Imagine a World

Where innovations could save the lives of 2 million more mothers and babies

by Melinda French Gates and Bill Gates

Co-Chairs, Bill & Melinda Gates Foundation

A mother and her newborn. © AlignMNH

When a mother dies during childbirth, the future dies with her.

The world doesn’t just lose everything she is and will be. We also—all too often—lose her child. The chance of a baby reaching their first birthday drops to less than 37 percent when their mother dies during childbirth.

This happens 800 times a day. Once every two minutes, a mother dies from complications due to childbirth. By the time you finish reading this introduction, it will happen again.

Two decades ago, that wasn’t the way progress was heading.

The early 2000s were a boom moment for virtually every measure of human well-being. Poverty rates. Educational achievement. Longevity. Things were improving. But nowhere was progress faster or more thrilling than with the health of mothers and their children.

This didn’t happen by accident. In 2000, world leaders drafted the Millennium Development Goals (MDGs), which included ambitious targets for the health of mothers and newborns. In response, big new organizations helped accelerate progress, like Gavi, the Vaccine Alliance and the Global Fund to Fight AIDS, Tuberculosis, and Malaria. For the first time in human history, basic lifesaving health care was made available to hundreds of millions of people: AIDS medications, contraceptives, childhood vaccines, bed nets to prevent malaria.

It was a thrilling moment—until it ended. And when COVID-19 hit, the virus overwhelmed the clinics and health workers that had helped women deliver their babies safely. Since then, progress has continued to stall.

Every year, approximately 5 million children die before they reach their fifth birthday. Nearly another 2 million babies never take their first breath—they’re stillborn. Although these deaths have continued to decline since the mid-2010s, they’re not declining fast enough, especially for infants. Most child deaths—74 percent—happen during a baby’s first year.

Meanwhile, for new mothers, progress has hit a brick wall. Globally, maternal mortality rates have remained stubbornly static over the past eight years, and in some countries, from the United States to Venezuela, they have risen.

Two SDG targets that are off track
Despite significant progress from 2000 to 2015, slowing improvement since then means the world is not on track to reach the Sustainable Development Goals for the survival of mothers or babies—not unless progress is accelerated.
No global goals
Maternal deaths per 100,000 live births
Bar charts showing the global progress of maternal and neonatal mortality from 1990 to 1999, during the Millennium Development Goals, the Sustainable Development Goals (SDGs) up to 2022, with projections to 2030. Projected progress during the SDGs shows we will not meet targets for maternal and neonatal mortality by 2030.
3% annualized rate of decline from 2000 to 2015
Only 0.5% since 2016
SDG Target
Neonatal deaths per 1,000 live births
Bar charts showing the global progress of maternal and neonatal mortality from 1990 to 1999, during the Millennium Development Goals, the Sustainable Development Goals (SDGs) up to 2022, with projections to 2030. Projected progress during the SDGs shows we will not meet targets for maternal and neonatal mortality by 2030.
2% annualized rate of decline since 2000 isn't fast enough
SDG Target

As we began developing this report, we knew we had to focus on these alarming statistics. It’s true, there are so many new and complex issues confronting the world, from climate change-induced heat waves to recent breakthroughs in artificial intelligence (AI). Still, we believe our most ancient public health problem—the survival of mothers and babies—remains the most urgent.

2023 marks the halfway point for the successors to the Millennium Development Goals—the Sustainable Development Goals. The ambition was to end all preventable child deaths by 2030, and to cut the maternal mortality rate to less than 70 out of every 100,000 births. We are far off track on both goals—but that doesn’t have to be the case.

In fact, there’s a new and remarkable irony about the problem of maternal and neonatal mortality: In the 2010s, just as the problem was about to get worse, it also became more solvable. Doctors uncovered revolutionary information about maternal and child health—everything from the exact diseases that are killing children, to the role anemia can play in increasing blood loss during childbirth, to previously unknown ways in which a baby’s health is linked to their mother’s.

It’s not an exaggeration to say that researchers have learned more about the health of mothers and babies over the past 10 years than they did in the century before that. Tragically, those solutions aren’t reaching families in the communities where mothers and kids need them most. That needs to change.

