Maternal morbidity & mortality perpetuates gender inequality & ill-health cycles across generations Print E-mail

 2007; 370:1347-1357

Women deliver for development

Kirrin Gill MS a,   Rohini Pande ScD b  and   Anju Malhotra PhD a

There is a large amount of research into maternal health as a health issue, but maternal health as a development issue has been less explored. This Review analyses the evidence from the past 20 years on the links between maternal health and development to examine maternal health within a development framework. We note that although existing evidence suggests that these links are strong, further research is needed to definitively substantiate how and to what extent maternal health and development affect each other. Further, we find that progress and investment in maternal health have lagged far behind estimates of what is needed to achieve the Millennium Development Goals.

The reproductive years for women are of central importance to their lives, their families and communities, and the next generation. During these years women not only bear and raise children, but are active members of society in many ways­as workers, leaders, and key actors in social change and development­and have the greatest potential to deliver not only for their own lives, but also for broader development. Since childbearing is a key part of the lives of most women in developing countries, maternal health probably has an important effect on their ability to fulfil this potential. However, although much public-health research has examined maternal health itself, there has been less focus on the assessment of evidence about how maternal health may interact with economic and social development at family (micro) and national (macro) levels. The Millennium Development Goals (MDGs) have identified maternal health as a key development outcome, and thus assessment of the importance of improving maternal health as a development goal is essential.

Key findings

•Progress in maternal health has been uneven, inequitable, and unsatisfactory, but successes in several countries show that change is possible

•Women's status and empowerment, in spheres such as education, employment, decision making, intimate partner violence, and reproductive health, affect their maternal health including access to and use of services during pregnancy and childbirth

•Maternal health has profound effects on neonatal and child survival and morbidity and grave implications for the long term wellbeing of children­particularly girls ­through its effect on their education, growth, and care

•Maternal death and illness is costly for families because of high direct health costs, loss of income, loss of other economic contributions, disturbed family relationships, and social stresses

•Maternal health affects economic productivity and overall health service delivery

•The investment needed for improved maternal health is a minor fraction of global spending and makes financial sense since maternal health interventions are cost effective

We examine the evidence so far on the links between maternal health and three of the several important aspects of development: women's own status and empowerment; economic and social development at the family level; and economic and social development at a national level. Studies up until now have tended to focus on specific aspects of development, and few, if any, have specifically examined the links between maternal health and several outcomes of women's status and empowerment. Our Review addresses these gaps and examines many aspects of development together to provide a holistic analysis.

Figure 1 shows our framework. As most research up until now has shown, maternal health most directly affects a woman's own health and survival and that of her newborn child. However, maternal health is linked to women's lives not only as a health issue. A woman's maternal health is affected by, and could influence, her status and empowerment as an individual. As a member of a family, maternal health affects the health and education of a woman's children and the finances and welfare of her household, whereas in her role in a community, maternal health affects a woman's and her nation's productivity. This framework shows how maternal health is not only central to women's potential, but also has telescopic, ripple effects for broader development concerns facing the world nowadays. We assess the empirical evidence for this notion. We first examine the situation for women as mothers and review progress in maternal health in recent decades.
Figure 1. Key links of maternal health and development

Women as mothers: progress in maternal health over the past 20 years
Status of maternal and neonatal health
Every year, more than half a million maternal deaths occur worldwide. Further, the ratio of maternal deaths to live births (the maternal mortality ratio) has remained unchanged over the past two to three decades. There are large regional variations­eg, a woman in Sweden has only a one in 29 800 risk of death related to pregnancy and childbirth in her lifetime, whereas the risk for a woman in Sierra Leone is one in six.1 Difficulties with method and measurement make cross-country and cross-time comparisons tenuous, except for estimates for 1990 and 2005, which have been calculated with the same method by Hill and colleagues.2 Still, the data overall do show some broad patterns. The first is that maternal mortality varies greatly between regions in the world (table 1).1–4 Revised estimates for 1990 and new estimates for 2005 suggest that in those parts of the world where maternal mortality was high in 1990 there is still a long way to go to reach acceptable maternal mortality ratios.2 Levels in sub-Saharan Africa are virtually unchanged between these two time periods. In south Asia, between 1990 and 2005 maternal mortality more than halved, but is still the highest maternal mortality ratio outside of Africa. In contrast, countries in southeast and southwest Asia have successfully reduced maternal mortality ratios to a half of that in the early 1980s. Thus, the greatest challenge is to address the high maternal mortality in sub-Saharan Africa and southern Asia.
Table 1. Maternal mortality ratios,* 1983–2005

