How many women die in childbirth?

According to the latest UN global estimates, 303,000 women a year die in childbirth, or as a result of complications arising from pregnancy. This equates to about 830 women dying each day – roughly one every two minutes.

The majority of deaths are from conditions that could have been prevented had women received the right medical care throughout their pregnancies and during birth. Severe bleeding and infections after childbirth are the biggest killers, but high blood pressure, obstructed labour and unsafe abortions all contribute.

Accurate maternal mortality figures require strong in-country data collection, which is often unavailable in developing countries, so the number of deaths is likely to be underreported.

Where do the deaths occur?

The overwhelming majority of maternal deaths occur in developing countries. About two-thirds of all maternal deaths take place in sub-Saharan Africa. Nigeria and India alone account for one-third of global deaths.

The maternal mortality ratio in the world’s least developed countries stands at 436 deaths for every 100,000 live births, which is in stark contrast to the corresponding number – just 12 – in wealthy countries.

Facebook Twitter Pinterest A pregnant woman suffers complications in Freetown’s Kroo Bay clinic. Sierra Leone had the world’s highest maternal mortality rate in 2015. Photograph: Lee Karen Stow/Alamy

World Bank figures show that in 2015 (the latest year for which there are records) Sierra Leone had the highest maternal mortality ratio in the world, with 1,360 deaths for every 100,000 live births – although this represents a 50% reduction since 1990.

What progress has been made to reduce deaths?

Despite the number of deaths, global figures reflect progress. In 1990 an estimated 532,000 women died annually, so there has been a 44% drop in a generation.

But while the reduction certainly merits celebration, it reflects a small return on big global commitments. At the first world conference on women, held in Mexico in 1975, a spotlight was shone on the high number of maternal deaths, and action urged to reduce them. In 1994, 179 governments at the international conference on population and development in Cairo made a joint promise that, by the turn of the century, they would halve the number of maternal deaths recorded in 1990, and then halve the figure again by 2015. This didn’t happen.

In 2001, UN member states agreed the millennium development goals, which included a call for the number of maternal deaths to be cut by three-quarters by 2015. While the MDGs boosted efforts, the goal was not met in the countries with the highest death rates. In fact, it was the target that made the slowest progress. According to the World Health Organization (WHO), between 1990 and 2005, maternal mortality rates decreased by an average of 2.3% a year – way below the 5.5% needed to achieve the MDGs. And now the decline seems to have plateaued.

Facebook Twitter Pinterest ‘It wasn’t an easy experience’: Sara, a mother in Lilongwe, gave birth to her son in March 2016. Malawi has many young mothers. Photograph: Unicef/Chikondi

Why has the figure plateaued?

When there is a high death rate, relatively simple interventions – raising awareness among women of the importance of seeking medical attention during pregnancy and childbirth, training local community health workers to spot signs of problems in labour – will bring fairly quick wins.

But moving the needle much further requires greater political will and more money, says Anneka Knutsson, chief of sexual and reproductive health at the UN population fund (UNFPA). “Any intervention that brings women to a health centre to have antenatal care, informs women of the importance of seeking care, or decreases the number of home births done alone, will have a great impact,” she says. “When you get to the level of about 200 deaths [for every 100,000 live births] there are so many more interventions that need to be in place in the health system to reduce it further. These relate to competent staff in place, and facilities that, in addition to safe normal deliveries, can provide blood transfusion, C-section or other types of assisted deliveries. It requires more long-term and complex investments in the health system. This is one reason why the pace of decrease slows down.”

Why are women dying?

There are a number of reasons, and they are rooted in poverty, inequality and sexism. The majority of women die in poorer, rural areas, where healthcare services are often inadequate or inaccessible, and where there is a severe shortage of trained medical staff. Women from such areas are less likely to give birth with a skilled health worker than wealthier women.

