AOGS E D I T O R I A L
Strategies to reduce global maternal mortality
LILL NYFLØT1 & VASILIS SITRAS2
1
Norwegian National Advisory Unit for Women’s Health, Oslo University Hospital, Oslo, and 2Fetal Medicine Unit,
Department of Obstetrics and Gynecology, Oslo University Hospital, Oslo, Norway
DOI: 10.1111/aogs.13356
A maternal death is a devastating event, with consequences
for the family and society. Direct causes, complications
that occur directly as a result of pregnancy or delivery,
account for 73 percent of maternal deaths worldwide, with
postpartum hemorrhage causing approximately one-third
of all maternal deaths (1). Indirect causes, or pre-existing
medical conditions deteriorating during pregnancy and
puerperium, account for the remaining 27 percent. Typi-
cally, countries with a low maternal mortality ratio (MMR,
defined as number of maternal deaths per 100 000 live-
births), have a lower proportion of direct compared to
indirect causes, because their health care systems tackle
direct causes of death more effectively.
During the period 1990–2015, the MMR fell by 44 per-
cent worldwide, to an estimated 216 maternal deaths per
100 000 livebirths in 2015 (2). The progress was significant,
but did not reach the United Nations (UN) Millennium
Development Goal of a 75 perccent reduction. Approxi-
mately 300 000 women still die each year due to conditions
related to pregnancy and childbirth. The majority of mater-
nal deaths are avoidable and occur mostly in low- and mid-
dle-income countries (1). Indeed, the 18 countries with a
very high MMR (>500) are in sub-Saharan Africa, while
Nigeria and India together account for one-third of all
maternal deaths, due to their vast populations.
The new UN Sustainable Development Goals towards
ending preventable maternal deaths were released in 2015
(3). The new aim is to reduce the global MMR to less than
70 by 2030. If this is not achievable in a country, the goals
are to reduce the 2010 baseline MMR by at least two-thirds
and that no country should have an MMR over 140.
Preventing maternal mortality
Skilled care before, during and after childbirth can reduce
maternal morbidity and mortality. In high-income coun-
tries, women have several antenatal care visits, are
attended by a skilled health worker during childbirth and
receive postpartum care. However, this is not the situa-
tion in most other countries (4). Many women have no
access to reproductive health care services due to poverty,
ª 2018 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 97 (2018) 639–640
long distances, lack of education, or cultural and religious
practices.
Before the UN Millennium Goal period, efforts were
typically put into the education of unskilled birth atten-
dants, community mobilization, and prediction and pre-
vention of pregnancy complications. These efforts were
insufficient because of the lack of health facilities to pro-
vide basic emergency obstetric care such as antibiotics,
uterotonic drugs, anticonvulsants and facilities for
removal of retained products of conception, assisted vagi-
nal delivery, cesarean section and blood transfusion. A
universal coverage of life-saving interventions needs to be
matched with comprehensive emergency care and overall
improvements in the quality of maternity care (5). Inter-
ventions need to be integrated into strategic programs,
because no single strategy will be adequate in all regions
and in all sub-populations (5). Education, gender equity,
poverty reduction, health system strengthening, and
improvements in quality of care need to happen simulta-
neously. Furthermore, the key requirements to reduce
maternal mortality in each country depend on the exist-
ing context. In countries with a low MMR, addressing
determinants of poor health, over-use of cesarean deliv-
ery, and risk factors such as older age at first delivery,
obesity and preexisting diseases are most important. On
the other hand, in countries with high MMR where most
maternal deaths are attributable to direct causes, focusing
on family planning and improving basic educational, as
well as social and health care systems are most important.
In particular, access to basic and higher education for
both girls and boys is crucial in order to promote sustain-
able development in a country. Increasing the level of edu-
cation will have a positive effect on many aspects, from
reducing poverty to increasing gender equality. In fact,
lower levels of maternal education have been reported to be
associated with higher MMR, even amongst women with
access to obstetric health care (7). Working towards gender
equality warrants women’s access to education, work,
health care, and family planning. Family planning is indeed
vital in order to avoid unwanted pregnancies, because both
teenage pregnancies and multiparity carry a high risk of
639
Editorial
maternal death. Moreover, abortions constitute eight per-
cent of all maternal deaths (1). Therefore, all women,
including adolescents, should have access to contraception,
safe abortion, and post-abortion care. Furthermore,
marginalized sub-populations remain a huge challenge in
all countries, when it comes to preventing maternal deaths.
Poverty and poor health, as well as lower access both to
health care and education, are typical challenges in minor-
ity populations. These subgroups are often not represented
in official statistics, making it even more difficult to deter-
mine how to best address their maternal health needs.
