Flavia Bustreo and Rajat Khosla
According to the recently released Trends in Maternal Mortality 2000 to 2020, global progress in reducing maternal mortality stagnated between 2000-2015 and worsened in some regions between 2016 and 2020. Overall only 69 countries show a reduction in the Maternal Mortality Ratio (MMR) when comparing 2020 with 2000 data. Worldwide in 2020 223 maternal deaths occurred per 100,000 livebirths, a rate equal to the death of a woman in childbirth every two minutes, totalling 800 women every day or 287,000 women in 2020. Director-General, of the World Health Organization (WHO) Dr Tedros Adhanom Ghebreyesus in his Foreword to the report stated that, “we are way off track to achieve the SDG target on maternal mortality”.
Looking at the most recent data from 2016 to 2020 shows divergent paths. In three regions of the world MMR rates increased (Americas, Europe, and Western Pacific). Countries such as Venezuela, Cyprus, Greece, the United States, Mauritius, Puerto Rico, Belize, and the Dominican Republic all saw significant increases in MMR between 2000-2020. Between 2016 and 2020 MMR rates declined (improved) in two regions, (Australia and New Zealand, and Central and Southern Asia); it stagnated in four regions (sub-Saharan Africa, Oceania (excluding Australia and New Zealand), Northern Africa and Western Asia, and Eastern and South-Eastern Asia), and increased (worsened) in Europe and Northern America.
WHO has classified Sub-Saharan Africa’s MMR as “very high” (545 maternal deaths per 100,000 live births), contributing now to 70% of global maternal deaths. That, as the report describes, is “136 times higher than the MMR in Australia and New Zealand.” A 15-year-old girl in sub-Saharan Africa in 2020 had the highest lifetime risk of a maternal death (1 in 40) of anywhere on the globe.
Despite these numbers and trends, the report’s release did not generate a global outcry, nor any urgent actions to address the situation. Perhaps that should not be a surprise. Over 30 years ago Professor Mahmoud Fathalla said, “Women are not dying of diseases we can’t treat… They are dying because societies have yet to make the decision that their lives are worth saving”. This remains the sad reality with the latest data confirming a failure of leadership to recognize the abject violation of women’s rights.
Although COVID-19 is sometimes blamed for derailment of progress towards SDG 3.1 (Maternal Mortality) and SDG 3.7 (ensure universal access to sexual and reproductive health care service by 2030), women’s health and sexual and reproductive health and rights in particular have met with numerous challenges over the last decade. This is visible not only in dwindling investments globally and domestically in programs and initiatives to implement evidence-based interventions but also in lack of political leadership which has systemically ignored and often undermined women’s rights and their access to basic services. For instance, studies have shown that the reintroduction of the US Global Gag Rule from 2016-2020 which blocked US Federal funding of foreign nongovernmental organizations who provide legal abortion services or referrals, or advocacy, had a devastating impact on access to safe abortion care and other reproductive health services. In countries which have introduced measures to undermine women’s rights a knock on effect on their health and well-being has been observed. The agenda and priorities of multilateral organisations are de-prioritising women’s health.
In confronting these challenges it is important to remember that this is not just a problem of public health but a fundamental violation of women’s rights. Death of a woman in childbirth reflects the systemic discrimination faced by women and girls in societies and a failure of governments to redress it. A closer look at the lived realities that result in death in childbirth shows the deep-seated patterns of inequalities, discrimination, and denial of basic human rights. Whether it is the denial of agency to make decisions about whom to marry, to have children, or to access the services they need, women continue to be denied their voice, choice, and autonomy. Black, indigenous or women belonging to minority communities are shown to have worse MMR in low- and high-income countries.
