Maternal Death Rates Declining Worldwide, but Progress Varies

In an article in the Lancet, a group of scientists from around the world analyzed the progress in the reduction of maternal deaths and found wide variation in the extent of improvement. The authors considered maternal deaths as: (1) deaths during pregnancy but before labor begins from causes related to the pregnancy; (2) death during labor and delivery or within 24 hours afterward; and (3) death within six weeks to one year due to causes related to the pregnancy and delivery. Causes related to the pregnancy are those in which the pregnancy is a contributing factor. The contribution may be direct, as in a complication of the pregnancy, childbirth, or postpartum period, or indirect, in which pregnancy or delivery aggravates a preexisting medical condition. The researchers compared the number and rate of maternal deaths from 1990 through 2013, noting a general decline in both the number and rate of maternal deaths worldwide. One key measure of success is the achievement of Millennium Development Goal 5 (MDG 5), the reduction of maternal mortality by 75 percent of the 1990 rate by 2015. This goal was established by the World Health Organization and the 191 countries that signed the Millennium Declaration in September 2000.

Variation in Data Capture and Definitions

The authors found variations both in the definition of maternal death and in the extent of record keeping. Some standards commonly used to measure maternal mortality consider the post-partum period to end six weeks after the delivery or other end of the pregnancy. In countries that have adopted ICD-10, deaths up to one year post-partum are considered late maternal deaths. The Millennium Development Goals would count all HIV-related deaths during pregnancy or up to six weeks post-partum as maternal deaths, but the United Nations group that estimates maternal mortality only counts 50 percent of deaths from HIV during the same period as maternal deaths. In some countries, suicide is considered incidental, or unrelated to maternity; in others, suicide is counted as indirectly related. The level of detail in records also varies.

Extent of Progress

Sixteen countries are on track to achieve MDG5. The most dramatic reductions have been in East Asia, which includes China, Taiwan, and North Korea. The maternal mortality ratio (MMR), i.e., frequency of maternal deaths per 100,000 live births, was 139.5 in 1990, 63.9 in 2003, and 18.2 in 2013. Most of the countries in south Asia also made significant progress, from 480.4 in 1990 to 399.7 in 2003 and 310.6 in 2013. The outlier was Afghanistan, where maternal mortality grew from 501 in 1990 to 885 in 2013.

Western Europe consistently had the lowest MMRs: 12.7, 8.1, and 6.3 in 1990, 2003, and 2013, respectively. Most of the 15 countries with MMRs below five in 2013 were in Central, Western or Southern Europe; they also included Australia and Singapore. In all of these countries, the MMR dropped steadily. In other areas, including much of Africa, maternal mortality grew from 1990 to 2003 but dropped significantly between 2003 and 2013.

North America an Outlier

Maternal mortality has increased in the United States, from 12.4 per 100,000 births in 1990 to 17.6 in 2003 and 18.5 in 2013. In Canada, maternal mortality rose from 7.4 to 9.2 by 2003 but dropped to 8.2 in 2013.

Causes

The authors believe that the reduction of maternal mortality requires addressing the variety of causes in each country. In low-income countries where sepsis and hemorrhage are the most common causes of maternal mortality, they recommend encouraging more women to give birth in facilities with skilled attendants and the use of prophylactic antibiotics. According to the study, the health care system must be strengthened to care for the mothers with preexisting conditions that contribute to maternal death.