Maternal Mortality: Real Progress, an Avoidable Gap

A woman dying while giving life in sub-Saharan Africa faces a lifetime risk, across her reproductive years, roughly 120 times higher than that of a woman in a high-income country. This is not a biological fact: it is a political one. The world has known for decades how to prevent almost all of these deaths, and three West African countries demonstrate it at home. The real question is therefore no longer whether the region is making progress, but why, a few hundred kilometres apart, a woman is four times more likely to survive childbirth on one side of a border than on the other.

An undeniable decline, at an insufficient pace

The progress is real. Across sub-Saharan Africa, the maternal mortality ratio fell from 727 deaths per 100,000 live births in 2000 to 442 in 2023, according to the United Nations inter-agency group (WHO, UNICEF, UNFPA, World Bank, UNDESA). Globally, the decline reaches 40 percent over the same period, from 328 to 197 deaths per 100,000 live births. This is a historic improvement, driven by the expansion of antenatal care, skilled birth attendance and vaccination campaigns.

But the pace remains structurally too slow, and it is slowing. Since 2016, the global ratio has fallen by only about 1.5 percent a year. Yet according to WHO, reaching a global ratio below 70 by 2030, the target of Sustainable Development Goal 3.1, would require an annual reduction of nearly 15 percent, a rate rarely achieved at the national level over a full decade. The gap between the required trajectory and the actual one therefore widens year after year. Meeting the target would mean accelerating the decline to nearly ten times the current pace.

The intermediate 2010 values (581 for sub-Saharan Africa, 256 for the world) are illustrative framing points placed on the trajectory published by the inter-agency group between the documented 2000 and 2023 endpoints; only those endpoints are official estimates.

Senegal shows that another trajectory is possible

To see that this lag is in no way inescapable, one need only look at a neighbour. Senegal has reduced its maternal mortality far faster than the regional average: its annual rate of reduction rose from about 3.26 percent over 2000-2017 to 4.88 percent over 2010-2017, according to the Exemplars in Global Health analysis. The country today records a ratio of 237 deaths per 100,000 live births, against 518 in Benin and 993 in Nigeria. This result did not fall from the sky: it rests on identifiable decisions, notably the national free delivery and caesarean policy (2005), which removed a decisive financial barrier to seeking care, and the national family planning plan (2012).

The lesson is twofold. First, acceleration is achievable within the same regional context, with comparable resources. Second, even Senegal, cited as an example, would still need to lift its rate of decline above 6 percent a year to meet its own 2030 target. In other words, what separates countries is not the potential for progress, but the speed at which they turn known policies into real coverage on the ground.

A geography of inequality

Behind the regional average lies a deep divide between countries. Nigeria has the highest ratio in the world, at 993 deaths per 100,000 live births in 2023, and alone accounts for about 28.8 percent of all maternal deaths worldwide, nearly 75,000 of the 260,000 recorded globally that year. Benin stands at 518 deaths per 100,000 live births. At the other end of the spectrum, Ghana (234) and Senegal (237) show that a far more favourable trajectory is possible within the same regional context. This gap of more than fourfold between neighbours is not inevitable: it reflects choices about investment, health coverage and the organisation of care.

A gap of more than fourfold between neighbouring countries is not a geographic fate; it is the reflection of investment choices.

The why: largely preventable deaths

Maternal mortality is not a medical mystery. Across sub-Saharan Africa, a systematic review of studies published between 2015 and 2020 attributes the vast majority of deaths to a handful of well-identified direct causes: obstetric haemorrhage (28.8 percent of deaths), hypertensive disorders of pregnancy such as eclampsia (22.1 percent), non-obstetric complications (18.8 percent) and pregnancy-related infections (11.5 percent). WHO estimates that globally, five major complications, including these four, account for about 75 percent of maternal deaths, and that most could be prevented.

What these causes have in common is that they kill fast, but can be treated. A postpartum haemorrhage can take a woman's life in under two hours; eclampsia can be controlled with simple, inexpensive drugs. What turns a common complication into a death is not the absence of medical knowledge, but the broken chain between the woman and care: the distance to an equipped facility, the lack of a skilled attendant at birth, the stockout of the right medicine, the cost of a caesarean. Each missing link is a system decision, not a clinical fate.

The levers for action follow directly from this breakdown:

• Haemorrhage: availability of uterotonics, accessible blood transfusion and staff trained in active management of the third stage of labour.
• Hypertension and eclampsia: antenatal blood-pressure screening, magnesium sulphate in stock and rapid referral to an operating theatre.
• Infections: aseptic delivery, available antibiotics and postpartum follow-up.
• All causes combined: a skilled health worker present at delivery and emergency obstetric care reachable within the hour.

