Major Medical Causes Of Maternal Mortality
Maternal mortality refers to the death of a woman during pregnancy, childbirth, or within 42 days of delivery due to complications directly or indirectly linked to the pregnancy.
Globally, most maternal deaths are preventable, yet they remain high in many regions, particularly sub-Saharan Africa and South Asia.
The major medical causes are as follows:
1. Severe Bleeding (Postpartum Haemorrhage)
Description: Severe bleeding, especially after childbirth, is the leading direct cause of maternal death worldwide. It usually occurs within 24 hours of delivery but can also happen later in the postpartum period.
Impact: It accounts for up to 27% of maternal deaths globally. Women in low-resource settings are more vulnerable due to a lack of timely access to blood transfusions, oxytocin, or surgical interventions.
Prevention/Treatment: Use of uterotonic drugs (oxytocin), timely surgical procedures, blood transfusions, and trained birth attendants significantly reduce risks.
Read More: World Health Organization – Maternal Mortality
2. Infections (Maternal Sepsis)
Description: Postpartum infections, also called puerperal sepsis, occur when bacteria enter the body during or after childbirth, often due to poor hygiene, prolonged labour, or unsterile medical procedures.
Impact: They contribute to around 10% of maternal deaths globally. Infections can progress rapidly to septic shock if untreated.
Prevention/Treatment: Ensuring hygienic delivery conditions, prompt use of antibiotics, and early recognition of symptoms can save lives.
Read More: UNICEF – Maternal Mortality
3. Hypertensive Disorders of Pregnancy (Pre-eclampsia and Eclampsia)
Description: These conditions involve dangerously high blood pressure during pregnancy, which can lead to seizures (eclampsia), organ failure, or death.
Impact: Hypertensive disorders are responsible for 10–14% of maternal deaths worldwide. They also pose risks to the unborn child, including preterm birth and stillbirth.
Prevention/Treatment: Regular antenatal care for early detection, administration of antihypertensive drugs, and magnesium sulfate for seizure prevention are crucial.
Read More: World Health Organization – Maternal Mortality
4. Complications From Delivery (Obstructed And Prolonged Labour)
Description: Obstructed labour occurs when the baby cannot pass through the birth canal due to size, position, or maternal pelvic structure. Without timely medical intervention, it can cause uterine rupture, fistula, or maternal death.
Impact: It remains a significant contributor in low-resource areas where access to emergency obstetric care (like cesarean sections) is limited.
Prevention/Treatment: Skilled birth attendants, timely referral, and access to surgical care can prevent fatalities.
Read More: UNICEF – Maternal Mortality
5. Unsafe Abortion
Description: Unsafe abortion refers to procedures performed by untrained persons or in environments lacking proper medical standards. It often leads to haemorrhage, sepsis, and injury to reproductive organs.
Impact: Accounts for nearly 8–13% of maternal deaths globally, especially in countries with restricted access to safe abortion services.
Prevention/Treatment: Expanding access to safe abortion care, post-abortion care, and family planning reduces mortality.
Read More: World Health Organization – Unsafe Abortion
6. Indirect Causes (Pre-existing Medical Conditions Complicated by Pregnancy)
Description: Conditions such as HIV/AIDS, malaria, anaemia, diabetes, and cardiovascular disease increase maternal risks during pregnancy and childbirth. While not direct obstetric causes, they are aggravated by pregnancy.
Impact: Indirect causes contribute to 20–25% of maternal deaths, especially in regions with high burdens of infectious diseases like malaria and HIV.
Prevention/Treatment: Strengthening antenatal care, managing chronic illnesses, and providing preventive treatment (e.g., malaria prophylaxis) are essential.
Read More: World Health Organization – Maternal Mortality
Health System Factors Of Maternal Mortality
The health system factors that contribute to maternal mortality in Nigeria include several critical factors:
- Leading Causes Of Maternal Mortality: The primary causes in Nigeria are obstetric haemorrhage, hypertensive disorders (eclampsia), sepsis, obstructed labour, and complications from unsafe abortion. These direct obstetric causes account for a significant portion of maternal deaths. Indirect causes include conditions such as anaemia, HIV, and sickle cell disease, which worsen pregnancy outcomes.
