New United Nations data show sharp decline in maternal deaths

New United Nations data show a 45% reduction in maternal deaths since 1990. An estimated 289 000 women died in 2013 due to complications in pregnancy and childbirth, down from 523 000 in 1990.

Another World Health Organization (WHO) study, also published today in The Lancet Global Health, adds new knowledge about why these women are dying. Global causes of maternal death: a WHO systematic analysis, finds that more than 1 in 4 maternal deaths are caused by pre-existing medical conditions such as diabetes, HIV, malaria and obesity, whose health impacts can all be aggravated by pregnancy. This is similar to the proportion of deaths during pregnancy and childbirth from severe bleeding.

“Together, the two reports highlight the need to invest in proven solutions, such as quality care for all women during pregnancy and childbirth, and particular care for pregnant women with existing medical conditions,” says Dr Flavia Bustreo, Assistant Director-General, Family, Women’s and Children’s Health, WHO.

They also underscore the importance of having accurate data.

"Thirty-three maternal deaths per hour is 33 too many," said Tim Evans, Director, Health, Nutrition and Population, World Bank Group. "We need to document every one of these tragic events, determine their cause, and initiate corrective actions urgently."

Steady progress

Trends in maternal mortality estimates 1990 to 2013 includes new data which were not captured in the last set of global estimates in 2012, as well as improved methods of estimating births and all female deaths.

Eleven countries that had high levels of maternal mortality in 1990 (Bhutan, Cambodia, Cabo Verde, Equatorial Guinea, Eritrea, Lao People’s Democratic Republic, Maldives, Nepal, Romania, Rwanda, Timor-Leste) have already reached the Millennium Development Goal (MDG) target of a 75% reduction in maternal mortality from the 1990 rate by 2015. Based on these latest trends however, many low- and middle-income countries will not achieve this goal.

Sub-Saharan Africa is still the riskiest region in the world for dying of complications in pregnancy and childbirth.

“A 15-year-old girl living in sub-Saharan Africa faces about a 1 in 40 risk of dying during pregnancy and childbirth during her lifetime,” says Dr Geeta Rao Gupta, Deputy Executive Director, United Nations Children’s Fund (UNICEF). “A girl of the same age living in Europe has a lifetime risk of 1 in 3300 – underscoring how uneven progress has been around the world.”

Despite advances in the last 20 years, there has been too little progress in preventing adolescent pregnancies, abortions, maternal deaths, sexually-transmitted infections and HIV, and there are significant gaps in availability, quality and access to comprehensive sexuality education and services for young people, especially in low-income countries.

“More than 15 million girls aged 15 to 19 years give birth every year – one in five girls before they turn 18 – and many of these pregnancies result from non-consensual sex,” highlights Ms Kate Gilmore, Deputy Executive Director, United Nations Population Fund (UNFPA). “Relatively simple and well-known interventions, like midwifery services and gender-based violence prevention and response, can make a huge difference if scaled up and coupled with investments in innovations, especially in the area of contraceptives.”

New information on causes of death

A related WHO study of causes of more than 60 000 maternal deaths in 115 countries shows that pre-existing medical conditions exacerbated by pregnancy (such as diabetes, malaria, HIV, obesity) caused 28% of the deaths.

Other causes included:

• severe bleeding (mostly during and after childbirth) 27%
• pregnancy-induced high blood pressure 14%
• infections 11%
• obstructed labour and other direct causes 9%
• abortion complications 8%
• blood clots (embolism) 3%

Strong health systems – with facilities that have adequate health workers and equipment and medicines – are key to delivering quality health care to save the lives of women and their newborn babies.

“The new data show a changing profile in the conditions that cause maternal deaths; reflecting the increasing burden of noncommunicable diseases in women throughout the world. Ending preventable maternal deaths will require both continued efforts to reduce complications directly related to pregnancy, and more of a focus on noncommunicable diseases and their effect in pregnancy. Integrated care for women with conditions like diabetes and obesity will reduce deaths and prevent long-lasting health problems,” says Dr Marleen Temmerman, Director, Reproductive Health and Research, WHO, and co-author of the study.

Better data needed to save lives

A major challenge in addressing maternal deaths is the lack of accurate data. Although knowledge on the number of women dying and the reasons behind their deaths is improving, much remains unrecorded and unreported. In many low-income countries, maternal deaths go uncounted and frequently the cause of death is unknown or not recorded correctly, particularly when women die at home. This is consistent with general global trends: only one-third of all deaths worldwide are recorded and fewer than 100 countries record the cause of death using WHO’s International Classification of Disease.

As a result, it is often hard for national health programmes to allocate resources where they are needed most. This is why the United Nations Commission on Information and Accountability for Women’s and Children’s Health is calling for better measurement of maternal and child deaths. The Commission requires that “by 2015, all countries have taken significant steps to establish a system for registration of births, deaths and causes of death”.

There is growing consensus worldwide that ending preventable maternal deaths can be achieved by ensuring that every woman has access to quality health care. Global and national targets beyond 2015 will be important for tracking progress in reducing maternal deaths and ensuring that maternal health continues to be a global development priority.

Highlights from Trends in maternal mortality estimates 1990 to 2013:

• Maternal mortality has declined: In 2013, the global maternal mortality ratio (MMR) was 210 maternal deaths per 100 000 live births, down from 380 maternal deaths per 100 000 live births in 1990 (a 45% reduction).
• Faster progress needed: The global reduction of MMR has accelerated, with a 3.5% annual decline from 2000-2013, as compared with 1.4% between 1990 and 2000. However, at current trends, most countries will not achieve the MDG target of a 75% reduction in MMR from 1990 to 2015. An average decline of 5.5% or more every year since 1990 is needed to meet the target on time.
• Ten countries carry most of the burden: Ten countries account for about 60% of global maternal deaths: India (50 000), Nigeria (40 000), Democratic Republic of the Congo (21 000), Ethiopia (13 000), Indonesia (8800), Pakistan (7900), United Republic of Tanzania (7900), Kenya (6300), China (5900) and Uganda (5900).
• Somalia and Chad have the highest risk: The highest lifetime risk of maternal death is in Somalia and Chad where women face a 1 in 18 and 1 in 15 lifetime risk respectively.