Ensure that women have ready and affordable access to skilled attendance at delivery	Target: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio

The challenge

Globally, more than half a million women die each year because of complications related to pregnancy and childbirth. Of the estimated 536,000 maternal deaths worldwide in 2005, developing countries accounted for more than 99 per cent. About half of the maternal deaths (265,000) occurred in sub-Saharan Africa alone and one third took place in South Asia (187,000).

Thus, sub-Saharan Africa and South Asia accounted for 84 per cent of global maternal deaths, with haemorrhage the leading cause of death in these regions. Sepsis, prolonged or obstructed labour, the hypertensive disorders of pregnancy, especially eclampsia, and complications of unsafe abortion, claim further lives.

Haemorrhage is the leading cause of maternal death in Africa and Asia
Causes of maternal death (1997–2002)

Note: Percentages in the charts do not total 100% because of rounding.
Source: Khan, Khalid S., et al., ‘WHO Analysis of Causes of Maternal Death: A systematic review’, The Lancet, vol. 367, p. 1069, 1 April 2006.

These complications can occur without warning at any time during pregnancy and childbirth. And for every woman who dies, approximately 20 more suffer injuries, infection and disabilities. Complications require prompt access to quality obstetric services equipped to provide lifesaving drugs, antibiotics and transfusions and to perform Caesarean sections and other surgical interventions.

The foundations for maternal risk are often laid in girlhood. Women whose growth has been stunted by chronic malnutrition are vulnerable to obstructed labour. Anaemia predisposes to haemorrhage and sepsis during delivery and has been implicated in at least 20 per cent of post-partum maternal deaths in Africa and Asia. The risk of childbirth is even greater for women who have undergone female genital mutilation, an estimated 2 million girls every year.

The factors that cause maternal morbidity and death also affect the survival chances of the foetus and newborn, leading to an estimated 8 million infant deaths a year (over half of them foetal deaths) occurring just before or during delivery or in the first week of life.

The global burden of maternal mortality

The maternal mortality ratio (MMR) is defined as the number of maternal deaths per 100,000 live births. Sub-Saharan Africa suffers from the highest MMR at 920 maternal deaths per 100,000 live births, followed by South Asia, with an MMR of 500. This compares with an MMR of 8 in industrialized countries.

The countries with the highest maternal mortality ratios are Sierra Leone (with 2,100 maternal deaths per 100,000 live births), Niger (1,800), Afghanistan (1,800), Chad (1,500), Somalia (1,400), Angola (1,400), Rwanda (1,300), and Liberia (1,200).

Maternal mortality is highest in countries of sub-Saharan Africa and South Asia
Maternal mortality ratios (MMR) per 100,000 live births (2005)

Source:  UNICEF, Progress for Children: A Report Card on Maternal Mortality, 2008

Lifetime risk is the probability that a woman will die from complications of pregnancy and childbirth over her lifetime; it takes into account both the maternal mortality ratio (probability of maternal death per childbirth) and the total fertility rate (probable number of births per woman during her reproductive years). Thus in a high-fertility setting a woman faces the risk of maternal death multiple times, and her lifetime risk of death will be higher than in a low-fertility setting. The lifetime risk of maternal death in the developing world as a whole is 1 in 76, compared with 1 in 8,000 in the industrialized world. This gap becomes a yawning chasm if the countries with the best and worst records are compared: In Ireland, women have a 1 in 47,600 lifetime risk of dying during pregnancy or from a birth-related cause, whereas women in Niger face a 1 in 7 lifetime risk.

Progress towards MDG 5

Millennium Development Goal Target 5A calls for a reduction in the maternal mortality ratio by three-quarters between 1990 and 2015. At the present rate of progress, the world will fall well short of the target for maternal mortality reduction.  The data suggest that to reach the target, the global MMR would have had to be reduced by an average 5.5 per cent a year between 1990 and 2015. The current average rate of reduction is less than 1 per cent a year. The estimated 0.1 per cent annual rate of reduction in sub-Saharan Africa, where levels of mortality are highest, is slower than in any other region.
 

Varied progress in maternal mortality across regions
Trends in the maternal mortality ratio, by region (1990 and 2005)

Source: UNICEF, Progress for Children: A Report Card on Maternal Mortality, 2008

Challenges to measuring maternal mortality

Maternal mortality is difficult and complex to monitor, particularly in settings where the levels of maternal deaths are highest. Information is required about deaths among women of reproductive age, their pregnancy status at or near the time of death and the medical cause of death - all of which can be difficult to measure accurately, particularly where vital registration systems are incomplete.

Maternal deaths are also relatively rare events, even in high-mortality areas, and are prone to measurement error. Therefore, UNICEF, the World Health Organization, the United Nations Population Fund, the United Nations Population Division and The World Bank have developed an approach to adjusting these data for underreporting and misclassification and producing model-based estimates for countries that lack reliable national-level data.

References

UNICEF. Progress for Children: A Report Card on Maternal Mortality. 2008.

WHO, UNICEF, UNFPA and The World Bank. 2007. Maternal Mortality in 2005. Geneva.

Khan, Khalid S. et al. 2006. WHO Analysis of Causes of Maternal Deaths: A Systematic Review.” The Lancet, 367(9516): 1066-1074.

G. Schmid, N. Broutet, L. deBernis, S. Hawkes, Neonatal Survival Series. The Lancet, Volume 365, Issue 9474, Pages 1845-1845.

WHO, UNICEF and UNFPA, Maternal Mortality in 2000: Estimates Developed by WHO, UNICEF and UNFPA. Geneva, 2004.

C. AbouZahr and T. Wardlaw, Maternal mortality at the end of the decade: What signs of progress? Bulletin of the World Health Organization, Vol. 79, No. 6, 2001 pp. 561-573.

WHO, UNICEF and UNFPA, Maternal Mortality in 1995: Estimates Developed by WHO and UNICEF. Geneva, 2001.

UNICEF, WHO and UNFPA, Guidelines for Monitoring the Availability and Use of Obstetric Services. October 1997.

WHO and UNICEF, The Sisterhood Method for Estimating Maternal Mortality. Guidance notes for potential users, 1997.

K. Hill, C. AbouZahr and T. Wardlaw, Estimates of Maternal Mortality for 1995, Bulletin of the World Health Organization, Vol. 79, No. 3, 2001, pp. 182-193).

WHO, UNICEF and UNFPA, Maternal Mortality in 2000: Estimates Developed by WHO, UNICEF and UNFPA. Geneva, 2004.