Maternal Mortality, Stillbirths, and Neonatal Mortality: A Transition Model Based on Analyses of 149 Countries

Abstract

Background: Maternal mortality, stillbirths and neonatal mortality account for almost 5 million deaths a year, and are often analysed separately in global health, despite having overlapping causes and interventions. We propose a comprehensive five-phase mortality transition model to improve analyses of country progress, current situation, and future trends and drivers of progress.

Methods: We used estimates for 149 countries to assess changes in maternal mortality and a single metric of stillbirths and neonatal deaths. Based on ratios of maternal to stillbirth and neonatal mortality, we identified five phases of transition, in which phase I has the highest mortality. We examined phase-specific changes during 2000-2017 for cause-of-death patterns, fertility and socioeconomic indicators, health workforce and financing, service coverage, inequalities with global estimates and data from 320 national surveys.

Findings: Among 113 countries in phases I to IV, 59% progressed at least one phase between 2000 and 2017, and four advanced two phases. The ratio of stillbirth and neonatal deaths to maternal deaths increased from less than 10 in phase I to well over 50 in phases IV and V. Progression was associated with a declining proportion of deaths due to infectious diseases and peri-partum complications, declining total and adolescent fertility rates, changes in health workforce densities, and skills mix from phase III onwards, increasing per capita health spending and reduced shares of out-of-pocket health expenditures. From phase I to V, the median coverage of first antenatal care visits increased from 78% to 98%, four or more ANC visits from 48% to 90%, institutional births from 42% to 98%, and caesarean-section rates from 3% to 27%. The transition in high mortality phases involved a major increase of births in lower-level health facilities, while subsequent progress was characterized by rapid increases in hospital births. Wealth-related inequalities decreased moderately for neonatal mortality during phase I to IV but reduced strongly for institutional birth coverage, including a shift from top to bottom inequality.

Interpretation: The five-phase maternal mortality, stillbirth and neonatal mortality transition model can be used to benchmark current situation at national or sub-national level, identify outliers to better assess drivers of progress, and inform strategic planning and investments towards SDG targets. It can also facilitate programming for integrated strategies to end preventable maternal mortality and neonatal mortality and stillbirths.

Funding: This work was conducted as part of the Maternal and Newborn Health Exemplars study, which is supported by Global Health Exemplars initiative of Gates Ventures, and the work of the Countdown to 2030 for Women’s, Children’s and Adolescents’ Health, supported by the Bill & Melinda Gates Foundation.

Declaration of Interest: The authors report no conflict of interest.

Keywords: Mortality transition, maternal mortality, stillbirths, neonatal mortality, causes of death, fertility, coverage, health systems, socioeconomic development