Research Article

A Global Ecological Analysis of Maternal Mortality Ratios: Income Level, Health Risks, and Socioeconomic Indicators

Volume: 17 Number: July, August, September 2026 September 4, 2026

A Global Ecological Analysis of Maternal Mortality Ratios: Income Level, Health Risks, and Socioeconomic Indicators

Abstract

Purpose: This study aimed to examine the associations between maternal mortality ratios, selected health risk factors, and socioeconomic indicators at the country level, and to evaluate whether socioeconomic indicators improved the explanatory power of models including population-level health risk factors. Method: This country-level ecological study used publicly available data from the World Health Organization Global Health Observatory and the World Bank Open Data platform. Data were primarily extracted for 2019, and the closest available year was used when 2019 data were missing. Descriptive analyses included up to 151 countries, while hierarchical regression analyses included 102 countries with complete data. The maternal mortality ratio was transformed using the natural logarithm [ln(MMR)] due to its skewed distribution. Associations with selected health risk factors and socioeconomic indicators were examined using Pearson correlation and hierarchical regression analyses. Results: The mean maternal mortality ratio was 126.11±185.90 per 100,000 live births, indicating substantial crosscountry variation. Maternal mortality differed significantly by income group, with the highest log-transformed values in low-income countries and the lowest in high-income countries. Maternal mortality was most strongly and negatively correlated with female secondary school enrollment. In hierarchical regression, health risk factors explained 44.7% of the adjusted variance in maternal mortality (adjusted R² = 0.447). After the addition of socioeconomic indicators, the adjusted explained variance increased to 61.8% (adjusted R² = 0.618). Female secondary school enrollment showed the strongest association with maternal mortality in the final regression model. Conclusions: Cross-country differences in maternal mortality were strongly associated with socioeconomic indicators, particularly female secondary school enrollment. These findings suggest that strengthening maternal health services together with investments in female secondary education, health literacy, gender equity, and nursing-oriented preventive strategies may contribute to improving maternal health outcomes.

Keywords

References

  1. 1. Souza JP, Day L, Rezende-Gomes A, et al. A global analysis of the determinants of maternal health and transitions in maternal mortality. Lancet Glob Health. 2023. DOI:10.1016/S2214-109X(23)00468-0
  2. 2. Tajvar M, Hajizadeh A and Zalvand R. A systematic review of individual and ecological determinants of maternal mortality in the world based on the income level of countries. BMC Public Health. 2022;22. DOI:10.1186/s12889-022-14686-5
  3. 3. World Health Organization. Trends in maternal mortality 2000 to 2020: Estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva: World Health Organization; 2023.
  4. 4. Hamal M, Dieleman M, De Brouwere V, et al. Social determinants of maternal health: a scoping review of factors influencing maternal mortality and maternal health service use in India. Public Health Rev. 2020;41. DOI:10.1186/s40985-020-00125-6
  5. 5. Costa M and Figueiredo F. Relationship between income inequality, socioeconomic development, vulnerability index, and maternal mortality in Brazil, 2017. BMC Public Health. 2021;21. DOI:10.1186/s12889-021-11861-y
  6. 6. Mensch BS, Chuang EK, Melnikas AJ and Psaki SR. Evidence for causal links between education and maternal and child health: systematic review. Trop Med Int Health. 2019;24:504-22. DOI:10.1111/tmi.13218
  7. 7. Bello-Álvarez L, Fernández-Félix B, Allotey J, et al. Effects of maternal education on maternal and perinatal outcomes: An individual participant data meta-analysis of 2,356,402 pregnancies. Int J Gynaecol Obstet. 2025;172:886-95. DOI:10.1002/ijgo.70401
  8. 8. Weitzman A. The effects of women’s education on maternal health: Evidence from Peru. Soc Sci Med. 2017;180:1-9. DOI:10.1016/j.socscimed.2017.03.004

Details

Primary Language

English

Subjects

Obstetrics and Gynocology Nursing

Journal Section

Research Article

Publication Date

September 4, 2026

Submission Date

May 5, 2026

Acceptance Date

July 21, 2026

Published in Issue

Year 2026 Volume: 17 Number: July, August, September 2026

APA
Ünal, E. (2026). A Global Ecological Analysis of Maternal Mortality Ratios: Income Level, Health Risks, and Socioeconomic Indicators. Acıbadem Üniversitesi Sağlık Bilimleri Dergisi, 17(July, August, September 2026). https://doi.org/10.31067/acusaglik.1944747
AMA
1.Ünal E. A Global Ecological Analysis of Maternal Mortality Ratios: Income Level, Health Risks, and Socioeconomic Indicators. Acibadem Univ Saglik Bilim Derg. 2026;17(July, August, September 2026). doi:10.31067/acusaglik.1944747
Chicago
Ünal, Esra. 2026. “A Global Ecological Analysis of Maternal Mortality Ratios: Income Level, Health Risks, and Socioeconomic Indicators”. Acıbadem Üniversitesi Sağlık Bilimleri Dergisi 17 (July, August, September 2026). https://doi.org/10.31067/acusaglik.1944747.
EndNote
Ünal E (September 1, 2026) A Global Ecological Analysis of Maternal Mortality Ratios: Income Level, Health Risks, and Socioeconomic Indicators. Acıbadem Üniversitesi Sağlık Bilimleri Dergisi 17 July, August, September 2026
IEEE
[1]E. Ünal, “A Global Ecological Analysis of Maternal Mortality Ratios: Income Level, Health Risks, and Socioeconomic Indicators”, Acibadem Univ Saglik Bilim Derg, vol. 17, no. July, August, September 2026, Sept. 2026, doi: 10.31067/acusaglik.1944747.
ISNAD
Ünal, Esra. “A Global Ecological Analysis of Maternal Mortality Ratios: Income Level, Health Risks, and Socioeconomic Indicators”. Acıbadem Üniversitesi Sağlık Bilimleri Dergisi 17/July, August, September 2026 (September 1, 2026). https://doi.org/10.31067/acusaglik.1944747.
JAMA
1.Ünal E. A Global Ecological Analysis of Maternal Mortality Ratios: Income Level, Health Risks, and Socioeconomic Indicators. Acibadem Univ Saglik Bilim Derg. 2026;17. doi:10.31067/acusaglik.1944747.
MLA
Ünal, Esra. “A Global Ecological Analysis of Maternal Mortality Ratios: Income Level, Health Risks, and Socioeconomic Indicators”. Acıbadem Üniversitesi Sağlık Bilimleri Dergisi, vol. 17, no. July, August, September 2026, Sept. 2026, doi:10.31067/acusaglik.1944747.
Vancouver
1.Esra Ünal. A Global Ecological Analysis of Maternal Mortality Ratios: Income Level, Health Risks, and Socioeconomic Indicators. Acibadem Univ Saglik Bilim Derg. 2026 Sep. 1;17(July, August, September 2026). doi:10.31067/acusaglik.1944747