Elsevier

The Lancet

Volume 368, Issue 9542, 30 September–6 October 2006, Pages 1189-1200
The Lancet

Series
Maternal mortality: who, when, where, and why

https://doi.org/10.1016/S0140-6736(06)69380-XGet rights and content

Summary

The risk of a woman dying as a result of pregnancy or childbirth during her lifetime is about one in six in the poorest parts of the world compared with about one in 30 000 in Northern Europe. Such a discrepancy poses a huge challenge to meeting the fifth Millennium Development Goal to reduce maternal mortality by 75% between 1990 and 2015. Some developed and transitional countries have managed to reduce their maternal mortality during the past 25 years. Few of these, however, began with the very high rates that are now estimated for the poorest countries—in which further progress is jeopardised by weak health systems, continuing high fertility, and poor availability of data. Maternal deaths are clustered around labour, delivery, and the immediate postpartum period, with obstetric haemorrhage being the main medical cause of death. Local variation can be important, with unsafe abortion carrying huge risk in some populations, and HIV/AIDS becoming a leading cause of death where HIV-related mortaliy rates are high. Inequalities in the risk of maternal death exist everywhere. Targeting of interventions to the most vulnerable—rural populations and poor people—is essential if substantial progress is to be achieved by 2015.

Section snippets

How big is the problem of maternal mortality?

Each year, an estimated 529 000 maternal deaths occur. This number is based on calculations for the year 2000, the most recent date for such crude data.2 Other measures of the burden of mortality besides the total count are available (panel 23), all of which tell a slightly different story. The global ratio of maternal deaths to livebirths (or maternal mortality ratio)—the most commonly used indicator of maternal mortality—is 400 per 100 000 livebirths for the same period. This measure captures

Are there any signs of progress?

The target set for MDG-5 is a 75% reduction in the maternal mortality ratio between 1990 and 2015. As with other health outcomes, judging progress for maternal mortality is sensitive to the indicator chosen. The maternal mortality ratio does not capture well reductions in risk owing to declining fertility, but such progress could emerge from tracking of trends in the number of maternal deaths. In 2000–05, the global total fertility rate was 2·65 children, about half that in 1950–55.5 As a

At what point during pregnancy and childbirth do women die?

Most maternal deaths seem to occur between the third trimester and the first week after the end of pregnancy.16, 17 Mortality can be extremely high on the first and second days after birth. In Matlab, Bangladesh, for example, new data show that the maternal mortality rate (expressed as deaths per 1000 woman-years of risk exposure) was more than 100 times higher on the first day after birth and 30 times higher on the second day after birth than in the second year postpartum (figure 43). These

Direct causes

Evidence suggests that the direct consequences of pregnancy and childbirth continue to account for most maternal deaths in developing countries. To obtain reliable information on the individual medical causes of maternal mortality is, however, extremely difficult, especially for deaths that occur at home.21 In a systematic review of studies of maternal mortality by WHO, severe bleeding, hypertensive diseases, and infections were the dominant causes.22 Although this pattern is common, the

Where do maternal deaths take place?

The table27, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63 shows a summary of published evidence for where women die. In many settings, a large proportion of all maternal deaths takes place in hospitals. This proportion includes three main types of cases: women who arrive in a moribund state too late to benefit from emergency care, women who arrive with complications who could have been saved if they had received timely and effective interventions, and women admitted for normal delivery who

What are the inequalities in the risk of maternal death?

The main differences in maternal mortality between world regions described earlier cannot simply be explained by variations in economic growth.6 For example, Vietnam and Sri Lanka have achieved much lower levels of maternal mortality than Yemen and Côte d'Ivoire, despite being matched on gross national income per head (figure 62, 67). National figures mask substantial internal variations—geographical, economic, and social—which are not confined to developing countries. There is ample evidence

What else do we need to know about maternal mortality?

Information for maternal mortality serves many different purposes globally and locally, ranging from, for example, improving awareness in local communities, to global monitoring of progress towards MDG-5. The requirements on the scope and quality of information also vary according to purpose and level. The need to be sure that deaths are not missed and that causes are known reliably is considerably greater in the case of monitoring the introduction of a drug such as misoprostol than in

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