The scarce historical data and issues with methods make comparisons across time very difficult for neonatal mortality. Nonetheless, neonatal mortality remains an important concern. Between 1980 and 2000, although child mortality after the first month of life fell by a third, neonatal mortality rates fell only by about a quarter. Thus, whereas in 1980, 23% of child deaths occurred in the first week of life, by 2000 this figure rose to an estimated 28%.5 Like maternal mortality, most neonatal deaths and stillbirths happen in west Africa and south-central Asia,6 since disorders that cause these deaths are often the same as those that result in maternal morbidity and mortality7­eg, obstetric complications8–11 and inadequate care during pregnancy, delivery, or in the immediate postpartum period.12 As with maternal mortality, most stillbirths and deaths to newborns and infants are preventable.8,10–13

Maternal morbidity is also a serious problem in developing countries, but research is scarce compared with analyses of maternal mortality. Estimates are poor but suggest that 10–20 million women have physical or mental disabilities every year because of complications of birth or its management.14,15 One in four women is estimated to have acute or chronic symptoms related to pregnancy.16 4–8% of women who deliver in hospitals have severe acute maternal morbidity or severe obstetric complications (so-called near miss).17 The morbidity associated with births without a skilled attendant­which consist of almost 50% of births in developing countries­can be much higher than this finding.18 However, further research is needed to improve understanding of the nature, extent, and consequences of maternal morbidity in various regions of the developing world.

Use of maternal-health services and inequities in access
Why has maternal mortality not improved in many developing regions? At least part of the reason is uneven and inequitable improvement in the use of maternal-health services. Furthermore, the low status and empowerment of women affects their access to and use of these services.

The largest increase in the use of maternal-health services between 1990 and 2000 has been in antenatal care (table 2),19 with an average increase of more than 20% across all regions of the world.20 The increase was especially large in Asia, where service use rose by 31%. However, women in Asia continue to have the lowest levels of antenatal-care use in the developing world. By contrast, although the increase was only 4% in sub-Saharan Africa, almost three-quarters of pregnant women were using antenatal care by 2000.20 However, the high level of maternal mortality accompanying these high levels of antenatal care in Africa suggest that there are difficulties with quality of care, such as the absence of adequately trained staff, which emphasises the importance of such quality and institutional factors in lowering maternal mortality.

Table 2. Antenatal care use, 1990–2000

The proportion of births attended by skilled health care personnel also rose in all regions of the developing world between 1990 and 2004, although this increase was uneven.21 The use of skilled birth attendants increased by almost 80% in southeastern Asia and northern Africa, but more than half the women in sub-Saharan Africa and two-thirds in south Asia still deliver their children without a skilled attendant.22 Since almost half the world's maternal deaths occur in these two regions, the low rates of skilled attendance have serious implications for maternal health.23

Furthermore, postpartum care has not improved much. Most deaths to mothers and newborn children occur in the postpartum period, with 45% of maternal deaths and 25–45% of newborn deaths occurring within 1 day of delivery.18,24 Yet, coverage for at least one postnatal visit is on average less than 30%, and as low as 5% in some developing countries.25

There are also strong inequalities in the distribution of services for maternal health. The poorest women in the poorest regions of the world have the lowest service coverage.21,26,27 A study in over 50 countries (figure 2)20 showed that on average more than 80% of births were attended for the richest women, compared with only 34% for the poorest women. This gap between the rich and poor is large in all regions of the world, except Europe and central Asia, and is especially wide in South Asia.20
Figure 2. Attended delivery by a medically trained person in poorest and richest quintile (1990–2005)