In 2014, the state of the world’s midwifery report noted that only 42% of the world’s midwives, nurses and doctors live and work in the 73 countries where the majority of deaths among women and newborn babies occur, and where the most stillbirths occur. Without professional help, women give birth alone or have to rely on female relatives or traditional birth attendants to support them, putting their lives in grave danger if complications arise. Women, particularly in rural areas, may live miles from any health centre, and might struggle to pay for the transport to get there if money is tight. The Guttmacher Institute estimates that just over half of women in Africa will give birth in a health centre, compared with more than 90% in Latin America.

Throughout pregnancy, women in poorer countries are much less likely to receive the eight antenatal appointments recommended by the WHO. These appointments are crucial in identifying problems or underlying issues that could cause difficulties in childbirth – if a woman has malaria, for instance, or needs special support because she is HIV-positive. Guttmacher estimated that while 63% of women in developing countries received at least four antenatal care visits during pregnancy, the corresponding figure in Africa was just 51%.

The institute calculates that if all women had the level of care recommended by the WHO, maternal deaths would drop by more than 60%, to about 112,000 annually.

And what about sexism?

Millions of women around the world are still unable to decide when or if they want to get married or have children. In developing countries, about 214 million women and girls aged 15-49 who don’t want to get pregnant are not using a modern form of contraception because they are unable to access it, or because their partners or communities frown on contraceptive use. The largest proportion of women without access to modern contraception is in sub-Saharan Africa.

Many countries only allow abortion when a women’s life is at risk, and a handful of countries still have outright bans, despite growing calls for liberalisation. This means many women resort to unsafe, illegal abortions. The WHO estimates that up to 13% of maternal deaths each year are the result of unsafe abortions. “Women are not being given their due respect with regard to sexual and reproductive health and rights,” says Sarah Onyango, technical director in the programmes division of the International Planned Parenthood Federation. “We know what it takes, we have the expertise and resources, broadly … but we ignore it and don’t put enough emphasis on the need to address women’s issues.”

Who is most at risk of dying?

Adolescent girls have a particularly high risk of death in childbirth. Last year the WHO found that complications in pregnancy and childbirth, together with unsafe abortion, were the biggest killers globally of girls aged 15 to 19. Hypertension and obstructed labour are among the main causes, since their bodies are not fully developed and ready to give birth. About half of all pregnancies among this cohort are unplanned.

Facebook Twitter Pinterest A woman receives a contraceptive implant in Gasita village, Botswana. Photograph: Pako Lesejane/The Guardian

No official statistics are collected for younger girls (official statistics for reproductive healthcare are only collected for women aged 15 to 49), but the Guttmacher Institute estimates that in 2016, 777,000 babies were born to girls aged 10 to 14.

UN member states have signed a resolution to end child marriage but, each year, 7.3 million babies are born to mothers under the age of 18, and nine in 10 births will be to girls who are married. Eighteen of the 20 countries with the highest rates of child marriage are found in Africa, the continent with the highest rates of maternal mortality.

Onyango believes conversations about sex need to begin early and contraceptives must be made available to young people. “Most institutions think these conversations are for 18-year-olds but, in reality, age-appropriate comprehensive sexuality education is very important, and needs to begin early.”

Is funding for maternal health a problem?

Worryingly, aid for maternal health has fallen by about 11% in the past few years, from $4.4bn (£3.4bn) in 2013 to $3.9bn last year. It is unclear why. In the past few years, however, some donor countries have redirected aid to deal with an influx of refugees at home.

The UNFPA has a funding gap of about $700m until 2020, not helped by Donald Trump’s decision to stop funding the agency last year.

What next?

After failing to achieve the MDGs, reducing maternal mortality was made a target of the sustainable development goals, signed by UN member states in 2015. The new global goals commit countries to reduce maternal deaths to fewer than 70 for every 100,000 live births. Ambitious, yes, but it is hoped that setting the bar high will at least spur significant progress.

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Onyango says strategic targeting of resources will be required to ensure that the poorest, most vulnerable women are better supported. Another of the sustainable development health targets is to ensure universal access to family planning services. There is also a standalone goal calling for gender equality, which specifically includes ending child marriage, and ensuring universal access to reproductive healthcare.

Expect lobbying on the issue at the international conference on family planning in Rwanda in November, and next year, which marks the 25th anniversary of the Cairo population and development conference.