www.thelancet.com Published online September 28, 2006 DOI:10.1016/S0140-6736(06)69384-7 1
Maternal Survival 5
Maternal health in poor countries: the broader context and a
call for action
Véronique Filippi, Carine Ronsmans, Oona M R Campbell, Wendy J Graham, Anne Mills, Jo Borghi, Marjorie Koblinsky, David Osrin
In this paper, we take a broad perspective on maternal health and place it in its wider context. We draw attention to the
economic and social vulnerability of pregnant women, and stress the importance of concomitant broader strategies,
including poverty reduction and women’s empowerment. We also consider outcomes beyond mortality, in particular,
near-misses and long-term sequelae, and the implications of the close association between the mother, the fetus, and
the child. We make links to a range of global survival initiatives, particularly neonatal health, HIV, and malaria, and to
reproductive health. Finally, after examining the political and fi nancial context, we call for action. The need for
strategic vision, fi nancial resources, human resources, and information are discussed.
We believe that the Millennium Development Goal for
maternal health (MDG-5) to reduce maternal mortality
by two-thirds by 2015, will best be achieved by adoption
of a core strategy of intrapartum care based in health
centres. The clustering of mortality around delivery, and
the dominance of haemorrhage, infections, and
hypertensive disorders as causes of death, mean that all
women should have access to skilled attendants at birth
and immediately after, and to timely referral for
The regions with the highest mortality burden—
sub-Saharan Africa and south Asia—face massive
deprivation in access to such care and the sheer scarcity of
staff and the excessive costs of care to mothers are
substantial barriers to progress.2 To achieve rapid coverage
requires training, deployment, and retention of midwives,
preferably in teams in small facilities.3 Financial barriers to
care, such as user fees, must also be removed. Overcoming
health system constraints to provide such interventions at
scale is possible, but donors will need to increase fi nancial
contributions for maternal health in low-income countries
to help overcome the resource gap.4
Pregnant women are economically and socially
Women are intensely vulnerable to the eff ects of costs
incurred during childbirth.4 User fees can be especially
high for emergency or technological procedures such as
caesarean section, sometimes reaching catastrophic
amounts, which push families into poverty.4,5 For example,
near-miss complications in Beninese women accounted
for 26% of average yearly household expenditure, and
many women often left the hospital before they were well
enough for discharge because they could not pay for the
care they received.6 User charges add to the costs of
transport and companion time, which can be substantial
for those living far from facilities. The time spent looking
for cash can also delay access to emergency life-saving
care in facilities.7 Women are encouraged to plan for their
deliveries, but the unpredictability of the outcomes and
costs makes planning diffi cult. Indeed, the fear of
anticipated cost can deter use of services.8 The huge
inequalities between poor and rich people in access to
skilled delivery care are therefore not surprising, and are
greater than those for uptake of child health services or
family planning.3,9,10 The socioeconomic diff erences in
maternal mortality can also be large with, for example, a
six-fold diff erence between the richest and poorest
quintiles in Peru.2
Catastrophic costs and adverse maternal health
outcomes, especially for the worst off , are not the only
concerns. Good maternal health is crucial for the welfare
of the whole household, especially children who are
dependent on their mothers to provide food, care, and
September 28, 2006
This is the fi fth in a Series of fi ve
articles about maternal survival
Maternal and Neonatal
Health Group (V Filippi PhD,
C Ronsmans MD,
O M R Campbell PhD), and
Department of Public Health
and Policy, London School of
Hygiene and Tropical Medicine,
London WC1E 7HT, UK
(A Mills PhD, Jo Borghi PhD);
Department of Obstetrics and
Gynaecology, University of
Aberdeen, Aberdeen, Scotland,
UK (Prof W J Graham DPhil)
Reproductive Health Unit,
Public Health Sciences Division,
ICDDR,B, Dhaka, Bangladesh
(M Koblinsky PhD); University
College London, Centre for
International Health and
Development, Institute of
Child Health, London, UK
(D Osrin MRCPCH)
Dr Véronique Filippi
Panel 1: Improving maternal survival: links to other
Millennium Development Goals
● MDG-1: poverty reduction: improved maternal health
services , which are available equitably can not only help
to reduce the gap in numbers of maternal deaths
between rich and poor people, but also reduce the
economic eff ect on poor families, both of catastrophic
payments owing to emergency care and of the death or
disability of an important productive member of the
● MDG-3: women’s empowerment: maternal mortality is
high where women’s status is low, especially with regard
to educational level.
