Maternal mortality and Millennium

Development Goal 5

N. R. van den Broek * and A. D. Falconer

Maternal Newborn Health Unit, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool
L35QA, UK, and Royal College of Obstetricians and Gynaecologists, London, UK

Introduction: The maternal mortality ratio (MMR) is a key indicator for

measurement of progress against Millennium Development Goal 5 (MDG 5).
For many countries, especially those with a presumed high number of maternal

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deaths, only estimates are available.
Sources of data: Recent global estimates and the reasons for high maternal
mortality are reviewed.

Areas of agreement: There is international consensus that efforts to reduce

maternal mortality globally need to be intensified.

Areas of controversy: Many countries lack accurate data on number of deaths in

women of reproductive age and number of births. Therefore, statistical
modelling has been used to calculate estimates, which generally have wide
confidence intervals and may be disputed by individual countries.
Growing points: There is renewed focus on MMR as 2015 approaches.

Areas timely for developing research: There is a need to adapt and implement
methods for measuring maternal mortality to generate more accurate estimates.
More data on cause of death are needed.

Keywords: maternal/mortality/estimates/contributing factors

Accepted: July 7, 2011

*Correspondence address.
Maternal Newborn
Health Unit, Liverpool
School of Tropical
Medicine, Pembroke
Place, Liverpool L35QA,
UK. E-mail: vdbroek@liv.
ac.uk

British Medical Bulletin 2011; 99: 2538 & The Author 2011. Published by Oxford University Press. All rights reserved.
DOI:10.1093/bmb/ldr033 For permissions, please e-mail: journals.permissions@oup.com
N. R. van den Broek and A. D. Falconer

Introduction
Recent estimates report that over 350 000 women worldwide die from
complications of pregnancy and childbirtha reduction from the pre-
vious estimates of 536 000 per year (WHO, 2007).1 4 Many more
women survive but will suffer ill health and disability as a result of
these complications sometimes leading to life long morbidity. The
difference in maternal mortality rates between developing and devel-
oped countries shows the greatest disparity of all health indicators.
Almost 90% of all global maternal deaths occur in South Asia and
sub-Saharan Africa.
In addition, an estimated 4 million neonatal deaths occur each year
accounting for almost 40% of all deaths under 5 years.5 Data suggest

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that 3.2 million babies are stillborn and up to 2 million peri-natal
deaths are intra-partum related.6,7 The health of the neonate is closely
related to that of the mother and majority of deaths in the first month
of life could also be prevented if interventions were in place to ensure
good maternal health.
There have been significant global efforts to reduce maternal and
newborn mortality and morbidity worldwide in the last few decades.
The Safe Motherhood Initiative was launched in Nairobi in 1987. One
of its stated aims was to reduce maternal mortality by 50% by the year
2000. However, figures at the turn of the millennium remained disap-
pointingly unchanged from the start of the initiative. This reflected
both the improved collection of data and documentation of the pro-
blems and also that reducing maternal and newborn health requires a
coordinated and multifaceted approach.
At the turn of the century nearly 190 countries signed up to the
Millennium Development Goals (MDGs) with MDG 5 specifically tar-
geted towards maternal and child health (Table 1). Very clearly defined
and pertinent indicators to monitor progress towards these goals were
also agreed. For MDG 5, the monitoring framework was revised
during the 2005 World Summit to include one new target (5b) and
four new indicators (5.3 5.6) (Table 2).

Table 1 The MDGs.

1 To eradicate extreme poverty and hunger

2 To achieve universal primary education
3 To promote gender equality and empower women
4 To reduce child mortality
5 To improve maternal health
6 To combat HIV/AIDS, malaria and other diseases
7 To develop a global partnership for development

26 British Medical Bulletin 2011;99

 Maternal mortality estimates and contributing factors

Table 2 Indicators for progress against MDG 5.

