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Impact of Disease

Causes of death and disability among women differ by age group, income level and geographic location. Many developing countries are experiencing the double burden of disease, as they strive to control communicable diseases while also dealing with the growing burden of non-communicable or chronic diseases.

Maternal conditions are a leading cause of death and disability among women of reproductive age. Multiple risks associated with pregnancy and birth can cause death or disability among women.
The leading infectious diseases that affect women include HIV/AIDS, sexually transmitted infections, malaria and tuberculosis.
The leading chronic illnesses that affect women during their lifespan include cardiovascular disease, malignant neoplasms and neuropsychiatric conditions.
Intentional and unintentional injuries are gaining more exposure as common causes of death among women and girls. Survivors can face devastating impacts on the productivity and quality of their lives.
Although nutrition is not listed as a leading cause of disability or illness, its impact on the health of women and their children is high throughout their lifespan.

Maternal Conditions

Maternal conditions are one of the leading causes of death and disability among women in the reproductive ages. Hemorrhage, sepsis, hypertensive disorders, obstructed labor, and unsafe abortion can have devastating consequences.

An estimated 536,000 women die of pregnancy-related causes each year, and about 10 million women suffer complications related to pregnancy or childbirth, many with life-long consequences, including obstetric fistula.^1-3 Complications may be physical, psychological, social or economic.
In addition to the impact on women, maternal chronic ill-health can affect the health and quality of life of the surviving children, as they depend on her for food and support.³ Children whose mothers die are three to 10 times more likely to die.⁴

Maternal deaths
The World Health Organization (WHO) has divided maternal deaths in two main groups:⁵

Direct obstetric deaths result from pregnancy complications occurring before, during or after delivery, due to inadequate or improper care. Evidence suggests that the direct causes account for the majority of the maternal deaths in developing countries. But it is very difficult to determine the exact cause of death, especially when the woman dies at home.

Worldwide, hemorrhage is the leading cause of maternal deaths among women of reproductive age, as it is responsible for more than a quarter of these deaths.⁶ Hemorrhage takes the largest toll on mothers in Africa and Asia, where it caused between 31 and 34 percent of total deaths between 1997 and 2002.^{7, 8}
Worldwide, unsafe abortions, sepsis (infection) and hypertensive disorders each cause between 10 and 15 percent of maternal deaths among women of reproductive age.⁶ Hypertension causes the largest proportion of maternal deaths among women of reproductive age in Latin America, where it is responsible for more than one-quarter of these deaths.⁷
Worldwide, obstructed labor is responsible for 7 percent of maternal deaths among women of reproductive age.⁶ Small-statured and under nourished women are at highest risk. Prolonged obstructed labor results in injuries to multiple organ systems.⁹

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Obstetric Complications⁵

Direct Obstetric Complications	Indirect Obstetric Complications
1. Hemorrhage	1. Anemia
2. Infection/ Sepsis	2. Malaria
3. Obstructed Labor	3. Hepatitis
4. Hypertensive Disorders of Pregnancy	4. Diabetes Mellitus
5. Abortion	5. Heart Disease
6. Others (including ectopic pregnancy, embolism, anesthesia-related causes)	6. HIV/AIDS

Global Distribution of the Causes of Maternal Deaths Among Women
of Reproductive Age⁶

Note: values do not sum to 100 percent due to rounding.

Where do maternal deaths occur?¹ More than 99 percent of maternal deaths occur in the developing world. Maternal mortality represents one of the largest gaps between high-income and low-income countries, reflecting a gap in the provision of basic health-care facilities. Sub-Saharan Africa – including West and Central Africa and Eastern and Southern Africa – and South Asia are especially hard hit. Of the 536,000 maternal deaths each year, about 84 percent occur in these regions.^{10, 11}

Proportion of Maternal Deaths by UNICEF Region¹

In 2005, the maternal mortality ratio for sub-Saharan Africa was estimated to be 920 per 100,000 live births: which is nearly two times that of South Asia, roughly seven times that of Latin America and the Caribbean and more than 100 times higher than that of developed countries.¹
A 15-year-old girl in sub-Saharan Africa has a one in 22 lifetime risk of dying from pregnancy or childbirth as compared to a one in 7,300 lifetime risk for women in developed countries.¹
The global estimate for lifetime risk of maternal death is one in 92. The highest risk is in Niger (one in seven); the lowest risk is in Sweden (one in 48,000).¹