● MDG-4: child survival: intrapartum and early postpartum
strategies will reduce the overwhelming burden of
neonatal deaths, and improved maternal survival will
also enhance the survival and well-being of young
● MDG-6: infectious diseases: good maternity care services
provide opportunities to prevent and treat malaria in
mothers and babies, and prevent mother-to-child
transmission of HIV and other sexually-transmitted
www.thelancet.com Published online September 28, 2006 DOI:10.1016/S0140-6736(06)69384-7
emotional support. The death or chronic ill-health of a
mother increases the probability of death and poor
growth and development of her children.11 Improvement
in fi nancial and geographical access to good quality
intrapartum care based in health centres is therefore
important in any poverty eradication strategy, as well as a
means of reaching MDG-5 (panel 1).12
The days before or after childbirth can be a period of
ambiguity for women. Some moments are joyful, and
childbearing is highly valued: if everything goes well, the
emotional, personal, and social benefi ts are great, but
women might become more vulnerable.13,14 Stressors
include lack of education, money, and decision-making
power (particularly in relation to care during pregnancy) as
well as the pressure to reproduce, the fear of complications,
and a perceived inability to control the danger. This
increased, repeated vulnerability linked to gender makes
maternal health a unique issue.
In countries with similar amounts of economic
development, maternal mortality is inversely proportional
to women’s status.15 Female ownership of assets16 and
secondary education increases use of maternal services,
even in adverse family or socioeconomic situations.17
Women in many developing countries have less freedom
to act, less personal autonomy, and less access to
information than their male partners or husbands. In
Benin, for example, men pay for maternity services as an
indication that they acknowledge paternity. The willing-
ness and ability of husbands to pay for care varies
considerably.18 Husbands are characteristically warned
not to abandon their wives when looking for money to
cover the cost of maternity care. Pregnant women can be
subjected to stigma and violence associated with their
position in society, in particular if they are single.19 The
long-term eff ect on maternal mortality of promotion of
MDG 3 (gender equality and women’s empowerment) is
likely to be substantial (panel 220).
Maternal health is more than survival
Near-misses, ill health, and long-term sequelae
In sub-Saharan Africa, one in 16 women dies in pregnancy
or childbirth. This risk is 175 times higher than that in
developed countries (one in 2800).21 The 529 000 maternal
deaths are the tip of the iceberg, and many more women
are estimated to suff er pregnancy-related illnesses
(9·5 million), near-miss events (1·4 million), and other
potentially devastating consequences
(fi gure 1).11,22,23
The consequences of near-miss events (severe, life
threatening complications that women survive) and
maternal deaths on women and their families can be
substantial, and recovery can be slow, with lasting
sequelae. An estimated 10–20 million women develop
physical or mental disabilities every year as a result of
complications or poor management.23,24 The incidence of
childbirth-related damage to pelvic structure can be high;
for example, the prevalence is 46% in Gambia, or can be
infrequent, but debilitating,
vesicovaginal fi stula.25 The long-term consequences are
not only physical, but are also psychological, social, and
economic (fi gure 2). Infertility after hysterectomy for
uterine rupture, for example, can lead to depression,
social isolation, and marital disharmony,26 as well as debt
because of the high cost of surgery.
Self-reported ill health in pregnancy is common.27,28
Rural Nepalese women report ill-health for 3–4 days a
week during the 9 months of pregnancy (symptoms
include fever, swollen feet, and vaginal bleeding).29
Although maternal mortality has been chosen as the
valued outcome for MDG-5, health-care systems cannot
ignore the suff ering that takes place and is indicative of a
potential need for health care, especially since the
frequency and duration of suff ering can be debilitating.