Target 5a To reduce maternal mortality by three quarters between 1990 and 2015:
5.1 Reduce the MMR
5.2 Increase the number of births attended by skilled health personnel
Target 5b To achieve universal access to reproductive health by 2015:
5.3 Increase the contraceptive prevalence rate
5.4 Reduce adolescent birth rate
5.5 Increase antenatal care coverage
5.6 Reduce unmet need for family planning

This begs the questioncan MDG 5 be achieved ? Medically speak-

ing the answer is yes, we know what is needed and we know what to
do in case of complications of pregnancy and childbirth. There needs
to be available and accessible to women an agreed continuum of care

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and priority interventions, which have been identified costed and
agreed.8 11

Size of the problemhow many women die?

Estimates of maternal mortality are crucial to inform planning and
resource allocation and to monitor progress. There are a variety of
measures of maternal mortality used in the literature and it is impor-
tant that like is compared with like (Box 1). The number of maternal
deaths in a population is related both to the risk of mortality associated
with each pregnancy or birth (MMRatio) and the number of pregnan-
cies experienced by women of reproductive age (reflected in MMRate).
There is still a lack of accurate data from many countries especially
from developing countries where maternal mortality is high. Civil regis-
tration systems of all births and deaths are helpful but in the absence
of active case finding may be misleadinge.g. if the death registration
form does not include a specific identifier of maternal death, then
maternal deaths may be missed or misclassified.
Where civil registration is in place, the addition of a national confi-
dential enquiry is used to further identify maternal deaths and cause of
deaths. This is considered the gold standard method and is in place in
the UK. Currently, only 63 countries worldwide have civil registration
data, which can be characterized as complete.4
In the absence of complete and accurate civil registration systems,
which are almost non-existent in resource poor settings, MMR esti-
mates are based on a variety of methods including household surveys,
sister-hood methods, reproductive age mortality studies (RAMOS)
and censuses (Box 2). Many countries conduct a 5-yearly Demographic
and Health Survey (DHS), which is available on line. These surveys
generally make use of a variation of the sisterhood method.

British Medical Bulletin 2011;99 27

N. R. van den Broek and A. D. Falconer

Box 1 Definitions of maternal mortality commonly used.

Maternal death
The death of a woman while pregnant or within 42 days of ter-
mination of the pregnancy, irrespective of the duration and the site
of pregnancy, from any cause related to or aggravated by the preg-
nancy or its management but not from accidental or incidental
causes.
Maternal mortality ratio
Number of maternal deaths during a given time period per
100 000 live births during the same time period.
Maternal mortality rate
Number of maternal deaths during a given time period per

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100 000 women of reproductive age (usually 15 50 years) during
the same time period.
Life-time risk of maternal death
The probability of dying from a maternal cause during a womans
reproductive lifespan.

The number of births used to estimate the MMR in a RAMOS may

not be accurate especially in situations where many women deliver at
home and/or not all births are registered. A RAMOS can be time con-
suming and expensive to undertake on a large scale but in the absence
of reliable routine registration can provide sub-national MMRs.
Since 1990, using all available data and/or a statistical model, esti-
mates have been developed by the UN agencies, which allow for inter-
national comparison and analysis of progress. In 2005 there were
536 000 estimated maternal deaths and the vast majority occurred in
developing countries with more than half in sub-Saharan Africa
(276 000) followed by South Asia (241 000). In 2010 new projections
of maternal mortality were published suggesting a reduction of about
33% globally (Table 3).
Confidence intervals around the MMRs continue to be high with an
estimated MMR (and 95% confidence interval) of 620 (450 890) for
Africa, 240 (160 350) for South East Asia and 21(1925) for Europe
compared with 12(11 14) for the UK in 2008.
The 172 countries included in the assessment were divided into three
groups depending on availability and source of data: (a) countries
where civil registration was complete and there is good attribution of
cause of death; (b) countries with other type of data available; (c)
countries with no national data available on maternal mortality.