In the following essays, we’ll describe how these insights are being turned into innovations and practices to accelerate progress and boost survival rates for mothers and babies. Typically, we focus only on low- and middle-income countries (LMICs), but researchers believe many of these breakthroughs could also be used to fight the epidemic of maternal mortality globally, including in the United Kingdom and the United States, where death rates for Black mothers have doubled since 1999.

What will these new innovations mean for the survival of mothers and babies? For this report, global health experts estimated how many additional lives might be saved if these new innovations were used widely in LMICs. The result? Nearly 1,000 mothers and babies each day through the end of the decade. Or 2 million lives.

Opportunity to save millions of lives
By making new innovations accessible to those who need them most, 2 million additional lives could be saved by 2030—and 6.4 million lives by 2040.
Sub-Saharan Africa
South Asia
Other LMICs
Millions of total lives saved
Stacked bar chart showing 2 million mothers and babies’ deaths prevented by 2030 and 6.4 million mothers and babies' deaths prevented by 2040 in low- and middle-income countries.
2 million by 2030
6.4 million by 2040

That’s 2 million families spared an unimaginable heartbreak—and 2 million more people who can shape and enrich our world.

You don’t need us to tell you what a remarkable achievement that would be.

Just look.

Close-up of mother kissing her newborn, in the United States. © Getty Images
Close-up of mother kissing her newborn, in the United States.
© Getty Images

Delivering hope

by Melinda French Gates

Co-Chair, Bill & Melinda Gates Foundation

New breakthroughs could ensure that more women survive pregnancy and childbirth

A mother holds her newborn daughter closely, in Canada. © Getty Images

In February, I was with my daughter, Jenn, when she gave birth to a daughter of her own. Welling up inside me were all the emotions a new grandparent feels: joy, excitement, pride—and, above all, immense gratitude.

In the best of circumstances, childbirth is an exhausting, emotional experience, something I knew from my own experience. It felt like just yesterday that I was giving birth to Jenn in a 14-hour labor that left me utterly drained and barely able to walk.

But in the worst of circumstances, childbirth isn’t just draining—it’s deadly, for mother and baby. Several years ago, I traveled to Malawi, where almost everyone I met had lost someone they loved. At a maternity clinic, the staff, dazed with grief, told me that just the week before, one of their own nurses had given birth, and they couldn’t save her.

I’ll never forget the pain I saw on their faces as they told me about the women they’d lost. The worst part is, so many of these deaths could have been prevented.

For nearly all of human history, we simply didn’t know enough about preventing or treating the common childbirth complications that lead to death, such as postpartum hemorrhage or infection. Today, we know a great deal. Yet, as is so often the case in global health, innovations aren’t making their way to the people who need them most: women in low-income countries like Malawi, as well as Black and Indigenous women in high-income countries like the United States, who are dying at three times the rate of white women, even when holding for economic and education levels.

Brilliant researchers have developed new interventions that could ensure more women have access to lifesaving care. Their work is opening up new—and, importantly, low-cost and mobile—avenues of preventing and treating deadly childbirth complications. When combined with better primary health care and more resilient health systems, the three innovations that follow have the potential to save thousands of mothers’ lives in LMICs around the world by 2030.

Here’s how.

A big impact for mothers
Low-cost innovations can prevent thousands of women in LMICs from dying during pregnancy and childbirth.
PPH management bundle
IV iron
Maternal azithromycin (intrapartum)
AI-enabled ultrasound
Thousands of total deaths prevented
Stacked area chart showing 200,000 mothers saved by 2040 with the use of postpartum hemorrhage bundle, IV iron, maternal azithromycin, and AI-enabled ultrasounds.

Treating postpartum hemorrhage

Postpartum hemorrhage (PPH) is the number one cause of maternal death. The World Health Organization estimates that PPH, which means losing more than half a liter of blood within 24 hours of childbirth, affects 14 million women every year—killing 70,000 of them, primarily in low-income countries. Those who survive often face long-term, disabling complications, such as heart or kidney failure.

Dr. Hadiza Galadanci, an obstetrician and researcher from Nigeria, explains that there is a critical flaw in the way PPH is diagnosed: Health care workers often have a hard time recognizing how much blood loss is too much blood loss. The only tool they have is a rough visual estimate. In a study they called E-MOTIVE, Dr. Galadanci and a team of researchers in four African countries with high maternal mortality found that about half of the women who experience PPH were never diagnosed at all. Therefore, they never got lifesaving treatment.

