Linda Martorella and Pasqua Putignano
Maternal mortality is a major global public health problem. It is the indicator where the most striking inequalities between rich and poor are recorded. It is one of the few mortality indicators that has not recorded significant improvements in recent years. It is an indicator that is strongly affected by the effectiveness and equity of health services.
Maternal mortality is a major global public health problem. According to the World Health Organization (WHO), in 2020, 287,000 women died during pregnancy, at the time of childbirth or in the following six weeks, a number equivalent to almost 800 deaths every day and approximately one death every two minutes. Unacceptably high numbers. Nearly 95% of all maternal deaths occurred in low- and middle-income countries in 2020, and most could have been prevented1. A fundamental requirement in actions aimed at reducing maternal deaths is understanding the causes of deaths, which are often preventable and treatable, to make effective decisions regarding health policies and programs2. Improving maternal health is one of WHO’s top priorities. WHO 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 for the development and implementation of effective policies and programmes.
As defined in “Strategies to end preventable maternal mortality” (Strategies toward ending preventable maternal mortality, EPMM) WHO is working with partners to support countries in achieving a range of goals to improve maternal and newborn health and survival. In the context of 17 Sustainable Development Goals (SDGs)which entered into force on 1 January 2016, global commitments directly related to health fall within theSDG 3: Ensuring healthy lives and promoting well-being for all at all ages. SDG 3 includes an ambitious goal: “reduce global maternal mortality to less than 70 per 100,000 live births by 2030 “. The goal of reducing the global maternal mortality rate was already declared in EPMMpublished by WHO in 2015 in anticipation of the launch of the SDGs, and was adopted as SDG 3.1.3 In 2020, the global maternal mortality rate (MMR) was estimated at 223 maternal deaths per 100,000 live births, down from 227 of 2015 and 339 of 2000. The average annual rate of reduction in global MMR (ARR) for the period 2000-2020 was 2.1%. However, progress was not uniform throughout the period. Globally, previous successes in reducing maternal mortality achieved during the Millennium Development Goals (MDG) era, 2000 to 2015, have stagnated in the first five years of the SDG era, 2016 to 2020.
The global average ARR between 2000 and 2015 was 2.7% but fell to a negative value between 2016 and 2020. Although the negative ARR indicates an increase in the maternal mortality rate and therefore a de facto worsening, considering the uncertainty ranges, it translates into a stagnation of the global MMR during the last reported period. Achieving a global maternal mortality rate below 70 by 2030 will require an annual reduction rate of 11.6%, which has rarely been achieved at the national level.
Figure 1. Maternal Mortality Rate for a stratified five-year period by five years, 2000-2020.
Global inequalities
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. Sub-Saharan Africa and South Asia account for approximately 87% (253,000) of estimated maternal deaths globally in 2020. Sub-Saharan Africa alone is responsible for approximately 70% of maternal deaths (202,000), while l ‘South Asia is responsible for approximately 16% (47,000). Sub-Saharan Africa was also the only region, among the SDG 3 regional groupings, with a very high MMR, estimated at 545 maternal deaths per 100,000 live births. This is 136 times higher than the MMR in Australia and New Zealand, where the MMR was lowest. The regions of Europe and North America (13), East and Southeast Asia (74), North Africa and West Asia (84), and Latin America and the Caribbean (88) all had an MMR below 100, defined as low, in 2020.
Figure 2. Maternal mortality rate, 2020. The maternal mortality rate is the number of women who die from causes related to pregnancy or within 42 of the end of pregnancy per 100,000 live births.
These regional differences in MMR correspond to substantial differences in the lifetime risk of death from maternal causes. In fact, a 15-year-old girl in sub-Saharan Africa has the highest lifetime risk (1 in 40), about 400 times higher than in Australia and New Zealand (1 in 16,000). The three countries with extremely high mortality (over 1000) are located in the sub-Saharan African region; among these is Nigeria, with 1047 maternal deaths per 100,000 live births, represents over a quarter (28.5%) of all estimated maternal deaths globally, with approximately 82,000 maternal deaths. Instead, 73 countries, most of them in Europe or Latin America and the Caribbean, were estimated to have only 20 or fewer maternal deaths in 2020. Substantial variation in maternal mortality numbers between regions also emerged based on development levels. Although only 13% of the world‘s population lives in least developed countries, this group of countries was responsible for approximately 42% of all maternal deaths in 2020, with an estimated MMR of 377 maternal deaths per 100,000 live births. In these countries, maternal deaths represent 18.2% of all deaths of women aged between 15 and 49 and the lifetime risk of death from maternal causes is 1 in 66.
Humanitarian, conflict and post-conflict contexts hinder interventions aimed at reducing maternal mortality. L’Fragile States Index 4, which is based on a series of risk indicators that provide a framework for evaluating conflicts, allows us to highlight the critical issues of individual states including political risk; using this tool you can define countries “at very high alarm” e “at high alarm”. In 2020, 9 countries fell into these two categories and had maternal mortality rates ranging from 30 (Syria) to 1223 (South Sudan). The average MMR for fragile states at high and very high alert in 2020 was estimated at 551 maternal deaths per 100,000, more than double the average world.
All the numbers we have seen must be interpreted taking into consideration the factors that prevent women from receiving or seeking assistance during pregnancy and which are the points on which to intervene to obtain a reduction in maternal deaths. Among the objectives to be pursued are: addressing inequalities in access and quality of care in order to achieve universal health coverage for sexual, reproductive, maternal and neonatal health; strengthen health systems to respond to women’s needs and priorities; understand all causes of maternal mortality, reproductive morbidity and related disabilities.5
Linda Martorella and Pasqua Putignano. Specialization school in Hygiene and Preventive Medicine. University of Florence.
Bibliography
https://www.who.int/news-room/fact-sheets/detail/maternal-mortality/Say L, Chou D, Gemmill A et al. Global Causes of Maternal Death: A WHO Systematic Analysis. Lancet Global Health. 2014;2(6): e323-e333.Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva: World Health Organization; 2023. Licence: CC BY-NC-SA3.0 IGO.Fragile States Index. Available at: https://fragilestatesindex.org/data/Strategies toward ending preventable maternal mortality (EPMM) by World Health Organization 2015; https://www.who.int/publications/i/item/9789241508483