Objective: The aim of this article is to describe the incidence and characteristics of pregnancy-related death in low- and middle-resource settings, in relation to the availability of key obstetric resources. Design: This is a secondary analysis of a stepped-wedge cluster randomised controlled trial. Setting: This trial was undertaken at ten sites across eight low- and middle-income countries in sub-Saharan Africa, India and Haiti. Population: Institutional-level consent was obtained and all women presenting for maternity care were eligible for inclusion. Methods: Pregnancy-related deaths were collected prospectively from routine data sources and active case searching. Main outcome measures: Pregnancy-related death, place, timing and age of maternal death, and neonatal outcomes in women with this outcome. Results: Over 20 months, in 536 233 deliveries there were 998 maternal deaths (18.6/10 000, range 28/10 000–630/10 000). The leading causes of death were obstetric haemorrhage (36.0%, n = 359), hypertensive disorders of pregnancy (20.6%, n = 206), sepsis (14.1%, n = 141) and other (26.5%, n = 264). Approximately a quarter of deaths occurred prior to delivery (28.4%, n = 283), 35.7% (n = 356) occurred on the day of delivery and 35.9% (n = 359) occurred after delivery. Half of maternal deaths (50.6%; n = 505) occurred in women aged 20–29 years, 10.3% (n = 103) occurred in women aged under 20 years, 34.5% (n = 344) occurred in women aged 30–39 years and 4.6% (n = 46) occurred in women aged ≥40 years. There was no measured association between the availability of key obstetric resources and the rate of pregnancy-related death. Conclusions: The large variation in the rate of pregnancy-related death, irrespective of resource availability, emphasises that inequality and inequity in health care persists. Tweetable abstract: Inequality and inequity in pregnancy-related death persists globally, irrespective of resource availability.

Original languageEnglish
Pages (from-to)1082-1089
Number of pages8
Issue number9
Early online date7 May 2020
Publication statusPublished - 1 Aug 2020


  • Epidemiology
  • low and middle resource
  • maternal mortality


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