Antenatal and postnatal care provide opportunities to deal
with recurrent problems, and can also represent an
opportunity for other actions, such as birth planning. An
overly restricted focus on emergency care might mean
for example with
Panel 2: Human rights, women’s empowerment, and community mobilisation
The key to reduction of maternal mortality is sometimes suggested to be use of
broader-based action, such as improvement of women’s education, income, or status.
There is no uncertainty, and little controversy, about the need for such initiatives within a
development agenda. Actions to improve these determinants of maternal health are
medium-term to long-term, but they also provide enabling conditions for more proximate
interventions (such as creation of demand for skilled delivery care) to succeed in terms of
population coverage and sustainability. Improvement of women’s education, for example,
is a big picture intervention, which produces multiple valued end-points, and not just
health-related ones. Distal-level interventions also exist, which are in fact vehicles for
change rather than interventions per se—namely, human rights, women’s empowerment,
or community mobilisation. For example, a human-rights-based approach to reduction of
maternal mortality provides a legal or development-centred framework or both for
strengthening policy and programme interventions, such as the targeting of resources for
the poorest and socially-excluded people. Another example is community-based action on
the demand side of health care, which shows promise as a means of both improving home
care and increasing uptake of services.20
Figure 1: Extent of maternal mortality, morbidity, and disabilities
Calculations assume 136 millions births, 1% near-miss, 7% serious
complications, and 20 million disabilities a year.11,22,23
www.thelancet.com Published online September 28, 2006 DOI:10.1016/S0140-6736(06)69384-7 3
opportunities to prevent complications are missed and
might be detrimental to maternal health in the broadest
sense, for example if women are saved too late but develop
chronic health problems. Moreover, women need health
services that respond to the health problems they perceive.
A pregnant woman who is not treated for a minor ailment
because it is not life threatening is unlikely to seek other
Mother and child outcomes are closely linked
Of the 136 million babies born every year, 3·2 million are
stillborn and 4 million die in the fi rst month of life,30,31
98% of whom live in low-income and middle-income
countries. Neonatal deaths contribute 38% of deaths in
those younger than 5 years, and are the main barrier to
attaining the MDG for child heath (MDG-4). Although
mother and child outcomes are associated across the
whole life-cycle and into the next generation, the most
radical eff ects of maternal mortality on child survival are
in the pregnancy and neonatal period. Obstetric
complications, particularly in labour, are a major source
of stillbirths and early neonatal deaths,32 perhaps
responsible for as much as 58% of such outcomes.33
Intrapartum risk factors increase the risk of perinatal or
neonatal death more than pre-pregnancy or antenatal
factors.30 Likewise, the repercussions for children who
survive the death of their mothers can be staggering. In
Nepal, for example, infants of mothers who died during
childbirth were six times more likely to die in the fi rst
week of life, 12 times more likely between 8 and 28 days,
and 52 times more likely to die between 4 and 24 weeks.34
Whereas many early deaths were attributable to obstetric
complications, later deaths were explained by an absence
of appropriate childcare and nutrition.
Mutual benefi ts for global survival initiatives
Health-centre-based intrapartum care and neonatal
Stillbirths, neonatal deaths, and maternal morbidity
and mortality fi t together as public health priorities.
Neonatal deaths are more common than maternal
deaths and can be reduced through a range of
approaches: institutional or community-based, ante-
partum, peripartum, and postpartum.35 Within this
spectrum, skilled birth attendance is particularly
advantageous for both maternal and neonatal survival.36,37
Associations between place of birth (or the presence of
a skilled attendant) and neonatal deaths are similar to
those for maternal deaths; 90% coverage of facility-based
clinical care alone could reduce neonatal mortality by
23–50%.38 If outreach and family-community care were
added and achieved similar coverage, the reduction
would be 31–61%. The three biggest causes of neonatal
death are preterm delivery, complications of presumptive
birth asphyxia, and infection. The fi rst two of these are
manifest at the time of birth and about three-quarters
of neonatal deaths occur in the fi rst week, most of them
in the fi rst 2 days. If we can achieve high coverage of
intrapartum care based in health centres, a qualitative
change in labour monitoring and in early care for
preterm newborn babies is likely to translate into a fall
in early neonatal mortality.
