Although research in maternal and perinatal health has made significant progress in recent years, most of this progress has been driven by the needs of health systems operating in the richest countries. This has resulted in the production of pregnancy- and childbirth-related interventions which translate poorly into low-resource settings, exacerbating the persistent gaps in women’s sexual and reproductive health conditions around the world. The paucity of research efforts targeted at conditions disproportionately affecting women in the developing- country context has simultaneously prevented the development of effective, affordable, and feasible preventive strategies that could be widely applied.

Haemorrhage and hypertensive disorders together account for the largest proportion of maternal deaths in developing countries, according to an HRP study, believed to be the first to use the systematic review approach to analyse causes of maternal mortality. The results of the review, which was recently published in the British medical journal The Lancet,(1) are based on an analysis of 160 datasets, or studies, that came from a multiplicity of sources—general and specialized databases, reference lists from studies produced by a search of these databases, personal contacts with WHO country representatives, nongovernmental organizations, journal articles and vital registry data, to mention only the major sources. These sources produced 64 585 titles of reports, from which 1143 potentially usable datasets were identified and finally whittled down to the 160 that were used for the analysis.
The previous and most commonly cited estimate, reported in 1991, on causes of maternal mortality also found haemorrhage to be the major killer among women in pregnancy or childbirth. The new study, however, provides insights into the differential ranking of other causes of maternal death in different regions. Deaths due to abortion, for example appear to be a frequent cause in Latin America and the Caribbean, account Africa, sepsis, accounting for 10% of maternal deaths, and HIV/AIDS, accounting for 6%, are clearly major problems. Logical conclusions emerge from the systematic review. The authors believe that governments in developing countries should give greater emphasis to programmes aimed at preventing and treating the leading cause of maternal deaths, namely haemorrhage, both pre- and postpartum. “At the very least,” they write, “most postpartum haemorrhage deaths should be avoidable by appropriate diagnosis and management.” As for hypertensive disorders, the second most common cause of maternal death, greater use of magnesium sulfate is clearly called for. Finally, deaths resulting from presumably unsafe abortion highlight the need for wider availability of “services that can help women avoid unwanted births”.
A situation in which a "very ill pregnant or recently delivered woman would have died had it not been for luck and good care" has entered the obstetric literature under the term “severe acute maternal morbidity (SAMM)”, more commonly known as “a near miss”. Of the studies included in the overall systematic review, 30 included reports of SAMM cases for the period 1997–2002. An HRP analysis of these reports showed prevalence rates ranging from 0.38% to 8.23% for the period of interest. Complicating the analysis is the existence of several definitions of SAMM. One common definition is based on the disease or disorder that caused the “near miss”, such as preeclampsia, haemorrhage, and so on. A second common definition focuses more on how the problem was managed, such as by hysterectomy or admission to an intensive care unit. A third, more exact, definition is based on failure of specific body organs as a result of pregnancy-related conditions. As per this last definition, the study showed that, of pregnant women who deliver in hospitals in resource-poor areas, 4%–8% will experience SAMM, versus about 1% for women delivering in more developed areas.

Uterine rupture, or tearing of the uterine wall during pregnancy or delivery, often results in the death of the baby and sometimes of the mother. In some cases, the uterus suffers irreparable damage and has to be removed. An HRP systematic review covering all the available data on this morbidity found that in most countries prevalence rates are in the 0.1%–1.0% range. The median prevalence rates of uterine rupture in community- and hospital-based studies were 0.05% and 0.31%, respectively. In women who had had a previous caesarean section, the prevalence of ruptured uterus was about 1%. The review was based on 86 groups of women participating in 83 studies. Less developed countries had a higher prevalence rate than more developed countries. Reports from four developing countries— Bangladesh, Ethiopia, Ghana and Nigeria—showed that about 75% of cases of uterine rupture occur in women with an unscarred uterus. They also found that in 1%– 13% of cases of uterine rupture the mother dies and that in 74%–92% of cases the baby dies. The authors of the systematic review suggest four approaches to reducing the prevalence of rupture of an unscarred uterus: (i) by reducing the number of unwanted pregnancies, particularly in high-parity women; (ii) by increasing access to obstetric services, including caesarean section for obstructed labour; (iii) by innovative solutions such as symphysiotomy or caesarean section with local analgesia in areas were conventional caesarean section facilities are unavailable; and (iv) by wide distribution of guidelines on the use of miso-prostol to induce labour to ensure that the drug is used in safe doses.

The prevalence of stillbirth is on average three times more common in the less developed areas of the world than in the more developed areas. This differential emerged clearly from a systematic review covering 50 countries and 70 studies. The review, which involved a meta-analysis, found that in less developed settings 1.17% of births were stillbirths versus 0.5% in more developed settings. This finding suggests that development status of a country or area is a strong predictor of its stillbirth prevalence. The highest stillbirth prevalence rates, ranging from about 3% to just over 6%, are in western Africa, the review found. The finding that even in developed countries about 1% of all births are stillbirths should, the authors of the review maintain, “alert policy-makers to initiate audit procedures to identify avoidable cases and take action”.