RICH MOTHER, POOR MOTHER:

THE SOCIAL
DETERMINANTS OF
MATERNAL DEATH
AND DISABILITY
Updated with technical feedback December 2012

Introduction
A woman’s chance of dying or becoming disabled during pregnancy and childbirth is
closely connected to her social and economic status, the norms and values of her culture,
and the geographic remoteness of her home. Generally speaking, the poorer and more
marginalized a woman is, the greater her risk of death. In fact, maternal mortality rates
reflect disparities between wealthy and poor countries more than any other measure of
health.1 A woman’s lifetime risk of dying as a result of pregnancy or childbirth is 1 in 39 in
Sub-Saharan Africa, as compared to 1 in 4,700 in industrialized countries.2

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The number of maternal deaths is highest in countries where women are least likely to have skilled
attendance at delivery, such as a midwife, doctor or other trained health professional. Likewise,
within countries, it is the poorest and least educated women who are most vulnerable to maternal
death and disability.3

High maternal mortality rates are an indication not only of poorly functioning health systems, but also
of deep-seated gender inequalities that leave women with limited control over decision-making and that
restrict their access to social support, economic opportunities and health care.4 These gender inequalities
manifest early in life; girls born into poverty are more vulnerable to child marriage and exploitation,
such as sex trafficking or forced labor. Adolescent girls frequently lack the power to decide whether

1 IN 10
contraception is used during sex, or whether sex takes places at all. This places them at high risk for
early pregnancy and its resulting complications.

GIRLS
In many developing countries, legal systems offer women and girls little support in protecting their
reproductive rights. In some cases, legislation deliberately denies such rights, such as laws that prohibit
adolescent girls from accessing contraception or that require permission from parents or husbands.5
Moreover, even where non-discriminatory laws exist, they are not universally enforced. This lack of
legal support only perpetuates gender inequalities that put women’s lives at risk.
BECOMES A MOTHER
BY AGE 16
The Current Situation
A full 36 per cent of 20 to 24 year-old women in the developing world were married before age 18.6
Rates of child marriage are three times higher among the poorest adolescent girls than among their peers
from the richest households. Early marriage puts girls at great risk for premature childbearing, disability
and death.7

In low- and middle-income countries, one in every 10 girls becomes a mother by age 16, with the
highest rates in Sub-Saharan Africa and South Central and Southeastern Asia. This compares to teen
pregnancy rates of about 3 per cent in high-income countries like Canada and Sweden.8 The risk of
maternal death is greatest for girls under age 15. Adolescent pregnancy forces many girls to drop out of
school, with long-term consequences for their futures—and those of their families and communities.9

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Poor, uneducated women in remote areas are the least likely to receive adequate maternal
health care. This is particularly true in regions with low numbers of skilled health workers, such as
Sub-Saharan Africa and South Asia. In high-income countries, virtually all women have at least four
antenatal care visits, are attended by a skilled health worker during delivery, and receive post-partum
care. In low- and middle-income countries, less than half of pregnant women receive this continuum
of care.10

In some communities, women’s health is valued less than that of men. Parents may prioritize their
sons’ over their daughters’ lives and health. Girls and women often do not have control over financial FEMALE LITERACY
resources or access to transportation, and are thus dependent on male relatives or mothers-in-law for
mobility and access to health services.11
RATES ARE A STRONG
Across the developing world, girls’ health is determined more by social forces than biological ones. PREDICTOR OF
Poverty and gender inequality put girls at risk for exploitation, physical abuse, early pregnancy and its
related risks, and sexually transmitted infections, including HIV.12
MATERNAL MORTALITY
Education is a critical determinant of women’s health. Education allows women to make informed RATES; THE MORE
choices and seek proper health care. A World Health Organization report on Asia and the Pacific
shows that female literacy rates are a strong predictor of maternal mortality rates; the more literate
LITERATE A FEMALE
the female population, the lower the maternal mortality rate.13 POPULATION, THE
The unmet need for contraception is highest among women who are poor, less educated, younger,
and living in rural areas. In many developing countries, women in the top income bracket are twice as
LOWER THE MATERNAL
likely to use modern contraceptives—women in the lowest bracket.14 Combined, 215 million women in MORTALITY RATE.
developing countries have an unmet need for contraception.15