There is little doubt that neonatal mortality is also
sensitive to other interventions.38 Assessments of cause
of death and trials in poorly-resourced settings suggest
that survival can be reduced substantially through
community-based initiatives.20,39–41 Skilled attendance is
uncommon in many places,37 and advocates for neonatal
care are pessimistic about the likelihood of achieving it:
at the current rate, and without extra resources, average
skilled attendant coverage in Africa will be less than
50% by 2015.37 Advocates for neonatal care hold out
greater hope for achievement of high coverage with
community workers attending in the fi rst few days
postpartum. If a particular country already has
community health workers present at delivery,
pragmatism would suggest that they should help
mothers as well as newborn babies; for example, by
referring women for appropriate care in an emergency.
However, no evidence exists that such interventions
work at scale and investment in community health
workers should not reduce funds for investment in
skilled attendants. Moreover, to see the skilled birth
attendance objective as utopian would be to imply that
maternal mortality reduction is not possible and
underestimate the core of pragmatism and system
Direct effects of childbirth:
lack of capital
Figure 2: Pregnancy-related illnesses and their consequences
www.thelancet.com Published online September 28, 2006 DOI:10.1016/S0140-6736(06)69384-7
engagement, which has been achieved by maternal-
health policy and programming. Maternal survival
initiatives have a historical head start on neonatal
initiatives, particularly in terms of engagement with
health systems and of putting programmes into eff ect.
Neonatal initiatives are at a stage at which the potential
programme options are few, because of little experience
of programme or health-system implementation.42 The
need for a continuum of care is evident—from
pre-pregnancy into childhood and from community to
hospital—but how such a continuum would manifest in
real settings is not yet clear43 and the results of initiatives
to take community-based interventions to scale are
awaited. To put in place a cadre of new workers, whether
skilled birth attendants or community workers, would
need substantial investment. The resource requirements
for logistics and supervision, and also sustainability of
community workers are rarely considered.11
Maternity and infectious diseases
Pregnancy interacts with other disorders (for example,
malaria, HIV, heart disease, and diabetes) to which
women are both more susceptible and more vulnerable
to severe manifestations.2 Malaria and HIV have been
global priorities and interventions target pregnancy and
delivery. Most programmes recognise the importance
of integrating with maternal health services for
successful scaling up.44,45 Both malaria and HIV
programmes benefi t from the relatively high coverage
of antenatal care, for example through intermittent
preventive treatment of malaria for pregnant women
and distribution of insecticide-treated nets, and through
improved access to intrapartum care for HIV-positive
mothers (a key strategy for the prevention of
mother-to-child transmission in low-income countries).
Programmes can only benefi t from strong investments
for safer motherhood in this area. However, these
strategies will work best with concerted action from
maternal health specialists; the result would be
disastrous if well funded HIV and malaria programmes
swept the best maternity staff away from the delivery
suites46 or if counselling and testing was provided
antenatally without ensuring that screening for
hypertensive diseases of pregnancy was provided.
Making political and fi nancial commitments
International commitment and tracking resources
Despite the commitment expressed with the Millennium
initiative, maternal, newborn, and child health have not
been given fi nancial priority internationally. Maternal
mortality only aff ects women in a narrow age range;
one dilemma is that the number of maternal deaths can
seem small compared with deaths due to other
disorders. Safe motherhood programmes compete for
funding with other priorities such as tuberculosis
(2·4 million yearly deaths), malaria (1 million), and
HIV/AIDS (3 million).47 Partitioning of maternal and
child health between diff erent vertical programmes, in
particular malaria and HIV, was recognised as a
problem in a previous Lancet series on child health.48
Competition for funds is fi erce, and advocates for well
funded disease initiatives even feel the need to compete
for the meagre resources of maternal health: one
website states that ”tuberculosis kills more women
worldwide than all causes of maternal mortality”.49
The MDG declaration after the 2005 G8 summit in
Scotland referred mostly to infectious diseases and did
not draw attention to maternal and child health as an
important problem to which further resources would
be channelled. The UK is the only major bilateral donor
Panel 3: Action called for
Donors and governments need to formulate a clear strategic vision of what it takes to
reduce maternal mortality:
● Intrapartum strategies are the priority. Complementary strategies, such as family
planning and safe abortion, also play an important part for those who need them.
