Africa has spent more than two decades reducing the risk that pregnancy and childbirth will kill women. But a new Africa Centres for Disease Control and Prevention report released Sept. 9 points to a more difficult question. Why did that progress begin losing momentum years before the current collapse in development assistance?
Across African Union member states, the maternal mortality ratio fell 42% between 2000 and 2023, from 666 deaths per 100,000 live births to 388. Yet the pace of improvement slowed sharply after 2016. At the long-term annual reduction rate of 2.4%, Africa CDC estimates the continent would reach about 330 maternal deaths per 100,000 live births by 2030, close to five times the Sustainable Development Goal target of fewer than 70.
That timing matters.
Development assistance for health in Africa has since undergone a severe contraction, falling from $25.8 billion in 2021 to about $13 billion in 2025, according to figures cited in the report. Those cuts threaten maternal health services and could make an already difficult trajectory worse.
But they cannot, on their own, explain why progress was already slowing five years earlier.
Africa CDC’s conclusion is that the deeper constraints are structural, including weak implementation, uneven quality of care, inadequate financing, gaps in referral systems, shortages of essential medicines and blood, workforce problems and, crucially, failures to act on evidence that health systems themselves already collect.
That shifts the maternal mortality debate from how much aid Africa is losing to what African health systems do with the resources, policies and information they already have.
A crisis increasingly concentrated in Africa
The scale of the problem is stark.
About 260,000 women worldwide died from pregnancy- and childbirth-related causes in 2023, according to the estimates used by Africa CDC. Roughly 178,600 of those deaths occurred in African Union member states, about 69% of the global total.
But even the continental figure obscures enormous disparities.
West Africa has a maternal mortality ratio of 682 deaths per 100,000 live births, compared with 439 in Central Africa, 260 in East Africa, 162 in Southern Africa and 50 in North Africa. West Africa alone accounts for 55% of maternal deaths in the AU. Five countries, Nigeria, the Democratic Republic of the Congo, Ethiopia, Tanzania and Chad, account for 64% of the continent’s maternal deaths, with Nigeria alone accounting for 42%.
At the other end of the spectrum, eight AU countries have already reached the SDG target. They are Egypt, Tunisia, Cabo Verde, Seychelles, Libya, Algeria, Mauritius and Morocco. Another six, including Zambia, Mozambique, Eswatini and South Africa, have maternal mortality ratios of 140 or lower.
The contrast is central to Africa CDC’s argument. The interventions needed to drive maternal mortality much lower are not hypothetical. Some African countries are already implementing them.
The challenge is understanding why they work in some health systems and fail to reach women in others.
More women reach facilities. That is no longer enough.
One of the report’s most important findings concerns a shift in where health systems are failing.
Historically, maternal health strategies have focused heavily on getting pregnant women into health facilities and increasing skilled birth attendance. That effort has produced substantial gains. More than 60% of African countries now report skilled health personnel attending more than 80% of births, compared with just 28% in 2010.
But expanding coverage has exposed another problem. A woman can reach a health facility and still die because the care she needs is unavailable, delayed or inadequate.
Africa CDC uses the “three delays” framework, covering delays in deciding to seek care, delays in reaching a facility and delays in receiving appropriate care after arriving.
The balance among those delays is changing.
In Uganda, the report says the first two types of delay have declined while the third, receiving adequate care after reaching a facility, increased.
A study in Namibia found the third delay was the largest contributor, at 40.4%.
A Sierra Leone review found 67% of maternal deaths occurred in hospitals and were related to quality of care.
Most strikingly, a national audit in Rwanda examining 987 deaths found substandard facility care contributed to 61.1% of them, compared with 30.3% attributed to patient and community factors.
That creates a different policy problem from the one African governments confronted two decades ago.
Building a clinic or persuading women to deliver in one is not sufficient if that clinic has no blood for transfusion, no functioning operating theater, no magnesium sulfate, inadequate staffing or clinicians who fail to identify complications quickly enough.
Africa CDC therefore argues that increased coverage without comparable improvements in quality may help explain why the decline in mortality has lost momentum.
