[This article has been published in Spanish in Planeta Futuro-El País]
The maternal health success story, as evidenced by a mortality rate that was almost halved, actually masked another story: the progress made did not affect everyone equally
During the years covered by the Millennium Development Goals, significant advances were made worldwide in health and, specifically, in maternal health, which improved in many countries. By the end of the period, maternal mortality had decreased by 45% with respect to 1990. However, this progress was largely achieved by concentrating resources on the groups most susceptible to improvement rather than by focussing on the most disadvantaged populations. This approach failed to remedy, and in some cases even exacerbated, the inequalities affecting the groups initially at a greater disadvantage, for whom more resources would have been required to improve indicators. By using targets that measured the overall improvement of national indicators in low-income countries, the MDGs provided little incentive for governments to reduce inequalities. This was perhaps their most negative legacy.
Sub-Saharan Africa now accounts for 66% of all maternal deaths in the world (up from 42% in 1990)
The maternal health success story, as evidenced by a mortality rate that was almost halved, actually masked another story: the progress made did not affect everyone equally. The situation did not improve everywhere and it definitely did not benefit all population groups. The indicators improved in some countries and for certain groups of women; in other groups, the situation remained the same or gaps even increased. Current evidence on variations in access to maternal and reproductive health services for groups of women in different circumstances reveals a pattern of marked differences. In both rural and urban areas and in countries with very different maternal mortality rates, most of the variations observed are associated with educational and income levels. Sub-Saharan Africa now accounts for 66% of all maternal deaths in the world (up from 42% in 1990). Among the interventions consistently distributed in a less egalitarian way, we find antenatal care and skilled attendance at delivery, in other words, the interventions that contribute most to improving maternal and neonatal care but which also require a robust health care system capable of providing women with an appropriate level of quality care.
On the other hand, if we compare the groups of countries with the highest  and lowest  rates of maternal mortality, we see that while the membership of both groups has varied very little over time the relative difference or gap between them has doubled in the last two decades.
Health is a precondition for development, a reality reflected in its continued presence as one of the 17 Sustainable Development Goals
What can we expect in this new phase? Health is a precondition for development, a reality reflected in its continued presence as one of the 17 Sustainable Development Goals (SDG3. Health and well-being for all), which is particularly striking in an agenda characterised by so many competing priorities. Moreover, the specific emphasis in SDG3 on maternal and child health implicitly recognises the debt owed to the unfinished agenda of maternal and infant health in the earlier phase (the MDGs). It also reflects the importance of the issue for both health systems and the viability of the 2030 agenda as a whole, if only because of the vast scale of the problem: women account for half of the world’s population and, at any time, some 52% of them are of childbearing age. An estimated 210 million women become pregnant every year and 140 million babies are born; of these, around 300,000 women and 6 million children will die in 2017 due to preventable causes.
Around 300,000 women and 6 million children will die in 2017 due to preventable causes
Furthermore, a global action plan with the motto “leave no one behind” clearly recognises the need to prioritise the reduction of inequalities and the need for a cross-cutting focus on equity across the whole agenda (ODS10. Reduce inequality within and among countries). But what does the term equity mean in this context? According to Margaret Whitehead’s classic definition, equity in health is the principle that seeks to eliminate systematic, avoidable and unjust health differences between populations who live in different circumstances. Equity is concerned with correcting differences in factors that we can control. Equity is social justice.
This focus on equity is particularly important in the case of maternal and child health. The maternal mortality rate—the proportion of women who do not survive childbirth as a percentage of the number of live births—holds the sad record of being the most unequal indicator in global health: the maternal mortality rate is 46 times higher (546 maternal deaths per 100,000 live births) in sub-Saharan Africa than in high-income countries (12 deaths per 100,000 live births). Before we can properly prioritise actions that seek to reduce discriminatory differences and evaluate progress, a necessary starting point is to recognise that the burden of maternal mortality and morbidity is very unequally distributed both between and within countries: in Nigeria, 26% of women in the lowest income group delivered alone compared to only 2% of women in the highest income group.
Real commitment to equity—social justice—in the maternal and infant health agenda must involve prioritising the expansion of health service coverage
Real commitment to equity—social justice—in the maternal and infant health agenda must involve prioritising the expansion of health service coverage (progressive universalisation) with a particular focus on the aspects of maternal and neonatal health that have the worst indicators. This expansion must prioritise the groups currently excluded from health care, an objective also linked to the SDG3.11 target (universal health coverage). At the same time, we must invest in improving the collection of data for monitoring progress (or deterioration) and for identifying the factors that contribute to progress in different contexts. We know that improved health coverage on the national level is primarily related to the capacity of countries to increase the coverage for the poorest quintiles.
The availability of data has greatly improved over the last three decades as a result of the work of organisations that carry out population surveys, such as the Demographic Health Surveys (DHS) Program, which has provided data for developing countries disaggregated by health determinants—educational level, income level, and access to health care. But there are still major deficiencies in the quantity and quality of the information available. We know very little about the relationship between the coverage, quality and equity of health care and almost nothing about what happens in the most disadvantaged settings, where we would expect to find the largest pockets of inequality. In 2017, two thirds of all births in the world, and an even higher proportion of all maternal deaths are not registered or are incorrectly classified.
More complete and accurate data are needed but, to measure the progress made towards the ultimate objective of “leaving no one behind”, we also need indicators that can capture differences in health care
More complete and accurate data are needed but, to measure the progress made towards the ultimate objective of “leaving no one behind”, we also need indicators that can capture differences in health care, identify the factors that contribute to such differences and ascertain how equitably basic services are distributed among women. In this context, the scientific community can make a contribution to furthering social justice in the 2030 agenda. Data is an area prioritised in ISGlobal’s Maternal, Child and Reproductive Health Initiative through projects like CaDMia-Plus, which seeks to develop tools for determining the causes of death in low-income countries, and through studies like Inequalities in Women’s and Girl’s Health Opportunities and Outcomes in Sub-Saharan Africa, in which, in collaboration with the World Bank, we have used the Human Opportunity Index (HOI) to analyse inequalities in access to 15 health opportunities for women of childbearing age in 29 countries in sub-Saharan Africa.
The reduction in the number of maternal deaths is one of the indicators used to measure the progress made by health systems, the SDGs and in universal health cover. In the coming years, we will see more efforts being channelled in this direction, particularly in sub-Saharan Africa, an area that accounts for 66% of all these deaths, where 50% of women still have no access to basic maternal and reproductive health services.
 Afghanistan, Botswana, Burundi, Cameroon, Central African Republic, Chad, Côte d’Ivoire, Equatorial Guinea, Eritrea, Ethiopia, Guinea, Guinea-Bissau, Liberia, Malawi, Mauritania, Myanmar, Papua New Guinea, Rwanda, Sierra Leone, South Sudan and Zimbabwe.
 Australia, Austria, Canada, Denmark, Slovenia, Spain, Estonia, Finland, Greece, Ireland, Israel, Italy, Montenegro, Norway, Sweden, Singapore and Switzerland.