UNFPAState of World Population 2004
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Maternal Health

New Approaches
Causes and Consequences
Maternal Morbidity
Obstetric Fistula
Reducing Maternal Mortality and Morbidity
Difficulties in Measurement
Holistic Responses
Antenatal Care
Skilled Attendance
Emergency Obstetric Care
Post-abortion Care
Quality of Maternal Health
Men and Maternal Health
UNFPA and Safe Motherhood

Obstetric complications are the leading cause of death for women of reproductive age in developing countries today, and constitute one of the world’s most urgent and intractable health problems.(1) Reducing maternal death and illness is recognized as a moral and human rights imperative as well as a crucial international development priority, including by the ICPD Programme of Action and the Millennium Development Goals.

Tragically, despite progress in some countries, the global number of deaths per year—estimated at 529,000, or one every minute—has not changed significantly since the ICPD, according to recent estimates by WHO, UNICEF and UNFPA;(2) 99 per cent of these deaths occur in developing countries. Millions more women survive but suffer from illness and disability related to pregnancy and childbirth. Although data are hard to come by, the Safe Motherhood Initiative, a coalition of UN agencies and NGOs, estimates that 30 to 50 morbidities—temporary as well as chronic conditions—occur for each maternal death.(3)

New Approaches

Recognizing that most of these deaths and injuries could be prevented with wider access to skilled care before, during and after pregnancy, the ICPD called on countries to expand maternal health services in the context of primary health care and develop strategies to overcome the underlying causes of maternal death and illness.(4)

Over the past 10 years, global priorities for reducing maternal death and illness have undergone a paradigm shift. In the past, researchers and practitioners thought that high-risk pregnancies could be detected and treated and that antenatal care could prevent many maternal deaths. They also called for training of traditional birth attendants (TBAs) to reduce risks of death or illness during pregnancy.

However, these two interventions did not reduce maternal mortality.(5) Broad agreement now exists among health professionals and policy makers that most maternal deaths stem from problems that are hard to detect or screen for—any woman can experience complications during pregnancy, childbirth and the post-partum period—but are almost always treatable, provided quality emergency obstetric care is accessible.

Since the mid-1990s, governments, international agencies, including UNFPA, researchers and civil society have focused on the interventions judged to be the most effective: expanding women’s access to skilled attendance at delivery; improving facilities for and women’s access to emergency obstetric care to treat pregnancy complications; and ensuring that referral and transport systems are in place so women with complications can receive needed care quickly.

Also high on the list of global safe motherhood priorities are making sure women have access to family planning services to reduce unwanted pregnancies; and improving the overall quality and capacity of countries’ health systems, especially at the district level; and strengthening human resources.

A FOCUS ON RIGHTS. An additional feature of the post-ICPD period is the recognition that maternal deaths and disability are violations of women’s human rights, and are strongly tied to women’s status in society and economic independence.(6) Various human rights conventions support the view that women have a right to health care that enhances the likelihood that they survive pregnancy and childbirth. (7) Rights-related issues like the role of gender inequalities in maternal health and the impact of gender-based violence on pregnancies are receiving greater attention at all levels.(8)

Still, ten years after Cairo, women’s needs often do not rank high on governments’ or communities’ lists of priorities. Women still lack full power to choose the obstetric care they want. Poverty, conflict and natural disasters worsen reproductive health and add new challenges to ensuring safe motherhood.(9)

The ICPD set a goal of reducing maternal mortality to one half of the 1990 levels by 2000 and a further one-half reduction by 2015. Countries were also urged to reduce the differences between developing and developed countries and within countries, and to reduce greatly the number of deaths and morbidity from unsafe abortion.


[Maternal health] services, based on the concept of informed choice, should include education on safe motherhood, prenatal care that is focused and effective, maternal nutrition programmes, adequate delivery assistance that avoids excessive recourse to Caesarian sections and provides for obstetric emergencies; referral services for pregnancy, childbirth and abortion complications; post-natal care and family planning….

—from the ICPD Programme of Action, para. 8.22.

The 1999 review of ICPD implementation stressed the connection between high levels of maternal mortality and poverty, and called on states to “promote the reduction of maternal mortality and morbidity as a public health priority and reproductive rights concern” by ensuring that “women have ready access to essential obstetric care, well-equipped and adequately staffed maternal health-care services, skilled attendance at delivery, emergency obstetric care, effective referral and transport to higher levels of care when necessary”. (10)

The Millennium Summit in 2000 also identified maternal health as an urgent priority in the fight against poverty. Millennium Development Goal 5 calls for a 75 per cent reduction by 2015 in the maternal mortality ratio (the number of maternal deaths for every 100,000 births) from 1990 levels.

Meeting these goals will be difficult. In the developing world as a whole, approximately 65 per cent of all pregnant women receive at least some care during pregnancy; 40 per cent of deliveries take place in health facilities; and skilled personnel assist slightly more than half of all deliveries. But just 35 per cent of deliveries in South Asia were attended by a skilled attendant in 2000; in sub-Saharan Africa it was 41 per cent (up from one third in 1985); in East Asia and in Latin America and the Caribbean, the proportion was 80 per cent.(11)

In many settings, available safe motherhood services cannot meet demand or are not accessible to women because of distance, cost or socio-economic factors. Pregnancy care may be consigned to a low place on household lists of priorities given its costs in time and money. Too many women are still seen as not worth the investment, with tragic consequences for them, their children, who are less likely to survive or thrive without a mother, and their communities and countries.

GLOBAL SURVEY RESULTS. In their responses to the 2003 UNFPA global survey, 144 countries reported having taken specific measures to reduce maternal deaths and injury; 113 reported multiple measures. The most common were training health care providers (76 countries); instituting plans, programmes or strategies 68), improving ante- and post-natal care (66), upgrading data collection and record keeping (45), and providing information or advocacy (40).

But only some countries have been successful in reducing maternal mortality (most are middle income; a few are poor). In China, Egypt, Honduras, Indonesia, Jamaica, Jordan, Mexico, Mongolia, Sri Lanka and Tunisia, deaths have been reduced significantly over the past decade. Common to all these countries’ safe motherhood efforts is the presence of skilled birth attendants, a capable referral system and basic or comprehensive emergency obstetric services.

Progress in most other countries has been slow, and maternal mortality and morbidity remain tragically high in several regions, including in most of sub-Saharan Africa and the poorer parts of South Asia. While some gains in combating maternal death and illness are expected in the next 10 years, current interventions will need to be scaled up and more resources directed towards them if significant inroads are to be made to protect women’s lives and health.

Table 1: Maternal mortality estimates by region, 2000

Maternal Mortality Ratio
(Maternal Deaths per
100,000 Live Births)
Number of
Maternal Deaths
Lifetime Risk of
Maternal Death, 1 in:
WORLD TOTAL 400 529,000 74
DEVELOPED REGIONS 20 2,500 2,800
Europe 24 1,700 2,400
Africa 830 251,000 20
Northern Africa 130 4,600 210
Sub-Saharan Africa 920 247,000 16
Asia 330 253,000 94
Eastern Asia 55 11,000 840
South-central Asia 520 207,000 46
South-eastern Asia 210 25,000 140
Western Asia 190 9,800 120
Latin America & the Caribbean 190 22,000 160
Oceania 240 530 83
Source: WHO, UNICEF, and UNFPA, 2003, Maternal Mortality in 2000: Estimates Developed by WHO, UNICEF, and UNFPA. Geneva: World Health Organization.
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