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Estimates of Maternal Mortality, 2005¹

United Nations MDG Regions	Maternal Mortality Ratio (maternal deaths per 100,000 live births)	Number of Maternal Deaths	Lifetime Risk of Maternal Death: 1 in
Africa	820	276,000	26
• Northern Africa	160	5,700	210
• Sub-Saharan Africa	900	270,000	22
Asia	330	241,000	120
• Eastern Asia	50	9,200	1,200
• South Asia	490	188,000	61
• Southeastern Asia	300	35,000	130
• Western Asia	160	8,300	170
Latin America and the Caribbean	130	15,000	290
Oceania	430	890	62

Developed Regions	9	960	7,300
Countries of the commonwealth of independent states (CIS)	51	1,800	1,200
Developing Regions	450	533,000	75

World	400	536,000	92

Most of the countries with the highest numbers of maternal deaths have a large population, such as India and Nigeria.

India records the highest number of maternal deaths (117,000).¹ Globally, this represents 20 percent of the maternal deaths.
The five countries with the highest numbers of maternal deaths, which include India, Nigeria, the Democratic Republic of Congo, Afghanistan and Ethiopia, account for 44 percent of the total global maternal deaths. The first 10 countries account for 63 percent of the total global maternal deaths.
The majority of the countries with high maternal mortality (including highest number of deaths and highest maternal mortality ratios) also have high child mortality. This demonstrates the inextricable link between the health of mothers and children.

The 10 Countries with the Highest Number of Maternal Deaths, 2005^{1, 12, 13}

	Population (in thousands)	Number of maternal deaths per year (in thousands)
India	1,148,000	117
Nigeria	146,255	59
Democratic Republic of Congo	70,418	32
Afghanistan	32,738	26
Ethiopia	82,545	22
Bangladesh	153,547	21
Indonesia	237,512	19
Pakistan	172,800	15
Niger	13,273	14
United Republic of Tanzania	40,213	13

Number of Child Deaths in Countries with Highest Maternal Deaths, 2005^{1, 13}

	Number of maternal deaths per year (in thousands)	Number of child deaths per year (in thousands)
India	117	2,103
Nigeria	59	1,113
Democratic Republic of Congo	32	621
Afghanistan	26	278
Ethiopia	22	370
Bangladesh	21	307
Indonesia	19	192
Pakistan	15	473
Niger	14	136
United Republic of Tanzania	13	187

Rates of Maternal Mortality and Child Mortality, 2005^{1, 13}

Country	Maternal Mortality (Deaths per 100,000 live births)	Child Mortality (Deaths per 1,000 live births)
Sierra Leone	2,100	254
Afghanistan	1,800	232
Niger	1,800	209
Chad	1,500	180
Angola	1,400	242
Somalia	1,400	220
Rwanda	1,300	168
Liberia	1,200	173
Burundi	1,100	190
Guinea-Bissau	1,100	193
Nigeria	1,100	193
Malawi	1,100	134
Democratic Rep. of the Congo	1,100	218

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Pregnancy and successful delivery are life-threatening activities for a woman living in the countries that exhibit the highest rates of maternal mortality ratios (MMR), in part, because of political, economic and social conditions that prevail in these regions of the world.

Of the 13 countries with the highest MMR, 12 are in Africa, Afghanistan being the exception.¹⁴
In 2005, the average MMR estimate for the world was 400 per 100,000 live births.¹

Maternal Morbidity

Complications during pregnancy and childbirth can cause long-term disability. Prolonged obstructed labor can have devastating implications on the mother, such as obstetric fistula, damaged pelvic structure and anemia. Mothers who experience complications may also suffer from depression, infertility and chronic infections. In addition to these health-related problems, women’s productivity is likely to be diminished.¹⁵ Often these conditions are left untreated as the cost of treatment would push families further into poverty.

Within each region, some countries have managed to maintain good levels of or improve maternal health, while maternal health in others has deteriorated or remained stagnant.¹⁴

The countries with the lowest levels of maternal mortality tend to be middle-income countries with higher GNI per capita, or economies with high levels of growth.¹⁶ They also have an average of nearly 20 physicians per 10,000 people and spend an average of nearly $70 per capita on health.