28 British Medical Bulletin 2011;99

 Maternal mortality estimates and contributing factors

Box 2 Measuring maternal mortality.

Civil registration system

Routine registration of births and deaths via civil registration.
Cause of death identified and recorded on standard medical
certificate.
Household surveys
Can be used where civil registration is not available. Usually ident-
ifies pregnancy-related deaths rather than maternal deaths. Large
sample sizes are required as maternal death is a relatively rare event.
The estimates will have large confidence intervals.
Sisterhood methods
Information is obtained by interviewing a representative sample of

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respondents about the survival or not of tall their adults sisters.
Determines the number of sisters, how many are alive, how many
dead and how many died during pregnancy, delivery or within 6
weeks of delivery. The measurement is of pregnancy-related rather
than maternal deaths. The sample size can be smaller than for a
household survey but estimates have wide confidence intervals and
are retrospective (over 10 years prior) rather than current.
DHS use a variant of the sisterhood approach with estimates relat-
ing to approximately 5 years prior to the survey.
Reproductive age mortality surveys (RAMOS)
A RAMOS identifies and investigates cause of all deaths of
women of reproductive age in a defined population using multiple
sources of data, including interviews with family members, vital
registration, health facility records, burial records, information from
community-based carers such as traditional birth attendants).
Inadequate identification of all deaths will result in underestimation
of the maternal death rate.
Census
A national census can produce reliable estimates of maternal mor-
tality with the addition of a limited number of questions. As it
includes all women, sampling errors are eliminated and trend analy-
sis is possible. Recent maternal mortality estimates can be obtained
(last 1 2 years) but a census is usually only conducted every 10
years.

Almost half of all countries fall in group (b) (49%) with 37% in
Group (a) and 14% in Group (c). Civil registration data were adjusted
for incompleteness and misclassification and available maternal

British Medical Bulletin 2011;99 29

N. R. van den Broek and A. D. Falconer

Table 3 Estimates of MMR, number of maternal deaths and life-time risk of dying by UN
regions for 2005 and 2008 (2010 WHO Report).

Region MMR Annual number of estimated MMR Annual number of estimated

2005 maternal deaths in 2005 2008 maternal deaths in 2008

Africa 820 276 000 590 207 000

Asia 330 241 000 190 139 000
Latin America and 130 15 000 85 9200
the Caribbean
Oceania 430 890 230 550
Developed regions 9 960 14 1700
World total 400 536 000 260 358 000

mortality death counts and corresponding births pooled for each 5 year
period assessed.

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For four countries in Group (a) and 109 in Groups (b) or (c), a multi-
level logistic regression model was developed to derive estimates or pro-
jections for each 5 year time period assessed. The model represents
deaths due to direct obstetric causes or indirect causes where pregnancy
was a substantial aggravating factor. HIV-related indirect maternal
deaths are treated separately. Covariates used in the model include the
gross domestic product per capita (GDP), general fertility rate and pro-
portion of births attended by a skilled birth attendant (SBA). As in
some countries HIV/AIDS is considered to have become a leading
cause of death during pregnancy and the postpartum period and there
are also more incidental deaths among HIV-positive women the intera-
gency group adopted a regression model that estimated the number of
maternal deaths not primarily due to HIV infection and added back
the estimated number of indirect maternal deaths to obtain the total
number of maternal deaths. The predicted proportion of maternal
deaths in women of reproductive age was converted into an MMR
using the number of female deaths at ages 15 49 estimated from
World Health Organization (WHO) death rates and the United
Nations Population Division population estimates.
In addition to the estimates published by WHO in 2010, Hogan
et al. used complex modelling and a variety of data sources including
vital registration data, sibling history data from household surveys
(sisterhood methods), data from censuses and surveys for deaths in the
household and published studies to estimate MMRs globally and per
country and reported a global estimate of 342 900 maternal deaths
(uncertainty interval of 302 100 394 300) for 2008 compared with
the UN estimate of 358 000 (265 000 503 000).1,4
For the estimates by Hogan et al. vital registration data were the
dominant source (82% of observations). The data set was constructed
based on the WHO mortality data base supplemented by an internet