In 2010, recognising the need and the imperative to address high levels of maternal mortality, the former UN Secretary General Ban Ki-moon, launched the Every Woman Every Child (EWEC) initiative with the aim to save the lives of 16 million women and children by 2015. This led to a global movement of international and national action by governments, multilaterals, the private sector, and civil society to address the major health challenges facing women and children. More than US $40 billion was pledged at the 2010 launch, and numerous partners made additional, and critical, financial, policy, and service delivery commitments. This was further reaffirmed with the launch in 2016 of the new Global Strategy for Women’s, Children’s and Adolescents’ Health building a holistic approach towards survive, thrive, and transform women, children and adolescent health. Reviews pointed to substantial increases in value of additional resources for maternal, newborn and child health over this period of time. Between 2010 and 2015 through the EWEC Global Strategy in 49 target countries, 2.4 million lives of women and children were saved and 870,000 additional health workers were trained. In its 2014 report the independent Expert Review Group (iERG) which was established to monitor and review global commitments for women and children’s health noted, that, “the pace of progress, despite many challenges and missed opportunities, is accelerating” and that increasing numbers of countries are accelerating their reductions in maternal, newborn, and child mortality through continuous commitment and innovation”. The report also noted that, “Heads of State are showing exemplary global political leadership”.
The latest WHO report is evidence of what happened next: a systematic erosion in commitment by governments and donors with declining funds for reproductive and maternal health. The transformation that the Global Strategy symbolized is all too forgotten. As priorities and the global development agenda changed, women and girls were left behind despite attempts by many groups to raise concern about the lack of focus on women’s health and rights.
It is imperative that any regression in women’s health and rights is addressed urgently. An important first step is to ensure women’s health and rights are at the center of post pandemic global health discussions and that governments and multilateral agencies reaffirm and recommit to making dedicated investments towards women’s health.
Flavia Bustreo is Chair, Governance & Ethic Committee, Partnership for Maternal, Newborn and Child Health, Geneva, Switzerland.
Rajat Khosla is Director, United Nations University-International Institute on Global Health, Kuala Lumpur, Malaysia. Email: email@example.com
 World Health Organization, Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division (2023).
 Ibid. p.xvi.
 Ibid. p.vii.
 Ibid. Foreword p.vii.
 Ibid, Annex 6, p.68; p.xvi.
 Ibid. p.xvi.
 C. Moyer, E. R. Lawrence, T. K. Beyuo, et al., “Stalled progress in reducing maternal mortality globally: what next?” Lancet 401/ 10382 (2023).
 see note 1, p. xiv.
 M. F. Fathalla, “Imagine a world where no woman is denied her right to health – Seven propositions”. Facts Views & Vision Obgyn 3/4 (2011).
 N. Kanem, “The battle for sexual and reproductive health and rights for all” Sexual and Reproductive Health Matters, 27:1 (2019)
 IHME, Financing Global Health 2021: Global Health Priorities in Time of Change (2021) p.55-56; R. Khosla, S. Fisseha, K. Iversen, et al. “Twenty five years after the Beijing Declaration we need to reaffirm that women’s rights are human rights” TheBMJOpinion (2020). Available at https://blogs.bmj.com/bmj/2020/03/08/twenty-five-years-after-the-beijing-declaration-we-need-to-reaffirm-that-womens-rights-are-human-rights/; C. Moyer, E. R. Lawrence, T. K. Beyuo, et al., “Stalled progress in reducing maternal mortality globally: what next?” Lancet 401/ 10382 (2023).
 Guttmacher Institute. The Global Gag Rule and the Helms Amendment: Dual Policies, Deadly Impact. Factsheet. May 2021. Available at https://www.guttmacher.org/fact-sheet/ggr-helms-amendment (accessed April 2023)
 R. Khosla and K. Gilmore, “Sex, sexuality, and sexual and reproductive health: the role of human rights” in Chase et al,(eds). Human Rights at Intersections: Bloomsbury Academic (2022).
 F. Bustreo and M. Temmerman. “Keeping Promises to Women, Children and Adolescents” Lancet 393/10180, ( 2019); R. Horton, “Offline: The World’s forgotten children,” Lancet April 8, 2023.
 see note 8
 C. Pitt, C. Grollman, M. Martinez-Alvarez, et al., “Tracking aid for global health goals: a systematic comparison of four approaches applied to reproductive, maternal, newborn, and child health,” Lancet Global Health (2018) 6: e859–74.
 UNSG. Progress Report Every Woman Every Child. 2015. Available at https://www.everywomaneverychild.org/global-strategy/ (accessd May 2023)
 see note 12 P.55-56 and 69.
 see note 16.
 F. Bustreo and C. Doebbler, “Universal Health Coverage: Are We Losing Our Way on Women’s and Children’s Health?” Health and Human Rights, 21/2 (2019).