HARARE, Zimbabwe – As maternal mortality remains the most lagging Millennium Development Goal and a new set of development goals is being written this year, one focus will undoubtedly stay fixed on decreasing maternal death rates in the developing world. Nations there account for 99 percent of global maternal deaths, with countries in sub-Saharan Africa and South Asia continuing to possess the highest rates worldwide.

But here in Zimbabwe, such deaths have decreased significantly over the last five years, indicating an improvement in the health care system. Despite progress, Zimbabwe’s maternal mortality rate is still one of the highest in the world and is heavily dependent on international aid.

In August 2014, Unicef released statistics suggesting that Zimbabwe’s maternal death rate had dropped 36 percent since 2009, to 614 per 100,000 live births from a whopping 960, nearly topping the list in Africa. The country with the highest estimated maternal death rate (in 2013) was Sierra Leone, in West Africa, at 1,100 deaths per 100,000 live births.

The European Union, the United Nations Development Program, the United Nations Population Fund and the United States Agency for International Development financed the Zimbabwe survey, which researched 17,000 households in every province of the country.

The numbers show that 70 percent of pregnant women in 2014 received prenatal care (up from 57 percent), and 78 percent of mothers gained access to care after birth (up from just 27 percent). Both prenatal and postnatal care have improved dramatically, including the number of check-ups performed and the distribution of information to mothers on how to care for themselves and their children.

The drop in the maternal death rate is viewed as remarkable, considering Zimbabwe’s long, debilitating economic recession that it is now rebounding from and that maternal deaths tripled in the 1990s and early 2000s, the Unicef report said. Despite progress during the country’s first decade of independence — which began in 1980 and saw access to health care services extended to 85 percent of the population — hyperinflation, political uncertainty, the HIV/AIDS epidemic and the crashing economy unraveled the country’s health care sector as it entered the 21st century.

The reasons for the large decline in maternal deaths vary. According to Dr. David Okello, director of the World Health Organization in Zimbabwe, explanations include major improvements in the availability of skilled personnel, which were brought about by staff retention schemes and medical personnel training programs. Dr. Okello also noted in an interview with PassBlue that the “policy environment has largely changed and become more supportive,” with nurses being given more license to perform certain lifesaving techniques, and the abolition of “user fees” for pregnant women at maternity clinics.

Critical to these measures was the support of the UN Population Fund to Zimbabwe’s government to strengthen maternal death surveillance — registering and determining the causes of deaths — to prevent future ones, said Cheikh Cisse, the agency’s representative here.

An increase of support for Zimbabwe’s Ministry of Health and Child Care to distribute necessary equipment and drugs has also played a part, as has a deliberate effort to enforce what Dr. Okello referred to as “high impact, low cost interventions,” such as enforcing regular antenatal and postnatal care visits and strong family planning programs. The availability of ambulance services, which has always been a problem in the country, has been strengthened, Dr. Okello said.

Reza Hossaini, Unicef’s representative to Zimbabwe, added that early treatment for conditions that aggravate complications during pregnancy, like malaria and HIV, has increased. The UN Population Fund, for example, supported large-scale HIV intervention programs, resulting in a reduction of maternal deaths from HIV-related morbidity, Cisse said. Additionally, 90 percent of mothers are now literate, influencing the use of contraceptives, Hossaini of Unicef said. Many of these initiatives have been financed by nongovernment organizations and international development partners in health, collaborating with the Zimbabwean government.

In 2009, the maternal mortality rate stood at 960 deaths for 100,000 births. The main causes of death included postpartum hemorrhage, sepsis and malaria. Deaths were also attributed to delays in seeking health care, finding appropriate facilities and being treated at a clinic or hospital. Many women delivered their babies at home, and health care remained unaffordable for a large proportion of the population. Only 66 percent of births were attended by a skilled health care worker.

Shortages in personnel and resources prevail, and in November 2014, doctors went on strike nationwide. Many rural villages do not have access to clean water or to electricity, and women often must travel great distances to seek medical attention, a common problem throughout sub-Saharan Africa. Weak public transport and road infrastructure has added to the problem of delayed referrals, Dr. Okello said.

Furthermore, a United Nations report published in 2013 found that patriarchal traditions based on male superiority that lie outside the legal protection system deny women access to health care, and Hossaini noted the difficulties of working with the social norms and religious values of the Apostolic faith, who account for 38 percent of maternal deaths among 15 to 19 year olds. Health insurance is unaffordable for a big segment of the population, and clinic and hospital fees remain high.

The Ministry of Health and Childcare did not respond to queries for this article, but one local newspaper argued in January 2014 that the government was focusing on the HIV/AIDS crisis rather than working to increase maternal health care resources. The total health care budget is about 9 percent of expenditures, Dr. Okello said.

Ultimately, “the continued inability of the country to adequately finance the health sector from its own resources” remains a challenge, Hossaini said. “The over-reliance on donor funding poses serious risks to the long-term sustainability of the gains achieved so far.”

Without international aid, Cisse of the UN Population Fund, added, “this reduction could not have been achieved, given the economic constraint in the country without such funding support.”

Trishula Patel

Trishula Patel is a journalist based in Harare, Zimbabwe, who contributes to ZimboJam, a digital website focused on arts and culture; and Sava360, a site on the South Asian community. Patel also worked as a freelance writer for Philadelphia Weekly and as an intern for The Washington Post’s city desk and The Philadelphia Inquirer’s health and science desk. She has a master’s degree in world history and a B.A. in history from the University of Pennsylvania as well as a master’s degree from the Columbia University Graduate School of Journalism.