An ‘unfinished agenda’: Maternal deaths fell 40% globally, as aid cuts threaten progress
Key takeaways:
- Global maternal mortality declined 40% between 2000 and 2023 as access to health care improved.
- The pace of improvement has slowed since 2016 and humanitarian funding cuts may further hamper progress.
Women are more likely than ever to survive pregnancy today because of global improvements in infrastructure and access to care, but researchers caution humanitarian funding cuts could reverse any large public health gains.
Maternal deaths declined 40% across 195 countries and territories between 2000 and 2023, according to a report from the United Nations Maternal Mortality Estimation Inter-Agency Group. Globally, an estimated 260,000 women died from a maternal cause in 2023, significantly fewer than the estimated 443,000 maternal deaths in 2000. The report represents the first time that no country was estimated to have “extremely high” levels of maternal mortality, defined as a maternal mortality ratio of over 1,000 maternal deaths per 100,000 live births. Over one-third of countries globally had “extremely low” maternal mortality, defined as a maternal mortality ratio of less than 20 maternal deaths per 100,000 live births.
“The good news is that women are more likely than ever to survive pregnancy,” Bruce Aylward, MD, MPH, assistant director-general of the universal health coverage, life course division at WHO, said during a press conference. “We made this progress because of the research, investment and action going on around the world in areas that matter most for vulnerable people. But 260,00 women are still dying every year due to causes related to their pregnancy — the vast majority of which are preventable. This is a death every 2 minutes. The majority of these are happening in low and low-middle income countries, countries facing the greatest challenges.”
Global advances, shortfalls
The U.N. Maternal Mortality Estimation Inter-Agency Group compiled data for global-, regional- and country-level estimates and trends for maternal mortality between 2000 and 2023, including 195 countries and territories. The global maternal mortality rate (MMR) in 2023 was estimated at 197 maternal deaths per 100 000 live births (uncertainty interval [UI], 174-234), down from 328 maternal deaths per 100,000 live births (UI, 308-352) in 2000, a reduction of 40% over the 24-year period.
The average annual rate of reduction (ARR) in the global MMR from 2000 to 2023 was 2.2% (UI, 1.4-2.8), meaning the global MMR declined by 2.2% every year between 2000 and 2023. Researchers noted that progress was uneven during this period and still falls short of U.N.’s Sustainable Development Goal target for maternal survival.
“If we assume that this pace of progress will continue until 2030, the global MMR will only be reduced to 177 per 100,000 live births, which is still two and a half times higher than the Sustainable Development Goal global target of 70,” the report states. “Achieving Sustainable Development Goal target 3.1 by 2030 would require an average ARR of 14.8% over the 7 years remaining for observation (2024 to 2030).
Sub-Saharan Africa accounted for approximately 70% of global maternal deaths and was the only Sustainable Development Goal region with a “high” MMR, estimated at 454 maternal deaths per 100,000 live births (UI, 387-572). Australia and New Zealand had the lowest MMR, estimated at 3 maternal deaths per 100,000 live births (UI, 2-4).
In analyses by country level, the lifetime risk of maternal mortality declined in all countries between 2000 and 2023 except for nine countries, where it remained stable: Botswana, Canada, Cyprus, Dominican Republic, Gabon, Greece, Portugal, the United States and the Bolivarian Republic of Venezuela.
“We cannot be complacent,” Jenny Cresswell, PhD, a scientist in the department of sexual health and research at WHO, said during the press conference. “There are significant inequalities and gaps that remain. More than nine in 10 maternal deaths occurred in low- and middle-income countries during the year 2023. Despite progress, sub-Saharan Africa alone counted for more than 70% of global maternal deaths in the year 2023, and this was followed by central and southern Asia, which counted for almost 17%.”
The U.N. report is also the first to capture the impact of the COVID-19 pandemic on maternal survival, according to the researchers. Researchers estimated that there were more than 40,000 additional maternal deaths in 2021 linked directly to complications from COVID-19, as well as widespread disruptions to maternity care.
Impact of aid cuts
The researchers cautioned that urgent investment is needed to further improve maternal mortality rates globally,
“These funding cuts ... are affecting access to lifesaving supplies and medicines, and especially treatments for some of the leading causes of maternal deaths,” Aylward said during the press conference. “Yes, there is good news in this report, but there is a huge, unfinished agenda, in which a quarter of a million women are still dying every year as a result of trying to give life. That is completely unacceptable.”
Aylward said improving maternal mortality “does not happen in a vacuum,” and overall efforts to enhance women’s health are also needed, including improving access to family planning services, preventing underlying health conditions like anemias, malaria and noncommunicable diseases and supporting programs that ensure girls stay in school.
“You have to consider issues like gender equality, access to reproductive health services and ensuring women can plan their fertility,” Aylward said.
Perspective
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Some of the news in this report is very heartening. With a 40% decline in maternal deaths globally over a 25-year period, one has to say that we are doing something right. However, this progress is not enough. Women continue to die from pregnancy and childbirth-related causes every single day. We need to see a marked decrease in every single country around the world. What are we going to do over the next decade? We have had a pandemic; we have wars and a climate crisis around the globe. Populations are displaced. All of these crises are accelerating. Women and children are impacted the worst.
The no. 1 cause of maternal death is maternal hemorrhage. Agencies like USAID have historically always partnered with low- and middle-income countries to help reduce the rate of maternal hemorrhage. If we in the United States look at ourselves as leaders in women’s health globally, we must continue our support where it is needed most.
Women’s health must be a priority. We need all leaders — with WHO, USAID and UNFPA — to address maternal mortality together. We know what to do. We know it takes medication and basic supplies, like blood pressure cuffs. It takes clean water. It takes IV fluids. It takes skilled workers to provide care, medications and transfusions.
Who can women around the world rely on? Grants and private donors cannot fill the gaps when the U.S. cuts financial aid, key positions and closes much-needed infrastructure. As past-president of the International Federation of Gynecology and Obstetrics, I have met the leaders of OB/GYN societies around the globe. None have the infrastructure and advocacy arms that ACOG does.
Globally, the United States has so much more to do. But we know what needs to be done. Data from the California Maternal Quality Care Collaborative show us how the right resources, toolkits and community engagement can promote healthy pregnancies, healthy births and drive down maternal deaths. That is what systematic approaches can do and that is what the U.S. needs to promote as a global health leader. It is up to us as physicians to continue to advocate that this important work continues.
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WHO. Trends in maternal mortality estimates 2000 to 2023: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division.
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