There is a simple, low-cost way to identify when blood loss is dangerously excessive: a drape that looks like a V-shaped plastic bag. When this calibrated obstetric drape is hung at the edge of the bed, collected blood rises like mercury in a thermometer. And in a busy hospital ward, that visual gauge tells providers which patients are in danger in just a single glance.

Dr. Galadanci reviewing the postpartum hemorrhage bundle with health workers, in Nigeria.
Dr. Galadanci reviewing the postpartum hemorrhage bundle with health workers, in Nigeria.
© Nelson Owoicho

When PPH is identified, doctors, nurses, and midwives have long relied on a series of five treatments to stop the bleeding: uterine massage, oxytocic drugs, tranexamic acid, IV fluids, and genital-tract examination. But those interventions were being delivered sequentially—and far too slowly. So the researchers asked providers to bundle the interventions, administering all five at once.

The results were dramatic: In a trial of 200,000 women, providers who used drapes and followed the updated E-MOTIVE guidelines were able to decrease cases of severe bleeding by a remarkable 60 percent.

Preventing PPH in the first place

A common cause of postpartum hemorrhage is anemia, or severe iron deficiency.

Anemia affects as many as 37 percent of pregnant women around the world. In some places in South Asia, that rate jumps as high as 80 percent. Anemia is a dangerous condition on its own, but it is also deeply intertwined with PPH: If a woman has severe anemia, she is much more likely to bleed heavily during her delivery. And even worse, because anemia reduces how much oxygen the blood can carry, anemic women cannot survive the same volume of blood loss as nonanemic women. It’s a vicious cycle.

Symptoms of anemia include fatigue or feeling faint or dizzy—things that might happen simply because you’re pregnant. Every pregnant woman should have access to maternal micronutrient supplements—high-quality prenatal vitamins that include iron—which can prevent most mild maternal anemia cases. But diagnosis and targeted treatment are necessary to address moderate and severe cases of anemia. So once again, a primary challenge is diagnosis. Screening for anemia during pregnancy is one of the most important tests we can do to ensure a woman’s health and survival. And just one example of why antenatal care is so important.

If anemia is diagnosed, the traditional treatment is supplemental iron delivered via tablets. But taking iron orally can cause unpleasant side effects and requires women to keep up with a consistent regimen for up to 180 days.

But a Nigerian obstetrician and researcher named Dr. Bosede Afolabi is working on bringing a promising new intervention to her home country: a one-time, 15-minute intravenous (IV) infusion of iron. It’s an IV drip that can replenish women’s iron reserves during pregnancy—or even after pregnancy—and it could help treat severe cases of anemia quickly and effectively.

IV iron quickly replenishes women’s iron reserves

IV iron quickly replenishes women’s iron reserves

Anemia isn’t just a cause of postpartum hemorrhage; it’s also an effect—one that can lead to long-term consequences ranging from heart disease to depression. So this solution could mean not just saving women’s lives but also helping them lead better ones.

Preventing infections

Another leading cause of maternal death and disability is infection that leads to sepsis—an extreme, full-body inflammatory reaction. In recent years, researchers have discovered that one of the most promising new ways to prevent infection during pregnancy happens to be one of the most commonly used antibiotics in the world.

For decades, azithromycin has been used to treat a variety of bacterial infections, most commonly eye and respiratory infections. Now we’re learning that when given during labor, azithromycin also reduces maternal infections, therefore preventing those infections from spiraling into sepsis. During a trial across sub-Saharan Africa, it reduced sepsis cases by a third. That’s a remarkable discovery—one that could be very useful in places where most births are at home.

And it could also be a game-changer in the United States, where 23 percent of maternal deaths are from sepsis.

Azithromycin reduces infection risk

Azithromycin reduces infection risk

The United States has some of the most abysmal—and most inequitable—maternal mortality rates among high-income countries. American women are more than three times more likely to die from childbirth than women in almost every other wealthy country. But, as I noted earlier, the biggest crisis is among Black and Indigenous women.

