Maternal mortality rates have dropped by 40% since 2000, largely due to improved access to essential health services. But WHO officials warn that the recent, deep cuts to international aid could be as disruptive as the COVID-19 pandemic, if not more so, to a woman’s chances of surviving pregnancy and childbirth.

And in 2023, more than a quarter million women still died from pregnancy and childbirth complications, according to a report on global maternal mortality released on Monday, World Health Day, which focused on maternal and newborn health.

That’s a death every two minutes. 

“This is not just a medical failure,” said Dr Pascale Allotey, director of the WHO Department of Sexual and Reproductive Health and Research, at the report’s launch. “It’s a failure of society.”

The report by UNICEF, WHO and the UN Population Fund (UNFPA) comes as the dismantling of most of USAID’s international health programmes, and other cuts to health and humanitarian aid send shockwaves through global health, forcing countries to roll back vital services for maternal, newborn and child health, the WHO said. 

Without urgent action, fading attention, funding cuts, and humanitarian crises will jeopardize pregnant women in conflict settings – and make the persistent tragedy of maternal mortality “alarmingly high,” warned WHO officials convened at a press conference last week. 

International aid cuts could mirror COVID-19 chaos

This year’s report is also the first to delve into how the pandemic affected deaths from pregnancy-related conditions.

“I hate to use the term ‘surviving’ pregnancy,” said Dr Bruce Aylward, WHO assistant director general for Universal Health Coverage and life course at a press conference. “But that’s what our reality is.”

The pandemic “shocked” health systems, said Aylward, meaning that many women could not access needed care for their pregnancies and deliveries.

As a result, more than 40,000 more women died in pregnancy and childbirth in 2021 (322,000) as compared to 2020 (282,000), the report concludes, as the pandemic was gathering steam in low-income regions such as Africa and South Asia.  

The upsurge in deaths was partly linked to direct complications caused by COVID-19 during pregnancy, but not only that. There were also widespread interruptions to maternity services – due to the competing demands of the pandemic on hospital beds and healthcare workers, limitations on travel, and other factors limiting access to hospitals and primary healthcare services. 

Severe bleeding, infections, preeclampsia and eclampsia, delivery complications, and unsafe abortions are the largest drivers of maternal mortality. 

Yet the spike in deaths during the pandemic was temporary. In 2022, the global MMR and number of maternal deaths were lower than they had been in the three years immediately prior to the COVID-19 pandemic, the report notes. 

Whether the disruptions now being experienced as a result of the broad funding cutbacks in international health assistance led by the United Strates, but also including the United Kingdom, will be as short-lived, remains to be seen.  

Aid crisis threatens to reverse decades of progress

To date, aid cuts have already led to facility closures and loss of health workers, while also disrupting supply chains for supplies and medicines for the pregnancy complications, WHO said in a joint statement with UNICEF. 

“Global funding cuts to health services are putting more pregnant women at risk, especially in the most fragile settings, by limiting their access to essential care during pregnancy and the support they need when giving birth. The world must urgently invest in midwives, nurses, and community health workers to ensure every mother and baby has a chance to survive and thrive,” UNICEF Executive Director Catherine Russell, said in the press statement. 

She added, “When a mother dies in pregnancy or childbirth, her baby’s life is also at risk. Too often, both are lost to causes we know how to prevent.”

Lead author Dr Jenny Cresswell also predicted a rise in unsafe abortions as one consequence of the recent funding cuts – which target reproductive health services, in particular.

“Any sudden disruptions will eventually lead to adverse outcomes,” she said.

US international assistance also “underpins” WHO’s ability to collect and analyse country data, and more importantly, support the “basic ability of a woman to survive during pregnancy,” Aylward noted at last week’s briefing. 

“The American people have been incredibly generous in the past 25 years – and share in the credit for progress so far. It makes a real difference” Aylward. This progress is now “at risk of disappearing.” 

And the most economically fragile countries are also the ones with the least ability to rapidly adjust to the abrupt funding halt, and are consequently at highest risk, he concluded.

Huge global disparities – particularly in conflict zones

The report gathers data from 195 countries and territories, with a third of all countries having “very low” maternal mortality ratios (MMR). No country was rated as having an “extremely high” ratio for the first time, defined as the number of deaths per 100,000 live births. 

In 2000, nearly a million women died from pregnancy-related conditions. In 2023, maternal morality had declined to 260,000.  That represents a 40% decline in the rate of maternal deaths, as compared to live births per 100,000 population. 

And while the WHO pointed to these significant improvements since 2000,  “there is a huge unfinished agenda in which a quarter million women die trying to give life,” said Aylward. 

The burden is not equal. Lower and middle income countries and countries caught in conflict are the places where the vast majority of maternal deaths occur – nine in ten in fact.  

Sub Saharan Africa did see the largest improvements over the past two decades. Even so, some 70% of maternal deaths still occur in that region, noted Cresswell. Globally, Chad, the Central African Republic (CAR), Nigeria, and Somalia face the highest burden of maternal mortality – along with Afghanistan. 

Conflict zones are especially vulnerable to high rates of maternal mortality. Countries in conflict – such as Afghanistan, Somalia, and CAR – accounted for three in ten deaths. 

The maternal mortality ratio is “significantly higher” in conflict-affected areas (504 deaths per 100,000 live births) compared to non-conflict of non fragile settings (99 per 100,000 live births), the report notes. 

Persistent social and economic inequalities underline uneven progress between regions. Post-2015, progress stalled in five regions: North Africa and Western Asia, Eastern and South-Eastern Asia, Oceania (excluding Australia and New Zealand), Europe and North America, and Latin America and the Caribbean.

“We cannot be complacent,” said Cresswell. 

Skilled health workers at the center of solutions

The most important factor in healthy pregnancy outcomes is having a skilled attendant at the time of childbirth – most deaths occur around the time of delivery. 

Part of the remarkable progress seen in the past two decades is attributable to the upsurge in midwifery programs, as well as in programmes targeted at reducing unsafe abortions, a major cause of complications. 

“Having a skilled health worker in place is key, and we have seen positive progress, particularly in Sub Saharan Africa,” said Cresswell. “There is still work to be done. There are still too many women who are delivering without a skilled health provider.”

Also imperative is improved access to family planning services, and preventing underlying health conditions like anaemias, malaria and noncommunicable diseases that increase pregnancy risks, the report notes. 

Allotey, from the department of sexual and reproductive health, also emphasized the role of access to comprehensive information throughout pregnancy. This means generally making sure girls stay in school and receive the knowledge and resources to protect their health.

“There are a whole range of preventive measures to make sure that women are safe,” she said. These include making sure the pregnancies are wanted, and therefore mothers are able to access better care, as well as political commitments.

In recent years, increased political support from African nations has begun to “move the needle” on maternal and child health. 

This year’s World Health Day theme “Healthy beginnings, hopeful futures,” aims to raise awareness on maternal and child health because “it is not okay for a woman to die trying to give birth,” said Aylward. 

“While this report shows glimmers of hope, the data also highlights how dangerous pregnancy still is in much of the world today – despite the fact that solutions exist to prevent and treat the complications that cause the vast majority of maternal deaths,” said Dr Tedros Adhanom Ghebreyesus, Director General of WHO. 

Image Credits: BMGF, WHO, Twitter.