Ending preventable maternal deaths: the time is now
Authors: Flavia Bustreo, Lale Say, Marge Koblinsky, Thomas W Pullum, Marleen Temmerman, Ariel Pablos-Méndez
Journal: The Lancet Global Health (2013)

Between 1990 and 2010, maternal mortality decreased globally by nearly 50%, from 543 000 maternal deaths per year to 287 000,1WHOUNICEFUNFPAthe World BankTrends in maternal mortality 1990 to 2010. World Health Organization, Geneva2012Google Scholar with the greatest reductions in the second half of this period. A major catalyst for this progress was the target set by Millennium Development Goal 5: reduction of the maternal mortality ratio by 75% between 1990 and 2015. Later, a second target on reproductive health was added, which has undoubtedly contributed to accelerated progress. In tandem, countries and the international community enhanced their commitment to support, develop, and implement effective interventions to improve the health of women, especially during pregnancy and childbirth, and post-partum. As 2015 approaches, attention turns to what has been achieved—and what lies ahead for the global development goals, including those for maternal and child health.2Langer A Horton R Chalamilla G A manifesto for maternal health post-2015.Lancet. 2013; 381: 601-602Summary Full Text Full Text PDF PubMed Scopus (32) Google Scholar In 2012, encouraged by the substantial reduction in mortality for children younger than 5 years, the global community (spearheaded by the governments of Ethiopia, India, and the USA, in collaboration with UNICEF, WHO, and other partners) put forward a vision of ending preventable child deaths.3UNICEFState of the world's children. United Nations International Children's Emergency Fund, New York, NY2012Google Scholar, 4Glass RI Guttmacher AE Black RE Ending preventable child death in a generation.JAMA. 2012; 308: 141-142Crossref PubMed Scopus (26) Google Scholar As a benchmark of this vision, a target for post-2015 was proposed. The target that "all countries should achieve a national under-5 mortality rate (U5MR) of below 20 deaths per 1000 live births by 2035, and the global average U5MR should decline to 15 deaths per 1000 in 2035" was ambitious but achievable, according to analyses and modelling of the potential effect of interventions to reduce child mortality.4Glass RI Guttmacher AE Black RE Ending preventable child death in a generation.JAMA. 2012; 308: 141-142Crossref PubMed Scopus (26) Google Scholar, 5Winfrey W McKinnon R Stover J Methods used in the Lives Saved Tool (LIST).BMC Public Health. 2011; 11: S32Crossref PubMed Scopus (59) Google Scholar As countries and international platforms engage in post-2015 planning, now is the time to envision the ending of preventable maternal deaths, as stressed in a recent manifesto for maternal health.2Langer A Horton R Chalamilla G A manifesto for maternal health post-2015.Lancet. 2013; 381: 601-602Summary Full Text Full Text PDF PubMed Scopus (32) Google Scholar The global health community should build on past successes, and accelerate progress towards elimination of all preventable maternal mortality within a specified period. WHO, the US Government, and many others have started processes to define a new vision for maternal health, including discussion of potential targets. The initial technical discussions convened by WHO as part of this process, with country-level programme managers, scientists, professional organisations, donors, and other partner agencies, resulted in proposals to take forward a bold vision of ending preventable maternal deaths, around which the international community can rally. The analyses done as a background to the discussions show the feasibility of this vision. An ambitious but realistic global target is to reduce maternal mortality ratios to less than 50 per 100 000 livebirths by 2035. Dependent on which target year is selected, this would translate to a maternal mortality ratio of less than 90 by 2025, or 70 by 2030 (figure). In view of the accumulated experience of the global health community, with many countries achieving rapid reductions in maternal mortality in recent years, we believe that this target can be reached worldwide. Additionally, we propose a new method to measure and track progress in every country, based on achievement of defined milestone values according to initial maternal mortality ratios. This method would help to focus planning for maternal survival. For all countries with estimated maternal mortality ratios of less than 400 in 2010, the goal would be a steady progression past a series of 5 year milestones to reach the global target. The expectation that every country would cross one milestone within every 5 year interval will provide a method to measure each country's progress, and will also contribute to global progress. The 5 year milestones for countries with high initial maternal mortality ratios (>400) would be individually designed and tracked. Countries with an estimated maternal mortality ratio of less than 100 would be expected to move to lower values according to defined milestones, but with a focus on internal subpopulations whose maternal mortality is higher than the national rate. New strategies to help to achieve rapid reductions in maternal mortality are needed. They need to be innovative and dynamic, with the aim to reach equity between and within countries. Targeted interventions should be implemented at scale, to address causes and conditions contributing to maternal deaths that vary across countries. Collection of data about the causes and conditions of every maternal death—eg, through maternal death surveillance and response—is a necessary first step. Improved information enables development of strategies to respond to needs, and to address both clinical and distal causes of deaths, and will allow for targeted monitoring, accountability, and action. Strategies can be adapted to specific local causes, whether they are directly related to maternal mortality (eg, haemorrhage, pre-eclampsia or eclampsia, sepsis, or unsafe abortion) or indirectly related (eg, HIV, malaria, tuberculosis, anaemia, or non-communicable diseases). Strategies to implement targeted interventions to reduce maternal mortality need to address more than the clinical causes of death—they should respond to changing demographics, meet the specific needs of women for reproductive health, and address contextual features such as challenges caused by changes in health-care systems. These challenges include financial incentives, the effects of decentralisation, the role of the private sector, and urbanisation. Universal access to high-quality health services, including family planning and information and services for reproductive health (especially for vulnerable and at-risk populations), should be put at the centre of efforts to achieve the vision of ending maternal deaths. To accelerate and sustain the gains already achieved, international and national commitments are needed, such as those made in response to the UN Secretary General's Every Woman Every Child report. Additionally, national-level processes to sharpen strategies for improvement of health and development beyond 2015 have already started in many countries. Ending of preventable maternal death is not a dream. Mahmoud Fathalla, past president of the International Federation of Obstetricians and Gynaecologists and former Chair of the WHO Advisory Committee on Health Research, said: "Women are not dying because of untreatable diseases. They are dying because societies have yet to make the decision that their lives are worth saving."6Fathalla MF Human rights aspects of safe motherhood.Clin Obstet Gynecol. 2006; 20: 409-419Scopus (38) Google Scholar Momentum to value women's lives is growing—let us strengthen it. We declare that we have no conflicts of interest. The views expressed here are those of the authors themselves and they do not necessarily represent the views of WHO or other organisations. © 2013 World Health Organization; licensee Elsevier. This is an Open Access article published without any waiver of WHO's privileges and immunities under international law, convention, or agreement. This article should not be reproduced for use in association with the promotion of commercial products, services or any legal entity. There should be no suggestion that WHO endorses any specific organisation or products. The use of the WHO logo is not permitted. 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