Divergent Epidemiology of Maternal Mortality in Sub‐Saharan Africa: The Case for Differentiated Regional Strategies to Achieve 2030 SDG Targets

BACKGROUND: Despite global efforts, sub-Saharan Africa continues to account for 70% of maternal deaths, yet systematic cause-specific analyses across African regions remain limited. We examined 33-year trends in maternal mortality to identify epidemiologic divergence and guide differentiated intervention strategies. METHODS: Using the 2023 Global Burden of Disease Study, maternal mortality ratios (MMR), cause-specific deaths, and age-specific patterns were analysed across five African regions (Central, Eastern, Northern, Southern, and Western Africa) from 1990 to 2023. Absolute and relative changes, average annual rates of change, cause-specific mortality proportions, and progress against Sustainable Development Goal targets were assessed. RESULTS: MMR reduction varied dramatically across regions. Northern Africa achieved the greatest decline (65.0%; 241.2 to 84.4 per 100,000 live births), while Central Africa achieved only 16.7% reduction (818.1 to 681.3). Cause-specific patterns diverged strikingly: HIV-related causes accounted for 87.3% of maternal deaths in Southern Africa versus 34.2% in Central Africa, while direct obstetric causes showed inverse patterns (6.3% vs. 39.9%). HIV-related maternal deaths increased 76%-454% across most regions despite antiretroviral therapy (ART) scale-up. Age-extreme populations faced 1.3- to 7.2-fold elevated risks; adolescents in Central Africa had an MMR of 852.3, and women aged 45-49 years reached 2233.0. Central Africa's MMR remained 3.6 times the global average, with sepsis burden (15.3%) more than double other regions (4%-7%). CONCLUSION: African regions demonstrate distinct epidemiologic profiles requiring tailored intervention strategies. Universal maternal health approaches inadequately address HIV-dominant versus obstetric-dominant regional burdens or age-extreme vulnerability. Central Africa's minimal progress signals that standard interventions fail under protracted humanitarian crises. Post-2025 strategies must integrate linked HIV-maternal care, emergency obstetric services, crisis-adapted approaches, and age-targeted programming while recognizing within-region heterogeneity to achieve equitable maternal health outcomes.