- Maternal Delay Factors: Maternal mortality is strongly linked to three types of delay in decision-making to seek care, delay in reaching healthcare facilities, and delay in receiving adequate care upon arrival at health facilities. These delays are due to socioeconomic barriers, poor health infrastructure, lack of skilled health personnel, cultural beliefs, and transport challenges, especially in rural areas.
- Access And Quality Of Healthcare: Limited access to skilled birth attendants, inadequate primary and tertiary healthcare facilities, poor quality of care, and insufficient health financing contribute to maternal deaths. Many women deliver at home or with traditional birth attendants due to perceived inefficacy or mistrust of formal health systems.
- Socioeconomic And Cultural Factors: Poverty, low educational levels, gender inequality, early marriage, and cultural practices also increase the risk of maternal mortality by limiting access to timely and appropriate maternal health services.
- Mental Health and Other Conditions: Maternal mortality is also influenced by maternal mental health conditions and the number of previous births, with a higher risk in multiparous women. Cardiovascular disease is an emerging contributor.
- Geographic Disparities: Maternal deaths are disproportionately higher in certain local government areas, making up 20% of areas but accounting for over 50% of maternal deaths, highlighting regional inequalities in health service provision.
Epidemiology And Burden Of Maternal Mortality
Global Overview
Maternal mortality remains a critical public health challenge worldwide. About 260,000 women died during and following pregnancy and childbirth in 2023, with approximately 92% of all maternal deaths occurring in low- and lower-middle-income countries. The global maternal mortality ratio (MMR) declined by 40% from 2000 to 2023, from 328 deaths to 197 deaths per 100,000 live births, representing an average annual rate of reduction of 2.2%.
Epidemiological Patterns
Geographic Distribution
The burden of maternal mortality is heavily concentrated in specific regions and countries. Most maternal deaths could have been prevented, highlighting significant disparities in healthcare access and quality between developed and developing nations. WHO data shows substantial variations in maternal mortality ratios across countries, with some nations reporting rates exceeding 1,000 deaths per 100,000 live births while others maintain rates below 10 per 100,000.
Temporal Trends
Despite overall improvements, progress toward achieving Sustainable Development Goal 3.1, which aims to reduce the global maternal mortality ratio to less than 70 per 100,000 live births, remains insufficient. Around 300,000 women globally died from pregnancy-related deaths in 2017, which is around 800 each day on average.
Leading Causes Of Maternal Mortality
Direct Obstetric Causes
According to a recent WHO systematic analysis, haemorrhage remains the leading cause of death, despite the existence of effective clinical interventions. The pattern of causes varies significantly by income level: in low-income countries, the most common cause of maternal death is obstetrical haemorrhage, followed by hypertensive disorders of pregnancy, while in high-income countries, the most common cause is thromboembolism.
Timing Of Deaths
The timing of most deaths in the postpartum period demands renewed commitment to improving the provision of postpartum care, emphasising the critical importance of comprehensive postnatal care services.
Risk Factors And Determinants
Socioeconomic Determinants
Research reveals that maternal mortality is correlated with multiple socioeconomic factors, health care system-associated factors, disease burden and their complex interactions. Analysis identifies that the underlying pathology is the lack of education, sanitation, accessible health care, as well as poor nutrition and poverty.
Clinical Risk Factors
Studies show that higher risks of maternal mortality were influenced by factors including low education, lack of prenatal visits, caesarean delivery, haemorrhage, and hypertension. Early screening is expected to reduce maternal mortality rates.
Healthcare System Factors
Analysis suggests that an undersupply of maternity providers, especially midwives, and a lack of access to comprehensive postpartum support, including maternity care coverage and mandated paid maternity leave, are contributing factors.
Burden And Impact
Disease Burden
These factors affect women during pregnancy and childbirth when they are more vulnerable. UNICEF data indicate that there are many social, economic, and environmental factors which influence the risk of maternal mortality.
Challenges For Health Systems
The Global Burden of Disease Study 2015 identifies that countries should establish or renew systems for the collection and timely dissemination of health data.
Expand coverage and improve the quality of family planning services, including access to contraception and safe abortion to address high adolescent fertility; invest in improving health system capacity, including coverage of routine reproductive health care and of more advanced obstetric care.
