An article published Online First and in an upcoming edition of The Lancet reports that many countries are making significant progress in reducing maternal mortality. These include China, Egypt, Ecuador and Bolivia. They are on track to meet Millennium Development Goal 5 (MDG5) (>5.5 percent decline in maternal mortality ratio per year). However, the data also reveal surprising increases in some high-income countries, for example the USA, Canada, and Denmark. The article is the work of Dr Christopher Murray, Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA, and colleagues.

For the period 1980 to 2008, the authors projected maternal deaths in 181 countries. They used vital registration data, censuses, surveys, and verbal autopsy studies. According to their findings, the number of women dying from pregnancy-related causes has decreased by over 35 percent in the past thirty years. In 1980, annual deaths were more than a half-million. They dropped to about 343,000 in 2008.

For each country, the research team also generated the maternal mortality ratio (MMR). MMR is the number of women dying for every 100,000 live births. The analysis indicates that globally, MMR declined from 422 in 1980 to 320 in 1990. It fell to 251 in 2008. The authors also say it is heading in the right direction for additional decreases.

According to Dr Murray, the findings are contrary to previous research. Earlier investigation showed very little variation in the maternal mortality ratio (MMR). This new study from the Institute for Health Metrics and Evaluation (IHME) reveals that between 1990 and 2008 maternal deaths have been declining at an annual rate of about 1.4 percent.

Research shows that the ongoing HIV epidemic has slowed the progress in reducing maternal mortality. Nearly one out of every five maternal deaths (a total of 61,400 in 2008) can be linked to HIV. In addition, many of the countries with large populations affected by HIV have had the most difficulty reducing their maternal mortality ratio.

In 2008, approximately 80 percent of all maternal deaths were concentrated in 21 countries. But 50 percent were in only six countries (India, Nigeria, Pakistan, Afghanistan, Ethiopia, and the Democratic Republic of the Congo). The best performing country was The Maldives, with an annual MMR drop of 8•8 percent between 1990 and 2008. Zimbabwe was the worst performing nation over the same period. It actually had an annual MMR increase of 5•5 percent.

Developing countries, in particular, have made substantial progress toward MDG5. Their MMR was reduced by 75 percent during the period 1990-2015. This is regardless of the fact that only 23 countries are on track to achieve the target of lowering the MMR by 75 percent between 1990 and 2015: Maldives, Egypt, Bhutan, Albania, Tunisia, El Salvador, United Arab Emirates, Lao People’s Democratic Republic, Oman, Romania, Qatar, Saudi Arabia, Lebanon, Libyan Arab Jamahiriya, Syrian Arab Republic, Morocco, Turkmenistan, Cape Verde, Myanmar, Jordan, Poland, Algeria, Bosnia and Herzegovina.

Countries such as Egypt, China, Ecuador, and Bolivia have been achieving accelerated progress in decreasing their MMR.

One of the most shocking findings was the increased MMR in the USA. It went from 12 in 1990 to 17 in 2008, which is an increase of 42 percent. The authors explain that this trend could be partly due to changes in the way maternal deaths are reported. However, they add that this does not explain why maternal deaths in the USA are occurring at more than double the rate in the UK, three times the rate in Australia and four times the rate in Italy. Canada’s MMR also increased from 6 to 7 over the same period. Denmark’s increased from 7 to 9. Austria, Norway, and Singapore also recorded rises.

In Western Europe, many countries followed a similar trend. This tendency decreases between 1980 and 1990 followed by a levelling off to 2008. The countries with the lowest MMR in 2008 in this region were:

• Italy MMR was 4 (the lowest in the world)
• Luxembourg and Sweden MMR were 5
• UK MMR was 8
• Germany and Spain MMR were 7
• France MMR was 10

Chile and Uruguay had the lowest MMRs in South America with 21 and 25 respectively. Bolivia, despite its accelerated decrease, still had the highest at 180. Performance across Africa was mixed. Some countries showed a sharp annual rise in MMR, such as Democratic Republic of Congo, Zimbabwe, and Mozambique. Others showed exceptional promising progress including Equatorial Guinea, Eritrea, Ethiopia, Somalia, and Sudan.

Australia continues to have one of the lowest MMRs worldwide at 5. China has seen a sharp drop from 165 in 1980 to 40 in 2008. In Asia, Vietnam, the Philippines and Laos were among the countries that saw a strong decline.

Dr Murray explains: “These findings are very encouraging and quite surprising. There are still too many mothers dying worldwide, but now we have a greater reason for optimism than has generally been perceived.”

He states further: “Finding out why a country such as Egypt has had such enormous success in driving down the number of women dying from pregnancy-related causes could enable us to export that success to countries that have been lagging behind.”

He says in closing: “In a year where there has been unprecedented policy interest in improving maternal and child health, this is a remarkable story of undiscovered progress that countries can build on in their efforts to reach international goals.”

In an associated note, Lancet Editor Dr Richard Horton labels the general data as ‘robust reason for optimism’. He continues by saying that the information clearly exposes the close correlation between HIV and maternal health.

He writes: “Given the dramatic difference between the results of these estimates and those last reported by the UN, a process needs to be put in place urgently to discuss these figures, their implications, and the actions, global and in country, that should follow. Ban Ki-moon is currently leading a Joint Effort on Women’s and Children’s Health. The purpose is to plan measures for the MDG Summit in September. One outcome of the UN Secretary-General’s important initiative might be to convene a high-level, intergovernmental MDG preparatory meeting as a satellite event at Women Deliver in June. The goal of such a preparatory meeting would be to bring the best available data to bear on formulating policies to launch in September.”

He says in conclusion: “Two decades of concerted campaigning by those dedicated to maternal health is working. Even greater investment in that work is likely to deliver even greater benefits. Women have long delivered for society, and, slowly, society is at last delivering for women. This is a moment to celebrate – and accelerate.”

“Maternal mortality for 181 countries, 1980 – 2008: a systematic analysis of progress towards Millennium Development Goal 5”
Margaret C Hogan, Kyle J Foreman, Mohsen Naghavi, Stephanie Y Ahn, Mengru Wang, Susanna M Makela, Alan D Lopez, Rafael Lozano,Christopher J L Murray
DOI: 10.1016/S0140-6736(10)60518-1

“Maternal mortality: surprise, hope, and urgent action”
Richard Horton
DOI: 10.1016/S0140-6736(10)60547-8
The Lancet

Written by Stephanie Brunner (B.A)