The World Health Organization (WHO) defines a maternal death as "the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes" (370). Behind the direct causes of maternal mortality—obstetric complications and unsafe abortions—lie the conditions of women's lives: inadequate care during delivery, chronic disease and malnutrition, poverty, isolation, and unwanted pregnancies.

Better care at childbirth and more access to that care would substantially reduce maternal mortality rates (23, 281). Most maternal deaths occur among poor women who live in remote areas (284). Studies in Cuba, Egypt, Indonesia, Jamaica, Tanzania, and Turkey have demonstrated that maternal mortality is higher where access to a hospital is more difficult (370). When access improves, death rates drop. For example, in Oran, Algeria, the maternal mortality ratio fell 42% between 1971-75 and 1976-80 after fees for public hospital services were waived, a policy that greatly reduced the number of home deliveries (269).

Yet many women give birth without any trained help. For example, in 12 of 26 countries surveyed by the Demographic and Health Surveys (DHS) between 1986 and 1989, women had received no trained assistance in half or more of all births in the five years before the survey (122).

Chronic diseases and malnutrition leave many women unable to meet the physical demands of pregnancy (187). For example, anemia, often a result of poor nutrition, affects about 40% to 60% of pregnant women in developing countries excluding China—more than twice the percentage in developed countries (380). (By comparison, about 20% of men have anemia.) Malaria, sexually transmitted diseases, and infectious hepatitis also cause serious problems for many pregnant women and, unless treated, may kill them or their infants (135).

A woman's age and parity affect her chances of dying in childbirth. Health risks related to age and parity have been summarized as "the four too's"—too young, too old, too many, too close together. First births and births after the fourth are more dangerous than the second through fourth births. Women under age 18 and, more dramatically, those over age 35 face greater risk than women between these ages (275, 363). Of course, age and parity are not risks in themselves; they stand in for the higher likelihood of specific risks associated with age and parity (378). For example, pregnancy can be dangerous to very young women because their pelvises are not yet large enough to accommodate birth. Many of these specific conditions can be managed if high-quality delivery care is available.

Some family planning programs have emphasized serving women in these high-risk age and parity categories, particularly older, high-parity women. The Mexican social security system found that this emphasis interested more doctors in family planning and thus helped expand contraceptive services (265). Still, the "four too's" do not justify overriding women's own informed decisions about whether and when to have children or to pressure them to use a contraceptive method that is not their preference (280).

Deaths from unsafe abortion. Many women resort to abortion to prevent unintended births (227, 363). Because abortions are illegal in most developing countries, many women seek them clandestinely and undergo unsafe procedures. Even in some places where abortion is legal, poor-quality services put women at risk.

An estimated 10 to 20 million illegal abortions are performed worldwide annually, and an estimated 100,000 to 200,000 women die as a result—about one in every 100. These deaths account for 20% to 40% of all maternal deaths (134). In some Latin American cities abortions account for over half of maternal deaths (284). In Romania unsafe, illegal abortions were responsible for 86% of maternal deaths (230). After the procedure was legalized in 1992, the overall maternal mortality ratio fell in the first year to 40% of the 1989 level (367). Women who survive an unsafe abortion may suffer chronic pelvic pain, chronic pelvic inflammatory disease, and/or infertility. They face a greater risk of ectopic pregnancy, premature delivery, and other adverse health consequences in the future (368).

The majority of deaths due to abortion can be prevented (60). Access to effective contraceptive methods reduces unwanted pregnancies. The procedure itself is safe if the practitioner uses safe techniques (372).

While contraceptive use can greatly reduce unwanted pregnancies, it cannot eliminate them (60). An estimated 25 million women become pregnant each year due to failure of their contraceptive method (31). Many women, especially young women, become pregnant as the result of forced sexual intercourse. A smaller number of women develop health conditions that make continued pregnancy unsafe. Many of these women will choose an unsafe abortion if they do not have access to a safe procedure.