The radical drop in maternal mortality was a public health miracle

The loss of a mother or a child during pregnancy or birth is a heartbreaking family tragedy, one that has been with humanity since the dawn of our species. Prior to the 20th century, pregnancy, childbirth, and post-birth recovery were among the times of greatest danger for all women. The risk was compounded significantly by global fertility rates, which remained very high for much of human history. The average American woman alive in 1820 had roughly 6.6 children, while the global average was 5.75. Every pregnancy was a life-or-death gamble, and the outcome for mother and child was too frequently grim.

Millennia of terrible loss

Some of the oldest reliable records for maternal mortality come from Sweden, and they show a rate of 1,205 mothers lost for every 100,000 live births in 1758. That figure is staggering, and it is highly representative of the global mortality rate at that time. (To put that figure into perspective, the maternal mortality rate today in Sweden is 7 per 100,000, a decrease of 99.4%.) Maternal mortality rates remained extremely high throughout the next two and a half centuries.

In 1904, the U.S., UK, and Australia respectively lost 790, 397, and 609 mothers per 100,000 live births. The maternal mortality rate remained high for millennia because little was done to address the causes effectively, the most common of which — both then and now — were severe bleeding and infection after childbirth, complications in delivery, obstructed labor, and to a lesser degree, complications arising from unsafe abortions. For much of history, doctors often did more harm than good. Physicians’ intentions may have been sound, but they worked from a place of deep ignorance of the workings of the female body, as well as of the germ theory of disease. Prior to the 20th century, women with the means to have a doctor attend their birth found their reserves of strength sapped by what was little more than guesswork. 

Prior to the advent of modern surgical procedures for addressing obstructed labor and other severe childbirth complications, doctors employed gruesome tools and techniques. In the face of highly obstructed labor, a not uncommon condition, families and physicians were forced into the position of trying to save the mother or the child, but rarely both.

A global turning point

Despite the lack of modern medical care, maternal mortality rates improved gradually throughout much of the 18th century and into the early 19th century. Better nutrition, access to clean water, cleaner birthing spaces, improved access to midwifery care, and improved sanitation were powerful forces that pushed maternal mortality down. But it was the introduction of effective and widely available antibiotic treatment that finally brought about major progress in saving the lives of mothers. 

Beginning in the early 1930s, much of the developed world experienced a sharp and sustained decline in maternal mortality, with the rate in the U.S. falling by 88% between 1930 and 1950. An almost identical rate of decline prevailed across the developed world in those decades. From the UK to France and from Australia to the Netherlands, fewer women per capita were dying as a result of pregnancy and childbirth than at any point in recorded history. It turned out that the same antibiotics that saved Allied lives in the battlefield hospitals of World War II were also remarkably effective at saving the lives of mothers. Their use, beginning with penicillin, was a game-changer in the fight to help mothers avoid life-threatening post-birth infections.

Combining antibiotics with more births taking place in medical facilities or attended by skilled healthcare staff resulted in yet more saved lives. In Afghanistan, the percentage of births attended by skilled healthcare staff climbed from just 12% in the year 2000 to 59% by 2018. Over that same stretch of time, the country saw a reduction in maternal mortality of 56%. The story is similar across the vast majority of low- and middle-income countries, especially in Asia and Africa. The number of women who have their pregnancy, birth, and post-birth attended by healthcare professionals rises with each passing year, and maternal outcomes are improving in lockstep.

The enormous strides taken over the last 50 years in the fight against maternal mortality were not the result of antibiotic therapy alone, nor indeed of any single breakthrough. Improvements came about as a number of smaller forces matured and as all these tools became more widely available. 

Closing the gap on maternal mortality

Economic growth and globalization helped bring the remarkable progress experienced by the world’s high-income countries to many of the world’s low- and middle-income countries. Between 2000 and 2017, the global maternal mortality rate fell by 38%. In low-income countries, the decline was more dramatic still, with a reduction of 46%. 

While the number of women who die in childbirth has declined significantly across the globe, there remains a large gap in outcomes between high-income countries and the rest. Today nearly all countries in Sub-Saharan Africa have maternal mortality rates that at their best lag dramatically behind those of rich countries. In 2017, Chad’s rate of 1,140 deaths per 100,000 live births, and South Sudan’s 1,150 deaths per 100,000, more than doubled the UK’s rate in 1850.

The more economically disadvantaged and poor a country is, the more likely it is that mothers will die during or shortly after childbirth. Today nearly all maternal deaths, almost 95%, are experienced by women living in low- and middle-income countries. In 2020, roughly 800 women every day were still succumbing to death from preventable causes related to pregnancy and childbirth.

As global economic opportunities continue to improve for the world’s poor, many countries are becoming better equipped to help save the lives of mothers and children. In short, countries with well-performing economies can afford the medical equipment, operating facilities, and trained healthcare professionals that save lives. Moreover, such countries also can improve accessibility to healthcare services, allowing more mothers the opportunity to receive life-saving care during and after birth.

Naturally, one of the least expensive and most readily deployable aids in reducing maternal mortality is effective family planning. When sexually active women have safe, inexpensive, and unobstructed access to contraceptive options, they are best equipped to plan their pregnancies. Such planning helps reduce the likelihood of becoming pregnant again too soon after giving birth, or too frequently over their reproductive lifetime. Access to contraceptives and condoms also dramatically reduces the likelihood of unplanned and unsafe abortions, another leading cause of high rates of maternal mortality, especially in the world’s poorest regions.

The slow road to progress

Undoubtedly, the overall story is one of progress, with maternal mortality falling gradually almost everywhere. Healthcare providers now have a comprehensive understanding of how to keep mothers and babies alive, and no major scientific or technological breakthroughs are needed. The economic and cultural challenges to improved maternal mortality outcomes that remain in many countries are considerable, but they are not insurmountable.