Each day, almost 800 women—99 percent in developing countries—die from preventable causes
related to pregnancy and childbirth. Of the women who die every day, about 440 live in Sub-Saharan
Africa, 228 in South Asia and 6 in wealthy countries.16

Most maternal deaths are avoidable, as the health-care solutions to prevent or manage
complications are well established. To save lives, women need access to antenatal care during
pregnancy, skilled care at delivery, and support in the weeks after childbirth.17

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What Must Be Done? MATERNAL HEALTH IS
Reducing maternal death and disability is not just a global health issue; it is a human rights issue. The
INTRICATELY TIED TO
solutions to save women’s lives during pregnancy and childbirth are readily available, but hundreds
of thousands of women continue to die each year because of poverty, ineffective health systems, and WOMEN’S SOCIAL AND
deep-seated gender inequalities that leave girls and women unable to make informed, independent
decisions to protect their health. Tackling these problems requires action at multiple levels. ECONOMIC STATUS
The international community must prioritize investment in maternal health and family planning
policies and programs, particularly for poor women. The UN Secretary-General Ban Ki-moon’s Global
Strategy for Women’s and Children’s Health, which was launched in 2010, shows encouraging
progress in this area by harnessing increased financial resources for women’s and children’s
health. Developing countries likewise must recognize maternal health as a key development issue
and commit to enhancing the quality and accessibility of reproductive health care. This requires
expanding and improving health systems, while also educating women about their health and
addressing social and cultural factors that may discourage some of the most vulnerable women from
seeking care.

A key component of this work involves examining the attitudes and behaviors of health care
providers, which often reflect dominant cultural norms and gender attitudes, some of which can be
discriminatory towards girls and women. Saving women’s lives demands challenging harmful social
biases that drastically limit women’s choices and that deter husbands, fathers, health care providers
and policymakers from investing in girls and women. Transforming these attitudes and behaviors
requires working not only with women, but also with men and boys to demonstrate the benefits that
gender equality brings to families and communities.

At the same time, because maternal health is intricately tied to women’s social and economic status,
investments in girls’ and women’s education and empowerment are critical for averting maternal
deaths. Global efforts toward achieving Millennium Development Goals 2 and 3—to achieve
universal primary education and promote gender equality and empower women, respectively—are
thus vital for improving the health of girls, women, and their families worldwide.

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Benefits of Action
Meeting the unmet need for modern family planning and maternal and newborn health
care would reduce maternal deaths by about two-thirds—from 287,000 to 105,000.18
Investing in family planning and improved maternal health care brings complementary
benefits: better timing and spacing of pregnancies, reduced risks of complications, and WOMEN WITH NO
improvements in the health of women and newborns.19
EDUCATION WERE
Girls’ and women’s education yields critical health benefits. Using data from the World
Health Organization’s Global Survey on Maternal and Perinatal Health, researchers found NEARLY THREE TIMES
that women with no education were nearly three times more likely to die during pregnancy
and childbirth than women who had finished secondary school.20 MORE LIKELY TO DIE
A mother’s education not only helps her survive, but also plays an influential role in her DURING PREGNANCY
child’s survival past age five. Research shows that better educated mothers tend to have
healthier children.21
AND CHILDBIRTH THAN
Reducing unintended pregnancies, particularly among adolescents, would improve WOMEN WHO HAD
education and employment opportunities for women, which would in turn help improve the
FINISHED SECONDARY
status of women, increase family savings, reduce poverty and spur economic growth.22

Improvements in maternal health yield social and economic gains, helping to break SCHOOL
the intergenerational cycle of poverty. When women and couples have planned, healthy
pregnancies, there are significant development benefits for them, their children, their
communities and their countries.23

