Nearly two-thirds of all maternal deaths worldwide occur in countries marked by conflict or fragility. The risk of a woman who lives in a country affected by conflict dying due to maternal causes is around five times higher for each pregnancy she undergoes compared to her peers in stable countries.
A new technical brief offers analysis as to why pregnant women living in certain countries are more likely to die in childbirth.
In 2023 alone, an estimated 160 000 women died from preventable maternal causes in fragile and conflict-affected settings, that is 6 in 10 maternal deaths worldwide, despite these countries accounting for only around one in ten of global live births.
The brief from World Health Organization (WHO) and HRP (the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction) aligns the latest maternal mortality ratio (MMR) estimates with whether a country is conflict-affected or considered fragile.
Maternal deaths concentrated in fragile settings
Countries classified as conflict-affected had an estimated MMR of 504 deaths per 100 000 live births, while countries considered institutionally and socially fragile had an MMR of 368. In contrast, countries outside both categories saw a much lower MMR of 99.
These findings deepen the picture provided in last year's maternal mortality estimates 2000-2023 , which showed that global progress has stalled and that maternal mortality remains staggeringly high in low-income and crisis-affected settings, which spurred this further analysis.
Fragility disrupts maternal health care
This new analysis confirms what many practitioners see on the ground: crises create conditions where health systems cannot consistently deliver lifesaving maternal care. The brief also identifies that the intersection of gender, ethnicity, age and migration status can increase the risk women and girls face who are both pregnant and living in fragile contexts.
The disparity of risk is stark: a 15-year-old girl living in a country or territory affected by conflict in 2023 had a 1 in 51 lifetime risk of eventually dying from a maternal cause, compared with a 1 in 79 risk in a country or territory affected by institutional and social fragility, and 1 in 593 for a 15-year-old girl living in a relatively stable country.
Country experiences illustrate what works
The publication also offers case studies of how frontline teams are striving to maintain maternal health services amid instability. Solutions in Colombia, Ethiopia, Haiti, Myanmar, Papua New Guinea and Ukraine demonstrate that even where health systems face extreme pressure, innovative approaches can protect maternal health. They show communities adapting services to cultural needs, health workers restoring disrupted services, hospitals reorganizing care under security threats and coordination mechanisms evolving to ensure continuity of care.
In Colombia, training traditional birth attendants shows how strengthening trusted local networks can ensure timely care even where access is limited due to geography, insecurity or mistrust. establishing continuity of care through mobile teams, renovated facilities and additional midwives
In Ethiopia, the emphasis is on reestablishing continuity of care through mobile teams, renovated facilities and additional midwives. These are practical measures that help restore services after disruption.
Haiti demonstrates the importance of removing cost and infrastructure barriers, with free or low-cost caesarean sections and reliable electricity power, making lifesaving care available to displaced women who would otherwise have no access.
Myanmar, Papua New Guinea and Ukraine show that, even amid complex crises or conflict, women benefit when systems focus on protecting essential maternal services, whether through planning at subnational level, improving respectful and safe childbirth practices or reorganizing patient pathways to safer facilities.
Using fragility-aligned MMR data for action
By linking MMR data to the fragility classification, HRP, WHO and partners now have a more precise tool to identify where health system strengthening is most urgently needed. The brief emphasizes the importance of investing in primary health care to maintain essential maternal services during crises; strengthening data collection in hard-to-reach settings, to ensure no deaths go uncounted, and supporting resilient health system design, able to absorb and adapt to shocks.
Together, these efforts can help accelerate progress toward reducing preventable maternal deaths, even in the world's most challenging environments.
