Effect of maternity care improvement, fertility decline, and contraceptive use on global maternal mortality reduction between 2000 and 2023: results from a decomposition analysis
Saifuddin Ahmed, Moazzam Ali, Iqbal Shah, Amy O. Tsui
Abstract
BACKGROUND: The number of global maternal deaths has reduced 41% from 443 000 in 2000 to 260 000 in 2023. Maternal mortality reduction is possible through improvement in maternity care, which reduces the risk per birth, and a decrease in the number of pregnancies, which reduces women's exposure to the associated mortality risks. We aimed to examine the effects of maternity care improvement, fertility reduction, and increased contraceptive use on maternal mortality decline between 2000 and 2023. METHODS: We conducted two sets of analyses. First, we measured the effects of maternity care improvement and fertility reduction on maternal mortality reduction at the global, regional, and national levels for 195 countries and territories with a simple decomposition method. Second, we employed a counterfactual approach to assess the effects of contraceptive use on maternal mortality reduction through fertility reduction. Data for this analysis came from the most recent database of maternal mortality trends estimations by WHO/Maternal Mortality Estimation Inter-Agency Group for 2000-23 and the UN's World Contraceptive Use 2024 database. FINDINGS: We estimated that 61·2% of global maternal mortality decline between 2000 and 2023 was attributable to improvements in maternity care and 38·8% was attributable to fertility reduction. An increase in contraceptive prevalence rate during this period prevented 77 400 maternal deaths in 2023 (approximately 24·0% of maternal deaths). The regional estimates showed that the fertility reduction effect on maternal mortality was most pronounced in Latin America and the Caribbean, sub-Saharan Africa, and eastern and southeastern Asia. INTERPRETATION: Our analysis suggests that both improved maternity care and fertility reduction, primarily through contraceptive use, substantially reduced maternal mortality globally. Accelerated efforts should be given to maternity care and family planning interventions for achieving the UN's Sustainable Development Goals 3. FUNDING: US Agency for International Development.