In the Stage I (MMR> 1,000 / 100,000) most women are experiencing a situation close to the natural history of pregnancy and childbirth, with very little being done – if anything at all – to reduce the risk of maternal mortality at the population level. Considering 2010 data, Chad and Somalia are countries that could illustrate this stage. Hopefully, as time passes (and progress occurs), no country will remain in this stage. Stage I is characterized by very high maternal mortality, high fertility and the predominance of direct causes of maternal deaths together with a substantial proportion of deaths attributable to communicable diseases such as malaria. In the Stage II (MMR: 999 – 300) mortality and fertility remain very high, with a similar pattern of causes as compared to the Stage I. However, a greater proportion of women in the population are being able to somewhat detach from the natural history of pregnancy and childbirth. Several countries in the Sub-Saharan Africa could illustrate the Stage II. For Stages I and II, the main issue is access to care. In general, these are countries with a substantial lack of basic infrastructure (such as roads, transportation, health facilities), very low education levels (particularly female literacy), weak health systems, severe shortages of skilled birth attendants and low capacity to deliver essential life-saving interventions. In this context, poor quality of care functions as deterrent for generating demand for health services. In countries in these stages, focus should be directed to creating the basic infra-structure and implement maternal-mortality primary prevention measures (e.g. family planning, iron supplementation, insecticide treated nets, intersectorial measures to remove barriers to access the health system). As the minimal infra-structure is created, health services should strive to deliver quality care in order to become a sensible alternative to pregnant women (demand generation). (21) In the<unk> , the tipping point occurs in the Stage III. In this stage the mortality is still high (MMR 299 – 100 maternal deaths / 100,000 live births), the fertility is variable and direct causes of mortality still predominates. This is a complex stage because access remain an issue for a great deal of the population, but as a large proportion of pregnant women are indeed reaching health facilities, quality of care becomes a major determinant of health outcomes. Not only primary prevention is important, but also secondary and tertiary prevention are critical for improving maternal health outcomes in this stage. In other words, quality of care, with skilled birth attendance and appropriate management of complications and disabilities, is essential to reduce maternal mortality. India, Guatemala and South Africa are countries that could illustrate this stage. In the Stage IV (MMR <50 maternal deaths / 100,000 live births), the maternal mortality is moderate or low, there is low fertility and the indirect causes of maternal mortality, particularly the non-communicable diseases, acquire greater importance. In order to further advance the reduction of maternal mortality, the main issue becomes quality of care and elimination of delays within health systems. Another aspect that emerges in this stage is the growing role of over medicalization as a threat to quality and improved health outcomes. Various Asian countries and most Latin American countries have joined developed countries in this stage. In the Stage V, all avoidable maternal deaths are indeed avoided. The maternal mortality rate is very low, the fertility is low or very low, and the non-communicable diseases are the main causes of maternal mortality. As this is an aspirational, largely theoretical stage at the moment, the maternal mortality levels remain uncertain, but could be lower than 5 maternal deaths per 100,000 live births. The main issue in this stage would be the sustainability of excellence in quality of care. It is worth noting that the main purpose of this framework is to illustrate different phases of a dynamic process and offer a rationale for different focus and solutions for reducing mortality according to the stage in the<unk> . The ranges of maternal mortality ratio uses to define the proposed stages of<unk>  are frequently in country stratification, (2, 16) but the boundaries between these stages are somewhat imprecise and one stage tends to fade into another. Progression is not always linear and, largely due to equity issues, different stages often co-exist in the same country.
Obstetric transition
Uterine hyperstimulation
Postpartum physiological changes
Ovarian hyperstimulation syndrome
Lactational amenorrhea
Cryptic pregnancy
Anovulatory cycle
Forced pregnancy