About 260,000 women died from pregnancy or childbirth in 2023, and sub-Saharan Africa carried around 70% of those deaths [1][3]. Nigeria alone recorded an estimated 75,000 maternal deaths, close to 29% of the global total [5][6]. Across the 15 ECOWAS countries plus Mauritania, Cameroon and Chad, only Cabo Verde has a maternal mortality ratio (MMR) below the SDG target of 70 deaths per 100,000 live births. Sierra Leone cut its ratio by about 78% since 2000, but Nigeria (993), Chad (748) and Liberia (628) remain far behind [4]. Since January 2025, cuts to US aid have hit contraceptive supplies, health workers and clinics across the region [25][26][27].
Why this matters
A maternal death is almost always preventable. Women die from haemorrhage, infection, high blood pressure in pregnancy and unsafe abortion, often because the nearest clinic has no midwife, no blood or no transport [32]. Under Article 14 of the Maputo Protocol, African states have committed to guarantee women’s right to health, including sexual and reproductive health. As RFLD’s country review puts it: “When a woman dies because the nearest clinic has no midwife, the State has an obligation it has not met” [32].
In April 2025, the UN Maternal Mortality Estimation Inter-Agency Group (WHO, UNICEF, UNFPA, the World Bank and UN DESA) published Trends in maternal mortality 2000 to 2023 [2][3]. It found that global maternal deaths fell by about 40% between 2000 and 2023, but that progress slowed sharply after 2016. The global MMR stood at 197 in 2023. To reach the SDG target, the world would need to cut the ratio by about 15% a year; it is falling by about 1.5% [1].
The same report shows how dangerous pregnancy remains in fragile settings. A 15-year-old girl in Chad faces a 1 in 24 lifetime risk of dying from a maternal cause. In Nigeria the risk is 1 in 25 [1]. Nigeria’s own 2023–24 Demographic and Health Survey puts it even higher, at about 1 in 19 [9].
The data: who is making progress and who is falling behind
The table below uses the UN estimates for 2000, 2015 and 2023, as published in the World Bank’s World Development Indicators (modelled MMR per 100,000 live births) [4]. These are modelled figures with wide uncertainty ranges, and they can differ from national surveys. Countries are sorted from lowest to highest MMR in 2023.
| Country | MMR 2000 | MMR 2015 | MMR 2023 | Change 2015–2023 | Change 2000–2023 | 2023 ratio vs SDG target (70) |
|---|---|---|---|---|---|---|
| Cabo Verde | 110 | 46 | 40 | -13% | -64% | Below target |
| Ghana | 472 | 310 | 234 | -25% | -50% | 3.3 times |
| Senegal | 581 | 357 | 237 | -34% | -59% | 3.4 times |
| Burkina Faso | 524 | 328 | 242 | -26% | -54% | 3.5 times |
| Cameroon | 678 | 417 | 258 | -38% | -62% | 3.7 times |
| Togo | 496 | 470 | 349 | -26% | -30% | 5.0 times |
| Niger | 845 | 473 | 350 | -26% | -59% | 5.0 times |
| The Gambia | 810 | 527 | 354 | -33% | -56% | 5.1 times |
| Sierra Leone | 1,603 | 730 | 354 | -52% | -78% | 5.1 times |
| Côte d’Ivoire | 378 | 505 | 359 | -29% | -5% | 5.1 times |
| Mali | 741 | 490 | 367 | -25% | -50% | 5.2 times |
| Mauritania | 644 | 469 | 381 | -19% | -41% | 5.4 times |
| Guinea | 951 | 642 | 494 | -23% | -48% | 7.1 times |
| Guinea-Bissau | 1,295 | 631 | 505 | -20% | -61% | 7.2 times |
| Benin | 529 | 606 | 518 | -15% | -2% | 7.4 times |
| Liberia | 786 | 784 | 628 | -20% | -20% | 9.0 times |
| Chad | 1,208 | 1,176 | 748 | -36% | -38% | 10.7 times |
| Nigeria | 1,136 | 1,168 | 993 | -15% | -13% | 14.2 times |
Source: UN MMEIG estimates (April 2025) via World Bank WDI, indicator SH.STA.MMRT, accessed October 2026 [4]. Percentages calculated by RFLD.
