4th June, 2010
On April 12, 2010, Margaret C Hogan, Kyle J Foreman and their colleagues published new estimates for maternal mortality in an article in the online version of The Lancet entitled “Maternal mortality for 181 countries, 1980 – 2008: a systematic analysis of progress towards Millennium Development Goal 5” (DOI: 10.1016/S0140-6736(10)60557-8).
The findings indicate that maternal deaths worldwide have fallen from a 1980 estimate of 526,300 ((uncertainty interval 446,400 to 629,600) to an estimated 342,900 (CI 302,100 – 394,300) in 2008. The global maternal mortality ratio was reported to have declined from an estimate of 422 (358 – 505) in 1980 to 251 (221 – 289) per 100,000 live births in 2008.
Since the publication of the article, great excitement and optimism has built around the new information as this is the first time in decades that estimated maternal deaths have declined from around the half a million mark which has appeared so intractable for decades. And of course this is great news as maternal death remains the biggest challenge in public health as it arises from mostly preventable causes, not to mention the devastation that visits families that lose a mother, especially in poor communities where the mother is the main determinant of child survival as well.
Indications from G8 countries are that this optimism might go as far as proposals for reduced funding towards maternal health programmes in developing countries. While such thinking is logical for any other problem that seemed to be on the verge of being solved, it would not only be the wrong response to this good piece of scientific work, but disastrous for maternal and women’s heath in Africa, as well. There is good justification for this conclusion. First, any number of maternal deaths, let alone 342,900 deaths of women from mainly preventable causes, is still a great tragedy.
Secondly, the global estimates mask very major differences in estimated reductions in various regions of the world. It is also important to note that while the data used may have improved in many countries, serious weaknesses remain in registration of vital events in most of Sub-Saharan Africa. AMREF acknowledges and recognises the great effort made to collect and validate the data used, but would like to point out that the authors did not comment on any change in quality of data from Sub-Saharan Africa, which has been a major issue in previous estimates.
Examination of the regional data presented in the article shows that there was in fact hardly any reduction in maternal mortality in Sub-Saharan Africa. The table below, abstracted from the Lancet article, shows the estimated reductions in various regions of Africa and other previously high mortality regions, compared to low mortality regions in Europe. The table speaks for itself – overall reduction in Sub-Saharan Africa was tiny at 3.3% between 1990 and 2008, and in fact there were increases in maternal mortality in at least two regions, quite sharp in the case of Southern Africa, due to the impact of HIV and AIDS. Three of the six countries that contribute about 50% of global maternal mortality – Nigeria, Democratic Republic of Congo, and Ethiopia – are the most populous countries of Africa.
Table 1: Reduction in Maternal Mortality in High Burden Regions, Central, Eastern and Western Europe – 1980 to 2008 (MMR = Number of maternal deaths/100,000 live births)
| Year/Region | 1980 | 1990 | 2000 | 2008 | % Reduction between 1990 and 2008* |
| Central Africa | 711 | 732 | 770 | 586 | 20.0 |
| East Africa | 707 | 690 | 776 | 508 | 26.4 |
| Southern Africa | 242 | 171 | 373 | 381 | -122.8 |
| West Africa | 683 | 582 | 742 | 629 | -8.1 |
| Total SS** Africa | 586 | 544 | 665 | 526 | 3.3 |
| North Africa | 299 | 183 | 111 | 76 | 58.5 |
| Oceania | 517 | 416 | 329 | 279 | 32.9 |
| Caribbean | 426 | 348 | 323 | 254 | 27 |
| South Asia | 788 | 560 | 402 | 323 | 59 |
| East Asia | 162 | 88 | 55 | 40 | 75 |
| Central Europe | 47 | 34 | 18 | 13 | 61.8 |
| Eastern Europe | 54 | 43 | 41 | 32 | 25.6 |
| Western Europe | 16 | 10 | 8 | 7 | 30 |
*1990 chosen to align progress with the MDG base year
** SS – Sub-Saharan Africa
In view of the evidence presented in the Lancet article, it would be difficult to justify anything else other than massive scaling up of efforts to build on the small reductions noted in some countries of Africa. The right response to the reported reductions in maternal mortality would, in AMREF’s view, be to raise the bar in advocacy and resource mobilisation to maintain the momentum that has built up from various regions that have made progress, borrowing heavily from strategies that have worked and applying them to Africa.
Access to skilled care and emergency obstetric services in the context of strong health systems remain the key to reducing maternal mortality, as does access to effective contraception services that enable women and families to avoid unwanted and too many pregnancies which often lead to unsafe abortion besides the complications associated with too many births. Focus must be maintained on making sure that no woman dies giving life if the world community can do anything about it.
In addressing this issue, there will be many competing priorities, not least that of HIV/AIDS which is becoming increasingly important as a contributor to maternal mortality. All the same, AIDS morbidity and mortality is something, in our view, that must begin to be seen in the context of the overall function of the health system, and managed as such, and thereby increase the resources that could be used to alleviate the most pressing health system problems related to maternal mortality and other problems arising from failed health systems, for example:
- Training and maintaining adequate numbers of midwives and other health personnel essential for reducing maternal mortality.
- Prevention of mother to child transmission of HIV, and its continuation as treatment for mothers and their spouses, is a key function of a working health system.
Dr John Nduba
AMREF Director of Community Partnering
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