Around 210 million women become pregnant annually, meaning that maternal health is not a marginal issue.1, 2 Maternal health is key to sustainable development and to future generations. Poor maternal health as measured by mortality and morbidity, however, remains an issue for marginalised women—those women who are vulnerable by virtue of where they live or who they are. As the world moves from Millennium Development Goals (MDGs) to Sustainable Development Goals (SDGs), patchy progress across regions and countries has been achieved in the reduction of maternal mortality. High mortality continues in some populations, presenting a major challenge to one of the strategic cornerstones of the SDG agenda—reducing inequities—“leaving no one behind”.3 In 1876, William Farr commented on maternal death as “A deep, dark continuous stream of mortality” and asked “how long is this sacrifice to continue?”.4 Drastic reductions in maternal mortality—ending the sacrifice to which William Farr refers—are realistic, and have already been achieved in some countries and for some women. The challenge to replicate this success for all populations by 2030 is complex but not insurmountable. In this Series paper, we examine two important contributors to the challenge: first, the increasing diversity in the magnitude and causes of maternal mortality and morbidity and, second, the widening inequities or divergence in these key indicators, between countries and within populations. This diversity and divergence emphasises the dynamic nature of the burden of maternal mortality and morbidity and hence the key need for dynamic health systems. We aim to use the best available evidence to further illuminate the changing burden and so provide insights for the new strategic frameworks for action in the SDG era.5, 6
Key messages
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Pregnancy and childbirth affects the lives of millions of women and families worldwide each year. At this scale, sustainable development goal (SDG) 3 will not be achieved without reducing the burden of poor maternal health in all populations.
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Progress has been made in reducing maternal mortality globally, but this is patchy at regional and national levels—the hard-won gains over the last 25 years in some countries are susceptible to slow down.
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The causes of maternal mortality and morbidity are increasingly diverse, including a shift in the contribution of non-communicable diseases, reflecting large-scale demographic, epidemiological, socioeconomic, and environmental transitions.
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This diversity of burden has major implications for the crucial policy and programmatic goal of matching needs with care. Diverse maternal health needs require diverse maternity services, within the framework of universal health coverage.
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At the dawn of the SDG era, the distribution of poor maternal health is highly inequitable between and within populations; the gap between the group of countries with the lowest and highest maternal mortality increased from around 100 times to 200 times difference between 1990 and 2013.
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The highest burden of maternal mortality and severe morbidity clusters where health systems are weakest and where the broader context is challenging, such as in fragile states.
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In all countries, the burden falls disproportionately on the most vulnerable groups of women. This reality presents a challenge both to the rapid catch-up required to achieve grand convergence and to the underlying aim of the SDGs—“to leave no one behind”.
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Reliable population-based data on poor maternal health, disaggregated by key indicators of vulnerability, are essential to monitor widening inequities, and to inform innovative policies and programmes to halt this divergence and to manage the increasing diversity of burden..
This paper is the first in the 2016 Lancet Series on maternal health. It focuses on creating the overall picture and thus relies heavily on aggregate evidence, which enables large-scale regional and international comparisons. Both the United Nations' Maternal Mortality Estimation Inter-agency Group (MMEIG)7 and the Global Burden of Disease (GBD)8 study estimated maternal health parameters at global, regional, and national levels, and used different but overlapping data inputs, data adjustments, and modelling methods. In this Series paper, we did not aim to compare and cross-validate different estimates, something that other papers have undertaken.9, 10, 11 Instead, we pluralistically use both UN and GBD sources, drawing on each depending on the degree of temporal or regional specificity the sources provide, along with other data to produce the most appropriately disaggregated statement of the burden of poor maternal health. We acknowledge that useful insights can also be obtained from large-scale studies and datasets from individual countries. Our focus, however, is on lessons across major world regions, and specifically for low-income and middle-income countries (LMICs) where levels of fertility (the primary exposure) and maternal death (the most adverse outcome of pregnancy-related health problems) are highest. This macro-level focus is inevitably limited by the availability of relevant data. We used three main approaches to creatively fill the gaps: our own review of systematic reviews12, 13 on a broad range of the morbidities identified by WHO;14, 15 a structured review of papers with international comparative analyses and grey literature published since 2005; and secondary analyses of large-scale international data series available in the public domain.