What the numbers show
- Fast movers. Sierra Leone halved its ratio since 2015. Cameroon (-38%), Chad (-36%), Senegal (-34%) and The Gambia (-33%) also made strong gains [4].
- Slow movers. Nigeria and Benin cut their ratios by only 15% since 2015, and both are barely below their 2000 levels. Côte d’Ivoire and Liberia also show little change over 23 years [4].
- The heaviest burden. Nigeria’s ratio is the highest of the 18 countries reviewed. Its 75,000 estimated deaths dwarf every other country in the region; Chad, the second-highest ratio in the group, recorded about 6,100 deaths [5].
- Nobody except Cabo Verde is on track. Even the best performers on the mainland would need to cut their ratios by more than two-thirds in seven years to reach 70 by 2030.
Sources do not always agree. Health Policy Watch gives Sierra Leone’s 2000 ratio as 1,682, not 1,603 [23]. RFLD’s country review, using national data, gives Senegal a 2023 ratio of about 261, higher than the UN’s 237 [32]. Burkina Faso’s health ministry reports a fall from 330 in 2015 to 198 in 2021 [20]. Readers should treat all figures as estimates.
Skilled care at birth: what the latest surveys say
- Nigeria (DHS 2023–24): only 46% of births had a skilled attendant; 63% of women received antenatal care. Under-five mortality fell to 110 per 1,000, from 132 in 2018, but neonatal mortality did not improve (41 per 1,000) [7][8].
- Ghana (DHS 2022): 87.6% of births had a skilled attendant, ranging from 72.9% among the poorest women to 98.4% among the richest [12]. Registry data for 2022 show facility births above 95% in several regions but near 70% in Savannah, Oti, Northern and North East [13].
- Côte d’Ivoire (DHS 2021): 84.1% skilled attendance, but only 67.1% among the poorest women against 97.4% among the richest. Only 56.3% of women made four or more antenatal visits [14].
- Senegal (continuous DHS 2023): 98.3% of urban births and 90.3% of rural births were assisted by a qualified provider; 68% of women made four or more antenatal visits [15].
- Benin: 87% of births take place in a health facility nationally, but only 62.1% in Borgou [32].
The pattern is clear. National averages hide deep gaps between rich and poor women, towns and villages, and the south and the conflict-affected north.
Cases and events, 2021 to 2026
2021
- Worldwide, COVID-19 year. The UN estimates that maternal deaths rose to 322,000 in 2021, about 40,000 more than in 2020, because of COVID-19 and disrupted maternity services [1].
- Côte d’Ivoire. The 2021 DHS recorded a 30-point gap in skilled birth attendance between the poorest and richest women [14].
- August 2021, Togo. The Council of Ministers adopted a decree creating the Wezou programme to cover, step by step, care for pregnant women from the confirmation of pregnancy to 42 days after birth, including antenatal consultations, tests and medicines [17].
2022
- Burkina Faso. By June 2022 the health ministry owed 22 billion to the central medicines purchasing agency (CAMEG) under the free care policy for pregnant women and children under five, in force since 2016 [19].
- Ghana. The 2022 DHS found 87.6% skilled birth attendance [12]; registry data later showed 88.2% of reported births in facilities [13].
2023
- February–March 2023, Togo. Amnesty International visited five maternity units. It found Wezou visible and appreciated, but not fully free: only some services were covered, only for women over 18, and post-birth antibiotics were excluded. Some women gave birth on the floor; there were only two midwives per 10,000 people [18].
- 13 June 2023, Burkina Faso. The transitional legislative assembly heard that the State owed health facilities more than 30 billion for free care as of 31 March 2023 [19].
- September–October 2023, Senegal. The universal health coverage agency (ANACMU) said it had covered about 150,000 caesarean sections and spent 15.9 billion FCFA on caesareans since 2015. Its figures on hospital debt differ: 15 billion FCFA owed as of April 2023 in one interview, 11.64 billion in a later presentation [21][22].