Despite this severe situation, there are success stories when poor maternal health has been substantially improved. Egypt, Honduras (panel 1),28,29 Malaysia, Sri Lanka (panel 2),30 Thailand, and parts of Bangladesh have all halved their maternal mortality ratios over the past few decades.26 These successes underscore the importance of effective health inputs to improving maternal health31 and suggest that MDG5, which calls for a 75% reduction in the maternal mortality ratio between 1990 and 2015, is achievable.26,32

Panel 1: Prioritisation of maternal health in Honduras28,29

The maternal mortality ratio in Honduras in 1990 was as high as 182 per 100 000 livebirths, and it was reduced to 108 per 100 000 livebirths by 1997


•Resources were directed towards the reduction of maternal mortality, which was made a national priority

•The availability of emergency obstetric care services was improved, and new services for emergency obstetric care focused on areas with high mortality ratios

•Referrals were improved for women who had complications both by traditional birth assistants as well as skilled birth assistants, thus a valuable link between the health system and clients was provided

•The number of deliveries made with skilled attendants was increased, showing both an increase in access and demand

Cost and cost effectiveness
Though government prioritisation and commitment played a large part, much was made possible through the support of various donors. Ministry of Health resources and foreign aid were redistributed towards resolving the problem. The country spends about 7·2% of its gross domestic product on health and social services

Despite being one of the poorest countries in the western hemisphere, Honduras challenged the problem of maternal mortality and has reduced maternal mortality by 38% over 7 years

Panel 2: Reduction of maternal mortality in Sri Lanka30

The maternal mortality ratio in Sri Lanka in the 1940s was over 1600 per 100 000 livebirths. As of 2000, this number has been reduced to 92 per 100 000 livebirths


Key actions contributing to the country's success included strong public investments in the overall health system, while taking special care to include crucial elements of maternal health care. Fundamental to their progress was sustained commitment for maternal-health care priorities with financial, managerial, and political support. Additionally, special attention was given to specific, sustained strategies in health, education, and nutrition, including equitable access to these services early in the development stage. Specific steps taken by the country for maternal health care included:

•Ensuring access through the expansion and provision of a free synergistic package of basic comprehensive health and social services, including maternal health care that reached poor people, even in rural areas

•Use of a judicious mix of health personnel to deliver services. Midwives were certified and provided an integral link between the women and the health units

•Effective management and use of health information to serve as a foundation, guiding decisionmaking and identifying problems

•Use of information for quality improvements, especially in identified vulnerable groups

•Empowering clients to provide information and to use services effectively

Cost and cost-effectiveness
In the late 1950s, Sri Lanka's gross national product per head was US$270 (1995 US equivalent), and about half the households were below the poverty line. The country was able to reduce maternal mortality despite a decreasing budget. Between 1950 and 1999, expenditures for maternal-health services decreased from an average of 0·28% of gross domestic product in the 1950s to 0·16% in the 1990s, with an average of 0·23% over the five decades from 1950–99

The country has shown the capacity to reduce maternal mortality ratio by 50% every 6–12 years

Poor maternal health is of serious concern beyond its importance as a health issue, because women's health as mothers can be linked with other aspects of women's lives and development more broadly. We assess what evidence exists to support these links.

Women as individuals: maternal health and women's status and empowerment

Research suggests that the MDGs will not be reached without addressing poverty and gender inequality.33 As WHO noted, “Maternal mortality is an indicator of disparity and inequity between men and women and its extent a sign of women's place in society and their access to social, health, and nutrition services and to economic opportunities”.12 The evidence reviewed below shows that women's status and empowerment­measured by education, employment, intimate partner violence, and reproductive health­affects women's capacity to access and use services during pregnancy and childbirth or otherwise maintain good maternal health. In some cases, the evidence also suggests that maternal health affects women's status and empowerment as well.