Developing Countries with the Lowest Maternal Mortality Rates^16-18

Rank	Country	Maternal Mortality (Deaths per 100,000 live births)	GNI per capita (PPP), 2005 (USD)	GDP per capita percent growth (2004-2005)	Per capita government expenditure on health at average exchange rate USD, 2005	Physicians density per 10,000 population, (year)
1	China	45	6,600	9.2	31	14 (2003)
2	Mexico	60	7,310	1.9	215	20 (2000)
3	Azerbaijan	82	4,890	25.0	15	36 (2006)
4	Brazil	110	8,230	0.9	164	12 (2000)
5	Egypt	130	4,440	2.9	30	24 (2005)
6	Turkmenistan	130	N/A	N/A	104	25 (2006)
7	Tajikstan	170	1,260	6.2	15	36 (2006)
8	Philippines	230	5,300	3.3	14	12 (2002)
9	Peru	240	5,300	5.1	61	12 (1999)
10	Morocco	240	4,360	0.4	33	5 (2004)

The countries with the highest levels of maternal mortality have low values of GNI per capita, or low levels of economic growth; some are currently experiencing conflicts which stress health systems and can cause their collapse. They spend an average of $8 per capita on health and have severe shortages of physicians.

Developing Countries with the Highest Maternal Mortality Rates^{14, 16, 17}

Rank	Country	Maternal Mortality (Deaths per 100,000 live births)	GNI per capita (PPP), 2005 (USD)	GDP per capita percent growth (2004-2005)	Per capita government expenditure on health at average exchange rate USD, 2005	Physicians density per 10,000 population, (year)
1	Sierra Leone	2,100	730	3.8	4	<1.0 (2004)
2	Afghanistan	1,800	N/A	N/A	N/A	N/A
2	Niger	1,800	800	1.1	5	<1.0 (2004)
3	Chad	1,500	1,470	2.3	9	<1.0 (2004)
4	Angola	1,400	2,210	11.5	30	<1.0 (2004)
4	Somalia	1,400	N/A	N/A	(2000) 4	<0.1 (1997)
5	Rwanda	1,300	1,320	3.2	11	<1.0 (2004)
6	Liberia	1,200	N/A	N/A	7	<1.0 (2004)
7	Burundi	1,100	640	-2.6	1	<1.0 (2004)
7	Guinea-Bissau	1,100	N/A	N/A	7	<1.0 (2004)
7	Nigeria	1,100	1,040	4.7	8	3 (2003)
7	Malawi	1,100	650	0.4	14	1 (2004)
7	Democratic Rep. of the Congo	1,100	720	3.5	2	1 (2004)

Obstetric fistula is a condition in which the tissues of the vagina and rectum are damaged due to prolonged obstructed labor and lack of timely medical care.³ The victims, suffering from incontinence, face abandonment by their husbands, families and communities. Although once a condition in industrialized countries, it is now most common in sub-Saharan Africa and Asia because of limited access to medical care during labor and delivery. In developing countries, at least 2 million women live with untreated obstetric fistula, with 50,000 to 100,000 new cases reported each year. Women with untreated fistula are at risk of infections, undernutrition, kidney diseases, nerve damage in the legs and even death.

Access to family planning options, skilled birth attendants and emergency obstetric care would prevent new cases.
Reconstructive surgery (costing an average of $300 for surgery, post-operative care and rehabilitation) can correct the condition with a 90 percent success rate for uncomplicated cases and 60 percent for complicated cases. Urostomy, in which women wear a urine collection bag, is an alternative to reconstructive surgery.
The impact on the woman’s social and family life are dramatic and include separation from husband, children and other family members, poor economic conditions, inability to find employment and exclusion from religious activities.^{19, 20}
The Campaign to End Fistula is a global movement to increase awareness, prevent, treat, and reduce stigma related to obstetric fistula by bringing together policy makers, health officials and women with fistula. Launched by UNFPA and its partners in 2003, the Campaign addresses obstetric fistula in more than 40 countries in sub-Saharan Africa, Asia and the Middle East.¹⁵

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Damaged pelvic structure, or uterine prolapse, occurs when the pelvic muscles, tissues and ligaments are weakened and the uterus is displaced.^{15, 21} In milder cases of prolapse, the uterus and cervix remain within the vagina; in more severe cases, the cervix or uterus may protrude from the vagina. This condition is associated with traumatic labor and delivery, disease, frequent pregnancies, inadequate antenatal care, age, and straining (e.g., carrying heavy weights or prolonged periods of coughing or difficult bowel movements).

