Abstract

Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

Kassebaum NJ Bertozzi-Villa A Coggeshall MS Shackelford KA Steiner C Heuton KR Gonzalez-Medina D Barber R Huynh C Dicker D Templin T Wolock TM Ozgoren AA Abd-Allah F Abera SF Abubakar I Achoki T Adelekan A Ademi Z Adou AK Adsuar JC Agardh EE Akena D Alasfoor D Alemu ZA Alfonso-Cristancho R Alhabib S Ali R Al Kahbouri MJ Alla F Allen PJ AlMazroa MA Alsharif U Alvarez E Alvis-Guzman N Amankwaa AA Amare AT Amini H Ammar W Antonio CA Anwari P Arnlov J Arsenijevic VS Artaman A Asad MM Asghar RJ Assadi R Atkins LS Badawi A Balakrishnan K Basu A Basu S Beardsley J Bedi N Bekele T Bell ML Bernabe E Beyene TJ Bhutta Z Bin Abdulhak A Blore JD Basara BB Bose D Breitborde N Cardenas R Castaneda-Orjuela CA Castro RE Catala-Lopez F Cavlin A Chang JC Che X Christophi CA Chugh SS Cirillo M Colquhoun SM Cooper LT Cooper C da Costa Leite I Dandona L Dandona R Davis A Dayama A Degenhardt L De Leo D del Pozo-Cruz B Deribe K Dessalegn M deVeber GA Dharmaratne SD Dilmen U Ding EL Dorrington RE Driscoll TR Ermakov SP Esteghamati A Faraon EJ Farzadfar F Felicio MM Fereshtehnejad SM de Lima GM Forouzanfar MH Franca EB Gaffikin L Gambashidze K Gankpe FG Garcia AC Geleijnse JM Gibney KB Giroud M Glaser EL Goginashvili K Gona P Gonzalez-Castell D Goto A Gouda HN Gugnani HC Gupta R Gupta R Hafezi-Nejad N Hamadeh RR Hammami M Hankey GJ Harb HL Havmoeller R Hay SI Pi IB Hoek HW Hosgood HD Hoy DG Husseini A Idrisov BT Innos K Inoue M Jacobsen KH Jahangir E Jee SH Jensen PN Jha V Jiang G Jonas JB Juel K Kabagambe EK Kan H Karam NE Karch A Karema CK Kaul A Kawakami N Kazanjan K Kazi DS Kemp AH Kengne AP Kereselidze M Khader YS Khalifa SE Khan EA Khang YH Knibbs L Kokubo Y Kosen S Defo BK Kulkarni C Kulkarni VS Kumar GA Kumar K Kumar RB Kwan G Lai T Lalloo R Lam H Lansingh VC Larsson A Lee JT Leigh J Leinsalu M Leung R Li X Li Y Li Y Liang J Liang X Lim SS Lin HH Lipshultz SE Liu S Liu Y Lloyd BK London SJ Lotufo PA Ma J Ma S Machado VM Mainoo NK Majdan M Mapoma CC Marcenes W Marzan MB Mason-Jones AJ Mehndiratta MM Mejia-Rodriguez F Memish ZA Mendoza W Miller TR Mills EJ Mokdad AH Mola GL Monasta L de la Cruz Monis J Hernandez JC Moore AR Moradi-Lakeh M Mori R Mueller UO Mukaigawara M Naheed A Naidoo KS Nand D Nangia V Nash D Nejjari C Nelson RG Neupane SP Newton CR Ng M Nieuwenhuijsen MJ Nisar MI Nolte S Norheim OF Nyakarahuka L Oh IH Ohkubo T Olusanya BO Omer SB Opio JN Orisakwe OE Pandian JD Papachristou C Park JH Caicedo AJ Patten SB Paul VK Pavlin BI Pearce N Pereira DM Pesudovs K Petzold M Poenaru D Polanczyk GV Polinder S Pope D Pourmalek F Qato D Quistberg DA Rafay A Rahimi K Rahimi-Movaghar V ur Rahman S Raju M Rana SM Refaat A Ronfani L Roy N Pimienta TG Sahraian MA Salomon JA Sampson U Santos IS Sawhney M Sayinzoga F Schneider IJ Schumacher A Schwebel DC Seedat S Sepanlou SG Servan-Mori EE Shakh-Nazarova M Sheikhbahaei S Shibuya K Shin HH Shiue I Sigfusdottir ID Silberberg DH Silva AP Singh JA Skirbekk V Sliwa K Soshnikov SS Sposato LA Sreeramareddy CT Stroumpoulis K Sturua L Sykes BL Tabb KM Talongwa RT Tan F Teixeira CM Tenkorang EY Terkawi AS Thorne-Lyman AL Tirschwell DL Towbin JA Tran BX Tsilimbaris M Uchendu US Ukwaja KN Undurraga EA Uzun SB Vallely AJ van Gool CH Vasankari TJ Vavilala MS Venketasubramanian N Villalpando S Violante FS Vlassov VV Vos T Waller S Wang H Wang L Wang X Wang Y Weichenthal S Weiderpass E Weintraub RG Westerman R Wilkinson JD Woldeyohannes SM Wong JQ Wordofa MA Xu G Yang YC Yano Y Yentur GK Yip P Yonemoto N Yoon SJ Younis MZ Yu C Jin KY El Sayed Zaki M Zhao Y Zheng Y Zhou M Zhu J Zou XN Lopez AD Naghavi M Murray CJ Lozano R
Lancet. 2014;384980-1004