Enablers for improved women's status: education and employment
Education and employment are termed enabling factors since they can be instrumental in enabling women to gain the knowledge, confidence, skills, and opportunities that they need to increase their social and economic status and power in the household and in society. Some studies have examined the links of both these enablers with maternal health.

Perhaps the clearest and best documented example of the link between women's status and maternal health is the effect of women's education on maternal health. Educational attainment is measured by years of schooling, levels of education, and leaving school before secondary school completion. Extensive reports show that women's education increases the use of maternal-health services, and is independent of related factors such as urban or rural residence or socioeconomic status, and across the range of services and stages of maternal care.34–40 Educated women are more likely than are uneducated women to use antenatal care, to use it early and frequently, and to use trained providers and medical institutions.34–40 Similarly, education is positively associated with safe delivery35,36,38–40 and an increased use of postnatal care.37 Education results in substantial improvements in a woman's own health as a mother, and also has positive intergenerational effects on the health and nutrition of her daughters and their households.41 Female education, along with trained delivery assistance, is also a strong predictor of maternal mortality, independent of income per head.42

Women's economic opportunity (measured in terms of involvement in gainful or paid employment, wages, type of occupation, status at work, sector of activity, work effort, and potential wage rate) also has the potential to affect maternal health. Employment can pose physical burdens, hazards, or stress on women, which could result in negative outcomes for maternal health. Conversely, experiences and roles as economic providers might empower women through increased control over income which, in turn, may increase their power in decisionmaking about health care and their ability to access and pay for the services that they need when they are pregnant. The evidence suggests that women's employment positively affects maternal health, although the research is scarce compared with that for the link between maternal health and education.

Existing research shows that employment is associated with reduced maternal mortality and morbidity and increased use of maternal-health services, even after considering other factors such as education, age, household assets, and neighbourhood characteristics.43–46 Studies in several countries have shown that unemployed women had over four times the chance of maternal death compared with employed women,46 and a substantially higher likelihood of episodes of illness in the 2 years after childbirth.44 Employment and participation in credit programmes were positively correlated with seeking antenatal and postnatal care services in China and the Philippines, respectively, and with women demanding formal health care in the event of an illness in Bangladesh.43,45,47

These studies suggest that women's participation in economic activities and control of own income is more important to improvement of maternal health than is household socioeconomic status per se, perhaps because economic control increases women's ability to access the resources that they need during pregnancy. Other research emphasises how economic disadvantage more generally affects maternal health negatively, through factors such as residence in a poor neighbourhood and absence of toilet facilities and potable water.46,48 Since women's economic contributions raise the standard of living of their households, they might contribute to improved maternal health through this additional route as well.

Women's empowerment: household decisionmaking and intimate partner violence
Several studies suggest that although education and employment might be enabling factors, decisionmaking in the household and experience of intimate partner violence are more direct measures of women's ability to make crucial life choices.48 These factors indicate the power dynamics women face in terms of other family members in their efforts to secure their own welfare and frequently, that of their children. They also show women's value in the household and the effort and resources that will probably be spent in ensuring their wellbeing. Although research into these links is scarcer than it is for education and employment, it does show some consistent findings.

Almost all the studies that connected decisionmaking with maternal health reported that, independent of other factors, women's involvement in decisionmaking on key aspects of life is associated with an increased use of maternal-health services.38,49–53 Moreover, the stronger the woman's decisionmaking power, the greater the effect on maternal health. Women with strong decisionmaking power were more than twice as likely to deliver their child at a health facility compared with women with little decisionmaking power.51 Similarly, women from households with a female head and those who alone had the final say on decisions were substantially more likely to use health services and deliver at a health facility than were other women.49–51 Finally, the association between women's decisionmaking and health service use was two to three times larger when both the husband and wife agreed that the wife had power in decisionmaking.49

Evidence for intimate partner violence from around the world shows that violence during pregnancy can be common.54 However, the relation of violence with pregnancy varies by location. Some studies report that pregnant women are more likely to experience violence than are women who are not pregnant.55,56 Surveys from several countries show that intimate partner violence during pregnancy in developing countries ranges from 1·3% of pregnant women in Cambodia57 to 27·6% in a province in Peru.58 However, these studies also suggest that there is no consistent pattern of change in violence during pregnancy; although in some countries the level of violence during pregnancy is higher than it is when a woman is not pregnant, in other areas the reverse may be true.

