The leading cause of death for women in developing countries is preventable.

Although 88 to 98 percent of maternal deaths are preventable,¹ pregnancy remains the leading killer of women in their reproductive years in developing countries.² More than half a million women—typically women who are poor, uneducated and living in rural areas or urban slums—continue to die every year during pregnancy and childbirth. Ninety-nine percent of these deaths take place in developing countries.³ This is despite 20 years of global campaigning to reduce maternal mortality. Indeed, goal 5 of the MDGs "Improve maternal health" has as one of its targets the reduction of the maternal mortality ratio by three-quarters between 1990 and 2015. For every woman who dies, as many as 30 others suffer chronic illness or disability.^{4 5} The burden of maternal mortality is greatest in sub-Saharan Africa and South Asia.

Levels of maternal mortality are indicative of the social injustices between rich and poor people, urban and rural areas, and men and women, and not only of the quality of a functioning health care system. Inadequate access to maternity care is only one of the causes of maternal mortality. Other indirect causes include poverty and gender inequity.

Maternal mortality—especially the lifetime risk of dying in pregnancy or childbirth—shows the largest gap between the rich and poor of all public health/development statistics. Many of the poorest women, or those with least access to safe delivery or family planning services, have high fertility and are at high obstetric risk of death from pregnancy or childbirth. Rural populations and the poor are at highest risk in general, as they cannot afford or reach the services they need. Men and women residing in rural and remote areas can neither be assured that a health outlet is reachable nor that when one is reached it will contain the needed health supplies and services. In Ethiopia, 90 to 95 percent of women deliver at home and are two hours or more away from a health facility. In Peru, maternal mortality among the poorest women is six times higher than among the richest.⁶

The most common cause of maternal death is bleeding, which can kill even a healthy woman within two hours if unattended. Sepsis and unsafe abortion are the second and third most frequent causes of death.¹² Access to timely and competent care is the key to saving the life of a hemorrhaging woman; approximately 45 percent of postpartum maternal deaths occur during the first 24 hours after birth, and more than two-thirds during the first week. Therefore, proper delivery care—where women deliver, who attends them and what emergency measures are available—is critical to the survival of mothers and babies.¹³ Half of the deaths caused by hemorrhage occur in sub-Saharan Africa, and one-third of them occur in South Asia, where quality delivery care is largely unavailable in most rural areas.

Because each pregnancy has an inherent obstetric risk, high fertility increases a woman's cumulative lifetime risk of death from pregnancy and childbirth. Lifetime risk of maternal death is over 250 times higher in the least developed countries than in developed countries. The projected decrease in the number of births in India between 1990 and 2015 is estimated to yield a 9 percent decrease in maternal mortality. In sub-Saharan Africa, however, the projected increase in the number of births will burden already overextended maternity services and contribute to increased maternal mortality.¹⁴

Voluntary family planning can reduce the number of maternal deaths by reducing unwanted pregnancies and preventing recourse to often-unsafe abortion. In developing countries, 41 percent of all pregnancies are unintended, and 26 percent of all births are unintended.¹⁵ In these countries, 35 percent of maternal deaths result from unintended pregnancies, and 13 percent of maternal deaths are attributed to induced abortion. One study found that if unwanted pregnancies were prevented, between a quarter and two-fifths of maternal deaths could be eliminated.¹⁶

Children whose mothers die may have three to 10 times' higher risk of dying than those with living parents.¹⁷ Nearly three-quarters of all infant deaths could be prevented if women were adequately nourished and received appropriate care during pregnancy, childbirth and the postnatal period.¹⁸ Each year, nearly 3.3 million babies are stillborn, and more than 4 million others die within 28 days of being born. The largest numbers of babies die in South-East Asia; 1.4 million newborn deaths and an additional 1.3 million stillbirths occur each year. While the actual number of deaths is highest in Asia, the rates for both neonatal deaths and stillbirths are greatest in sub-Saharan Africa. One in five African women loses a baby during her lifetime, compared with one in 25 in rich countries.

Every day, 1,800 children, most of them newborn, become infected with HIV. HIV makes these children more vulnerable to other childhood diseases, less responsive to drugs that treat these diseases, and more likely to die from these diseases than HIV-negative children. Without antiretroviral therapy, 45 percent of HIV-infected children die before the age of 2.¹⁹ While the prevention of mother-to-child transmission (PMTCT) of HIV has gained more attention recently, in high-prevalence countries most pregnant women do not have access to HIV testing.

Some countries, including low-income countries, have successfully reduced maternal mortality. Some of these countries are Romania, Thailand, Malaysia, Sri Lanka, Egypt and Honduras. Their successes stem from a number of factors, including increasing access to hospital and midwifery care, improving quality of care and referrals through training, and controlling infectious diseases.²⁰ They also invested in making health care available to most of their people by building on and improving already existing service delivery models, networks of health centers and outposts, health care infrastructure, and health care personnel (See Box on Sri Lanka). All this leads to more timely access to quality services, to better knowledge on how to use these services and, consequently, to reduction in maternal mortality.