The paradigm of Sri Lanka
The maternal mortality trend in Sri Lanka illustrates the
different principles of intervention well. Sri Lanka has suc-
cessfully reduced its number of maternal deaths over the
last decades, even though the country has suffered from a
devastating 30-year civil war. Today, the World Bank ranks
the Democratic Social Republic of Sri Lanka as a middle-
income country. Free education and health care services are
offered to the whole population of 23 million people. In
2015, the MMR was 30 per 100 000 live births, which is
quite impressive compared to its closest neighbors; India
(MMR = 174), Nepal (MMR = 258), and Bangladesh
(MMR = 176).
The key to this success is believed to be the increasing pres-
ence of skilled birth attendants around the country. At the
start of the UN Millennium Goal period, Sri Lanka had
approximately 5000 skilled birth attendants across the coun-
try, while in 2016 the number of skilled birth attendants
increased to 15 000. Today, the antenatal care coverage rate
is 99 percent, and almost all deliveries occur in a hospital.
Moreover, 85 percent of hospitals have an obstetrician on
call. Importantly, Sri Lanka has a national system for surveil-
lance of the incidence and causes of maternal deaths. How-
ever, there are significant disparities in the different districts
in Sri Lanka. While urban parts of the capital (Colombo),
where the Singhalese majority predominantly resides, have
an MMR of 19, the MMR is around 70 in areas populated
mainly by the minority Tamil population (8). The majority
of households in rural Tamil areas fall into the lowest socio-
economic group, and the rates of gender-based violence,
teenage pregnancies, and unwanted pregnancies are higher
compared to the rest of the country.
Today, the main causes of maternal deaths in Sri Lanka
are rheumatic heart disease, respiratory disease (H1N1 flu),
and septic abortions. Therefore, specific actions such as flu
vaccination and management of cardiac disease in preg-
nancy need to be addressed in order to further reduce
maternal morbidity and mortality. Strengthening family
planning education is probably the most important inter-
vention, as almost 50 percent of maternal deaths in Sri
640 ª 2018 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 97 (2018) 639–640
Lanka have been reported to be due to an unmet need for
contraception/safe abortion in one way or another (9).
In conclusion, sustainable development of our world is
dependent on young women having access to adequate
health care, to education and to paid work. Collaborative
efforts from politicians, healthcare professionals and
researchers are needed in the important arena of women’s
reproductive health issues. The first step towards these efforts
is ensuring the availability of continuous, reliable and com-
parable measures of maternal mortality. Thereafter, several
targeted interventions, depending on different community
needs, can prevent deaths related to pregnancy. Importantly,
family planning and skilled care before, during, and after
childbirth are essential steps towards saving mothers’ lives.
References
1. Say L, Chou D, Gemmill A, Tuncßalp O, € Moller A, Daniels
J, et al. Global causes of maternal death: a WHO systematic
analysis. Lancet Glob Health. 2014;2:e323–33.
2. Trends in maternal mortality: 1990 to 2015: estimates by
WHO, UNICEF, UNFPA, World Bank Group and the
United Nations Population Division. http://www.who.int/
reproductivehealth/publications/monitoring/maternal-morta
lity-2015/en/. Accessed on 16 April 2018.
3. UN Sustainable Development Goals on Maternal Mortality,
Strategies towards ending preventable maternal mortality
(EPMM), WHO, 2015. http://apps.who.int/iris/bitstream/
10665/153540/1/WHO_RHR_15.03_eng.pdf. Last Accessed
16 April 2018.
4. Maternal mortality Fact Sheet, WHO, 2016 http://www.who.
int/mediacentre/factsheets/fs348/en/. Last accessed April
2018.
5. Souza JP, G€ ulmezoglu AM, Vogel J, Carroli G, Lumbiganon
P, Qureshi Z, et al. Moving beyond essential interventions
for reduction of maternal mortality (the WHO
Multicountry Survey on Maternal and Newborn Health): a
cross-sectional study. Lancet. 2013;381:1747–55.
6. Nyamtema AS, Urassa DP, van Roosmalen J. Maternal
health interventions in resource limited countries: a
systematic review of packages, impacts and factors for
change. BMC Pregnancy Childbirth. 2011;11:30. https://doi.
org/10.1186/1471-2393-11-30.
7. Karlsen S, Say L, Souza JP, Hogue CJ, Calles DL, G€ ulmezoglu
AM, et al. The relationship between maternal education and
mortality among women giving birth in health care
institutions: analysis of the cross sectional WHO Global Survey
on Maternal and Perinatal Health. BMC Public Health.
2011;11:606. https://doi.org/10.1186/1471-2458-11-606.
8. Family Health Bureau, Ministry of Health, Sri Lanka.
Maternal & Child Morbidity, Mortality Surveillance. http://
fhb.helath.gov.lk. Accessed on 16 April 2018.
9. Weerasekera D. Presidential address – 2017. Sri Lanka J
Obstet Gynaecol. 2017;39:1–7.