Although the extent of violence during pregnancy varies, studies consistently show that violence is associated with many negative outcomes for maternal and fetal health, including premature and low birthweight babies, low maternal weight gain, infections, anaemia, smoking, alcohol and drug use, and depressive symptoms.55,59–61 Analyses across several developing countries show that women who experienced violence were substantially more likely to have a terminated pregnancy or non-livebirth than were women who did not experience violence.57,62 They are also likely to have poorer maternal health because they are less likely to access antenatal, delivery, and postnatal care.57,58 They are twice as likely as other women to delay antenatal care until the third trimester,55 and have a 37% increased risk of obstetric complications requiring admission to hospital before delivery.61 Violence can also indirectly contribute to women's isolation during pregnancy through its control over their lives and access to resources.61,63

Reproductive health: contraception, abortion, and HIV/AIDS
Options and constraints that women face regarding other reproductive health issues such as contraception, abortion, and risks of HIV can affect their health as mothers. Because of gender-based power dynamics with regard to sexuality in many cultures, women often do not have the power to negotiate safe sex or to prevent or safely abort unwanted pregnancy. As a result, women can be vulnerable to increased risks of maternal morbidity and mortality, especially in the context of HIV, because of risky sexual experiences as well as pregnancies that arise under difficult circumstances.

Extensive research shows that contraceptive use contributes to improved maternal health and lower maternal mortality, by contributing to fewer births, fewer unwanted pregnancies, and a lower proportion of births that are high risk.64–66 There is little research into the effect of maternal health on contraception, but a few studies show that women who use maternal-health services are more likely to use contraception than are women who do not use maternal care.67,68

The negative effect of unsafe abortion on maternal health is also well documented. Unsafe abortions increase both maternal mortality and morbidity­eg, through haemorrhage and infection, severe pain, secondary infertility, and death.69 WHO estimates that about 68 000 maternal deaths­mostly in developing countries­are due to abortion every year, which is probably a large underestimate because of widespread problems with reported abortion rates.70 Maternal deaths related to abortion are highest in Latin America and the Caribbean, where abortion is largely illegal. Unsafe abortion is one of the major direct causes of maternal mortality and morbidity in developing countries, and it accounts for 13% of maternal deaths.70 Conversely, safe or legal abortion poses little risk; in developing countries, the mortality risk is only four to six per 100 000 cases for legal abortion compared with 100–1000 per 100 000 cases for illegal abortions.70 Thus women's options for safe abortion services are an important determinant of maternal-health outcomes.

HIV is becoming an increasingly important cause of maternal morbidity and mortality. Women are especially at risk of HIV; over 17 million women are infected with HIV, and every year two million pregnancies occur in women who are HIV positive.71,72 AIDS is now the leading cause of maternal deaths in some areas of Africa.72 HIV directly increases the risk of complications of pregnancy, delivery, and induced abortion such as anaemia, haemorrhage, and sepsis, thereby causing a high number of maternal deaths and complications.73–75 HIV indirectly increases susceptibility to episodes of moderate to severe maternal morbidity75 and the chance of a maternal death due to opportunistic infections such as pneumonia, tuberculosis, and malaria.73,76–80

Maternal health is also thought to affect HIV because pregnancy can accelerate disease progression in women who are HIV positive, although the supporting evidence has produced varying conclusions. Research results from developed countries show no effect of pregnancy on HIV disease progression, immunodeficiency, or AIDS.81–83 However, evidence from developing countries, where HIV is accompanied by a greater degree of symptomatology than it is in developed countries, suggests that there could be a link.73,84–87

Thus there is strong evidence that indicators of women's status and empowerment such as education, decisionmaking, contraception, unsafe abortion, intimate partner violence, and HIV status affect outcomes for maternal health. However, research is scarce for the effect of employment on maternal health. Evidence on the reverse links­ie, the effect of maternal health on women's status and empowerment­is even scarcer. Yet poor maternal health could plausibly affect women's ability to exercise power or improve other dimensions of their lives such as employment opportunities. Further research is needed to verify these links, and to investigate how maternal health affects overall development through its effect on factors related to women's status and empowerment.