Skilled personnel, the leading driver of the gap

The most visible determinant of the regional divide is the presence of skilled health personnel at delivery. In Niger, only about 44 percent of births are attended by a skilled worker (2021 data), and the country records 350 deaths per 100,000 live births. In Nigeria, skilled birth attendance rose to about 52 percent at the time of the 2023-24 Demographic and Health Survey, and antenatal care attendance climbed from 57 to 68 percent between 2018 and 2023: real gains, but starting from low levels and still insufficient given the country's burden.

Landlocked countries such as Mali (367) and Niger face persistent difficulties tied precisely to this low coverage and to distances. Access to emergency obstetric care, able to manage a haemorrhage or eclampsia within the hour, remains the decisive link. This is where, in concrete terms, the difference plays out between countries that progress quickly and those that stall.

The presence of skilled personnel is not, however, sufficient on its own: they still need to be equipped, supplied and connected to a referral level. A midwife without magnesium sulphate facing eclampsia, or without a way to refer quickly to an operating theatre for a caesarean, remains powerless. This is why successful countries do not simply train health workers: they build a complete chain, from the local health post to the district hospital, with an emergency transport system and reliable supply logistics. Coverage of personnel measures intent; the quality of the chain measures the result.

The cost of inaction

Inaction has a price, and it can be quantified. Beyond the human tragedy, each maternal death lastingly drains the economy: the loss of the woman's output, but also the deterioration of the prospects of her surviving children, whose risk of death and of dropping out of school rises. A study published in BMC Pregnancy and Childbirth calculated that the 147,741 maternal deaths that occurred in 2010 across 45 countries of the WHO African Region represented a non-health gross domestic product loss of about 4.5 billion international dollars (in purchasing power parity).

The same study estimates the loss per maternal death at about 139,219 international dollars in high or upper-middle-income countries, 35,440 in lower-middle-income countries and 16,397 in low-income countries, the gap reflecting differences in economic productivity between countries. These orders of magnitude, already dated and judged conservative by their authors, are enough to frame the reasoning: applied to the roughly 75,000 maternal deaths in Nigeria alone in 2023, they imply an illustrative annual economic loss running into the hundreds of millions, even billions, of dollars. Maternal mortality is not only a health issue, it is a measurable brake on growth.

The mechanism of this loss is, moreover, intergenerational. The disappearance of a mother does not only remove a worker from the economy: it deprives her surviving children of their main caregiver, raising their own risk of death, malnutrition and dropping out of school. A maternal death thus propagates across two generations, and its real cost, hard to quantify but very real, far exceeds the single year's lost output. Declining to invest in maternal health means accepting this double penalty, silent but cumulative, on the region's human capital.

Public financing, a lever with a demonstrated effect

If the gap between countries reflects choices, the first of these is budgetary. A study published in BMC Women's Health in 2024, covering seven countries of the West African Economic and Monetary Union over the period 1996-2018, establishes a negative and statistically significant association between public health spending and the maternal mortality ratio: the more the state directly funds health, the more maternal mortality falls. Conversely, health spending borne by households (out-of-pocket payment, falling on women) is associated with higher mortality.

This asymmetry carries weight for public decision-making. It validates targeted free-care policies, like the one Senegal pursued for deliveries and caesareans: shifting the cost of care from the household to the state is not welfare, it is an investment with a measurable health return. Out-of-pocket payment, by contrast, works like a tax on maternal survival, deterring the use of care at the worst possible moment.

What averages hide, and the CRAD angle

A national ratio like Benin's 518 is an average, and every average lies by omission. It adds together opposite realities: a capital with referral hospitals and rural areas where the nearest maternity ward is several hours down a dirt track. A woman's real risk does not depend on the national figure, but on where she gives birth, her income level and the season. A stable average can mask a divide that is worsening between districts. This is precisely what public decision-making cannot see if it stops at the national figure.

This is where the value of fine-grained measurement lies. For a West African decision-maker, the useful question is not "what is the country's ratio?", but "in which districts, for which women, and because of which missing link are deaths concentrated?". Answering requires data disaggregated by district, by income level and by cause, geolocated on the health map and linked to the actual supply of care. This is CRAD's work: turning a comparable national statistic into an operational map that says where to place the next maternity ward, the next ambulance, the next stock of magnesium sulphate. An average measures the problem; disaggregated data directs the spending.

A national average measures the problem. Only data disaggregated by district says where to place the next maternity ward and the next ambulance.

A gender injustice above all

No other health statistic weighs so heavily on a single sex. The risk that a woman will die of a maternal cause during her reproductive life is about 1 in 66 in low-income countries, against 1 in 7,933 in high-income countries, according to WHO. This gap of more than a hundredfold sums up a global inequality that plays out exclusively on women's bodies, and overwhelmingly on those of poor and rural women in sub-Saharan Africa.

Reducing maternal mortality is therefore not only a public health objective: it is one of the most direct markers of equity between the sexes and between territories. The policies that drive it down, access to care, women's financial autonomy, family planning, are also policies of empowerment. To measure precisely where women die is to document where gender inequality kills most, and therefore where to correct it first.

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