Although its measurement may be difficult, the maternal mortality ratio (MMR) is a key indicator of maternal health globally. In Pakistan each year over five million women become pregnant, and of these 700 000 (15% of all pregnant women) are likely to experience some obstetrical and medical complications. An estimated 30 000 women die each year from pregnancy-related causes, and the most recent estimates indicate that the MMR is 276 per 100 000 births annually. In this review, we describe the status of maternal health and survival in Pakistan and place it in its wider context of key determinants. We draw attention to the economic and social vulnerability of pregnant women, and stress the importance of concomitant broader strategies, including poverty reduction and women’s empowerment. Undernutrition for girls, early marriage, and high fertility rates coupled with unmet needs for contraception are important determinants of maternal ill health in Pakistan. Our review also examines factors influencing the under-utilization of maternal health services among Pakistani women, such as the lack of availability of skilled care providers and poor quality services. Notwithstanding these observations, there are evidence-based interventions available that, if implemented at scale, could make important contributions towards reducing the burden of maternal mortality in Pakistan