Macroeconomic determinants of maternal and neonatal mortality: a global panel analysis.

backgroundMaternal mortality ratio (MMR) and neonatal mortality rate (NMR) are key indicators of population health and health system performance. Yet longitudinal cross-country evidence on how macroeconomic conditions-such as income growth, inflation, and unemployment-relate to maternal and neonatal mortality remains limited.

methodsWe assembled a balanced country-level panel of 152 countries for 1991-2023 using World Health Organization mortality series and World Bank World Development Indicators. Outcomes (MMR, NMR) were modelled in natural logarithms; GDP per capita was log-transformed, inflation was expressed as ln(1 + IR/100), and unemployment as the first difference of log unemployment. Cross-sectional dependence was assessed using Pesaran's CD test, and-given dependence-stationarity was evaluated with Pesaran's second-generation CIPS test. Associations were estimated using two-way fixed-effects panel regressions (country and year effects) with Driscoll-Kraay standard errors (lag = 2), with sensitivity analyses using lagged GDP per capita (t - 1, t - 2) and continent-stratified models.

resultsIn the global two-way Driscoll-Kraay fixed-effects models (country and year fixed effects; Driscoll-Kraay standard errors, maximum lag = 2), GDP per capita was inversely associated with both ln(MMR) (B = - 0.233, p < 0.001) and ln(NMR) (B = - 0.139, p < 0.001), while inflation (LINF) was positively associated with both outcomes (lnMMR: B = 0.055, p < 0.001; lnNMR: B = 0.042, p < 0.001). Changes in unemployment (dLUR) were positively associated with ln(NMR) in the global model (B = 0.102, p < 0.05) and in Asia (B = 0.063, p < 0.05), but were not significant for ln(MMR) in continent-specific models under the contemporaneous income specification (Table 6). This pattern may partly reflect measurement limitations of official unemployment rates in settings with large informal sectors and weaker labour-market registration; however, in the lagged-income specification (GDP per capita t - 1), dLUR was positive and statistically significant in Europe (Supplementary Table S2), suggesting that unemployment effects on maternal mortality may be specification- and context-dependent and should be interpreted cautiously.

conclusionMacroeconomic conditions were associated with maternal and neonatal survival. Globally, higher GDP per capita was associated with lower maternal and neonatal mortality, and this inverse association remained in sensitivity analyses using lagged GDP per capita (t - 1, t - 2). Although the strength of income-mortality associations varied across continents and some region-outcome models were imprecisely estimated, particularly in Oceania (small number of countries), the overall pattern suggests that macroeconomic conditions may be relevant correlates of RMNCH outcomes. Inflation was related to worse outcomes in some settings, underscoring the importance of growth that preserves purchasing power and protects health-system inputs, but the inflation-mortality relationship was heterogeneous across regions. Unemployment effects appeared context-specific, with evidence most clearly observed for neonatal mortality in Asia, suggesting that labour-market and social-protection responses may be most relevant where vulnerability and out-of-pocket financing are high. These findings should be interpreted as adjusted associations rather than causal effects. Aligning macroeconomic management with RMNCH financing and access policies may help support progress in preventable maternal and neonatal deaths. CLINICAL TRIAL NUMBER: Not applicable.