30 British Medical Bulletin 2011;99

 Maternal mortality estimates and contributing factors

search of national statistical offices. Changes in coding and

International Classification of Disease (ICD) rules as well as misclassi-
fication (maternal deaths incorrectly assigned to other causes) were
addressed. Sibling history data were obtained from country DHS and
the Centres for Disease Control and Prevention International reproduc-
tive Health Surveys. Of a total of 2186 observations, 26 were based on
survey or census information. Data from 61 studies from countries
without vital registration systems were identified via the literature
review and from 22 studies that had used verbal autopsy methods.
Similar to the UN estimates, the proportions of female deaths attribu-
table to maternal causes in the reproductive age period of 15 49 years
were estimated and applied to the new time series of adult female mor-
tality. The mathematical modelling applied, includes the covariates,

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total fertility rate (TFR), GDP per head, HIV sero-prevalences, neo-
natal mortality, age-specific female education but not proportion of
births with skilled birth attendance.

Areas of controversy and growing points

The new global and regional estimates for the MMR as estimated by
Hogan et al. and the UN are largely similar to overlapping confidence
intervals. It must be noted that these new estimates often vary signifi-
cantly for specific countries with examples of both much higher and
much lower estimates occurring. In addition, individual countries do
not always accept these estimates especially if these are dissimilar to
those the country itself reports for example as a result of the most
recent DHS. Analysis of trend shows that at the global level the
decrease in maternal mortality between 1990 and 2005 was ,1% per
year. In 2010 this is calculated to be 1.3% (Hogan et al.) or 2.3% (UN
figures). Overall it can be argued this is indeed an improvement but
these estimates are still well below the estimated 5.5% decrease needed
annually to achieve the MDG 5a indicator by 2015.3,4

Causes of maternal deathwhy do women die?

A seminal review by Thaddeus and Maine in 199412 introduced the
three-delay model. Acknowledging that there are numerous factors
that contribute to maternal mortality and that when obstetric compli-
cations occur, with prompt adequate treatment the outcome is usually
satisfactory, they examined the factors that affect the interval between
the onset of an obstetric complication and its outcome. The three
delays described and examined are: (i) delay in deciding to seek care,

British Medical Bulletin 2011;99 31

N. R. van den Broek and A. D. Falconer

Box 3 The three-delay model.

Delay 1: are women aware of the need for care and the danger signs
of pregnancy?
Delay 2: are services in-accessible because they are not available,
because of distance and/or cost of services or do socio-cultural bar-
riers prevent women from accessing services?
Delay 3: is the care received at the facility timely and effective?

(ii) delay in reaching the health-care facility and, (iii) delay in receiving
care after getting to the health-care facility. This framework is still

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widely used to examine and address factors contributing to maternal
deaths in many countries (Box 3).
Medically, the main direct causes of maternal deaths are obstetric
haemorrhage, hypertensive disorders, i.e. ( pre-)eclampsia, sepsis or
infection, complications of obstructed labour and abortion.13,14 The
still commonly cited WHO review from 1991 reported relative contri-
butions by cause globally with haemorrhage the most common cause
of death (25%) followed by infection (15%), complications of abortion
(13%), eclampsia (12%), complications of obstructed labour (8%) and
a further 8% due to other direct causes of maternal mortality. An esti-
mated 20% of deaths globally were attributed to indirect causes.
A more recent systematic review to determine the distribution of
causes of maternal deaths globally identified data sets for over 35 000
maternal deaths.2 A total of 34 population-based data sets representa-
tive for the populations concerned were included. All reported on
specific conditions leading to maternal deaths after 1990 and for at least
25 maternal deaths reported per data set. There is variation in attributed
cause of maternal death both across and within geographical regions.
Overall haemorrhage was confirmed to be the leading cause of maternal
death in Africa and Asia (33.9 and 30.8%, respectively). Hypertensive
disorders were the commonest reported cause of death in Latin America
and the Caribbean (25.7%). Sepsis was more frequently reported as
cause of maternal death in Africa (9.7%), Asia (11.6%), Latin America
and the Caribbean (7.7%) compared with developed countries (2.1%).

