Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Overview of maternal mortality and morbidity

Haywood L Brown, MD
Maria J Small, MD, MPH
Section Editor
Lynn L Simpson, MD
Deputy Editor
Kristen Eckler, MD, FACOG


An estimated 300,000 women died globally in 2015 as a result of pregnancy-related conditions [1]. Although maternal mortality ratios remain elevated in many areas, the maternal mortality ratio has decreased by 1.3 percent per year globally since 1990, with the greatest annualized rate of reduction in developed countries (-3.1 percent versus -1.4 percent in developing countries). During the same time period, however, the maternal mortality ratio in the United States increased [2]. Globally, reduction in maternal mortality has been attributed to reduction in the total fertility rate, increase in maternal education, and increased access to skilled birth attendants [2]. Other factors associated with maternal mortality reduction include the promotion of policies to reduce anemia and malnutrition, prevent malaria in pregnancy, provide calcium and micronutrient supplementation, encourage delivery in facilities properly resourced for emergency obstetric care, discourage early motherhood, and reduce unsafe pregnancy termination.


The International Code of Diseases (ICD-10) definitions for maternal death and its subclassifications are as follows [3,4]:

Maternal death — The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes [3]. Most (62 percent) maternal deaths occurred in sub-Saharan Africa (179,000 deaths) [5]. Nearly a third of maternal deaths worldwide occurred in two countries: 17 percent in India (50,000 deaths in 2013) and 14 percent in Nigeria (40,000 deaths).

Late maternal death — The death of a woman from direct or indirect obstetrical causes more than 42 days, but less than one year, after termination of pregnancy.

Pregnancy related death — Death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death. These deaths may be from accidental or incidental causes.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Oct 04, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Alkema L, Chou D, Hogan D, et al. Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group. Lancet 2016; 387:462.
  2. Hogan MC, Foreman KJ, Naghavi M, et al. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010; 375:1609.
  3. AbouZahar, C, Wardlaw, T. Maternal Mortality in 2000: estimates developed by WHO, UNICEF and UNFPA. WHO. 2003. Geneva, Switzerland.
  4. International statistical classification of Diseases and Related Health Problems, Tenth Revision (ICD 10). Geneva, Switzerland, World Health Organization 1992.
  5. Gulland A. Worldwide maternal mortality rate falls by 45% in 13 years. BMJ 2014; 348:g3150.
  6. Say L, Chou D, Gemmill A, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health 2014; 2:e323.
  7. GBD 2015 Maternal Mortality Collaborators. Global, regional, and national levels of maternal mortality, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388:1775.
  8. Louie JK, Acosta M, Jamieson DJ, et al. Severe 2009 H1N1 influenza in pregnant and postpartum women in California. N Engl J Med 2010; 362:27.
  9. Moaddab A, Dildy GA, Brown HL, et al. Health Care Disparity and State-Specific Pregnancy-Related Mortality in the United States, 2005-2014. Obstet Gynecol 2016; 128:869.
  10. Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, et al. Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384:980.
  11. Berg CJ, Chang J, Callaghan WM, Whitehead SJ. Pregnancy-related mortality in the United States, 1991-1997. Obstet Gynecol 2003; 101:289.
  12. MacKAy AP, Berg CJ, Liu X, et al. Changes in pregnancy mortality ascertainment: United States, 1999-2005. Obstet Gynecol 2011; 118:104.
  13. Maternal mortality and related concepts. VItal and Health Statistics. Dept of Health and Human Services. February 2007.
  14. Horon IL. Underreporting of maternal deaths on death certificates and the magnitude of the problem of maternal mortality. Am J Public Health 2005; 95:478.
  15. Graham WJ, Ahmed S, Stanton C, et al. Measuring maternal mortality: an overview of opportunities and options for developing countries. BMC Med 2008; 6:12.
  16. Donati S, Senatore S, Ronconi A, Regional maternal mortality working group. Maternal mortality in Italy: a record-linkage study. BJOG 2011; 118:872.
  17. de Swiet M. Maternal mortality: confidential enquiries into maternal deaths in the United Kingdom. Am J Obstet Gynecol 2000; 182:760.
  18. Lewis G, Drise J, Botting B, et al. Why mothers die: Report on Confidential Enquiries into Maternal Deaths in the United Kingdom, 1997-1999, Department of Health on behalf of the controller of Her majesty's Stationery Office, London 2001.
  19. Geller SE, Rosenberg D, Cox SM, et al. The continuum of maternal morbidity and mortality: factors associated with severity. Am J Obstet Gynecol 2004; 191:939.
  20. Saving Mothers' Lives: Reviewing Maternal Deaths to Make Childhood Safer - 2003-2005. In: The Confidential Enquiry into Maternal and Child Health (CEMACH), Lewis G (Ed), CEMACH, London 2007.
