Maternal mortality in Peru: trends, determinants, inequalities, and the impact of COVID-19

Background: Maternal mortality is a global public health priority, with the Sustainable Development Agenda and the Sustainable Health Agenda for the Americas setting ambitious targets for its reduction by 2030. Despite progress in poverty reduction and increased life expectancy, Peru faces urgent health challenges, including persistently high maternal mortality, exacerbated by the COVID-19 pandemic. To analyze maternal mortality trends and epidemiological characteristics in Peru, explore its determinants during 2010–2021, and quantify its inequalities before and during the COVID-19 pandemic. Methods: An ecological study used administrative data from the 25 Peruvian regions (2010–2021). Maternal mortality ratio (MMR) trends and key characteristics were analyzed. A mixed-effects negative binomial regression model assessed associations between MMR and proximal (e.g., skilled birth attendance [SBA]) and distal (e.g., unmet basic needs [UBN]) determinants. Inequality trends in MMR and SBA coverage were evaluated using standard metrics. Results: MMR declined from 82.0 to 55.6 maternal deaths per 100,000 live births between 2010 and 2019 but rose to 86.7 in 2021 during the COVID-19 pandemic. Excess maternal mortality during 2020–2021 (44.8%) was concentrated among older mothers, primiparas, and those without prenatal care, with indirect causes playing a major role. The reduction in MMR (2010–2019) correlated with decreased UBN and increased SBA. Ecosocial inequalities in MMR remained significant, with maternal mortality disproportionately affecting regions with higher UBN (78.7, 85.3, and 75.3 excess deaths per 100,000 live births in 2010–2014, 2015–2019, and 2020–2021, respectively). SBA coverage improved nationally, narrowing regional inequalities from a 30.6-point deficit in 2012 to 14.9 in 2021. Conclusions: Maternal mortality in Peru declined significantly before 2020, but the COVID-19 pandemic reversed this progress, with MMR rising to pre-2010 levels. Ecosocial inequalities persist, disproportionately affecting disadvantaged regions. However, SBA coverage improvements highlight the impact of proximal determinant interventions. Strengthened social reforms targeting distal determinants are crucial to reducing maternal mortality and inequalities in Peru.