Areas of controversy and growing points

The review by Khan et al. highlighted the problems with both avail-
ability and interpretation of data on cause of maternal mortality,

32 British Medical Bulletin 2011;99

 Maternal mortality estimates and contributing factors

including inadequate or unavailable definition of maternal mortality

and confirmation of cause of death and sometimes high proportions of
unclassified deaths.
Accurate identification and classification of the causes of maternal
deaths may prove difficult in the absence of clear criteria and guidance
because of the complexities in the definitions of maternal deaths and
the relationships between different conditions that may be reported as
cause(s) of death.
Based on the need for much better identification and understanding
of the causes of maternal deaths, a WHO Technical Working Group
examined and reached a consensus on a new classification system for
cause of maternal death in 2009.15,16 This new classification is aligned
with ICD 10 and will feed into the new ICD 11 system of classifi-

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cation. The new classification needs to be made operational and
support will be needed to ensure it is used widely.

Areas of agreementstrategies to reduce maternal mortality

Provision of SBA and availability of Essential (or Emergency) Obstetric
Care (EOC) coupled with Newborn Care are key strategies that if
implemented will reduce maternal and neonatal mortality and morbid-
ity. A skilled birth attendant is defined as a health provider who has at
least the minimum knowledge and skills to manage normal childbirth
and provide basic (first-line) emergency obstetric care.8,17,18
To measure progress towards MDG 5, two indicators: the MMR and
proportion of births attended by skilled health personnel were selected.
For skilled attendance at birth, the international community set a
target of 80% by 2005, 85% by 2010 and 90% coverage by 2015.
However, in 2008 globally only 65.7% of all women were attended to
by a skilled attendant during pregnancy, childbirth and immediately
postpartum with some individual countries having ,20% coverage.19
Developed countries had over 99% coverage while East Africa had the
least coverage (33.7%), with 41.2% coverage in Western Africa and
46.9% in South Central Asia.
A comprehensive review by Stanton et al. reported an increase
between 1990 and 2000 for births attended by a skilled worker from
45 to 54% for most developing countries, but for large parts of South
Asia and sub-Saharan Africa this increase was not demonstrable. It is
now commonly agreed that a more intensive effort is needed to be able
to achieve the target of 85% coverage by 2010.20,21
For an estimated 10 15% of all women, unexpected complications
will occur which may prove to be life-threatening unless she has access
to essential (emergency) obstetric care.22,23 Having the skills to

British Medical Bulletin 2011;99 33

N. R. van den Broek and A. D. Falconer

Box 4 Signal functions of essential obstetric and newborn care.

BEOC:
intravenous/intramuscular (i.v./i.m.) antibiotics,
i.v./i.m. oxytocics,
i.v./i.m. anti-convulsants,
manual removal of a retained placenta,
removal of retained products of conception [e.g. by manual vacuum
aspiration (MVA)],
assisted vaginal delivery (vacuum extraction),
neonatal resuscitation using bag and mask.