  21. Kurinczuk JJ, Draper ES, Field DJ, et al. Experiences with maternal and perinatal death reviews in the UK--the MBRRACE-UK programme. BJOG 2014; 121 Suppl 4:41.
  22. www.who.org/reproductive-health/publications/rht_97_28/RHT_97_28_chapter2.en.html (Accessed on August 28, 2008).
  23. MacKay AP, Berg CJ, Duran C, et al. An assessment of pregnancy-related mortality in the United States. Paediatr Perinat Epidemiol 2005; 19:206.
  24. Davis NL, Hoyert DL, Goodman DA, et al. Contribution of maternal age and pregnancy checkbox on maternal mortality ratios in the United States, 1978-2012. Am J Obstet Gynecol 2017; 217:352.e1.
  25. Horon IL, Cheng D. Effectiveness of pregnancy check boxes on death certificates in identifying pregnancy-associated mortality. Public Health Rep 2011; 126:195.
  26. MacDorman MF, Declercq E, Cabral H, Morton C. Recent Increases in the U.S. Maternal Mortality Rate: Disentangling Trends From Measurement Issues. Obstet Gynecol 2016; 128:447.
  27. Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med 1994; 38:1091.
  28. Barnes-Josiah D, Myntti C, Augustin A. The "three delays" as a framework for examining maternal mortality in Haiti. Soc Sci Med 1998; 46:981.
  29. Berg CJ, Harper MA, Atkinson SM, et al. Preventability of pregnancy-related deaths: results of a state-wide review. Obstet Gynecol 2005; 106:1228.
  30. Cantwell R, Clutton-Brock T, Cooper G, et al. Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer: 2006-2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011; 118 Suppl 1:1.
  31. Saucedo M, Deneux-Tharaux C, Bouvier-Colle MH, French National Experts Committee on Maternal Mortality. Ten years of confidential inquiries into maternal deaths in France, 1998-2007. Obstet Gynecol 2013; 122:752.
  32. Frölich MA, Banks C, Brooks A, et al. Why do pregnant women die? A review of maternal deaths from 1990 to 2010 at the University of Alabama at Birmingham. Anesth Analg 2014; 119:1135.
  33. WHO. Ten leading causes of death in women aged 15–44 years by country income group, 2004. http://www.who.int/gender/women_health_report/womenandhealth_report_chart_chp4_table1.pdf.
  34. Chang J, Berg CJ, Saltzman LE, Herndon J. Homicide: a leading cause of injury deaths among pregnant and postpartum women in the United States, 1991-1999. Am J Public Health 2005; 95:471.
  35. Fildes J, Reed L, Jones N, et al. Trauma: the leading cause of maternal death. J Trauma 1992; 32:643.
  36. Harper M, Parsons L. Maternal deaths due to homicide and other injuries in North Carolina: 1992-1994. Obstet Gynecol 1997; 90:920.
  37. Palladino CL, Singh V, Campbell J, et al. Homicide and suicide during the perinatal period: findings from the National Violent Death Reporting System. Obstet Gynecol 2011; 118:1056.
  38. Metz TD, Rovner P, Hoffman MC, et al. Maternal deaths from suicide and overdose in Colorado, 2004-2012. Obstet Gynecol 2016.
  39. Grigoriadis S, Wilton AS, Kurdyak PA, et al. Perinatal suicide in Ontario, Canada: a 15-year population-based study. CMAJ 2017; 189:E1085.
  40. South Africa Every Death Counts Writing Group, Bradshaw D, Chopra M, et al. Every death counts: use of mortality audit data for decision making to save the lives of mothers, babies, and children in South Africa. Lancet 2008; 371:1294.
  41. Trends in maternal mortality: 1990 to 2008 Estimates developed by WHO, UNICEF, UNFPA and The World Bank http://www.who.int/reproductivehealth/publications/monitoring/9789241500265/en/index.html (Accessed on March 14, 2011).
  42. Anema A, Au-Yeung CG, Joffres M, et al. Estimating the impact of expanded access to antiretroviral therapy on maternal, paternal and double orphans in sub-Saharan Africa, 2009-2020. AIDS Res Ther 2011; 8:13.
  43. Creanga AA, Berg CJ, Syverson C, et al. Pregnancy-related mortality in the United States, 2006-2010. Obstet Gynecol 2015; 125:5.
  44. Berg CJ, Callaghan WM, Syverson C, Henderson Z. Pregnancy-related mortality in the United States, 1998 to 2005. Obstet Gynecol 2010; 116:1302.