Women as family members: effects of maternal health on children and families
That maternal health and mortality are of fundamental importance to the survival and wellbeing of children is well-documented. However, the evidence of the costs of maternal death and illness on families is scarce.

Many studies have shown that a child's risk of dying increases substantially after the mother's death.88–93 Moreover, maternal death seems to be one mechanism for perpetuating gender inequality in the next generation; the child's risk of death when the mother dies is higher for girls than for boys.88,89 Children whose mothers die are also more likely to be stunted94 and less likely to attend school.92–94 When a mother dies or is severely ill, children are more likely to be sent to foster care, where they might have an increased chance of death, disability, and poor nutrition and of receiving less education and health care.95 Studies on orphanhood are exploring these negative effects, as well as potential benefits, of foster care.96–99

Poor maternal health perpetuates the cycle of ill-health across generations. Women who do not gain enough weight during pregnancy increase the chance that their newborn children are of low birthweight. Girls who are born underweight are more likely to be stunted, underweight adults and to have obstructed labour, which endangers their lives and that of their newborn child.100 Birth asphyxia can cause brain damage and impede cognitive development, and poor health at birth can affect adult wellbeing­eg, through increased chance of death from cardiovascular and cerebrovascular diseases.4

An increasing amount of evidence draws attention to the costs of a maternal death or illness to a household.10,101–104 These costs can drain family resources and savings, change patterns of consumption, and reduce households to debt and poverty.102,105 For instance, in Indonesia, a hospital delivery with complications cost 14% of an average yearly income.102 In Ghana and Benin, families could spend US$115 or $256, respectively, to treat near-miss complications. In 2000, these costs represented 8% of average annual cash expenditures for Ghanaian families and 34% in Benin.106 When women are important economic contributors within their families, maternal illness means fewer hours of paid work, less income, and reduced resources for a family, exacerbating economic insecurity. Research in Ghana shows that women lost an average of 26 days of work because of reduced productivity during pregnancy and 23 days during postpartum.102 A review of US studies linked the poor health of mothers with reduced wages and labour-market participation, and increased welfare dependency.107 Poor maternal health also restricts women's important non-paid economic contributions such as food production, water collection, health care, and caring for children, those who are ill, and elderly people.103,104,108

The psychological and social consequences of poor maternal health and mortality are less extensively documented than are the economic costs, but existing published work suggests these factors are important. Rahman and co-workers' study showed that one in four women in Pakistan had antenatal or postpartum depression,109 which is a disorder that has been linked to disturbed relationships with children, marital discord, and poor performance of household tasks,109–111 but which can be ameliorated with good health care.101 In many societies, men are not raised, taught, or expected to manage household affairs and they are poorly equipped to care for children and families. When maternal illness or death occurs, there is evidence of increased depression and psychological problems in the family, and increased numbers of children leaving school because they are compelled to help earn income.112

Despite these negative results of maternal morbidity and mortality, women's low status in a household typically means that women's health-care needs are ignored and given low priority. Further, childbearing is regarded as an expected part of a woman's role. Thus, families are reluctant to invest in maternal care and women may be unable to negotiate better care; thus, the risks and costs of maternal morbidity and mortality persist.113

Women as citizens: maternal health benefits for national productivity and health service delivery
In view of the costs and negative consequences associated with poor maternal health for women and their families, the cumulative effect of maternal mortality and morbidity probably affects national and global development outcomes. Of all the three aspects of development that we have presented in this Review, research is most scarce for the relation between maternal health and national development. However, existing published work does point to a negative effect of poor maternal health on development.

