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

Nicholas J. Kassebaum, Amelia Bertozzi-Villa, Megan S. Coggeshall, Katya A. Shackelford, Caitlyn Steiner, Kyle R. Heuton, Diego Gonzalez-Medina, Ryan Barber, Chantal Huynh, Daniel Dicker, Tara Templin, Timothy M. Wolock, Ayse Abbasoglu Ozgoren, Foad Abd-Allah, Semaw Ferede Abera, Ibrahim Abubakar, Tom Achoki, Ademola Adelekan, Zanfina Ademi, Arsène Kouablan AdouJosé C. Adsuar, Emilie E. Agardh, Dickens Akena, Deena Alasfoor, Zewdie Aderaw Alemu, Rafael Alfonso-Cristancho, Samia Alhabib, Raghib Ali, Mazin J. Al Kahbouri, François Alla, Peter J. Allen, Mohammad A. AlMazroa, Ubai Alsharif, Elena Alvarez, Nelson Alvis-Guzmán, Adansi A. Amankwaa, Azmeraw T. Amare, Hassan Amini, Walid Ammar, Carl A.T. Antonio, Palwasha Anwari, Johan Ärnlöv, Valentina S.Arsic Arsenijevic, Ali Artaman, Majed Masoud Asad, Rana J. Asghar, Reza Assadi, Lydia S. Atkins, Alaa Badawi, Kalpana Balakrishnan, Arindam Basu, Sanjay Basu, Justin Beardsley, Neeraj Bedi, Tolesa Bekele, Michelle L. Bell, Eduardo Bernabe, Tariku J. Beyene, Zulfiqar Bhutta, Aref Bin Abdulhak, Jed D. Blore, Berrak Bora Basara, Dipan Bose, Nicholas Breitborde, Rosario Cárdenas, Carlos A. Castañeda-Orjuela, Ruben Estanislao Castro, Ferrán Catalá-López, Alanur Cavlin, Jung Chen Chang, Xuan Che, Costas A. Christophi, Sumeet S. Chugh, Massimo Cirillo, Samantha M. Colquhoun, Leslie Trumbull Cooper, Cyrus Cooper, Iuri Da Costa Leite, Lalit Dandona, Rakhi Dandona, Adrian Davis, Anand Dayama, Louisa Degenhardt, Diego De Leo, Borja Del Pozo-Cruz, Kebede Deribe, Muluken Dessalegn, Gabrielle A. DeVeber, Samath D. Dharmaratne, Uʇur Dilmen, Eric L. Ding, Rob E. Dorrington, Tim R. Driscoll, Sergei Petrovich Ermakov, Alireza Esteghamati, Emerito Jose A. Faraon, Farshad Farzadfar, Manuela Mendonca Felicio, Seyed Mohammad Fereshtehnejad, Graça Maria Ferreira De Lima, Mohammad H. Forouzanfar, Elisabeth B. França, Lynne Gaffikin, Ketevan Gambashidze, Fortuné Gbètoho Gankpé, Ana C. Garcia, Johanna M. Geleijnse, Katherine B. Gibney, Maurice Giroud, Elizabeth L. Glaser, Ketevan Goginashvili, Philimon Gona, Dinorah González-Castell, Atsushi Goto, Hebe N. Gouda, Harish Chander Gugnani, Rahul Gupta, Rajeev Gupta, Nima Hafezi-Nejad, Randah Ribhi Hamadeh, Mouhanad Hammami, Graeme J. Hankey, Hilda L. Harb, Rasmus Havmoeller, Simon I. Hay, Ileana B.Heredia Pi, Hans W. Hoek, H. Dean Hosgood, Damian G. Hoy, Abdullatif Husseini, Bulat T. Idrisov, Kaire Innos, Manami Inoue, Kathryn H. Jacobsen, Eiman Jahangir, Sun Ha Jee, Paul N. Jensen, Vivekanand Jha, Guohong Jiang, Jost B. Jonas, Knud Juel, Edmond Kato Kabagambe, Haidong Kan, Nadim E. Karam, André Karch, Corine Kakizi Karema, Anil Kaul, Norito Kawakami, Konstantin Kazanjan, Dhruv S. Kazi, Andrew H. Kemp, Andre Pascal Kengne, Maia Kereselidze, Yousef Saleh Khader, Shams Eldin Ali Hassan Khalifa, Ejaz Ahmed Khan, Young Ho Khang, Luke Knibbs, Yoshihiro Kokubo, Soewarta Kosen, Barthelemy Kuate Defo, Chanda Kulkarni, Veena S. Kulkarni, G. Anil Kumar, Kaushalendra Kumar, Ravi B. Kumar, Gene Kwan, Taavi Lai, Ratilal Lalloo, Hilton Lam, Van C. Lansingh, Anders Larsson, Jong Tae Lee, James Leigh, Mall Leinsalu, Ricky Leung, Xiaohong Li, Yichong Li, Yongmei Li, Juan Liang, Xiaofeng Liang, Stephen S. Lim, Hsien Ho Lin, Steven E. Lipshultz, Shiwei Liu, Yang Liu, Belinda K. Lloyd, Stephanie J. London, Paulo A. Lotufo, Jixiang Ma, Stefan Ma, Vasco Manuel Pedro Machado, Nana Kwaku Mainoo, Marek Majdan, Christopher Chabila Mapoma, Wagner Marcenes, Melvin Barrientos Marzan, Amanda J. Mason-Jones, Man Mohan Mehndiratta, Fabiola Mejia-Rodriguez, Ziad