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Maternal mortality, or the death of a woman during pregnancy or within 42 days of the end of pregnancy, is a serious global health issue that affects millions of families every year. According to the World Health Organization (WHO), about 295,000 women died from pregnancy-related causes in 2017, with 94% of the deaths occurring in low- and middle-income countries.

The maternal mortality ratio (MMR), or the number of maternal deaths per 100,000 live births, is a key indicator of the quality and accessibility of maternal health care, as well as the social and economic status of women. The global MMR was 211 in 2017, with significant regional variations: from 11 in high-income countries to 462 in sub-Saharan Africa.

The United Nations Sustainable Development Goals (SDGs) aim to reduce the global MMR to less than 70 by 2030, but the progress has been slow and uneven.

The causes of maternal death are complex and multifactorial, but they can be broadly classified into direct and indirect causes. Direct causes are those related to complications arising from pregnancy or childbirth, such as hemorrhage, infection, eclampsia, and unsafe abortion. Indirect causes are those related to pre-existing medical conditions that are aggravated by pregnancy, such as cardiovascular disease, diabetes, HIV/AIDS, and malaria.

The leading causes of pregnancy-related deaths in the U.S. are heart conditions and stroke, which account for more than one-third of the deaths. In the UK, the main cause of death was thrombosis and thromboembolism, or blood clots in the veins, followed by COVID-19. Most maternal deaths are preventable, as the health-care solutions to prevent or manage complications are well known.

Risk Factors

The risk factors for maternal death vary by context, but some of the common ones are:

• Age: Teenage pregnancy and pregnancy after 35 years of age are associated with higher risks of complications and death.
• Parity: Having multiple pregnancies or closely spaced pregnancies increases the risk of maternal death.
• Socioeconomic status: Poverty, lack of education, and low empowerment of women are linked to poor access to quality health care, nutrition, sanitation, and family planning.
• Geographic location: Rural and remote areas often have limited health facilities, skilled health workers, and transportation options, which hinder timely and adequate care for pregnant women.
• Ethnicity and race: Ethnic and racial minorities often face discrimination, stigma, and barriers to health care, which contribute to disparities in maternal outcomes. For example, in the UK, black women are three times more likely to die during pregnancy or soon after compared with white women, and Asian women are twice as likely. In the U.S., black women are two to three times more likely to die from pregnancy-related causes than white women.

Prevention

The prevention of maternal death requires a comprehensive and coordinated approach that addresses the underlying determinants of maternal health, as well as the immediate causes of complications. Some of the key strategies are:

• Improving pre-pregnancy health: To avoid maternal deaths, it is 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. Pre-pregnancy health care should also include screening and treatment of chronic conditions, such as hypertension, diabetes, and anemia, as well as counseling and education on healthy behaviors, such as nutrition, exercise, and smoking cessation.
• Providing antenatal care: Antenatal care is the care that a woman receives during pregnancy to monitor her health and that of her baby. It is recommended that pregnant women have at least eight contacts with a skilled health provider throughout their pregnancy, starting from the first trimester. Antenatal care can help detect and manage potential complications, such as preeclampsia, gestational diabetes, and fetal growth restriction, as well as provide essential interventions, such as immunization, iron and folic acid supplementation, and prevention of mother-to-child transmission of HIV.
• Ensuring skilled birth attendance: Skilled birth attendance is the presence of a trained health professional, such as a midwife, nurse, or doctor, who can provide basic emergency obstetric and newborn care, such as managing prolonged or obstructed labor, administering oxytocin to prevent postpartum hemorrhage, and resuscitating the newborn. Skilled birth attendance can reduce the risk of maternal and neonatal death by up to 75%, but globally, only 81% of births are attended by skilled health personnel.
• Improving access to emergency obstetric and newborn care: Emergency obstetric and newborn care (EmONC) is the care that is required for women and newborns who develop life-threatening complications during pregnancy, delivery, or postpartum. EmONC includes basic and comprehensive services, such as blood transfusion, cesarean section, and neonatal intensive care. EmONC should be available 24/7 at designated health facilities, and referral systems should be in place to ensure timely and safe transportation of women and newborns who need higher-level care.
• Providing postnatal care: Postnatal care is the care that a woman and her baby receive after delivery, up to six weeks postpartum. It is recommended that women have at least three postnatal contacts with a skilled health provider, within the first 24 hours, between days three and seven, and at six weeks after birth. Postnatal care can help prevent and treat postpartum complications, such as hemorrhage, infection, and depression, as well as promote breastfeeding, family planning, and immunization.
• Strengthening health systems: Health systems are the organizations, people, and resources that deliver health services to meet the needs of the population. Strengthening health systems is essential to improve the quality and accessibility of maternal health care, as well as to address the social and environmental determinants of health. Some of the key elements of a strong health system are: adequate financing, human resources, infrastructure, equipment, supplies, information, governance, and accountability.
• Promoting women’s rights and empowerment: Women’s rights and empowerment are the recognition and respect of women’s dignity, autonomy, and agency in all aspects of their lives. Promoting women’s rights and empowerment can improve maternal health by enabling women to make informed decisions about their reproductive health, access health services without discrimination or coercion, and participate in the planning and implementation of health policies and programs. Women’s rights and empowerment also entail addressing the root causes of gender inequality, such as violence, child marriage, female genital mutilation, and lack of education and economic opportunities.

Maternal mortality is a preventable and unacceptable tragedy that affects millions of women and their families every year. It is also a reflection of the inequities and injustices that women face in their societies. To reduce maternal mortality and achieve the SDGs, urgent action is needed to bolster the quality and accessibility of maternal health care, ensure it is respectful and responsive to the needs and preferences of women, and repair the damage inflicted by the COVID-19 pandemic on women’s health services more generally. Moreover, it is imperative to address the social and structural determinants of maternal health, such as poverty, discrimination, and violence, and to empower women to exercise their rights and choices in all aspects of their lives.