- November 2023, Senegal. The continuous DHS 2023 key indicators report was published [15].
2024
- September 2024, Nigeria. The DHS 2023–24 key indicators report was released [7].
- November 2024, Abuja, Nigeria. The federal government launched the Maternal Mortality Reduction Innovation Initiative (MAMII), with free caesarean sections for poor and vulnerable women at facilities accredited by the National Health Insurance Authority. It targets 172 local government areas that account for over half of the country’s maternal deaths [10][11].
- 17 December 2024, Freetown, Sierra Leone. The Safe Motherhood and Reproductive Health Bill was tabled in Parliament and sent to the Legislative Committee [23].
2025
- January 2025, regional. The new US administration cut off funding to global health programmes. Global health aid fell 21% in 2025, driven largely by a US$9 billion US cut [26].
- 2025, Kebbi State, Nigeria. After USAID support ended, state officials reported “no family planning supplies at all” and some clinics using expired contraceptives [25].
- 7 April 2025, Geneva. UN agencies published the 2000–2023 estimates and warned that aid cuts were closing facilities, cutting health workers and disrupting supplies of medicines for haemorrhage, pre-eclampsia and malaria [1][2].
- July 2025, Mali. UNFPA reported that fewer than a quarter of health facilities were functional, with insecurity in Timbuktu, Gao, Mopti and Ménaka; its humanitarian appeal was 80% unfunded [28].
- 2025, Sierra Leone. The bill stalled. In April an opposition leader said it would not pass within three years. Activists kept campaigning in August [23][24].
- 17 October 2025, Nigeria. The government formally launched the full NDHS 2023–24 report: 46% skilled birth attendance [8].
- Late 2025, Liberia. Liberia signed a five-year US health compact worth up to US$124 million, about US$25 million a year against roughly US$70 million a year under USAID [27].
2026
- 19 January 2026, Ouagadougou, Burkina Faso. The health ministry reported that 82% of free care bills had been paid, named financing and medicine supply as the main problems, and announced digital billing [20].
- 24 March 2026, Liberia. Experts warned that US support for health commodities would drop from over US$10.5 million in 2026 to about US$540,000 by 2030, risking shortages of contraceptives and maternal medicines. The compact uses a maternal mortality baseline of 116, far below the UN estimate of 628 [27].
- April 2026, Ghana. President John Mahama launched a Free Primary Healthcare policy, starting in 150 underserved districts, with national rollout planned for 2027–2028. The launch statement does not mention antenatal or maternal care specifically [30].
- May 2026, Burkina Faso. The Safeguarding Health in Conflict Coalition counted 13 incidents of violence against health care in 2025, with six health workers killed, and said people in hard-to-reach areas remained cut off from maternal and neonatal care [29].
- August 2026, Sierra Leone. The Safe Motherhood Bill was still pending, with a new dispute over spousal consent [23].
- 14 September 2026, Abuja. Nigeria launched new incentives for antenatal registration, skilled birth attendance and facility delivery. Officials said over 60,000 women had received free caesarean sections and emergency obstetric care through the national health insurance authority [9].
- 22 October 2026. RFLD published its country review of maternal and child health in West Africa [32].
What works, and why it is not enough
Free care has saved lives. Niger introduced free caesareans in 2005, Sierra Leone launched its Free Health Care Initiative in 2010, and Guinea offers free care to pregnant women and children under five [32]. Burkina Faso’s policy covers pregnant women, children under five and contraception, reaching about 30% of the population [19]. Senegal funds free caesareans through its universal coverage agency [22].
But free care is only as good as its funding. In Burkina Faso and Senegal, the State fell months behind in paying facilities [19][21][22]. In Togo, “free” care still left women paying for key medicines [18]. RFLD’s review found that informal payments still keep many women away from clinics [32]. And where conflict closes clinics, as in parts of Mali, Burkina Faso and North-East Nigeria, policies on paper do not reach women at all [28][29][32].