The women are often dying from conditions medicine already knows how to treat
There is another reason Africa CDC sees the problem primarily as one of delivery rather than medical discovery.
Obstetric hemorrhage was the leading recorded cause of maternal death in 18 of the 25 member states that provided a quantified distribution. Hypertensive disorders were generally second.
These are not obscure diseases awaiting scientific breakthroughs.
Postpartum hemorrhage can require rapid access to uterotonics, tranexamic acid, blood transfusion and emergency obstetric care. Hypertensive emergencies require timely diagnosis and treatment, including access to magnesium sulfate.
Yet Africa imports about 80% of its health commodities, according to the report, including about 60% of the tranexamic acid used to treat postpartum hemorrhage. Commodity stock-outs were reported as a barrier by 51% of member states.
The consequences appear repeatedly in national death reviews.
Across the countries that explicitly assess whether maternal deaths could have been prevented, not one found that most were unavoidable. Estimates of avoidability ranged from 58% to 96%.
Eswatini judged 96% of deaths from direct obstetric causes avoidable.
Morocco’s confidential inquiry put the figure at 89% for direct causes.
Namibia found 72% of deaths potentially avoidable.
The implication is uncomfortable but important. Many women are dying despite the existence of interventions capable of saving them.
The missing link is accountability
Africa CDC identifies perhaps its strongest explanation for stalled progress in what happens after a woman dies.
Maternal death reviews are supposed to establish what went wrong and produce recommendations so that the same failures are not repeated.
Yet among the 34 member states whose death-review reports Africa CDC examined, only 14 reported progress against recommendations from previous review cycles. Only one country both analyzed the three types of delay, assessed whether deaths were avoidable and tracked implementation of previous recommendations.
Nigeria illustrates how badly the chain can break.
Its national maternal and perinatal death surveillance system recorded 83.6% of maternal deaths as notified from 2019 to 2021, but only 17.8% were reviewed. More recent data suggest the review system weakened further. The proportion of maternal deaths recorded in the health information system that passed through review fell from 41% in 2022 to 17% in 2025.
That does not mean fewer women were dying. It means fewer deaths were completing the process intended to identify why they died and prevent the next death.
The distinction helps explain Africa CDC’s emphasis on what it calls the “accountability loop.”
Countries may have policies, collect statistics and convene committees. But if a hospital repeatedly identifies shortages of blood, referral failures or poor clinical management and nothing changes afterward, the surveillance system documents mortality without preventing it.
That is why some of Africa CDC’s highest-priority recommendations require relatively little additional money. It wants governments to ensure that deaths recorded in national information systems are actually notified for review, and that subsequent national reports state whether recommendations from previous reviews were implemented.
Tanzania shows what changing several parts of the system can achieve
Tanzania provides one of the report’s strongest counterexamples.
The country’s maternal mortality ratio fell from 556 deaths per 100,000 live births in 2015-16 to 104 in 2022, according to national data cited by Africa CDC.
Africa CDC does not attribute that decline to a single program. Instead, Tanzania combined investments in primary health facilities, skilled birth attendants and expansion of emergency obstetric care with an emergency referral system known as m-mama.
The system uses a 24-hour toll-free dispatch service, government ambulances and more than 4,200 contracted community drivers connected through digitally mapped routes.
It now operates nationally, providing about 54,000 emergency transports a year at an annual government cost of less than $2 million, according to the report.
In regions where the program was evaluated, maternal deaths fell 38%.
The lesson is not simply that Africa needs more ambulances. Tanzania paired transport with expanded capacity to provide emergency obstetric care.
A referral system saves lives only if there is somewhere capable of treating the woman when she arrives.
Rwanda tackled another part of the chain
Rwanda illustrates why the solution must change according to the bottleneck.
Its experience shows that getting women into facilities does not automatically guarantee safe childbirth. The national audit cited by Africa CDC found facility-level deficiencies contributing to more than six in 10 maternal deaths reviewed.
But Rwanda has also developed interventions aimed directly at those health-system weaknesses.
Its community-based health insurance system covers roughly 91% of the population, while performance-based financing has been associated with a 23% increase in institutional deliveries. The country has also used drones for last-mile delivery of blood and other medical commodities, reducing delivery times from hours to minutes and reducing blood wastage.