I still remember the shock I felt when I read tennis star Serena Williams’s account of how close she came to dying from serious blood clots after giving birth—simply because her own doctors wouldn’t believe her that something was wrong. That shock only grew when I read, just this past April, that Tori Bowie, a Black American track and field Olympian, died from childbirth complications in her home. And these are just the stories we hear about in headlines.

It’s remarkable that a common antibiotic like azithromycin has the potential to address the cause of nearly a quarter of American maternal deaths.

But as Serena’s harrowing experience and Tori’s tragic death demonstrate, one antibiotic is not enough. The systemic inequalities that deny the highest-quality care to Black and Indigenous women also need to be addressed—urgently.

A powerful engine for progress

These are three of the innovations that are reshaping maternal health—and there are others just on the horizon, especially as researchers learn more about how to use AI to improve maternal health care.

Of course, these breakthroughs aren't silver bullets on their own—they require countries to keep recruiting, training, and fairly compensating health care workers, especially midwives, and building more resilient health care systems. But together, they can save the lives of thousands of women every year. And that’s not all.

Improving maternal health also means improving infant health and survival. It means stronger families, more vibrant communities, and more prosperous societies. We have seen over and over again that when countries actually prioritize and invest in women’s health, they unleash a powerful engine for progress that can reduce poverty, advance gender equality, and build resilient economies.

"Improving maternal health also means improving infant health and survival. It means stronger families, more vibrant communities, and more prosperous societies."
—Melinda French Gates

That’s why, more than anything, we need to rally the will to invest in these breakthroughs—so they actually get to the women who need them most—and fund the remarkable researchers who will discover the next ones.

Dr. Afolabi explained that in the Yoruba language, the traditional greeting to a woman who has given birth is “Eku ewu omo,” which translates to, “Well done for getting through the danger of childbirth.”

Thanks to her, and others like her, more women will live long enough to hear those words. And maybe one day, when breakthroughs have reached women all around the world and childbirth is far less dangerous, all they'll hear is “Well done.”

The baby knowledge boom

by Bill Gates

Co-Chair, Bill & Melinda Gates Foundation

A decade of research into why kids in the poorest places die is now unlocking ways to save millions

A mother and her two healthy babies, in Senegal. © AlignMNH

It’s been almost a decade, but it’s still hard for me to tell this story without choking up.

It was 2016, and I was visiting a hospital in Johannesburg, South Africa—specifically, Soweto, the township on the city’s outskirts, which had some of the highest child mortality rates in the world.

Even at wakes and funerals it’s sometimes shocking for me to see a dead body, but this didn’t look like any dead body I had seen before. It was so small, covered in plastic. Only after I stepped closer did I recognize it was a newborn baby, maybe a day or two old.

Afterwards, I collected myself and went outside. The child’s parents were there.

I had met parents who’d lost children before, but not like this. When children died in poorer countries, they were never brought to a hospital or a morgue. Sometimes, a health worker would travel to the home and ask what had happened, but medical examiners and doctors didn’t perform an autopsy—not until CHAMPS.

Child Health and Mortality Prevention Surveillance, CHAMPS, is an initiative our foundation started in 2015. The idea was to learn more about the root causes of child death by taking blood and tissue samples from children who’d died, but no one was quite sure whether, on the worst day of their lives, the parents would agree. The couple outside the Soweto hospital were among the first to volunteer, and I wanted to learn why.

“We just don’t want this to happen to another family,” they told me.

That's what sticks with me—not simply the tragedy, but the kernel of hope. Those parents saw a bigger picture on the day their greatest fear was realized. And it was up to the rest of the world to do better by them and millions of parents like them: We had to find out why children were dying to keep them alive.

CHAMPS supervisor presents data collection processes at the commissioning of the Makeni Regional Hospital Laboratory, in Sierra Leone.
CHAMPS supervisor presents data collection processes at the commissioning of the Makeni Regional Hospital Laboratory, in Sierra Leone.

Even ten years ago, public health officials had only the vaguest information about why babies were dying. Back then, any record of a child’s death would generally list one of the four most common causes: diarrhea, malnutrition, pneumonia, or premature birth. But each was a vast ocean of different illnesses, with scores of different causes and cures. Pneumonia, for example, is linked to more than 200 types of pathogens.

