Maternal mortality: Pregnancy is 'shockingly dangerous'

Pregnancy means new life to most of us — and a unique experience every time, bringing your baby into this world. But in all too many cases, pregnancy also means the end of a life.

In late February 2023, the United Nations released a new report on maternal mortality around the world. The report described how one woman dies every two minutes due to child birthor complications experienced in pregnancy.

"Pregnancy is tragically still a shockingly dangerous experience for millions around the world," said Tedros Adhanom Ghebreyesus, director-general of the World Health Organization (WHO).

In the year 2000, the global maternal mortality rate (MMR) stood at 339. That means that 339 pregnant people of child-bearing age died per 100,000 live births.

In 2020, the global MMR was 223.

But according to the UN report, most countries around the globe have failed to lower their maternal mortality rate (MMR) significantly in that 20-year period.

The UN report says there had been a small decrease between the years 2000 and 2015, but that since 2016 the global maternal mortality rate has stagnated. And that is unacceptable, said Jenny Cresswell, a scientist at the WHO and co-author of the report.

"Stagnation is absolutely not good enough," Cresswell told DW. "The Sustainable Development Goal [SDG] target is to reduce the global maternal mortality ratio to less than 70 maternal deaths per 100,000 live births by 2030. We are currently far off-track to meet this target."

The US: An increasing maternal mortality rate

In some countries, including developed ones like the US, the maternal mortality rate has been rising for years.

At more than 23, the US has by far the highest MMR of all industrialized countries. The rate increased by roughly 78% between 2000 and 2020.

With low total numbers, even minor changes make for a high increase in the percentage of a number. But that doesn't change the fact that the number of pregnant people who die during pregnancy, childbirth or shortly thereafter, has been rising for decades in one of the richest countries in the world.

What is going wrong in the US?

It is not easy to explain why the MMR is going up in the US said Munira Gunja, a senior researcher with the Commonwealth Fund, a foundation that supports independent research on health care issues in the US.

Gunja said that a number of factors may be contributing to the situation, including "a lot of underlying health conditions [that] have been on the rise for years now."

Then there is the fact that many Americans do not have health insurance and can not afford to visit their doctor. The cost of health services has gone up as well. And there is a shortage of midwives who can help people through their pregnancies. 

"The rate at which people in the US skip [medical] care is dramatically higher compared to other developed countries," Gunja said. It all comes together to contribute to "this unacceptable maternal mortality rate," Gunja said.

But that is not all. The MMR among Black Americans is about three times higher than among white Americans.

That stark difference is due to "structural racism," Gunja said. "[Black Americans] are at a disadvantage from the start: Where they live, their education level, their jobs and salary. And when they see a doctor, they are often faced with direct racism."

Changing health care on multiple levels

Gunja said it would make a big difference already if there were more active midwives in the US. Midwives can build a close relationship with the pregnant person, take care of them at home and check in during the post-partum period, too ― which is when half of all maternal deaths in the US occur.

But things may also need to change on clinical and on policy levels.

On the clinical level, healthcare professionals need to spot the warning signs right before, during and after a baby is delivered, said Usha Ranji, associate director for women's health policy at the Kaiser Family Foundation, a nonprofit organization focusing on health issues in the US.

"Some of the factors contributing to maternal deaths were hemorrhaging during and after delivery as well as sepsis [blood poisoning], eclampsia and pre-eclampsia [seizures during childbirth]," said Ranji.

When these things go unnoticed, they can be deadly.

Ranji said training among doctors and nurses was improving, those who worked in labor and delivery, and that there was "a lot more emphasis on listening and better communication with the patients."

On the policy level, Ranji said it is crucial to get everyone on health insurance because 10% of women of childbearing age are still uninsured in the US and, as a result, less likely to seek and receive the medical care they need.

"It's important to get people into care well before they're pregnant," to make sure they're in overall good health, Ranji said. "But it's hard to get into care when you don't have health insurance."

India: On the way to a success story

The UN report says South Asia is one of the few world regions where the maternal mortality rate is decreasing. And India has seen the biggest improvement in its MMR.

Maternal mortality fell in India by more than 73% between the years 2000 and 2020. 

In 2020, India's MMR was at 103 nationwide. That is still a lot higher than the MMR in the US. But while maternal mortality in the US increased at an annual rate of 2.88% from 2000 to 2020, it fell at an annual rate of 6.64% in India during the same time period.

Rajib Dasgupta, a professor at the Centre of Social Medicine and Community Health at Jawaharlal Nehru University in New Delhi, said India had started to see the benefits of a more liberalized and growing economy in the past two decades.

"There has been an overall decline in absolute poverty, a sustained increase in key determinants such as women's education and income, and a growing infrastructure," said Dasgupta.

These social factors all contribute significantly to improving maternal health and preventing deaths during and after pregnancy, according to the UN report.

Countries in South Asia that have seen their MMR decrease over the past 20 years "have made good progress in terms of economic development, increasing female education and other important areas that all play a role," Cresswell told DW. "They have demonstrated sustained political commitment to increasing women’s access to quality maternity services."

Tackling the disparity between Indian states

But the experts say India needs more political commitment to spread these improvements across the country.

"To make it to the SDG target [a maternal mortality rate below 70], the inequity between the Indian states should receive more attention," Dasgupta said.

A number of Indian states have achieved the SDG target.

At 19, the state of Kerala does not only have the lowest rate in India, but also a lower MMR than the United States, for example.

At the other end of the spectrum is the state of Assam, with a maternal mortality rate of 195, more than 10 times higher than Kerala's MMR.

But even in Assam things are moving in the right direction. Down to Earth, an Indian magazine on environmental and development policy, reported at the end of 2022 that Assam's MMR was 237 between 2014 and 2016. That shows a drop of more than 40 deaths in pregnancy per 100,000 live births.

India is on the right path, said Dasgupta — it has invested in medical infrastructure and increased the number of medical personnel across the country and now "it is the time to build upon this strength."     

Editor's note: This article was originally published on March 27, 2023. Wording was changed to make it clear that Kerala's MMR is among the lowest in India.

Edited by: Zulfikar Abbany