Armed conflict and maternal mortality: A micro-level study of sub-Saharan Africa, 1989–2013

There is existing country-level evidence that countries with more severe armed conflict tend to have higher Maternal Mortality Rates (MMR). However, during armed conflict, the actual fighting is usually confined to a limited area within a country, affecting a subset of the population. Hence, studying the link between country-level armed conflict and MMR may involve ecological fallacies. We provide a more direct, nuanced test of whether local exposure to armed conflict impacts maternal mortality, building on the so-called “sisterhood method”. We combine geo-coded data on different types of violent events from the Uppsala Conflict Data Program with geo-referenced survey data from the Demographic and Health Surveys (DHS) on respondents' reports on sisters dying during pregnancy, childbirth, or the puerperium. Our sample covers 1,335,161 adult sisters aged 12–45 by 539,764 female respondents in 30 countries in sub-Saharan Africa. Rather than aggregating the deaths of sisters to generate a maternal mortality ratio, we analyze the sisters’ deaths at the individual level. We use a sister fixed-effects analysis to estimate the impact of recent organized violence events within a radius of 50 km of the home of each respondent on the likelihood that her sister dies during pregnancy, childbirth, or the puerperium. Our results show that local exposure to armed conflict events indeed increases the risk of maternal deaths. Exploring potential moderators, we find larger differences in rural areas but also in richer and more educated areas.