Answering “Why did a child die?” felt a little bit like being asked to find a child lost at sea—except you were only told which ocean to search in, Atlantic or Pacific. There was an expanse of missing information, so our foundation decided to help fill that void by funding research including three landmark studies. In addition to CHAMPS, which was aimed at explaining the most inscrutable causes of death, there was also the Pneumonia Etiology Research Child Health Study, PERCH, which examined the causes of childhood pneumonia, while the Global Enteric Multicenter Study, GEMS, did the same for diarrheal diseases.

As doctors compiled and compared case after case, a clearer (and often surprising) picture of child death emerged. For instance, some pathogens were less likely than was expected, like pertussis, which causes whooping cough, but others were more likely than we expected, like Klebsiella, which can be harder to treat.

Imagine if doctors didn’t know why American men were susceptible to heart attacks—and then, in the span of two years, they discovered the links to high cholesterol and smoking. That’s what happened with infant pneumonia, and the new information about Klebsiella is leading doctors to change what antibiotics they use.

More precise understanding of why children die
CHAMPS data provides hyper-detailed information about which pathogens are causing deaths, guiding the development of improved treatments and vaccines.
Pie charts showing how CHAMPS data provides additional information about which pathogens and specific serotypes are cause child deaths, guiding the development of improved treatments and vaccines.

This is the crux of what I call “the baby knowledge boom.” Thanks to studies like CHAMPS, GEMS, and PERCH, the medical field has begun to understand precisely when and why some babies are dying, which allows them to keep others alive.

Another great example is how doctors are helping premature babies breathe—by using novel methods to “fast-forward” their lung growth. If a doctor sees that a mother is going to give birth prematurely, they can give her antenatal corticosteroids, or ACS. The ACS “exercises” the fetus’s lungs, which accelerates their growth, packing a few weeks’ worth of maturation in just a few days. Our foundation estimates that ACS could save the lives of 144,000 infants in sub-Saharan Africa and South Asia by 2030 and nearly 400,000 by 2040.

But that’s just a fraction of the lives we can save if we apply what researchers learned about nutrition in the past decade.

Antenatal corticosteroids fast-forward baby’s lung growth

Antenatal corticosteroids fast-forward baby’s lung growth

Gut check

If you’ve seen medical TV shows like CSI or House, MD, you already have some sense for how an initiative like CHAMPS works. Doctors and pathologists sit on a “decode panel,” reviewing cases, batting ideas back and forth, until they come to a full conclusion on all the steps that led to a person’s death.

This level of detail is important because, outside of unexpected accidents, few people die for just one reason. Instead, death is a chain reaction. For example, a baby who dies of pneumonia likely wasn’t just fine before getting sick. She likely was born premature or was undernourished. The best way to keep a child alive isn’t to treat the pneumonia that will kill her. That’s a last resort. Rather, we should try to stop the first link in the causal chain from being formed in the first place.

Studies like CHAMPS helped us understand that often that first link is malnutrition.

Believe it or not, I think this is positive news. Because our growing understanding of why children die has proceeded alongside a second, arguably bigger knowledge boom—this one involving our grasp of nutrition.

If we’ve packed 100 years of learning about maternal and child mortality into the past decade, researchers have probably crammed 1,000 years’ worth of knowledge about the microbiome in the same decade, which is the teeming universe of bacteria that lives inside our digestive tracts. For example, the child health field used to think of breastmilk as only food for the newborn. But we’ve now learned that it’s also food for the bacteria that naturally live in the gut of the baby.

These bacteria—the most common ones are called bifidobacteria—break down specific sugars in the milk, turning it into nutrients. Without these good bacteria it doesn’t matter how well you feed your baby; their digestive system would still have a really hard time absorbing the milk’s nutrients. Which is why doctors are now recommending that babies—especially those born too soon or too small—are given a probiotic supplement with bifidobacteria in it.

B. infantis improves baby’s gut microbiome

B. infantis improves baby’s gut microbiome

This next part is gross, but amazing. Bifidobacteria are different depending on where you’re from. Babies in India have different gut bacteria than babies in the United States, so these probiotics have to be tailored hyper-locally—or in this case, “diaper locally.” Researchers swab the poop of a baby, isolating the bacteria that live in their intestines, then analyze the unique way they work in their digestive tract and can create locally tailored probiotics based on that research.