These measures attack different stages of the same chain, including the financial barrier to seeking care, the incentive for facilities to deliver services and the availability of lifesaving commodities once emergencies occur.
Africa CDC draws a broader lesson from Rwanda and other successful programs. The strongest results tend to come when governments intervene across several health-system weaknesses rather than funding one isolated maternal health project.
In Congo, reaching care remains the problem
The Democratic Republic of the Congo shows why a uniform continental strategy would be inadequate.
While the decisive delay in countries such as Rwanda, Uganda and Namibia increasingly occurs inside facilities, the DRC’s 2025 review attributed 70% of contributory delays to the two stages before adequate facility care, deciding to seek care and reaching it.
Ethiopia’s latest review similarly identified reaching care as the most frequently recorded delay, at 45%.
For such countries, emergency transport, proximity to comprehensive obstetric services and functioning referral networks remain critical.
The comparison highlights a central finding of the Africa CDC report. Africa does not have one maternal mortality problem.
A country where women cannot reach emergency obstetric care needs a different investment strategy from one where most women already deliver in facilities but encounter inadequate treatment after arrival.
Aid cuts will make the crisis worse. They did not start it.
None of this minimizes the threat posed by falling development assistance.
The funding contraction is severe, and Africa CDC warns that maternal, newborn, family planning and adolescent health programs are especially vulnerable.
Governments have not compensated for the losses. Only three AU member states, Rwanda, Botswana and Cabo Verde, met the Abuja commitment to allocate 15% of government expenditure to health on the most recent figures cited in the report.
But the chronology complicates the argument that restoring donor financing is the central answer.
Maternal mortality improvements began slowing after 2016. The sharp contraction in development assistance came later.
Africa CDC therefore concludes that restoring external funding alone would not restore the previous trajectory. The report identifies a combination of weak governance, inadequate domestic financing, workforce constraints, commodity shortages, poor-quality care and failures to implement recommendations generated by death reviews.
That distinction matters as governments and donors decide how to respond to the financing crisis.
Replacing lost money without addressing those failures risks financing the same systems that were already losing momentum.
Africa’s strongest evidence may be its own countries
The report’s more hopeful conclusion is that successful models do not need to be imported wholesale from outside the continent.
Tanzania has demonstrated how emergency transport can be integrated with expanded obstetric services.
Rwanda has combined insurance, performance-linked financing and faster delivery of blood and commodities.
Ethiopia increased government financing for family planning commodities roughly nineteenfold under a domestic co-financing compact.
Uganda raised staffing levels after increasing rural salaries and later scaled results-based financing to more than 1,300 facilities.
Across these examples, Africa CDC identifies a recurring pattern involving political leadership, financial and physical access, measurable results, reliable data and community participation.
The challenge is scaling those practices in countries carrying the largest share of deaths.
That is particularly important because the continent is running out of time. At the current pace, Africa will remain far from the 2030 maternal mortality target even while continuing to reduce deaths.
The question raised by the slowdown after 2016 is therefore larger than whether international donors restore funding.
It is whether African governments can make the transition from expanding access to guaranteeing effective care, and from counting maternal deaths to acting on what those deaths reveal.
Africa CDC’s evidence suggests that much of what is required is already known.
The harder problem is making sure it happens every time a woman needs it.
Africa Centres for Disease Control and Prevention (Africa CDC) is a continental autonomous health agency of the African Union established to support public health initiatives of Member States and strengthen the capacity of their public health institutions to detect, prevent, control and respond quickly and effectively to disease threats.
Africa CDC supports African Union Member States in providing coordinated and integrated solutions to the inadequacies in their public health infrastructure, human resource capacity, disease surveillance, laboratory diagnostics, and preparedness and response to health emergencies and disasters.
Established in January 2016 by the 26th Ordinary Assembly of Heads of State and Government and officially launched in January 2017, Africa CDC is guided by the principles of leadership, credibility, ownership, delegated authority, timely dissemination of information, and transparency in carrying out its day-to-day activities. The institution serves as a platform for Member States to share and exchange knowledge and lessons from public health interventions.