  45. Berg CJ, Atrash HK, Koonin LM, Tucker M. Pregnancy-related mortality in the United States, 1987-1990. Obstet Gynecol 1996; 88:161.
  46. Creanga AA, Syverson C, Seed K, Callaghan WM. Pregnancy-Related Mortality in the United States, 2011-2013. Obstet Gynecol 2017; 130:366.
  47. Lisonkova S, Haslam MD, Dahlgren L, et al. Maternal morbidity and perinatal outcomes among women in rural versus urban areas. CMAJ 2016; 188:E456.
  48. Chang J, Elam-Evans LD, Berg CJ, et al. Pregnancy-related mortality surveillance--United States, 1991--1999. MMWR Surveill Summ 2003; 52:1.
  49. Louis JM, Menard MK, Gee RE. Racial and ethnic disparities in maternal morbidity and mortality. Obstet Gynecol 2015; 125:690.
  50. Centers for Disease Control and Prevention Pregnancy Mortality Surveillance System. Reviewed January 31, 2017. www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html (Accessed on June 05, 2017).
  51. Centers for Disease Control and Prevention (CDC). State-specific maternal mortality among black and white women--United States, 1987-1996. MMWR Morb Mortal Wkly Rep 1999; 48:492.
  52. Tucker MJ, Berg CJ, Callaghan WM, Hsia J. The Black-White disparity in pregnancy-related mortality from 5 conditions: differences in prevalence and case-fatality rates. Am J Public Health 2007; 97:247.
  53. Knight M, Kurinczuk JJ, Spark P, et al. Inequalities in maternal health: national cohort study of ethnic variation in severe maternal morbidities. BMJ 2009; 338:b542.
  54. Nair M, Kurinczuk JJ, Knight M. Ethnic variations in severe maternal morbidity in the UK- a case control study. PLoS One 2014; 9:e95086.
  55. Reime B, Janssen PA, Farris L, et al. Maternal near-miss among women with a migrant background in Germany. Acta Obstet Gynecol Scand 2012; 91:824.
  56. Zwart JJ, Jonkers MD, Richters A, et al. Ethnic disparity in severe acute maternal morbidity: a nationwide cohort study in the Netherlands. Eur J Public Health 2011; 21:229.
  57. Jonkers M, Richters A, Zwart J, et al. Severe maternal morbidity among immigrant women in the Netherlands: patients' perspectives. Reprod Health Matters 2011; 19:144.
  58. Grotegut CA, Chisholm CA, Johnson LN, et al. Medical and obstetric complications among pregnant women aged 45 and older. PLoS One 2014; 9:e96237.
  59. McCall SJ, Nair M, Knight M. Factors associated with maternal mortality at advanced maternal age: a population-based case-control study. BJOG 2017; 124:1225.
  60. The Joint Commission. Sentinel Event Alert. Preventing Maternal Death. Issue 44. January 2010. http://www.jointcommission.org/assets/1/18/SEA_44.PDF (Accessed on March 22, 2011).
  61. Hasegawa J, Ikeda T, Sekizawa A, et al. Recommendations for saving mothers' lives in Japan: Report from the Maternal Death Exploratory Committee (2010-2014). J Obstet Gynaecol Res 2016; 42:1637.
  62. Knight M, Nair M, Tuffnell D, Kenyon S, Shakespeare J, Brocklehurst P, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care - Surveillance of maternal deaths in the UK 2012-14 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-14. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2016. https://www.npeu.ox.ac.uk/mbrrace-uk/reports (Accessed on December 21, 2016).
  63. Shields L, Weisner S, Klein C, et al. Use of maternal early warning trigger tool reduces marternal morbility. Am J Obstet Gynecol 2016; 214:527.e1.
  64. The Joint Commission. Sentinel Event Alert. Preventing Maternal Death. Issue 44. January 2010. http://www.jointcommission.org/assets/1/18/SEA_44.PDF (Accessed on June 22, 2012).
  65. California Maternal Quality Care Collaborative, Hemorrhage Taskforce. Improving Healthcare Response to Obstetric Hemorrhage Toolkit. Palo Alto; CMQCC; 2010. www.cmqcc.org/ob_hemorrhage (Accessed on June 22, 2012).
  66. Clark SL, Christmas JT, Frye DR, et al. Maternal mortality in the United States: predictability and the impact of protocols on fatal postcesarean pulmonary embolism and hypertension-related intracranial hemorrhage. Am J Obstet Gynecol 2014; 211:32.e1.
  67. Main EK, McCain CL, Morton CH, et al. Pregnancy-related mortality in California: causes, characteristics, and improvement opportunities. Obstet Gynecol 2015; 125:938.
  68. Gelson E, Gatzoulis MA, Steer P, Johnson MR. Heart disease--why is maternal mortality increasing? BJOG 2009; 116:609.
