Globally, the maternal mortality ratio nearly halved between 1990 and 2015. However, progress was patchy, with only nine countries with an initial maternal mortality ratio greater than 100 achieving the Millennium Development Goal (MDG) 5 target of 75% reduction.1 26 countries made no progress, and in 12 countries—including the USA— maternal mortality ratios increased.1 A woman’s lifetime risk of dying as a result of pregnancy and childbirth remains more than 100 times higher in sub-Saharan Africa than in high-income countries.1 Deaths of newborn babies have also declined at a slower rate than those of older infants and children, and stillbirths remain high.2, 3, 4
Yet maternity service use has increased substantially in the past 10 years since the 2006 Lancet maternal health Series: three-quarters of women now deliver with a skilled birth attendant and two-thirds receive at least four antenatal care visits worldwide.5, 6 This mismatch between burden and coverage exposes a crucial gap in quality of care. Millions of women receive services that are delayed, inadequate, unnecessary, or harmful,7, 8, 9 minimising the opportunity for health gains for both mothers and babies.
In parallel to the women accessing services but receiving poor-quality care, millions of women and adolescents who undertake their journey through pregnancy and childbirth outside the health system are left behind from the progress in coverage. They represent a vulnerable population facing multiple challenges that arise from their individual circumstances. Statistics show a growing divergence within and between countries in coverage of maternity services for women, mirrored by a doubling of the gap in levels of maternal mortality between the best and worst performing countries in the past 20 years.10
The dual streams of poor-quality or inaccessible care coexist everywhere—a universality that spans countries of low, middle and high income, including fragile and conflict-affected nations; and those considered economically and politically stable. Every woman, everywhere, has a right to access quality maternity services, and the benefits of such access extend to the fetus, newborn babies, children, and adolescents. Effectively addressing maternal health requires integrated programming that takes into account these inextricable linkages, and requires connections with the broader social and political context in which women live (appendix). The breadth and complexity of such linkages are reflected across the Lancet Series and other publications on stillbirths, newborn babies, midwifery, and adolescent health.
In this paper, we highlight the most pressing issues in maternal health and ask two questions: what actions can be taken in the next 5 years to achieve the Sustainable Development Goal (SDG) target of a global maternal mortality ratio less than 70 maternal deaths per 100 000 livebirths by 2030, with no single country having a maternal mortality ratio greater than 140 maternal deaths per 100 000 livebirths? What steps can be taken to ensure that high-quality maternal health care is prioritised for every woman (including adolescents) and baby everywhere, supporting the vision of the Global Strategy for Women’s, Children’s, and Adolescent Health?
We consulted experts, reviewed the literature, and carefully analysed the five papers of this Series; our overall themes are to improve maternal health, ensure the quality of maternal health care for all women and adolescents, and guarantee access to care for those left behind who are most vulnerable. These themes underlie the priority areas for action summarised in panel 1.
Key messages
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The MDG5 target to reduce maternal mortality by 75% was not achieved. The gap between countries with highest and lowest mortality has increased despite increased use of maternity care.
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This mismatch exposes an important gap in quality of care—delayed, inadequate, unnecessary, or even harmful services—minimising the opportunity for health gains for mothers and babies.
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In parallel, millions of pregnant women and adolescents are left behind from the progress in coverage.
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Poor-quality and inaccessible care coexist everywhere—in countries of low, middle, and high income; in fragile nations; and in those considered economically and politically stable.
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Five priorities require immediate attention to catalyse action and support the vision of global initiatives to achieve the SDG3 global target of a maternal mortality ratio of less than 70: (1) prioritise quality maternal health services that respond to local specificities of need and meet emerging challenges; (2) promote equity through universal coverage of quality maternal health services, including for the most vulnerable women; (3) increase resilience and strength of health systems by optimising the health workforce and improving facility capability; (4) guarantee sustainable financing for maternal–perinatal health; and (5) accelerate progress through evidence, advocacy, and accountability.
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Crucial to achieving equity will be the growing pressure on national and regional governments in even the poorest countries to provide universal health coverage.
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As conditions evolve, and women’s preferences change and diversify, these priorities will require strong partnerships between the maternal health community and those addressing reproductive, newborn, child, and adolescent health care more broadly; those focused on the increasing burden of non-communicable diseases, malnutrition, infectious diseases, and mental ill-health; and those focused on other SDG targets, from ending poverty to building resilient infrastructure.
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To achieve and accelerate these actions will result in benefits for women, newborn babies, and stillbirths, that will extend to children, families, and the community, in this generation and the next.
