The performance of the maternal mortality ratio in Africa signals an urgent need for action in order for goal 5 to be attained. According to a WHO study (2008), almost 265 000 maternal deaths, or half of global maternal deaths were recorded in Sub-Saharan Africa. The number of maternal deaths per 100 000 live births varies from 2 100 in Sierra Leone to 23 in Mauritius, with 8 countries registering rates of over 1 000. With a less than 1 per cent reduction in the ratio between 1990 and 2007, a great deal of ground remains to be covered to reach the target. With the exception of Eastern Africa, which experienced a 49 per cent reduction from relatively high initial rates, in other regions maternal health has stagnated or declined.
Only 26.9 per cent of countries made sufficient efforts to reach the target by 2015. While Mauritius, Cape Verde, Tunisia and South Africa have reached the target from poor starting ratios, Rwanda, Eritrea, and Mozambique have performed remarkably well reducing mortality by more than 50 per cent (or more than 60 per cent for some). With ratios now below 1 000, this progress has enabled these countries to improve their standing in terms of this target. In contrast, in 21 countries, maternal health has deteriorated with increases in the mortality ratio sometimes in excess of 60 or 70 per cent. The situation is particularly worrying in Liberia, Guinea, Mali, Malawi and Central Africa Republic where ratios are near the critical threshold of 1 000 as well as for Sierra Leone and Angola for which the ratio of 1 000 appears increasingly out of reach.
Maternal mortality is linked to complications arising from pregnancy or childbirth. The main causes, in decreasing order of importance, are: haemorrhage; sepsis and infections, including HIV; hypertensive disorders; complications following abortion; and obstructed labour. In Niger the risk of maternal mortality over a lifetime is highest, with a mortality rate linked to pregnancy of 1 in 7, compared with 1 in 3300 women in Mauritius (1 in 15 women in Mali). Lastly, the number of adolescent pregnancies represents a risk factor. Despite a noticeable decrease since the 1990s (from 121 per 1 000 in 1997 to 103.5 in 2007), adolescent fertility remains particularly high in Southern Africa (185.3) and Western Africa (124.1); with a rate of 218.8, Liberia has the highest level of adolescent births. These causes could be avoided through improved access to and quality of health care for women, universal access to reproductive health services, access to family planning, prevention of unwanted pregnancies and improved education levels of women. In 2007, only 50 per cent of women gave birth under the supervision of a qualified health worker, compared with a rate of 45 per cent in 1990 with strong country differences, ranging from 10 per cent in Ethiopia to 95 per cent in Algeria. Even when initiatives existed, they could be beyond the reach of the poorest segments of the population. Beyond the challenge of inadequate quality, access to health services can be determined by place of residence in the absence of good communication infrastructure between urban and rural areas, as well as by household wealth or the education level of women.