A. Memish, Walter Mendoza, Ted R. Miller, Edward J. Mills, Ali H. Mokdad, Glen Liddell Mola, Lorenzo Monasta, Jonathan De La Cruz Monis, Julio Cesar Montañez Hernandez, Ami R. Moore, Maziar Moradi-Lakeh, Rintaro Mori, Ulrich O. Mueller, Mitsuru Mukaigawara, Aliya Naheed, Kovin S. Naidoo, Devina Nand, Vinay Nangia, Denis Nash, Chakib Nejjari, Robert G. Nelson, Sudan Prasad Neupane, Charles R. Newton, Marie Ng, Mark J. Nieuwenhuijsen, Muhammad Imran Nisar, Sandra Nolte, Ole F. Norheim, Luke Nyakarahuka, In Hwan Oh, Takayoshi Ohkubo, Bolajoko O. Olusanya, Saad B. Omer, John Nelson Opio, Orish Ebere Orisakwe, Jeyaraj D. Pandian, Christina Papachristou, Jae Hyun Park, Angel J. Paternina Caicedo, Scott B. Patten, Vinod K. Paul, Boris Igor Pavlin, Neil Pearce, David M. Pereira, Konrad Pesudovs, Max Petzold, Dan Poenaru, Guilherme V. Polanczyk, Suzanne Polinder, Dan Pope, Farshad Pourmalek, Dima Qato, D. Alex Quistberg, Anwar Rafay, Kazem Rahimi, Vafa Rahimi-Movaghar, Sajjad Ur Rahman, Murugesan Raju, Saleem M. Rana, Amany Refaat, Luca Ronfani, Nobhojit Roy, Tania Georgina Sánchez Pimienta, Mohammad Ali Sahraian, Joshua A. Salomon, Uchechukwu Sampson, Itamar S. Santos, Monika Sawhney, Felix Sayinzoga, Ione J.C. Schneider, Austin Schumacher, David C. Schwebel, Soraya Seedat, Sadaf G. Sepanlou, Edson E. Servan-Mori, Marina Shakh-Nazarova, Sara Sheikhbahaei, Kenji Shibuya, Hwashin Hyun Shin, Ivy Shiue, Inga Dora Sigfusdottir, Donald H. Silberberg, Andrea P. Silva, Jasvinder A. Singh, Vegard Skirbekk, Karen Sliwa, Sergey S. Soshnikov, Luciano A. Sposato, Chandrashekhar T. Sreeramareddy, Konstantinos Stroumpoulis, Lela Sturua, Bryan L. Sykes, Karen M. Tabb, Roberto Tchio Talongwa, Feng Tan, Carolina Maria Teixeira, Eric Yeboah Tenkorang, Abdullah Sulieman Terkawi, Andrew L. Thorne-Lyman, David L. Tirschwell, Jeffrey A. Towbin, Bach X. Tran, Miltiadis Tsilimbaris, Uche S. Uchendu, Kingsley N. Ukwaja, Eduardo A. Undurraga, Selen Begüm Uzun, Andrew J. Vallely, Coen H. Van Gool, Tommi J. Vasankari, Monica S. Vavilala, N. Venketasubramanian, Salvador Villalpando, Francesco S. Violante, Vasiliy Victorovich Vlassov, Theo Vos, Stephen Waller, Haidong Wang, Linhong Wang, Xiao Rong Wang, Yanping Wang, Scott Weichenthal, Elisabete Weiderpass, Robert G. Weintraub, Ronny Westerman, James D. Wilkinson, Solomon Meseret Woldeyohannes, John Q. Wong, Muluemebet Abera Wordofa, Gelin Xu, Yang C. Yang, Yuichiro Yano, Gokalp Kadri Yentur, Paul Yip, Naohiro Yonemoto, Seok Jun Yoon, Mustafa Z. Younis, Chuanhua Yu, Kim Yun Jin, Maysaa El Sayed Zaki, Yong Zhao, Yingfeng Zheng, Maigeng Zhou, Jun Zhu, Xiao Nong Zou, Alan D. Lopez, Mohsen Naghavi, Christopher J.L. Murray, Rafael Lozano

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Abstract

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 diff erent 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.

Original languageEnglish
Pages (from-to)980-1004
Number of pages25
JournalThe Lancet
Volume384
Issue number9947
DOIs
StatePublished - 22 Sep 2014

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    Kassebaum, N. J., Bertozzi-Villa, A., Coggeshall, M. S., Shackelford, K. A., Steiner, C., Heuton, K. R., Gonzalez-Medina, D., Barber, R., Huynh, C., Dicker, D., Templin, T., Wolock, T. M., Ozgoren, A. A., Abd-Allah, F., Abera, S. F., Abubakar, I., Achoki, T., Adelekan, A., Ademi, Z., ... Lozano, R. (2014). Global, regional, and national levels and causes of maternal mortality during 1990-2013: A systematic analysis for the Global Burden of Disease Study 2013. The Lancet, 384(9947), 980-1004. https://doi.org/10.1016/S0140-6736(14)60696-6