Cost estimates in recent years have tried to quantify the effects of maternal deaths and illnesses on national budgets and productivity, on the basis of various assumptions. The US Agency for International Development (USAID) estimated global maternal mortality costs of over US$15 billion every year because of diminished potential productivity caused by the death of women and neonates.114 Estimates for four countries suggest that costs of total productivity losses per year associated with poor maternal, newborn, and infant health range from US$8 million in Mauritania to $95 million in Ethiopia, on the basis of figures for 2001.115 Annual productivity losses per head range from $1·5 in Ethiopia to over $3 in Uganda and Mauritania, and almost $5 in Senegal.112 With somewhat different assumptions, and household and health centre costs added to such estimates, the annual cost for lost productivity in Uganda is closer to $102 million per year or $4·25 per head per year.112

Further evidence shows that maternal morbidity and mortality represent an important burden of disease in the developing world. In women of reproductive age, maternal ill health is one of the leading single causes of death and disability, accounting for 13% of deaths and 13% of DALY's (disability-adjusted life years).116–118 Furthermore, maternal health and the quality of obstetric and newborn care are directly associated with perinatal disorders (birth asphyxia, trauma, and low birthweight), which are the second leading cause of premature death and disability in children younger than 5 years and which account for about 20% of the burden of disease in that age group.16

Although research has not explicitly explored the effect of poor maternal health on economic growth, evidence suggests a positive relation between health overall and economic growth.119–121 Since estimates for the burden of disease show that maternal mortality and morbidity is one of the largest single causes of ill-health for women, it can reasonably be assumed to account for an important portion of the effect of overall adult health on economic growth. Studies for the economic effect of AIDS support such an assumption. Since individuals are affected in the prime of their productive lives, AIDS substantially alters economic growth, productivity, investment, domestic savings, poverty, and inequity.122–124 Like AIDS, maternal morbidity and mortality also affects women at the prime of their lives when they have the greatest ability to contribute to society and the economy, and it has severe economic repercussions for families and represents a large burden of disease. National economic outcomes are similarly affected. However, further research is needed specifically on the consequences of maternal death and disability to provide the empirical evidence to support these theoretical links.

Evidence suggests that investment of resources in maternal health can at least partly address these issues through its positive effect on overall health service delivery and use. Maternal health indicators are so closely associated with key service delivery issues such as equity and efficiency that they have been used to assess the functioning of health systems125 and proposed as a measure of the performance of a country's overall health system.16 Investments in key maternal-health facilities­eg, essential obstetric care­can be used for other types of services such as operations and blood transfusions for accidents.126 Prevention of maternal morbidity avoids the large costs of treating maternal-health problems.101 Finally, research shows that women who use maternal-health services are more likely to use other reproductive-health services than are those who do not use such services, thus creating a multiplier benefit for several reproductive-health outcomes.68

Investments in maternal health: shortfalls and potential
Investments in maternal health continue to fall below what the development community knows is necessary to achieve the benefits of maternal health and the MDG goal for safer maternity. Although there are many other important barriers to improving maternal health­such as access, quality of care, and cost­adequate investment in maternal health is an essential first step to addressing them all.

There are several estimates of what it would cost countries to try and reach MDG5, ranging from as low as US$1 billion in 2006 to as high as $6 billion in 2015. Cost estimates per head range from $0·22 to $1·40.127–129 Estimates of costs and investments make different assumptions and are not strictly comparable, but available evidence shows a wide gap between present investments and what is needed to meet MDG5.125,130–132 International development assistance for maternal and neonatal health was estimated to be $664 million in 2003 and $530 million in 2004.130 Analyses of the outlook for future overseas development funding are mixed,125,130 but they suggest that donor funding will need to increase over 11 times its 2004 level to achieve the $6·1 billion that WHO estimates is needed for 2015.

