The human right to safely give birth: Data from 193 countries show that gender equality does affect maternal mortality.

Abstract Background While a reduction in the global maternal mortality ratio (MMR) has slowed, newer strategies are needed to achieve an ongoing and sustainable reduction of the MMR. Previous studies have investigated the association between health system-related factors such as wealth inequalities, healthcare access and use on maternal mortality. However, a women’s rights-based approach to address MMR has not been studied, excluding the health system-related factors. This study aimed to analyse the association between gender equality and MMR globally.Methods Using structural equation modelling (SEM), secondary and open access data from the United Nations and other international agencies from 193 countries were analysed using structural equation modelling (SEM). Gender-sensitive variables that represented the theoretical, conceptual framework of the study were selected. The association between latent variable gender equality and the outcome, MMR, was examined in the SEM. A second SEM model (n=158) was designed to include two variables related to gender-based violence.Findings Out of 521 gender-sensitive variables, we used 11 variables to estimate two models in SEM (Goodness of Fit Index=0‧929 for Model 1 and 0‧939 for Model 2). The latent variable, gender equality, was negatively associated with MMR (p<0‧001, Z=–6‧96, 95% CI: –6508.98 to –3141.89 for Model 1 and p<0‧001, Z=–7‧23, 95% CI: –6045.356 to –3467.515 for Model 2).Interpretation Gender equality was significantly associated with maternal mortality. Investing in higher education for women, improving their paid employment opportunities, increasing participation in leadership roles and politics, reducing intimate partner violence (IPV) and ending child marriage can significantly reduce maternal mortality.