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BACKGROUND: The fifth Millennium Development Goal (MDG 5) established the goal of a 75% reduction in the maternal mortality ratio (MMR; number of maternal deaths per 100,000 livebirths) between 1990 and 2015. We aimed to measure levels and track trends in maternal mortality, the key causes contributing to maternal death, and timing of maternal death with respect to delivery. METHODS: We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to analyse a database of data for 7065 site-years and estimate the number of maternal deaths from all causes in 188 countries between 1990 and 2013. We estimated the number of pregnancy-related deaths caused by HIV on the basis of a systematic review of the relative risk of dying during pregnancy for HIV-positive women compared with HIV-negative women. We also estimated the fraction of these deaths aggravated by pregnancy on the basis of a systematic review. To estimate the numbers of maternal deaths due to nine different causes, we identified 61 sources from a systematic review and 943 site-years of vital registration data. We also did a systematic review of reports about the timing of maternal death, identifying 142 sources to use in our analysis. We developed estimates for each country for 1990-2013 using Bayesian meta-regression. We estimated 95% uncertainty intervals (UIs) for all values. FINDINGS: 292,982 (95% UI 261,017-327,792) maternal deaths occurred in 2013, compared with 376,034 (343,483-407,574) in 1990. The global annual rate of change in the MMR was -0.3% (-1.1 to 0.6) from 1990 to 2003, and -2.7% (-3.9 to -1.5) from 2003 to 2013, with evidence of continued acceleration. MMRs reduced consistently in south, east, and southeast Asia between 1990 and 2013, but maternal deaths increased in much of sub-Saharan Africa during the 1990s. 2070 (1290-2866) maternal deaths were related to HIV in 2013, 0.4% (0.2-0.6) of the global total. MMR was highest in the oldest age groups in both 1990 and 2013. In 2013, most deaths occurred intrapartum or postpartum. Causes varied by region and between 1990 and 2013. We recorded substantial variation in the MMR by country in 2013, from 956.8 (685.1-1262.8) in South Sudan to 2.4 (1.6-3.6) in Iceland. INTERPRETATION: Global rates of change suggest that only 16 countries will achieve the MDG 5 target by 2015. Accelerated reductions since the Millennium Declaration in 2000 coincide with increased development assistance for maternal, newborn, and child health. Setting of targets and associated interventions for after 2015 will need careful consideration of regions that are making slow progress, such as west and central Africa. FUNDING: Bill & Melinda Gates Foundation.