Health complications and mortality risk from childbirth has been a tragic but not uncommon event for mothers throughout history.
The chart below shows the decline of maternal mortality in recent centuries. Going back to the 19th century and looking at countries that have the best health today we see that about 500 to 1,000 mothers died for every 100,000 births. Every 100th to 200th birth led to the mother’s death.
Since women gave birth much more often than today the death of the mother was a tragic but not uncommon tragedy. This changed over the last century and today most rich countries have a maternal mortality ratio below 10 deaths per 100,000 births – the countries with the lowest maternal mortality reached a level of around 1% of the death rate in the 19th century.
The countries that achieved the lowest maternal mortality ratio are Finland, Greece, Iceland, and Poland. For every 100,000 births, 3 mothers die.
The 100-fold decline of maternal mortality is due to the modern scientific understanding of the cause of maternal mortality and the adoption of practices which appear surprisingly simple in hindsight. The common reason for the mother to die was puerperal fever (or childbed fever) which was caused by unhygienic medical staff and medical equipment by which the mother’s genital tract is infected during childbirth.
It was the physician Ignaz Semmelweis who first noticed the link between hygiene and the survival of mothers in the middle of the 19th century. He urged his colleagues to wash their hands with chlorinated lime solutions but was ignored. The germ theory of disease was not yet known and therefore he could not explain why there should be a link between hygiene and the survival of women during childbirth. The rejection by the medical community of the time turned Semmelweis bitter and every conversation he had revolved around childbed fever. He was eventually committed to an mental asylum where he died a miserable death. He was never to see how right he was and never knew how many mother’s lives he saved!
After Semmelweis’ death, when Louis Pasteur developed the germ theory of diseases, the recommendations of Semmelweis were finally adopted and maternal mortality started to decrease. A procedure as simple as the doctor washing his hands meant that puerperal fever – a killer of thousands of mothers – declined sharply. We see the decline in Finland over the course of the 2nd half of the 19th century. In the 20th century the availability of antibiotics made it possible to treat cases of puerperal fever and the death of a mother is today fortunately very rare. As it is often the case we see that it is much harder for a pioneer to make advancements than for a country that catches up later. The decline of maternal mortality in Finland began in the middle of the 19th century and didn’t reach today’s low level more than a century later. Malaysia in contrast achieved this progress in only a few decades.
Maternal mortality has fallen globally, and for some countries there has been a dramatic decline. But is this true for all countries? Is maternal mortality falling everywhere?
The visualization below compares the maternal mortality ratio in 1990 and one generation later, in 2016. The grey line shows where countries would fall in which the rate remained unchanged. Here we see that almost all countries lie above this line: that is, the maternal mortality rate in 1990 was higher than in 2016. For the majority of countries in the world the maternal mortality rate has fallen over the past generation.
There are, however, a few countries where a young women today is more likely to die in childbirth than her mother was a generation ago: the United States, Serbia, Georgia, Saint Lucia, the Bahamas, North Korea, Jamaica, Tonga, Venezuela, South Africa, Suriname, Guyana and Zimbabwe.
The risk of women dying during child birth has declined around the world. But how do rates across the world compare today?
In the visualization below you see the maternal mortality ratio across the world. Here we see a large variation: the lowest countries have rates of 3 mothers per 100,000 live births; the other end of the spectrum is more than 100 times higher at over 500 per 100,000 live births.
In 1990 more than half a million women died of causes related to child birth. Since then the number of deaths has declined – reaching just over 300,000 in 2015. Two-thirds of all maternal deaths in 2015 were in Sub-Saharan Africa.
How many maternal deaths occur in each country?
In the chart below we see the global map of maternal deaths. Here you can use the timeline to see how deaths have changed from 1990 through to 2015 for any country.
An important factor in a safe delivery for both the mother and baby is good advice, care and supervision by trained medical staff. But not all births are attended by skilled personnel to do so.
In the first chart below we see the relationship between the maternal mortality rate and the share of births which are attended by skilled health staff. Here we see a strong cluster in the bottom-right corner: this means where the maternal mortality rate is low, almost all births are attended by skilled personnel. But we also see countries with much lower staff coverage: in Chad, for example, only every 5th pregnancy was delivered with trained staff. For countries where health staff coverage was lower, we see that typically maternal mortality was much more likely.
In the second chart below we see global coverage of the share of births which are attended by skilled health staff. Again, we see that for most countries this is close to 100%. But there are still some countries where healthcare access is very low.
As countries get richer, does the maternal mortality rate fall?
In the chart below we see the relationship between the maternal mortality ratio and average income across the world. Overall we see a strong correlation: the maternal mortality rate is lower in countries with higher incomes. But not every country that achieved economic growth also achieved a reduction of maternal mortality. The large spread of countries at a given level of income makes clear that not only income is important: clearly there are other differences – such as healthcare and nutrition – which also drive a decline.
For Kenya Evans and Miguel (2007)1 estimated that school participation falls by 5.5 percentage points immediately following the death of a parent. This decrease appears to be driven by the death of the mother: the post-death decrease in school participation to be 9.3 percentage points and the pre-death decrease to be 6.5 percentage points.
Beegle and Adhvaryu (2012)2 find that in Tanzania, children who lose a mother before turning 15, on average, complete one less year of schooling than other children.
Gourlay et al (2014)3 find that in Zimbabwe, female double-orphans (girls that have lost both parents) are 13 percentage points less likely to be enrolled in school than non-orphans.
There are two metrics of maternal mortality that are commonly used:4
- The Maternal Mortality Ratio (MMRatio) refers to the ratio of the number of maternal deaths to the number of births in the same period.
- The Maternal Mortality Rate (MMRate) on the other hand refers to the number of maternal deaths in a period to the number of person years lived by women of reproductive age (normally 15 to 49) in the same period.
According to the report the data comes from several sources. In the best cases data from the civil registration systems were used directly to calculate the estimates of maternal mortality rates (MMRs). When these data were not available two-part multi-level regression model were used to estimate MMRs for all target years. The three selected predictor variables in the regression model are: GDP, the general fertility rate (GFR) and the proportion of skilled attendants at birth.
- Data: Maternal mortality ratio (per 100,000 live births)
- Geographical coverage: Global – by country
- Time span: Mostly the last decades but historical time series are available for the following countries: Australia (since 1871), Belgium (since 1851), Denmark (1921-1949 & since 1970), Finland (since 1751), Germany (since 1952), Ireland (since 1871), Japan (since 1935), Malaysia (since 1933), The Netherlands (since 1867), New Zealand (since 1972), Sri Lanka (since 1900), Sweden (since 1751), United Kingdom (since 1847), United States (since 1900) – this data is visualized above in this data entry.
- Available at: Online at Gapminder.org.
- The various original sources of this data are documented by Gapminder here.
- Gapminder also includes data on 'Births attended by skilled staff'.
World Development Indicators (WDI) – World Bank
- Data: Maternal mortality ratio (modeled estimate, per 100,000 live births)'
- Geographical coverage: Global – by country and world region.
- Time span: Since 1990 – observations every 5 years for almost all countries.
- Available at: Online here.
- Related data in the WDI is available on 'Pregnant women receiving prenatal care (%)' and 'Births attended by skilled health staff (% of total)'.