● To reduce maternal mortality, all women should be able to deliver in health centres
with midwives working in teams (health-centre intrapartum care strategy).
● Deliberate eff orts are needed to target the women in greatest need, particularly poor
women in rural areas. At international level, sub-Saharan Africa and south Asia should
continue to be priorities. These regions are where the maternal mortality ratio and
lifetime risk of death are the highest and infrastructure and human resource
constraints the greatest.
The international community must recognise that reduction of maternal mortality is a
long-term eff ort with no single solution. With the complex challenges of working
through health systems, an acceleration in progress requires long-term support
(>10 years). We call for donors to channel funds through sector-wide support, with
special investment in resource-tracking mechanisms to hold all countries, donors, and
other actors to account.
The introduction of user fees has done great damage to the use and quality of
maternity-care services, particularly for the poorest women. We call on countries to adopt
policies to protect the poorest families from the catastrophic consequences of
unaff ordable delivery charges.
We call on governments to:
● Start planning now for the training and deployment of the required human resources,
especially midwives. Investment in community health workers should not be at the
expense of funds for skilled attendants.
● Invest in eff orts to retain existing staff , including discouragement of international
brain drain, particularly by improving working conditions and off ering appropriate
incentives for good quality care.
We call for better monitoring of progress made in improving maternal health, with an
expanded set of indicators (panel 4) and targeted research on intrapartum care based
in health centres (panel 5). We also call for an improvement in data quality, the
creation of a monitoring and evaluation of maternal outcomes group and a statement
on data quality as it relates to maternal health (panel 4).
www.thelancet.com Published online September 28, 2006 DOI:10.1016/S0140-6736(06)69384-7 5
to have a strategy on how it will address MDG-5
(McConville F, UK Department for International
Development, personal communication). Furthermore,
maternal health represents only a tiny proportion of the
overall aid budget (1% of the aid budget of one of the
main donor countries).48 Global development assistance
to maternal and neonatal health has been estimated at
more than US$663 million in 2003.50 An estimated
extra US$1 billion in 2006, increasing to US$6·1 billion
in 2015, is needed to increase coverage to desired
levels;11 such estimates omit the cost of incentives to
improve quality of care, ensure staff retention in rural
areas, and deter the imposition of informal charges.4
The extent to which such health system investment will
aff ect maternal health is diffi cult to quantify and is a
challenge to cost-calculating exercises.
Political commitment at country level
Eff ective health interventions exist for mothers and
babies, and several proven means of distribution are
available that can be used to put these in place and take
them to scale. However, none of them will work if
political will is absent where it matters most: at national
and district levels.51 Shiff man and colleagues52 noted
substantial progress in getting maternal health onto the
national political agenda in Nigeria and India, two
countries that contribute up to a third of all maternal
deaths worldwide. Several factors helped this progress
in Nigeria, including interest from the federal
government, the emergence of local political champions
in the national assembly, an increased health budget,
and an active civil society. Crucial barriers to successful
implementation remain, however, such as absence of
adherence to the cause at district level and of
commitment of domestic revenues, with maternal
health seen as funded mostly by donors. Further
political sensitisation is needed at local level, particularly
with local policy makers. Improvements towards safe
motherhood are not as visible to the public as a
successfully constructed road.52
Call for action
In September, 2000, 189 countries pledged to support
the MDGs. The fi fth goal demands a reduction in the
maternal mortality ratio by three-quarters between 1990
and 2015. Malaysia, Thailand, Sri Lanka, Honduras,
Bangladesh, and Egypt have all shown that to reduce
maternal mortality by 75% in 25 years is possible.2
However, in the present demographic, economic, and
political context, most African and some Asian countries
are unlikely to achieve this by 2015.