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CEOC:
All seven BEOC functions, plus:
caesarean section,
blood transfusion.

recognize and then respond effectively to such unexpected events is a

key part of a skilled attendants role.
As these life-threatening complications are generally not predictable,
it is important that all women have access to maternal health-care ser-
vices, particularly skilled attendance at birth as well as timely access to
EOC to reduce maternal mortality.
Two levels of EOC can be distinguished: Basic Essential Obstetric
Care (BEOC) and Comprehensive Essential Obstetric Care (CEOC). In
addition to agreement on the components (signal functions) of EOC,
there are agreed specifications for levels of coverage needed. Thus, the
UN agencies recommend that for a population of 500 000 there should
be at least one health facility that is able to provide the nine signal
functions of CEOC and at least four that provide the seven signal func-
tions of BEOC (Box 4). It is important that these facilities are equitably
distributed geographically with regard to accessibility. In addition, the
signal functions must be available continuously (24 h a day and 7 days
a week) for the facility to be considered fully functional. For monitor-
ing and evaluation of six process, indicators have been recommended.
These measure the availability, accessibility, utilization and quality of
EOC (Box 5).
A number of surveys have assessed the availability, accessibility and
quality of EOC in high maternal mortality countries and consistently
find that coverage with facilities able to provide EOC is inadequate

34 British Medical Bulletin 2011;99

 Maternal mortality estimates and contributing factors

Box 5 UN process indicators for monitoring availability, utilizations and

quality of essential obstetric care.

1. Availability of BEOC and CEOC facilities per 500 000 popu-

lation (at least 1 CEOC facility and 4 BEOC facilities).
2. Geographical distribution of EOC facilities.
3. Proportion of all births conducted in EOC facilities (at least
15%).
4. Proportion of women estimated to have emergency obstetric
complications, who are treated in EOC facilities (met need for
EOC).
5. Caesarean sections as per cent of all birth in the population (5
15%).

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6. Case-fatality rate of direct emergency obstetric complications
treated in CEOC facilities (,1%).

and minimum UN agreed standards for coverage are still unmet.24 27

In many settings there are relatively large numbers of health facilities
but these are often not providing the full complement of signal func-
tions for either BEOC or CEOC. In addition the geographical distri-
bution of facilities is such that these tend to be clustered in urban areas
with poor coverage particularly in more rural areas. Greater efforts are
needed to ensure equitable geographical location of health facilities
coupled with a functional referral system both from the community to
the facility and between facilities.

Areas for research

There is a need for more and better data on how many maternal deaths
occur and why. These data are needed for monitoring progress globally
as well as for targeted and rational planning of implementation of
interventions that are known to reduce maternal as well as neonatal
deaths that result from complications of pregnancy and childbirth.
Medically and technically speaking, the interventions needed to
reduce maternal and newborn mortality and morbidity globally are
largely known.28 30 Some countries have made huge progress and there
is a need to better evaluate how and what worked to improve pregnancy
outcome in these settings. It could be argued that for maternal and
newborn health in particular there is a need for good implementation
or translationalresearch. To reduce maternal deaths a package of
interventions is needed and analysis of effect of complex interventions

British Medical Bulletin 2011;99 35

N. R. van den Broek and A. D. Falconer

can be particularly difficult. This requires a multidisciplinary approach

and development of robust evaluation methodology.31,32

Conclusions
The difference in maternal mortality rates between developing and
developed countries shows the greatest disparity of all health indicators.
More than 350 000 women die each year as a result of complications of
pregnancy and childbirth. This is the leading cause of death in women
aged 15 49 years. There are an estimated 3.0 million stillbirths
annually and 2.8 million early neonatal deaths. Probably, the majority
of these could be avoided with provision of skilled birth attendance and

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EOC together with early NC. Majority of maternal deaths globally are
the result of direct obstetric causes including haemorrhage, eclampsia,
sepsis and complications of obstructed labour and abortion. The main
causes of neonatal death are prematurity, asphyxia and infection.
Women and their babies need access to and availability of a conti-
nuum of care that includes antenatal, intra-partum and postnatal care,
newborn care and family planning services. In order for care to be
effective, this care must be evidence based and of good quality.
There is an urgent need for more accurate data on numbers of
maternal death and cause of maternal death, especially from countries
with high maternal mortality rates. A renewed focus on implemen-
tation research is needed especially in the area of maternal and neo-
natal health.33

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