Maternal mortality in the Americas, 2000–2023: an ecological study of temporal trends, socioeconomic inequalities, and progress towards 2030 targets

Background Maternal mortality rose sharply during 2019–2021, coinciding with the COVID-19 pandemic, against a backdrop of already fragile progress in maternal survival across the Americas. We assessed whether the subsequent decline restored sufficient and equitable progress towards the 2030 regional benchmark. Methods We conducted an ecological country-year observational analysis using Maternal Mortality Estimation Inter-Agency Group (MMEIG) estimates for 36 countries and territories, together with the regional series for the Americas, from 2000 to 2023. Temporal trends were assessed using continuous log-linear models with zero to four joinpoints. Social inequalities were quantified using the slope index of inequality (SII), relative index of inequality (RII), and health concentration index (CIx). We also estimated the annual rate of reduction required for each country and territory to reach a maternal mortality ratio (MMR) of 30 per 100,000 live births by 2030. As the principal external comparison of the pandemic-period signal, country-year MMRs officially reported to the Pan American Health Organization were compared with the corresponding MMEIG estimates. Findings Regional maternal deaths averaged 9408 annually during 2000–2019, peaked at 14,498 in 2021, and declined to 7813 in 2023. The maternal mortality ratio (MMR) decreased from 70.4 in 2000 to 58.5 in 2023, despite rising from 58.9 in 2019 to 106.8 in 2021. Joinpoints occurred in 2014, 2019, and 2021; the 2000–2023 average annual percentage change was −0.9%. Reaching an MMR of 30 by 2030 would require a 9.6% annual regional reduction. In 2023, the SII was −123.6 (95% CI −181.7 to −65.6), the RII was 9.9 (4.4–22.5), and the CIx was −39.6% (−52.4 to −15.3). These measures describe concentration of MMEIG-estimated mortality among countries at the lower end of the GDP distribution and are not interpreted as independent effects of GDP. Interpretation The post-2021 decline is consistent with recovery, but it did not restore an adequate or equitable long-term trajectory. The pandemic-period rise was also evident in many independently reported country series, although its magnitude and timing varied and causal attribution cannot be established from this ecological analysis. Reaching the 2030 benchmark requires sustained acceleration, differentiated country support based on mortality and target gaps, stronger maternal-death surveillance and response, and equitable access to high-quality care.