Tracking the impact of maternal health service coverage on maternal mortality across 137 low- and middle-income countries in the progress toward Sustainable Development Goals

Background Achieving Sustainable Development Goal (SDG) 3, particularly targets 3.1 (reducing the global maternal mortality ratio (MMR) to less than 70 per 100,000 live births) and 3.8 (universal health coverage), requires sustained reductions in maternal mortality and equitable access to essential maternal health services (MHS). Despite global progress, large disparities persist. Low- and middle-income countries (LMICs) account for more than 90% of maternal deaths worldwide, largely reflecting gaps in access to essential MHS. However, multi-country evidence examining how improvements in MHS during the SDG period translate to reductions in MMR remains limited. This study assessed disparities in MHS coverage and their associations with MMR across LMICs.Methods We conducted a longitudinal panel analysis of 137 LMICs, using country-level data from the World Health Organization Global Health Observatory and the World Bank from 2015 to 2023. Indicators included coverage of at least four antenatal care visits (ANC4+), facility-based delivery (FBD), and skilled birth attendance (SBA). We estimated associations between MHS coverage and MMR using generalised linear mixed models with a gamma-log link, with analyses stratified by country income group and maternal education.Results The median MMR of the 137 LMICs declined from 109.3 to 85.5 deaths per 100,000 live births from 2015 to 2023. Coverage of FBD and SBA increased by 5.6% and 5.0%, respectively. Higher coverage of ANC4+ (β = -0.01, P = 0.02) and FBD (β = -0.01, P = 0.03) was significantly associated with lower MMR. These associations were stronger in lower-middle-income and upper-middle-income countries than in low-income countries. Stratified analyses showed larger reductions in MMR among women with moderate-to-high levels of maternal education.Conclusions Although maternal mortality decreased during the SDG period, progress remains insufficient and inequitable. Strengthening equitable access to essential MHS is critical to accelerating MMR reductions and supporting progress toward SDG targets in LMICs.