Depression is another common and often neglected complication of pregnancy and childbirth. Depression has negative effects on both the mother and child.¹⁵

More than 15 percent of mothers in developing countries suffer serious depression during and after childbirth. The latter is commonly termed as postpartum depression, which occurs in 50 percent of women.
Perinatal depression is a severe disorder and needs appropriate medical care. It is associated with maternal physical morbidity, substance abuse and suicide.
Perinatal depression of the mother also has an impact on her child by causing low birth weight, premature delivery, poor growth, malnutrition and stunted emotional, behavioral and cognitive development.

Antenatal, perinatal and postpartum care. Provision of antenatal, perinatal and postpartum care improves the health of mother and newborn. Effective strategies are needed to provide skilled birth attendants, facilitate emergency obstetric care and reduce the consequences of pregnancy-related complications. Improvements in antenatal, perinatal, and postpartum care of mother and newborn are needed.

A third of all pregnant women receive no health care during pregnancy, 60 percent of deliveries take place outside health facilities. ^{4, 22}
Skilled attendance at birth is rising, but nearly 40 percent of women globally still do not have a skilled attendant present during delivery.²³

Pregnancy and postpartum visits provide an opportunity to integrate other services into women’s lives, including family planning and testing and counseling for HIV/AIDS and sexually transmitted infections.

Delayed care. Maternal mortality is associated with delayed care, which may occur at the household, community or facility level. ²⁴ Research indicates distance, cost, quality of care and severity of the condition are crucial risk factors for maternal mortality. Recognition of maternal health problems and prompt response are important in saving the lives of both mother and child.

Delay 1: Delay in decision to seek care – occurs at the household level. Members of the household fail to recognize the seriousness of complications during pregnancy and delay seeking professional assistance. Delays could be due to:
- Lack of awareness of the danger signs related to giving birth.
- Lack of trust in health-care providers or facilities.
- Preference for traditional practices related to pregnancy and child birth.
Delay 2: Delay in arrival at a health facility – occurs at the community level. Delays could be due to:
- Lack of transportation to the clinic or hospital.
- Long commute to the facility or inaccessible roads that delay travel.
- Inadequate financial resources to pay for health-care services or related costs.
Delay 3: Delay in provision of adequate care – occurs at the health facility level. Delays in receiving care could be due to:
- Lack of available trained health-care personnel.
- Lack of life saving drugs and/or equipment.
- Discriminatory attitude toward poor women and post-abortion care patients.

These three types of delays are interconnected; indeed, their effects tend to be multiplicative. For example, if a family had a negative experience at a health facility in the past, they may be more likely to delay care-seeking during pregnancy or assistance with delivery.

Rural health care. The health facilities in rural areas may not be adequately equipped to address obstetric emergencies. In developing countries, skilled birth attendants are a key intervention, as is the development of reliable referral systems to track and address complicated deliveries.

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Infectious Diseases

HIV/AIDS and Sexually Transmitted Infections
The impact of HIV/AIDS and sexually transmitted infections (STIs) on women and girls has been particularly devastating. Women and girls now comprise 50 percent of those aged 15 and older living with HIV.¹ For women between the ages of 15 and 49, STIs are the second most important cause of healthy years of life lost and may result in health complications, including infertility.^{19, 25}

Young women are at a higher risk due to gender inequity, poverty, limited access to education, and inadequate health care. Gender-based violence compromises the reproductive health of one in every three women.
Women have less power in the decision-making processes involving intercourse and use of protection. Many are unable to control decisions to have sex or to negotiate safer sexual practices, placing them at great risk of STIs, HIV and unwanted or mistimed pregnancies.²³ A study of married women with HIV in India found that although the women were often accused of infecting their husbands, nearly 90 percent of husbands had transmitted the disease to their wives.²⁶
About 420,000 children were newly infected in 2007, most of whom contracted the disease from their mothers. Mother-to-child transmission may occur during pregnancy, labor, or breastfeeding and is easily preventable.²⁷
In sub-Saharan Africa, 1.6 million pregnant women have undiagnosed syphilis. Symptomatic and asymptomatic STIs can be passed to infants or result in infertility.

