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 language | English |
|---|---|
| Pages (from-to) | 980-1004 |
| Number of pages | 25 |
| Journal | Lancet |
| Volume | 384 |
| Issue number | 9947 |
| DOIs | |
| Publication status | Published - 2014 |
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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, Nicholas; Bertozzi-Villa, Amelia; Coggeshall, Megan; Shackelford, Katya; Steiner, Caitlyn; Heuton, Kyle; Gonzalez-Medina, Diego; Barber, Ryan; Huynh, Chantal; Dicker, Daniel; Templin, Tara; Wolock, Timothy; Ozgoren, Ayse; Abd-Allah, Foad; Abera, Semaw; Abubakar, Ibrahim; Achoki, Tom; Adelekan, Ademola; Ademi, Zanfina; Adou, Arsene; Adsuar, Jose; Agardh, Emilie; Akena, Dickens; Alasfoor, Deena; Alemu, Zewdie; Alfonso-Cristancho, Rafael; Alhabib, Samia; Ali, Raghib; Al Kahbouri, Mazin; Alla, F; Allen, Peter; AlMazroa, Mohammad; Alsharif, Ubai; Alvarez, Elena; Alvis-Guzman, Nelson; Amankwaa, Adansi; Amare, Azmeraw; Amini, Hassan; Ammar, Walid; Antonio, Carl; Anwari, Palwasha; Arnlov, Johan; Arsenijevic, Valentina; Artaman, Ali; Asad, Majed; Asghar, Rana; Assadi, Reza; Atkins, Lydia; Badawi, Alaa; Balakrishnan, Kalpana; Basu, Arin; Basu, Sanjay; Beardsley, Justin; Bedi, Neeraj; Bekele, Tolesa; Bell, Michelle; Bernabe, Eduardo; Beyene, Tariku; Bhutta, Zulfiqar; Abdulhak, Aref; Blore, Jed; Basara, Berrak; Bose, Dipan; Breitborde, Nicholas; Cardenas, Rosario; Castaneda-Orjuela, Carlos; Castro, Ruben; Catala-Lopez, Ferran; Cavlin, Alanur; Chang, Jungchen; Che, Xuan; Christophi, Costas; Chugh, Sumeet; Cirillo, Massimo; Colquhoun, Samantha; Cooper, Leslie; Cooper, Cyrus; Da Costa Leite, Iuri; Dandona, Lalit; Dandona, Rakhi; Davis, Adrian; Dayama, Anand; Degenhardt, Louisa; Faraon, Emerito; Farzadfar, Farshad; Felicio, Manuela; Fereshtehnejad, Seyed; De Lima, Graca; Forouzanfar, Mohammad; Franca, Elisabeth; Gaffikin, Lynne; Gambashidze, Ketevan; Gankpe, Fortune; Garcia, Ana; Geleijnse, Johanna; Gibney, Katherine; Giroud, Maurice; Glaser, Elizabeth; Goginashvili, Ketevan; Gona, Philimon; Gonzalez-Castell, Dinorah; Goto, Atsushi; Gouda, Hebe; Gugnani, Harish; Gupta, Rahul; Gupta, Raj; Hafezi-Nejad, Nima; Hamadeh, Randah; Hammami, Mouhanad; Hankey, Graeme; Harb, Hilda; Havmoeller, Rasmus; Hay, Simon; Pi, Ileana; Hoek, Hans; Hosgood III, H; Hoy, Damian; Husseini, Abdullatif; Idrisov, Bulat; Innos, Kaire; Inoue, Manami; Jacobsen, Kathryn; Jahangir, Eiman; Jee, Sunha; Jensen, Paul; Jha, Vivekanand; Jiang, Guohong; Jonas, Jost; Juel, Knud; Kabagambe, Edmond; Kan, Haidong; Karam, Nadim; Karch, Andre; Karema, Corine; Kaul, Anil; Kawakami, Norito; Kazanjan, Konstantin; Kazi, Dhruv; Kemp, Andrew; Kengne, Andre; Kereselidze, Maia; Khader, Yousef; Khalifa, Shams; Khan, Ejaz; Khang, Young-Ho; Knibbs, Luke; Kokubo, Yoshihiro; Kosen, Soewarta; Defo, Barthelemy; Kulkarni, Chanda; Kulkarni, Veena; Kumar, Gautam; Kumar, Kaushalendra; Kumar, Ravi; Kwan, Gene; Lai, Taavi; Lalloo, Ratilal; Lam, Hilton; Van, Lansingh; Larsson, Anders; Lee, Jongtae; Leigh, James; Leinsalu, Mall; Leung, Ricky; Li, Xiaohong; Li, Yichong; Li, Yongmei; Liang, Juan; Liang, Xiaofeng; Lim, Stephen; Lin, Hsien-Ho; Lipshultz, Steven; Liu, Shiwei; Liu, Yang; Lloyd, Belinda; London, Stephanie; Lotufo, Paulo; Ma, Jixiang; Ma, Stefan; Machado, Vasco; Mainoo, Nana; Majdan, Marek; Mapoma, Christopher; Marcenes, Wagner; Marzan, Melvin; Mason-Jones, Amanda; Mehndiratta, Man; Mejia-Rodriguez, Fabiola; Memish, Z; Mendoza, Walter; Miller, Ted; Mills, Edward; Mokdad, Ali; Mola, Glen; Monasta, Lorenzo; De La Cruz Monis, Jonathan; Hernandez, Julio; Moore, Ami; Moradi-Lakeh, Mazier; Mori, Rintaro; Mueller, Ulrich; Mukaigawara, Mitsuru; Naheed, Aliya; Naidoo, Kovin; Nand, Devina; Nangia, Vinay; Nash, Denis; Nejjari, Chakib; Nelson, Robert; Neupane, Sudan; Newton, Charles; Ng, Marie; Nieuwenhuijsen, Mark; Nisar, Muhammad; Nolte, Sandra; Norheim, Ole; Nyakarahuka, Luke; Oh, Inhwan; Ohkubo, Takayoshi; Olusanya, Bolajoko; Omer, Saad; Opio, John; Orisakwe, Orish; Pandian, Jeyaraj; Papachristou, Christina; Park, Jaehyun; Caicedo, Angel; Patten, Scott; Paul, Vinod; Pavlin, Boris; Pearce, Neil; Pereira, David; Pesudovs, Konrad; Petzold, Max; Poenaru, Dan; Polanczyk, Guilherme; Polinder, Suzanne; Pope, Dan; Pourmalek, Farshad; Qato, Dima; Quistberg, Duane; Rafay, Anwar; Rahimi, Kazem; Rahimi-Movaghar, Vafa; Rahman, Sajjad; Raju, Murugesan; Rana, Saleem; Refaat, Amany; Ronfani, Luca; Roy, Nobhojit; Pimienta, Tania; Sahraian, Mohammad; Salomon, Joshua; Sampson, Uchechukwu; Santos, Itamar; Sawhney, Monika; Sayinzoga, Felix; Schneider, Ione; Schumacher, Austin; Schwebel, David; Seedat, Soraya; Sepanlou, Sadaf; Servan-Mori, Edson; Shakh-Nazarova, Marina; Sheikhbahaei, Sara; Shibuya, Kenji; Shin, Hwashin; Shiue, Ivy; Sigfusdottir, Inga; Silberberg, Donald; Silva, Andrea; Singh, Jasvinder; Skirbekk, Vegard; Sliwa, Karen; Soshnikov, Sergey; Sposato, Luciano; Sreeramareddy, Chandrashekhar; Stroumpoulis, Konstantinos; Sturua, Lela; Sykes, Bryan; Tabb, Karen; Talongwa, Robert; Tan, Feng; Teixeira, Carolina; Tenkorang, Eric; Terkawi, Abdullah; Thorne-Lyman, Andrew; Tirschwell, David; Towbin, Jeffrey; Tran, Bach; Tsilimbaris, Miltiadis; Uchendu, Uche; Ukwaja, Kingsley; Undurraga, Eduardo; Uzun, Selen; Vallely, Andrew; Van Gool, Coen; Vasankari, Tommi; Vavilala, Monica; Venketasubramanian, N; Villalpando, Salvador; Violante, Francesco; Vlassov, Vasiliy; Vos, Theo; Waller, Stephen; Wang, Haidong; Wang, Linhong; Wang, Sharon; Wang, Yanping; Weichenthal, Scott; Weiderpass, Elisabete; Weintraub, Robert; Westerman, Ronny; Wilkinson, James; Woldeyohannes, Solomon; Wong, John; Wordofa, Muluemebet; Xu, Gelin; Yang, Claire; Yano, Yuichiro; Yentur, Gokalp; Yip, Paul; Yonemoto, Naohiro; Yoon, Seokjun; Younis, Mustafa; Yu, Chuanhua; Jin, Kimyun; El Sayed Zaki, Maysaa; Zhao, Yong; Zheng, Yingfeng; Zhou, Maigeng; Zhu, Jun; Zou, Xiaonong; Lopez, Alan; Naghavi, Mohsen; Murray, Christopher; Lozano, Rafael; De Leo, Diego; Del Pozo-Cruz, Borja; Deribe, Kebede; deVeber, Gabrielle; Dharmaratne, Samath; Dilmen, Ugur; Ding, Eric; Dorrington, Rob; Driscoll, T; Ermakov, Sergei; Esteghamati, Alireza.