Implications For Policy And Practice
Policy and programs targeted to improve maternal health and reduce maternal deaths should consider population dynamics and address the complex interplay of factors contributing to maternal mortality. The evidence suggests that comprehensive approaches addressing both direct clinical interventions and underlying socioeconomic determinants are essential for achieving meaningful reductions in maternal mortality rates globally.
Sociocultural Determinant
1. Early Marriage And Teenage Pregnancy: In northern Nigeria, child marriage is prevalent, with adolescent girls facing increased risks of complications during childbirth due to biological immaturity (Adebowale & Palamuleni, 2014).
2. Gender Inequality: Women often have limited decision-making power regarding healthcare access, as male household heads control financial and health-related decisions (Doctor et al., 2019).
3. Traditional Beliefs And Practices: Preference for traditional birth attendants (TBAs) over skilled birth attendants persists in rural communities due to cultural trust, affordability, and accessibility, increasing the risk of maternal deaths (Okonofua, 2021).
4. Education: Women with little or no formal education are less likely to seek antenatal care and facility-based deliveries, contributing to higher mortality rates (Fagbamigbe & Idemudia, 2015).
Economic Determinant
1. Poverty: Over 40% of Nigerians live below the poverty line, which hinders access to quality healthcare services and transportation to health facilities (National Bureau of Statistics, 2022).
2. Health System Financing: Out-of-pocket expenditure constitutes the major source of health financing in Nigeria, placing financial burdens on pregnant women and discouraging facility-based delivery (Adewunmi et al., 2018).
3. Urban-Rural Disparities: Rural areas lack adequate healthcare infrastructure, skilled personnel, and emergency obstetric services, resulting in disproportionate maternal mortality rates compared to urban centres (Doctor et al., 2019).
4. Employment And Income: Women engaged in low-income or informal employment often lack health insurance, limiting access to safe delivery services.
Policy Implications And Intervention
Addressing maternal mortality requires tackling its sociocultural and economic roots. Interventions include the following
1 – Promoting female education and empowerment to enhance decision-making and health-seeking behaviour.
2 – Strengthening healthcare financing through health insurance schemes such as the National Health Insurance Authority (NHIA).
3 – Culturally sensitive community engagement to shift reliance from TBAs to skilled birth attendants.
4 – Expanding maternal health infrastructure in rural areas and improving referral systems.
Policy And Governance On Maternal Mortality
The policy governance of maternal mortality in Nigeria prioritises reducing high maternal death rates through integrated health strategies, intersectoral collaboration, and targeted interventions in high-risk areas.
The Nigerian government has developed and implemented policies such as the Integrated Maternal, Newborn and Child Health Strategy, which has stages focusing on increasing skilled birth attendance and emergency obstetric care.
Initiatives like the Maternal and Neonatal Mortality Reduction Innovation and Initiatives (MAMII) align resources and actions under a sector-wide approach to address root causes in priority locations with the highest mortality rates MAMII initiative details and governance approach.
Governance challenges include regional disparities, underfunding, systemic corruption, and sociocultural barriers. Efforts also include task forces, partnerships with WHO and UNICEF, and health insurance schemes aimed at making maternal care more accessible and affordable.
Health Systems Strengthening (HSS), where political leadership and resource mobilisation are essential. There’s enhanced workforce capacity, infrastructure, technology, and referral systems.
Performance-based financing, applied in several African nations, has been proven to improve service quality and outcomes but depends on systemic capacity.
The universal health coverage must be equitable, enhancing ownership and relevance and ensuring access across income, geography, and ethnicity.
Data & Transparency, which implement death audits, quality reporting, and share findings widely, provision of skilled care, free services, and equitable access, health financing and allocation of resources, possibly through performance-based financing, and use of targets and indicators to guide progress.
Abiye (Safe Motherhood) Project – Ondo State is an example of a project that began in 2014. This initiative incentivised Traditional Birth Attendants (TBAs) to refer expectant mothers to health facilities via vouchers, training, and microfinance support. It successfully reduced maternal mortality by over 80% (from 745 to 112 per 100,000 live births). It operates within a human rights–based framework, emphasising accountability and dignity in health delivery.
Conclusion
The major medical causes of maternal mortality include severe bleeding, infections, hypertensive disorders, delivery complications, unsafe abortion, and indirect health conditions.
These causes are largely preventable with timely access to quality healthcare, skilled attendants, emergency obstetric services, and preventive measures.