Share of Deaths and DALYs Caused by HIV/AIDS Among Women Aged 15–44
by Age and World Bank Country Income Level²⁸

List of Countries by Income Level

Click here for more information about the impact of HIV/AIDS on women and girls.

Click here for more information on sexual and reproductive health.

Tuberculosis (TB)
Tuberculosis is one of the leading infectious causes of death and disability among women in the developing countries, affecting many in their most productive years.^{29, 30}

About 28 percent of all TB cases are found in Africa. Of new cases, about half occur in Asia – in Bangladesh, China, India, Indonesia, Pakistan and the Philippines.²⁹
More than 3 million women contract TB each year – about 17 million disability adjusted life years (DALY) are lost.³⁰
This disease has a profound impact beyond the young women infected. The social and economic condition of the household is diminished, as her contribution to the family’s income is less than it might otherwise have been.³⁰

Malaria
Pregnant women are at a high risk for malaria infection due to decreased immunity from carrying a child. Malaria infection in pregnant women increases the risk of abortion, stillbirth, premature delivery and low birth weight.³¹

Certain malaria infections in pregnant women increase the risk of anemia, which causes 10,000 maternal deaths per year.
Pregnant adolescent women are at an even higher risk of malaria infection, partly due to their lack of seeking antenatal care.
Malaria coupled with HIV infection in pregnant women can lead to severe anemia and problems during birth.
Malaria infection during pregnancy causes 200,000 infant deaths per year.³²

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Chronic Diseases
List of Countries by Income Level

For women in low-income countries, chronic diseases account for 52 percent of the total disease burden among women age 15 and older.²⁸ As infectious diseases are being controlled or eliminated, chronic conditions are increasingly causing higher burdens of mortality and disability.

Cardiovascular diseases, including rheumatic heart disease, hypertensive disease, ischemic heart disease, and cerebrovascular diseases (stroke).⁶

About 3 million women ages 15 and older die each year of cardiovascular diseases in low-income countries, making these diseases the leading cause of death among women in low-income countries and the world.
Cardiovascular diseases correspond to a disease burden of 29.2 million DALYs in women aged 15 and older in low-income countries, ranking second behind neuropsychiatric conditions.
Cardiovascular diseases comprise more than 40 percent of total deaths among women older than 45 in low-, lower-middle and high-income countries.²⁸

Death and DALYs due to Cardiovascular Disease in Women by World Bank
Country Income Level and Age²⁸

Malignant neoplasms are also referred to as tumors or cancers. There are various types including lung, ovarian, liver, breast, skin and oral. Several of these have known preventable causes, such as tobacco or alcohol use, and many others can be eliminated if detected and treated early.

Malignant neoplasms are the third leading cause of death among women aged 15 and older in lower-income countries after cardiovascular diseases and HIV/AIDS.
In low-income countries alone, 850,000 women die annually.²⁸ In the same age and income group, the disease burden of malignant neoplasms is about 10 million DALYs.³³

Neuropsychiatric conditions, including depressive disorders, schizophrenia, alcoholic or drug use disorders, obsessive-compulsive disorders, dementia, epilepsy, and insomnia, are the leading cause of DALYs among all women.²⁸

Around the world, one in four women suffer from depression at some point in their lives. These conditions lead to a disease burden of 31.9 million DALYs in women aged 15 and older in low-income countries.
These conditions are often ignored because they do not result in high mortality rates, though they substantially lower the quality of life and productivity level for women.
Women in developing or low-income countries are 1.5 to 2 times more likely to suffer from depression than women in high-income countries.¹⁵

Death and DALYs due to Neuropsychiatric Conditions in Women by World Bank
Country Income Level and Age²⁸

Other chronic diseases rank among the top five causes of death or disability for women aged 15 and over, including chronic respiratory diseases, digestive diseases and sense organ diseases.