What the law says, and the gaps
- Maputo Protocol, Article 14. All 18 countries in this review are African Union members. The Protocol obliges states parties to guarantee women’s right to health, including sexual and reproductive health [32]. RFLD’s Maputo Barometer tracks ratification and reservations.
- Abuja Declaration (2001). African governments pledged 15% of national budgets for health. No African country has met it consistently in 25 years [27][18].
- Free care laws and decrees exist in Burkina Faso, Niger, Senegal, Sierra Leone, Guinea and Togo, but most are decrees or programmes, not laws with guaranteed budget lines [17][19][32].
- Unsafe abortion. In Sierra Leone, abortion is still governed by an 1861 law. Unsafe abortion accounts for around 10% of maternal deaths there, and the Safe Motherhood Bill remains stuck [23][24].
- Data gaps. Most countries lack complete death registration, so maternal deaths are estimated, not counted. Liberia’s US compact baseline shows how weak data can distort targets [27].
What RFLD asks for
- Put free maternal care into law, with a protected budget line. Pay facilities on time and publish payment data every quarter.
- End informal fees. Set up complaint lines and sanction staff who charge women for services that are free by law.
- Deploy and keep midwives in rural and conflict-affected areas, with housing, security and fair pay.
- Protect health care in conflict. Investigate attacks on health workers and facilities and keep emergency obstetric care open in the Sahel and North-East Nigeria.
- Replace lost aid with domestic funding. Move towards the Abuja target of 15% and ring-fence funds for contraceptives, oxytocin, magnesium sulphate and blood.
- Pass Sierra Leone’s Safe Motherhood and Reproductive Health Bill and review abortion laws in line with the Maputo Protocol.
- Count every maternal death. Strengthen civil registration and maternal death surveillance and response, and publish results by region.
- Include women’s organisations in the design, monitoring and budget review of maternal health programmes, including Nigeria’s MAMII and Ghana’s Free Primary Healthcare policy.
RFLD tools you can use today
- Maternal and Child Health in West Africa (2025 report): RFLD’s 15-country study of coverage, infrastructure, policies that work and barriers [31].
- Maternal and child health in West Africa: what our country review shows: country-by-country findings [32].
- Women’s Rights Laws by Country: check health and reproductive rights laws, for example in Nigeria, Sierra Leone or Chad.
- Maputo Barometer 2026: see where each state stands on the Maputo Protocol.
- The Maputo Protocol in your language: Hausa, Yoruba, Igbo, Twi, Zarma and more, for community health dialogues.
- Maputo Protocol Training Manual: train health advocates on Article 14.
- West Africa women’s rights laws: paper vs practice: why free care decrees do not always reach women.
- CEDAW and UPR review calendar: plan shadow reports on maternal health.
- RFLD Academy, including the free course Advocacy Theory and Practice.
- Tenders and grants for women’s organisations: find funding to replace lost aid.
Closing
West Africa has shown that maternal deaths can fall fast. Sierra Leone, Senegal, Cameroon and The Gambia prove that free care, more midwives and better referral systems work. But Nigeria, Chad, Liberia and Benin show how slowly change comes when care is unaffordable, clinics are unsafe and data are weak. Aid cuts since 2025 now threaten even the gains already made. Every government in the region has committed to women’s right to health as a member of the African Union. The question is no longer what works. It is whether states will pay for it, protect it and answer to the women whose lives depend on it.