There are other new supplements to fight malnutrition, but maybe the biggest innovation is when doctors are providing them: in the womb. The medical field used to think that you couldn’t treat malnutrition until a child was about six months old and started eating. But new research has found that the baby’s microbiome and the mother’s are connected. If a pregnant woman has abundant bifidobacteria, good bacteria can spread from her digestive tract to the child’s; this way, the baby is born already having a healthy gut.

Studies show these probiotics help babies gain an additional 5 grams of weight per day in the late stages of pregnancy and can improve baby’s growth when given to the baby after birth.

Delivering healthy babies and saving millions of lives
Low-cost innovations can prevent millions of stillbirths and infant deaths in LMICs.
Multiple micronutrient supplements
Maternal azithromycin (pregnancy)
B. infantis
Infant azithromycin
Antenatal corticosteroids
AI-enabled ultrasound
Millions of total deaths prevented
Stacked area chart showing over six million babies saved by 2040 when multiple micronutrient supplements, maternal azithromycin, b. Infantis, Infant azithromycin, antenatal corticosteroids, and AI-enables ultrasounds are adopted and scaled in low- and middle-income countries.

Remembering Soweto

“We just don’t want this to happen to another family.”

What those parents in Soweto said to me has echoed in my mind for over seven years, and I’ve often wondered how I might respond if I saw them again.

I think I would be honest. It might not be possible to protect every family, to guarantee a world of zero newborn deaths. Zero is a hard number.

But that doesn’t mean we can’t come very, very close.

Over the past decade, the field of child health has moved faster and farther than I thought I’d see in my lifetime. And if our delivery can keep pace with our learning—if researchers can keep developing new innovations and health workers can get them to every mother and child that needs them—then doctors could all but guarantee a baby would survive their crucial first days.

That’s what I would tell them. That’s what, together, I believe we can show them.

"Over the past decade, the field of child health has moved faster and farther than I thought I’d see in my lifetime."
—Bill Gates

A final word

One last note to our readers, by Melinda French Gates and Bill Gates

If there’s one thing you take away from this report, we hope it’s hope itself—the belief that the world can save the lives of 1,000 more mothers and babies every day through the end of the decade.

But you should also know: It’s not a done deal. Those lives will be saved only if all mothers and babies have access to both quality health care services and the innovations we wrote about in this report.

We need policy changes, political will, more investment into women’s health, and health care workers—including midwives. We need to listen to what women want and ensure that women have a say in their own health care. And ultimately, we need to commit together that we no longer accept preventable deaths of mothers and babies around the world.

The world has come so far so quickly in our understanding of how to save the most fragile lives. Together, we can translate that knowledge into tangible progress.

To paraphrase our friend, the late Dr. Paul Farmer, “The biggest failure we have in providing health care to mothers and children is a failure of imagination… If we can send a rover to Mars, we can imagine a world where mothers and babies can live long and healthy lives.”

Incredible progress is possible again.

We now know a lot about why mothers and babies die; new breakthroughs could save their lives.

A video message from Melinda

Melinda French Gates

A video message from Bill

Bill Gates

Explore the data

Each year, Goalkeepers share the latest estimates on 18 indicators, ranging from poverty to education. These indicators help us understand the progress toward the Sustainable Development Goals—where innovation and investment are creating bright spots, and where we’re collectively falling short. This data reminds us that progress is possible, but not inevitable.

Halfway to the deadline for the SDGs, the world is off track. Urgent action is needed if the world is going to meet the SDG targets and create a more equitable and safe future for all by 2030.

No Poverty


Zero Hunger


Zero Hunger


Good Health & Well-Being

Maternal Mortality

Good Health & Well-Being

Under-5 Mortality

Good Health & Well-Being

Neonatal Mortality

Good Health & Well-Being


Good Health & Well-Being


Good Health & Well-Being


Good Health & Well-Being

Neglected Tropical Diseases

Good Health & Well-Being

Family Planning

Good Health & Well-Being

Universal Health Coverage

Good Health & Well-Being


Good Health & Well-Being


Quality Education


Gender Equality

Gender Equality

Clean Water and Sanitation


Decent Work and Economic Growth

Financial Services for the Poor