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What is UNFPA Doing? UNFPA’S MATERNAL
UNFPA works to uphold the reproductive rights of girls and women by influencing policy and HEALTH PROGRAMS
legislation; helping governments to strengthen their health care systems; mobilizing community-
based leaders and organizations to change behaviors and attitudes; engaging men as partners SPAN MORE THAN
in reproductive health; empowering young people through sexuality education and access to
90 COUNTRIES
equitable health services; and encouraging girls’ and women’s participation in decision-making
at all levels. The Fund is at the forefront of advocating for women and defending their rights to
education, health, and freedom from exploitation and violence.24

Safe motherhood is a critical component of women’s well-being and empowerment. UNFPA’s

maternal health programs span more than 90 countries and focus on making long-term
improvements in health systems to prevent maternal death and disability, including obstetric
fistula. In 2008, UNFPA established the Maternal Health Thematic Fund to increase the
capacity of national health systems to provide a broad range of quality
maternal health services, reduce health inequities, and empower
women to exercise their right to maternal health. UNFPA also
works in partnership with UNAIDS, UNICEF, the World Bank,
and the World Health Organization to accelerate progress on
saving the lives of women and mothers in countries with
the highest maternal mortality rates.25

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NOTES
1 World Health Organization, “Health in Asia and the Pacific,” 2008.
2 World Health Organization, UNICEF, UNFPA and The World Bank, “Trends in Maternal Mortality:
1990-2010,” 2012.
3 United Nations, “The Millennium Development Goals Report 2011.”
4 World Health Organization, “Health in Asia and the Pacific,” 2008.
5 Center for Global Development, “Start with a Girl: A New Agenda for Global Health,” 2009. For more information on
6 Ibid.
7 UNICEF, “The State of the World’s Children 2011.” UNFPA’s work, please
8 Guttmacher Institute, “Facts on American Teens’ Sexual and Reproductive Health,” Accessed March 25, 2012.
9 World Health Organization, “Adolescent Pregnancy.” Accessed March 6, 2012. visit www.unfpa.org.
10 Ibid.
11 World Health Organization, “Health in Asia and the Pacific,” 2008.
12 Center for Global Development, “Start with a Girl: A New Agenda for Global Health,” 2009.
13 World Health Organization, “Health in Asia and the Pacific,” 2008. Information about the United
14 UNFPA and Guttmacher Institute, “Adding it Up: The Costs and Benefits of Investing in Family Planning and
Maternal and Newborn Health,” 2009.
Nations Every Woman Every Child
15 Guttmacher Institute, “Facts on Satisfying the Need for Contraceptive Use in Developing Countries,” June 2010. campaign can be found at
16 World Health Organization, UNICEF, UNFPA and The World Bank, “Trends in Maternal Mortality: 1990-2010,” 2012.
17 World Health Organization, “Maternal Mortality Fact Sheet,” November 2010.
www.everywomaneverychild.org.
18 World Health Organization, UNICEF, UNFPA and The World Bank, “Trends in Maternal Mortality: 1990-2010,” 2012.
19 UNFPA and Guttmacher Institute, “Adding it Up: The Costs and Benefits of Investing in Family Planning and
Maternal and Newborn Health,” 2009.
20 Karlsen, Saffron et al., “The relationship between maternal education and mortality among women giving birth in
health care institutions: Analysis of the cross sectional WHO Global Survey on Maternal and Perinatal Health,”
BMC Public Health 2011, 11: 606.
21 United Nations, “The Millennium Development Goals Report 2011.”
22 UNFPA and Guttmacher Institute, “Adding it Up: The Costs and Benefits of Investing in Family Planning and
Maternal and Newborn Health,” 2009.
23 Ibid.
24 UNFPA website, “Advancing Human Rights,” Accessed February 20, 2012.
25 UNFPA website, “Safe Motherhood: Overview,” Accessed February 20, 2012.

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