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1514 www.thelancet.com Vol 389 April 15, 2017 and without access to life-saving health services. The authors correctly underline the potential snowballing of errors when estimations are not quoted precisely and in all instances. In fact, the estimate was generated to highlight that state fragility often co-exists with poverty, and where governments are struggling to stabilise areas of grave insecurity, those efforts deflect resources from national infrastructure and human capital investments needed to prevent maternal mortality and other poor health outcomes. Prevention of maternal mortality requires deep investments in health, education, economic development, and women’s rights—but it also requires peace and security.