Chronic respiratory diseases include asthma, chronic obstructive pulmonary disease, obstructive sleep apnea syndrome and pulmonary hypertension. Chronic respiratory diseases account for the loss of 8.4 million DALYs in women aged 15 and older in low-income countries, ranking fifth among the non-communicable diseases.^{28, 34}
Digestive diseases include peptic ulcer, cirrhosis of the liver and appendicitis.²⁸ These diseases cause the death of 302,000 women in low-income countries. This group of diseases is the tenth leading cause of death and disability among women in their reproductive years, 15–44.
Sense organ diseases, including cataracts, vision disorders, and hearing loss, affect 17.7 million women in low-income countries and 63.8 percent are of the oldest age category, 45+ years.²⁸ Many of these diseases occur prematurely and are preventable.
Over time, sense organ diseases greatly debilitate a woman’s ability to work, care for her family or seek health care. Sense organ diseases are the fifth leading cause of disability-adjusted life years lost and the fourth among non-communicable diseases.³³

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Injuries
List of Countries by Income Level

Injuries are one of the leading causes of death and disability among women throughout their life cycle. An estimated 1.4 million women ages 15 and older die due to injuries. In low- and middle-income countries, self-inflicted injuries and road traffic injuries are two of the top five leading causes of death in women between the ages of 15–19 years.²⁸

Click here for information on gender-based violence.

Select Intentional and Unintentional Injuries^{6, 35}

Select Unintentional Injuries	Select Intentional Injuries
Road Traffic Accidents	Self-inflicted
Venomous plants and animals	Interpersonal violence
Workplace accidents	War
Exposure to extreme temperatures	Injuries due to legal intervention

An estimated 1.7 million women die due to injuries. Of these, almost 50 percent of the deaths occur in the HMCs and 42 percent of these deaths occur within the ages 15–44.²⁸
Globally, self-inflicted injuries are most prevalent in women between the ages of 15–29 years old, killing 92,703 women annually. In low- and middle-income countries, 88,432 women between the ages of 15–29 years die annually from self-inflicted injuries.
In a study of injury-related deaths among women aged 10–50 years in Bangladesh, poisoning was the most frequent cause of death, and most poisonings were suicide related. This may be because poisons, such as pesticides and insecticides, are readily available to Bangladeshi women.³⁶
Of the 1.2 million people killed as a result of road traffic collisions, 27 percent are women.³⁷ Road traffic accidents are the fifth leading cause of death for girls between the ages of 5–14 years old, the fourth leading cause of death for women between the ages of 15–29.³⁸
Overall, women are at greater risk of fire-related burn injuries than men.³⁵ In low- and middle-income countries of South East Asia, the number of DALYs lost to fire-related burns by women exceeds the number lost by both sexes in any other region.³⁹
In South Africa, 8.8 women per 100,000 are murdered by their husbands or boyfriends. This is the highest rate of intimate partner homicide in the world.⁴⁰
Africa, China and India have the highest drowning mortality rates for women.³⁹

Death Rates and DALYS Lost because of Unintentional Injuries³⁵

Category	Global	LMICs
Deaths (per 100,000 population)
All unintentional injuries	41	44
RTIs	11	11
Poisonings	4	5
Falls	5	5
Fires	6	7
Drowning	4	5
Other unintentional injuries	11	11
DALY losses (per 1,000 population)
All unintentional injuries	14	16
RTIs	3	4
Poisonings	1	1
Falls	2	2
Fires	2	2
Drowning	1	1
Other unintentional injuries	5	6

* All figures rounded to the nearest 1,000

Deaths and DALYs due to Unintentional Injury in Women by World Bank
Country Income Level and Age²⁸

Deaths and DALYS due to Intentional Injury in Women by World Bank
Country Income Level and Age²⁸

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Nutrition

Women's nutrition affects a wide range of health and social issues, including economic development, poverty reduction, work-capacity, physical and mental development, pregnancy outcomes, family care, and household food security. Education enhances women’s status and power, which in turn leads to improved self and child nourishment.¹¹

Underweight is often the result of undernutrition. In impoverished developing countries, underweight is a factor in increasing household food insecurity, poor childcare, maternal undernutrition, unhealthy environment, and poor health care.

