, S. Bhattacharya, C. H.W. Bullough, Z. Quayyum, and K. Rogo. 2006. “Maternal and Perinatal Conditions.” In Disease Control Priorities in Development Countries, 2nd ed. D. T. Jamison, J. G. Breman, A. R. Measham, G. Alleyne, M. Claeson, D. B. Evans, P. Jha, A. Mills, and P. Musgrove, table 26.2. New York: Oxford University Press.

Note: The regions are those used by the United Nations Children’s Fund.