References
- UNICEF, WHO, UNFPA, “Aid cuts threaten fragile progress in ending maternal deaths, UN agencies warn”, press release, 7 April 2025. unicef.org
- World Health Organization, “Trends in maternal mortality estimates 2000 to 2023: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division”, 7 April 2025. who.int
- UNFPA, “Trends in maternal mortality 2000 to 2023”, April 2025. unfpa.org
- World Bank, World Development Indicators, “Maternal mortality ratio (modeled estimate, per 100,000 live births), SH.STA.MMRT”, data for 18 countries, last updated 8 October 2026. api.worldbank.org
- World Bank, World Development Indicators, “Number of maternal deaths, SH.MMR.DTHS” (Nigeria, Chad, World, 2023), accessed October 2026. api.worldbank.org
- The Express Tribune, “Pakistan in top four for maternal deaths”, 8 April 2025. tribune.com.pk
- Federal Ministry of Health and Social Welfare, National Population Commission and ICF, “Nigeria Demographic and Health Survey 2023–24: Key Indicators Report”, September 2024. dhsprogram.com
- Federal Ministry of Information and National Orientation (Nigeria), “FG launches 2024 NDHS report, unveils data on fertility, child mortality, others”, 18 October 2025. fmino.gov.ng
- Federal Ministry of Information and National Orientation (Nigeria), “FG flags off incentives to boost maternal, newborn care utilisation, reduce maternal and neonatal mortality”, 14 September 2026. fmino.gov.ng
- TheCable, “FG announces free cesarean sections for vulnerable women to combat maternal mortality”, November 2024. thecable.ng
- News Central TV, “Nigeria expands access to C-sections for low-income mothers”, 8 November 2024. newscentraltv.com
- Countdown to 2030, “Ghana DHS 2022” equity profile, February 2025. countdown2030.org
- Ghana News Agency (Agnes Ansah), “Over 80% of births occurred in health facilities in 2022”, 10 May 2024. gna.org.gh
- Countdown to 2030, “Côte d’Ivoire DHS 2021” equity profile, February 2025. countdown2030.org
- ANSD and ICF, “Sénégal: Enquête Démographique et de Santé Continue (EDS-Continue) 2023, Rapport des indicateurs-clés”, November 2023. dhsprogram.com
- Countdown to 2030, “Senegal MNH one-pager brief”, 2025. countdown2030.org
- Bénin Web TV, “Togo: pour la réduction du taux de mortalité néo-natale, Faure Gnassingbé innove”, 26 August 2021. beninwebtv.bj
- Amnesty International via ReliefWeb, “Togo: Some women give birth on the floor amid staff shortages and poor facilities”, 2023. reliefweb.int
- Burkina 24, “Gratuité des soins au Burkina Faso: l’État doit 30 milliards aux formations sanitaires”, June 2023. burkina24.com
- Burkina 24, “Gratuité des soins au Burkina Faso: un bilan encourageant, malgré des défis persistants”, 19 January 2026. burkina24.com
- Seneweb / emedia (Ndèye Anna Ndiaye), “Bilan, dette envers les hôpitaux… Bocar Mamadou Daff, DG de la CMU sans détour”, 19 September 2023. seneweb.com
- Seneweb, “Remboursement de la CMU aux structures de santé”, 10 October 2023. seneweb.com
- Health Policy Watch (Abdulai Gbla), “Why Sierra Leone’s Safe Motherhood Bill is still in limbo”, 19 August 2026. healthpolicy-watch.news
- Kaata Minah, “Sierra Leone: A real commitment to women’s lives – pass the Safe Motherhood Bill”, allAfrica, 27 August 2025. allafrica.com
- EngenderHealth, “‘We have resorted to using substandard and expired family planning commodities’: the hidden cost of USAID cuts in Nigeria”, 2025. engenderhealth.org
- MSI Reproductive Choices, “USAID impacts report: one year on”, January 2026. msichoices.org
- FrontPageAfrica (Joyclyn Wea) via allAfrica, “Liberia: Funding cuts, weak oversight, and hidden traps – experts sound the alarm on Liberia’s new U.S. health deal”, 24 March 2026. allafrica.com
- UNFPA, “Mali situation report, July 2025”, August 2025. unfpa.org
- Safeguarding Health in Conflict Coalition and Insecurity Insight, “Violence against health care in conflict: Burkina Faso 2025”, May 2026. insecurityinsight.org
- National Health Insurance Authority (Ghana), “Prez Mahama launches Free Primary Healthcare Policy”, 17 April 2026. nhis.gov.gh
- RFLD, “Maternal and Child Health in West Africa”, report, 2025. rflgd.org
- RFLD, “Maternal and child health in West Africa: what our country review shows”, 22 October 2026. rflgd.org