Underweight is a serious issue for women of reproductive age whose prevalence of undernutrition in the poorest countries measured from 27–51 percent.
Underweight can cause major complications during childbirth and adversely affect productivity.^{4, 9, 41}

Undernutrition is generally caused by inadequate diet and chronic infection, and is attributable to inseparable direct, indirect and basic causes. Maternal and child undernutrition – too few nutrients to sustain growth and development – contributes to 3.5 million deaths each year and is responsible for about 11 percent of the total global disease burden.^{42, 43}

As adults, malnutrition in women can cause thinness, lethargy, heart disease, hypertension, anemia or diabetes.
Direct causes of undernutrition include productivity loss by physical weakness and illness due to inadequate dietary intake.
Indirect consequences are insufficient household food security, physical and cognitive stunting, compromised schooling, and increased healthcare cost or inadequate health care services.
Human, financial and technical resources are the potential basic causes in development of undernutrition.

Framework for Understanding Causes of Malnutrition^{44, 45}

Pregnancy and Malnutrition
About 210 million women become pregnant each year, most of them in developing countries.⁴ Many of these women suffer from both ongoing nutritional deficiencies and cumulative effects of long-term undernutrition.⁴⁶

Poor health and nutrition during pregnancy can lead to maternal anemia, and, in newborns, can result in low birth weight, high risk of infection and various disorders or complications, such as neural tube defects, stunted growth and decreased immune function.^{47, 48}

High rates of maternal malnutrition and low birth weight may also underlie the high burden of non-communicable diseases in adults, such as coronary artery disease, hypertension, and diabetes.⁴⁹

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¹	World Health Organization, UNICEF, UNFPA, World Bank. 2007. Maternal mortality in 2005. Available from: www.who.int/whosis/mme_2005.pdf
²	Nanda G, Switlick K, Lule E. 2005. Accelerating progress towards achieving the MDGs to improve maternal health. World Bank. Available from: here.
³	United Nations Population Division. Surviving childbirth, but enduring chronic ill-health. (accessed August 16, 2007), Available from: www.endfistula.org/q_a.htm
⁴	World Health Organization. 2005. World health report 2005: make every mother and child count. Geneva: WHO. Available from: www.who.int/whr/2005/en/
⁵	Ronsmans C, Graham W. 2006. Maternal mortality: who, when, where, and why. The Lancet 368:1189-99.
⁶	World Health Organization. 2008. WHO global burden of disease (GBD) 2004 estimates. Available from: www.who.int/healthinfo/global_burden_disease/estimates_regional/en/index.html
⁷	UNICEF. 2008. Progress for children: a report card on maternal mortality. Available from: www.unicef.org/childsurvival/files/Progress_for_Children-No._7_Lo-Res_082008.pdf
⁸	Khan KS, Wojdyla D, Say L, Gulmezoglu AM, Van Look PF. 2006. WHO analysis of causes of maternal death: a systematic review. Lancet 367:1066-74.
⁹	Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M, et al. 2008. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet 371:243-60.
¹⁰	Cost Effective Strategies for the Excess Burden of Disease in Developing countries. Priorities in Health, 2002. p. 59-96.
¹¹	United Nations Population Division. State of the world population 2005: the promise of equality: gender equity, reproductive health and the Millennium Development Goals. New York: UNFPA. Available from: www.unfpa.org/swp/2005/pdf/en_swp05.pdf
¹²	U.S. Census Bureau. International Data Base. (accessed June 12, 2008), Available from: www.census.gov/ipc/www/idb/
¹³	Murray CJ, Laakso T, Shibuya K, Hill K, Lopez A. 2007. Can we achieve Millennium Development Goal 4? New analysis of country trends and forecasts of under-5 mortality to 2015. Lancet 370:1040-54.
¹⁴	Countdown Coverage Writing Group. 2008. Countdown to 2015 for maternal, newborn, and child survival: the 2008 report on tracking coverage of interventions. Lancet 371:1247-58.
¹⁵	United Nations Population Division. 2006. Mental, sexual and reproductive health. Available from: www.unfpa.org/upload/lib_pub_file/764_filename_mhenglish.pdf
¹⁶	World Bank. 2007. Development and the next generation. World development report.
¹⁷	World Health Organization. WHO Statistical Information System. (accessed June 27, 2008), Available from: www.who.int/whosis/en/index.html
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