A recent World Health Organization report warns that the health related millennium development goals (MDGs) will not be met without a dramatic increase in investments in national health systems.1 Assessments of progress towards the goals to date have found that we have made the least progress towards MDG 5—to improve maternal health—particularly in sub-Saharan Africa. In some African countries the situation has got worse; maternal mortality in Malawi has almost doubled between 1992 and 2000 despite increased resources for health.2 Women's lifetime risk of pregnancy related death in Malawi is now 1 in 7, compared with 1 in 2800 in industrialised countries.3 It is critical and timely to lobby for more resources, but this is insufficient without attention to the issues of gender and power which underlie maternal morbidity and mortality, both within communities and within health systems.

Every minute, a woman dies in pregnancy or childbirth.4 Nearly half of these deaths (47%) occur in Africa, and the vast majority are avoidable through skilled care in delivery and access to emergency obstetric care.3 For every woman who dies because of obstetric complications, 30-50 women suffer morbidity and disability.3 MDG 5 rightly focuses attention on urgent action to address this unacceptable situation. It is widely agreed that the high maternal mortality ratio in many sub-Saharan African countries is a reflection of the status of women in these societies, since it vividly illustrates how acceptable a society finds such avoidable deaths.3 Meeting goal 5 is therefore inextricably linked to meeting goal 3—to promote gender equality and empower women.