This Maternal Survival series promotes childbirth in
health facilities as the most likely strategy to prevent
maternal deaths. Prevention of the death of a mother is
the single most important intervention for the health of
a child. We acknowledge that there are trade off s,
particularly in relation to resources for health rather
than those for mortality. But to remain focused on the
MDG target, while “keeping an eye on the broad
picture” is important.53 Concerted action is needed at all
levels, from governments to the international com-
munity, health professionals to academics, individuals
to civil society, and between global initiatives. The new
Panel 4: Tracking progress in maternal health
The challenge of reliably measuring trends in maternal mortality is substantial, and
thus no simple solutions for monitoring progress towards MDG-5 are available.
Rather, all opportunities should be seized to gather data, such as decennial censuses,
indirect approaches embedded in large surveys, innovations in sampling, population
surveillance sites, and adjusted routine facility-based data. Countries should report
the maternal mortality ratio and the total number of maternal deaths. At a
minimum, mortality estimates should separate abortion from other direct obstetric
causes, and so-called coincidental causes should be identified within maternal
● Total number of maternal deaths, by cause
● Maternal mortality ratio, by cause
● Midwife to population ratio
● Availability of basic and comprehensive obstetric care facilities per
500 000 population54
● Proportion of births attended by skilled health personnel by place of delivery
● Proportion of births with caesarean section55,56
● Proportion of births with life saving surgery56,57
● Proportion of women who stayed in a health facility for 24 h or more after delivery
● Mortality rate among women of reproductive age
Progress cannot be assessed with maternal mortality alone, since policy decisions need
to build on a good understanding of the mechanisms that underlie the changes in
mortality. We have suggested indicators to track progress with the health-centre
intrapartum care strategy. Monitoring of service use by equity parameters is essential to
measure progress in care for those who need it most.
To raise awareness that data quality matters and to strengthen country capacity to
interpret, gather, and use reliable data, we propose setting-up an international
reference group to monitor and evaluate maternal-health outcomes. Such a group
would have similar roles and responsibilities to the Child Health Epidemiology
Reference Group58 and would link with specialist groups in monitoring of perinatal
outcomes. One of the first tasks of such a group could be to launch a statement to
draw attention to the importance of data quality. This statement would consist of a
checklist of considerations in reporting, such as definitions and an algorithm for
deciding appropriateness of data for specific purposes.
Panel 5: Generating evidence
New evidence is crucial if progress towards safer motherhood, and in particular MDG-5, is
to be sustained. Research is especially needed on how to train, deploy, and retain large
numbers of skilled birth attendants, fi nance maternal health services, and ensure
equitable access. A great deal has been written about maternal and neonatal deaths and
near-misses being diffi cult or impossible to record. Whenever possible, evaluation
schemes should be encouraged to use maternal mortality, near-miss events, and perinatal
or neonatal mortality as endpoints, as well as process indicators and costs. This would
help meta-analyses of the cost-eff ectiveness of innovative interventions on mortality.
www.thelancet.com Published online September 28, 2006 DOI:10.1016/S0140-6736(06)69384-7
For further information on the
Partnership in Maternal,
Newborn and Child Survival see
international Partnership in Maternal, Newborn and
Child Survival is well-positioned to spearhead a revival
of such energies and eff orts. The action we call for is
shown in panels 3–5.54–58
Too many women die in their prime in pregnancy.
What needs to be done is clear. Governments have
committed to reduction of maternal mortality; we
should not falter in our eff orts: the future depends on
what we do in the present.
Confl ict of interest statement
We declare we have no confl ict of interest.
We thank all the participants at the Maternal Survival Series review
meeting in Geneva in January, 2006, for helpful suggestions and the
Initiative for Maternal Mortality Programme Assessment Outcome After
Pregnancy group for ideas. Additional work for the series was supported
directly by the UK Department for International Development through a
grant to the London School of Hygiene and Tropical Medicine, and by the
Initiative for Maternal Mortality Programme Assessment. The funding
sources had no role in the content of, the information provided, or views
expressed in this paper.
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