  69. The Joint Commission. Comprehensive accreditation manual for hospitals, Update 2, January 2015: Sentinel Events: SE-1. http://www.jointcommission.org/assets/1/6/CAMH_24_SE_all_CURRENT.pdf.
  70. Say L, Pattinson RC, Gülmezoglu AM. WHO systematic review of maternal morbidity and mortality: the prevalence of severe acute maternal morbidity (near miss). Reprod Health 2004; 1:3.
  71. World Health Organization. Evaluating the quality of care for severe pregnancy complications, The WHO Near-Miss Approach for Maternal Health, WHO, Geneva, Switzerland, 2011, http://whqlibdoc.who.int/publications/2011/9789241502221_eng.pdf.
  72. Ronsmans C, Graham WJ, Lancet Maternal Survival Series steering group. Maternal mortality: who, when, where, and why. Lancet 2006; 368:1189.
  73. Mantel GD, Buchmann E, Rees H, Pattinson RC. Severe acute maternal morbidity: a pilot study of a definition for a near-miss. Br J Obstet Gynaecol 1998; 105:985.
  74. Wilson RE, Salihu HM. The paradox of obstetric "near misses": converting maternal mortality into morbidity. Int J Fertil Womens Med 2007; 52:121.
  75. Tunçalp Ö, Souza JP. Maternal near-miss audits to improve quality of care. BJOG 2014; 121 Suppl 4:102.
  76. van Roosmalen J, Zwart J. Severe acute maternal morbidity in high-income countries. Best Pract Res Clin Obstet Gynaecol 2009; 23:297.
  77. Filippi V, Brugha R, Browne E, et al. Obstetric audit in resource-poor settings: lessons from a multi-country project auditing 'near miss' obstetrical emergencies. Health Policy Plan 2004; 19:57.
  78. Geller SE, Rosenberg D, Cox SM, Kilpatrick S. Defining a conceptual framework for near-miss maternal morbidity. J Am Med Womens Assoc (1972) 2002; 57:135.
  79. Kilpatrick SJ, Berg C, Bernstein P, et al. Standardized severe maternal morbidity review: rationale and process. Obstet Gynecol 2014; 124:361.
  80. UKOSS. www.npeu.ox.ac.uk/ukoss.
  81. Pattinson RC, Hall M. Near misses: a useful adjunct to maternal death enquiries. Br Med Bull 2003; 67:231.
  82. Geller SE, Cox SM, Kilpatrick SJ. A descriptive model of preventability in maternal morbidity and mortality. J Perinatol 2006; 26:79.
  83. Geller SE, Cox SM, Callaghan WM, Berg CJ. Morbidity and mortality in pregnancy: laying the groundwork for safe motherhood. Womens Health Issues 2006; 16:176.
  84. Mantel GD, Buchmann E, Rees H, Pattinson RC. Severe acute maternal morbidity: a pilot study of a definition for a near-miss. Br J Obstet Gynaecol 1998; 105:985.
  85. Ozimek JA, Eddins RM, Greene N, et al. Opportunities for Improvement in Care Among Women with Severe Maternal Morbidity. Am J Obstet Gynecol 2016.
  86. Filippi V, Ganaba R, Baggaley RF, et al. Health of women after severe obstetric complications in Burkina Faso: a longitudinal study. Lancet 2007; 370:1329.
  87. Mhyre JM, DʼOria R, Hameed AB, et al. The maternal early warning criteria: A proposal from the national partnership for maternal safety. Obstet Gynecol 2014; 124:782.
  88. Singh A, Guleria K, Vaid NB, Jain S. Evaluation of maternal early obstetric warning system (MEOWS chart) as a predictor of obstetric morbidity: a prospective observational study. Eur J Obstet Gynecol Reprod Biol 2016; 207:11.
  89. Lewis, G (ed) 2007. The Confi dential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer - 2003-2005. The Seventh Report on Confi dential Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH http://www.publichealth.hscni.net/sites/default/files/Saving%20Mothers'%20Lives%202003-05%20.pdf (Accessed on November 07, 2016).
  90. Kilpatrick SJ, Abreo A, Gould J, et al. Confirmed severe maternal morbidity is associated with high rate of preterm delivery. Am J Obstet Gynecol 2016; 215:233.e1.
  91. Howell EA, Egorova NN, Balbierz A, et al. Site of delivery contribution to black-white severe maternal morbidity disparity. Am J Obstet Gynecol 2016; 215:143.
  92. Howell EA, Egorova NN, Janevic T, et al. Severe Maternal Morbidity Among Hispanic Women in New York City: Investigation of Health Disparities. Obstet Gynecol 2017; 129:285.