The good news is that the gap between present and needed investment for maternal health represents only a small fraction of donor gross national product and of total development aid. Even the much larger $5 billion shortfall in estimated funds that is needed by 2015 to meet both maternal health and child health MDGs consists of only 0·016% of global gross national product and 2% of aid.133 The investment that is needed to improve maternal health is a small fraction of world spending, and it makes financial sense because maternal health interventions are cost effective.33,104,116,125,126,134 A World Bank study116 noted that antenatal and delivery care and family planning were two of the six most cost-effective interventions selected for the essential package of clinical services for low-income and middle-income countries. A recent study33 showed that primary care interventions for mothers and neonates, and preventive community-level interventions for newborn children, were highly cost effective for settings in sub-Saharan Africa and southeast Asia where the rates of adult and child mortality are high. Hospital-based interventions were also reported to be cost effective and essential to efforts to substantially reduce maternal and newborn mortality.

The continued scarcity of progress in maternal health over the past two or more decades in several parts of the world is disturbing. The little progress is especially of concern for south Asia and sub-Saharan Africa, which have consistently presented the worst maternal health in the world. Our Review suggests that the fact that these regions also lag in progress on a range of broader development outcomes, including poverty reduction and the status of women, is no coincidence; even the little research so far points to the likelihood of a strong link between maternal health and other women's status and development outcomes. Similarly, that many countries in southeast Asia have made great progress is also no coincidence; in many of these countries, investments in improving the availability and quality of maternal care services have gone hand-in-hand with investments in education and employment for women, and in the provision of a range of reproductive health services. Thus, the examples of countries like Thailand26 and Malaysia30 suggest that MDG5 is achievable with appropriate financial and political commitment.

Our Review emphasises some key limitations in the published work. Most notably, additional research is needed on how poor maternal health affects women's status; the many ways in which it affects women's productivity, household wellbeing, and national economic growth; and on how women's status and broader development, in turn, change the patterns and extent of improvements in maternal health. However, additional evidence alone will not be enough to ensure future progress. Concerted efforts also are needed to change public perceptions about the severity of the problem and the solutions that are available, and to create a coalition of stakeholders committed to improving maternal health.135 The convergence of such actions, along with a growing understanding of the links between maternal health, women's status and broader development, and adequate investment in maternal health and in women will enable women to fulfil their potential to deliver as mothers, individuals, members of families, and citizens.

Search strategy and selection criteria
All searches were done with literature databases such as POPLINE, PubMed, Proquest, Social Science Citation Index, and the websites of international organisations and universities such as WHO, the World Bank, UNICEF, the UN, UNFPA, the US Agency for International Development, Population Reference Bureau, the Global Health Council, the London School of Economics, the London School of Hygiene and Tropical Medicine, Oxfam International, and the Immpact Initiative. Searches were limited to published work produced in the past 10 years, with the exception of key articles in the discipline. Searches on maternal health included the following key terms: “maternal mortality”, “maternal morbidity”, “obstetric morbidity”, and “maternal health services utilization” (antenatal, delivery, and postnatal care). Key terms used for investments in maternal health included: “investments”, “(donor) funding”, and “millennium development goals”. For the relations of economic opportunities to maternal health, we added: “employment”, “wages”, “enterprise”, “savings”, “assets”, “economic opportunity”, “occupation”, and “microcredit”. Searches for links of maternal health with development outcomes used search terms such as: “disability-adjusted life years (DALYs)”, “burden of disease”, “cost-effectiveness”, “child education”, “household finances”, “family”, “individual effects”, “household-level effects”, and “adult mortality consequences”.

Conflict of interest statement
We declare that we have no conflict of interest.

We thank Michelle Lee, our research assistant, who identified, reviewed, and managed all the literature for us, as well as giving very useful input into the paper; and Ann Starrs at Family Care International for comments on previous versions of this paper. Work for this Review was supported by Family Care International through a grant to the International Center for Research on Women. The funding source had a role in the review of content for this article, but has no responsibility for the information provided or views expressed in this paper.


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a. International Center for Research on Women, Washington, DC, USA

Correspondence to: Rohini Pande, International Center for Research on Women, 1120 20th Street NW, Suite 500N, Washington, DC 20036, USA