b6 | maternal mortalIt y: need for a broad frameworK of InterventIon

Global burden of maternal mortality The number of maternal deaths is unconscionably high. An estimated 500,000 women die each year in pregnancy and childbirth.1 An estimated 10 million more women suffer serious maternal morbidities,2 including debilitating and socially devastating conditions such as uterine prolapses and obstetric fistulae.3 In addition, substantial proportions of the 3 million newborn deaths and 4 million stillbirths that occur each year are the result of maternal conditions or of acute events in and around the time of delivery.4 The World Health Organisation (WHO) defines maternal mortality as ‘the death of a woman while pregnant or within 42 days of termination of pregnancy or from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes’, with an additional classification of ‘direct’, ‘indirect’ or ‘incidental’.5 Direct deaths result from obstetric complications, while indirect deaths result from a condition that is not directly related to obstetric causes but is aggravated by the effects of pregnancy. In developing-country settings, studies indicate that 20 per cent or more of all maternal deaths are due to indirect causes. The patterns of maternal mortality reveal large levels of inequity between and within countries – 99 per cent of maternal deaths occur in developing countries, with 86 per cent occurring in South Asia and sub-Saharan Africa alone.6 Fourteen countries have maternal mortality rates (MMRs) of at least 1,000 per 100,000 live births, of which all except Afghanistan are in sub-Saharan Africa: Afghanistan, Angola, Burundi, Cameroon, Chad, the Democratic Republic of Congo, Guinea-Bissau, Liberia, Malawi, Niger, Nigeria, Rwanda, Sierra Leone, and Somalia. Wide disparities also exist within countries. Class, too, plays a defining role in maternal mortality and morbidity statistics, with studies in multiple countries showing that the MMR amongst poor women is four times higher than amongst wealthier groups.7 Three fundamental causes of maternal mortality can be identified:8