Why is Morocco an Exemplar?

Exemplar countries for neonatal and maternal mortality are defined as those that have demonstrated exceptional progress at reducing neonatal and maternal mortality—beyond what could be attributable to their socioeconomic progress alone. Figure 1 shows the association between gross national income (GNI) per capita increases and declines in the neonatal mortality rate (NMR) and maternal mortality ratio (MMR) across low- and middle-income countries with populations of at least 2 million that have not yet reached the SDG targets for NMR/MMR. A fitted linear regression line is overlaid, indicating the expected relationship between GNI per capita change and mortality change. Countries falling below the fitted line are those that have experienced faster declines in mortality than what would be expected based on their GNI per capita increases alone.

Morocco achieved reductions in both neonatal and maternal mortality that are faster than would be expected based on economic development alone. Figure 1 shows that Morocco’s progress is also faster than regional peers. According to UN estimates, maternal mortality in Morocco decreased from 244.2 to 71.9 maternal deaths per 100,000 live births between 2000 and 2020.¹ This decline constitutes an average annual rate of reduction (AARR) of 5.9%, which outpaces the average for the Northern Africa region at 4.2%.¹ Similarly, neonatal mortality in Morocco decreased from 28.4 to 11.1 neonatal deaths per 1,000 live births.² This progress constitutes an AARR of 4.4%, which also outpaces the average decline experienced across the Northern Africa region at 2.6%.²

Maternal mortality

Morocco achieved impressive reductions in maternal mortality in recent decades, although specific trendlines vary slightly by source. Figure 2 includes estimates from both the Institute for Health Metrics and Evaluation (IHME) and the United Nations Maternal Mortality Estimation Inter-Agency Group (UN MMEIG). The UN MMEIG estimates, which include a slightly more current time trend, are predominantly used in analyses throughout this narrative, but we leverage IHME estimates to explore causes of maternal death. Estimates from UN MMEIG show that between 2000 and 2020, the MMR decreased from 244.2 to 71.9 maternal deaths per 100,000 live births.

This reduction constitutes a 71% reduction overall at an AARR of 5.9%, which outpaces the average rate of progress seen across Northern Africa and sub-Saharan Africa. This rate of progress also positions Morocco to reach the national SDG target of 44.6 maternal deaths per 100,000 live births by 2030. More detailed information about Morocco’s progression toward SDG targets can be found in the Benchmarking Progress in Morocco section.

IHME estimates, shown in Figure 3, suggest that in 2021, the causes that contributed the most to maternal mortality in Morocco were other direct maternal disorders, hemorrhage, and hypertensive disorders—respectively representing 23.4%, 19.3%, and 17.3% of maternal deaths.³ Other direct maternal disorders include a variety of obstetric complications, including embolism, postpartum complications, and other complications directly related to pregnancy.⁴ Hemorrhage and hypertensive disorders were the most common causes of maternal death in 1990; however, other direct maternal disorders have become more common as a proportion of maternal deaths over time. IHME estimates from 1990 suggest that the third most common cause of death in Morocco was abortion/miscarriage, which constituted 17.6% of maternal deaths.³ Between 1990 and 2021, MMR due to abortion/miscarriage declined from 63.4 to 7.6 maternal deaths per 100,000 live births—a decrease of 89%.³ Morocco also experienced a major reduction in deaths due to sepsis and other infections, with MMR from these causes declining from 31.0 to 3.6 maternal deaths per 100,000 live births between 1990 and 2021—an 88% decrease.³

Nationally representative, cause-specific maternal mortality data in Morocco is fairly limited, but a 2010 Maternal Death Surveillance System report found that 86% of maternal deaths were due to direct causes.⁵ This survey found that approximately 46% of maternal deaths were due to hemorrhage—higher than IHME’s estimate of 26% for 2010.^3,5 The next most common causes of maternal death identified in this survey were preeclampsia and eclampsia, infections, and abortion-related complications, which respectively constituted 21%, 7%, and 5% of maternal deaths.⁵ Indirect causes were cumulatively found to represent 10% of maternal deaths, with the most common being cardiac diseases at 3% of total maternal deaths.⁵ Reports from Morocco’s Maternal Death Surveillance System (SSDM) in 2010, 2011, and 2015 also found that hemorrhage, preeclampsia and eclampsia, and infection were the most common causes of death, and that these causes declined substantially during this period.^6,7 More information about the SSDM is discussed in the How did Morocco implement? section.

Maternal mortality in Morocco remains higher in rural communities than in urban communities, as shown in Figure 4. However, progress has been rapid for both rural and urban populations. While Morocco’s 2003–2004 Demographic and Health Survey (DHS) found that MMR was higher in rural areas than urban areas by 81 maternal deaths per 100,000 live births, by the 2018 Enquête Nationale sur la Population et la Santé Familial (ENPSF), this gap had declined slightly to 66.5 maternal deaths per 100,000 live births.^8,9

Neonatal mortality

Morocco has also made rapid progress in reducing the NMR in recent decades, as shown in Figure 5. Estimates from the United Nations Inter-Agency Group for Child Mortality Estimation (UN IGME) indicate that the NMR declined from 28.4 to 11.1 neonatal deaths per 1,000 live births between 2000 and 2021.² This represents a 61% decrease during that time span at an AARR of 4.4%, which outpaces the rate of progress seen on average across Northern Africa and sub-Saharan Africa.² With an NMR of 11.1, Morocco has achieved the SDG target of 12 neonatal deaths per 1,000 live births—a remarkable achievement.² More details about Morocco’s progress compared to SDG targets can be found in the Benchmarking Progress in Morocco section.

According to the World Health Organization (WHO) Maternal and Child Epidemiology Estimation Group, Morocco’s most common causes of neonatal death in 2017 were prematurity, birth asphyxia/trauma, and congenital anomalies, as shown in Figure 6.¹⁰ These three causes respectively constituted 33.2%, 21.6%, and 15.3% of neonatal deaths in Morocco in 2017.¹⁰ While prematurity and birth asphyxia/trauma have been the two most common causes of neonatal death in Morocco since 2000, the distribution of other causes has notably shifted.¹⁰ In 2000, sepsis and other infections were the third most common cause of neonatal death, constituting 14.4% of neonatal deaths.¹⁰ Congenital anomalies have therefore begun to represent a slightly larger portion of neonatal deaths in Morocco since 2000.

While neonatal mortality levels in Morocco have historically been slightly higher among rural communities, this disparity has narrowed slightly in more recent years as shown in Figure 7. In Morocco’s 2003–2004 DHS, rural communities were found to have an NMR that was 9 neonatal deaths per 1,000 live births higher than urban communities.⁸ By the 2018 ENPSF, this gap had narrowed so that NMR was only 5.1 neonatal deaths per 1,000 live births higher in rural communities.⁹

Stillbirths

According to UN IGME estimates, the stillbirth rate in Morocco decreased from 20.6 to 13.2 stillbirths per 1,000 live births between 2000 and 2021 (Figure 8).¹¹ This decline represents a 36% decrease, at an AARR of 2.1%, which is higher than the average AARR for Northern Africa at 0.8%.¹¹ With a rate of 13.2 stillbirths per 1,000 total births, Morocco has nearly reached the Every Newborn Action Plan target of 12 stillbirths per 1,000 total births. If Morocco sustains the AARR experienced from 2000 to 2021, Morocco will achieve this target, another remarkable achievement.