In: Lancet, Vol. 384, No. 9947, 2014, p. 980-1004.Research output: Contribution to journal › Article
TY - JOUR
T1 - Global, regional, and national levels and causes of maternal mortality during 1990-2013: A systematic analysis for the Global Burden of Disease Study 2013
AU - Kassebaum, Nicholas
AU - Bertozzi-Villa, Amelia
AU - Coggeshall, Megan
AU - Shackelford, Katya
AU - Steiner, Caitlyn
AU - Heuton, Kyle
AU - Gonzalez-Medina, Diego
AU - Barber, Ryan
AU - Huynh, Chantal
AU - Dicker, Daniel
AU - Templin, Tara
AU - Wolock, Timothy
AU - Ozgoren, Ayse
AU - Abd-Allah, Foad
AU - Abera, Semaw
AU - Abubakar, Ibrahim
AU - Achoki, Tom
AU - Adelekan, Ademola
AU - Ademi, Zanfina
AU - Adou, Arsene
AU - Adsuar, Jose
AU - Agardh, Emilie
AU - Akena, Dickens
AU - Alasfoor, Deena
AU - Alemu, Zewdie
AU - Alfonso-Cristancho, Rafael
AU - Alhabib, Samia
AU - Ali, Raghib
AU - Al Kahbouri, Mazin
AU - Alla, F
AU - Allen, Peter
AU - AlMazroa, Mohammad
AU - Alsharif, Ubai
AU - Alvarez, Elena
AU - Alvis-Guzman, Nelson
AU - Amankwaa, Adansi
AU - Amare, Azmeraw
AU - Amini, Hassan
AU - Ammar, Walid
AU - Antonio, Carl
AU - Anwari, Palwasha
AU - Arnlov, Johan
AU - Arsenijevic, Valentina
AU - Artaman, Ali
AU - Asad, Majed
AU - Asghar, Rana
AU - Assadi, Reza
AU - Atkins, Lydia
AU - Badawi, Alaa
AU - Balakrishnan, Kalpana
AU - Basu, Arin
AU - Basu, Sanjay
AU - Beardsley, Justin
AU - Bedi, Neeraj
AU - Bekele, Tolesa
AU - Bell, Michelle
AU - Bernabe, Eduardo
AU - Beyene, Tariku
AU - Bhutta, Zulfiqar
AU - Abdulhak, Aref
AU - Blore, Jed
AU - Basara, Berrak
AU - Bose, Dipan
AU - Breitborde, Nicholas
AU - Cardenas, Rosario
AU - Castaneda-Orjuela, Carlos
AU - Castro, Ruben
AU - Catala-Lopez, Ferran
AU - Cavlin, Alanur
AU - Chang, Jungchen
AU - Che, Xuan
AU - Christophi, Costas
AU - Chugh, Sumeet
AU - Cirillo, Massimo
AU - Colquhoun, Samantha
AU - Cooper, Leslie
AU - Cooper, Cyrus
AU - Da Costa Leite, Iuri
AU - Dandona, Lalit
AU - Dandona, Rakhi
AU - Davis, Adrian
AU - Dayama, Anand
AU - Degenhardt, Louisa
AU - Faraon, Emerito
AU - Farzadfar, Farshad
AU - Felicio, Manuela
AU - Fereshtehnejad, Seyed
AU - De Lima, Graca
AU - Forouzanfar, Mohammad
AU - Franca, Elisabeth
AU - Gaffikin, Lynne
AU - Gambashidze, Ketevan
AU - Gankpe, Fortune
AU - Garcia, Ana
AU - Geleijnse, Johanna
AU - Gibney, Katherine
AU - Giroud, Maurice
AU - Glaser, Elizabeth
AU - Goginashvili, Ketevan
AU - Gona, Philimon
AU - Gonzalez-Castell, Dinorah
AU - Goto, Atsushi
AU - Gouda, Hebe
AU - Gugnani, Harish
AU - Gupta, Rahul
AU - Gupta, Raj
AU - Hafezi-Nejad, Nima
AU - Hamadeh, Randah
AU - Hammami, Mouhanad
AU - Hankey, Graeme
AU - Harb, Hilda
AU - Havmoeller, Rasmus
AU - Hay, Simon
AU - Pi, Ileana
AU - Hoek, Hans
AU - Hosgood III, H
AU - Hoy, Damian
AU - Husseini, Abdullatif
AU - Idrisov, Bulat
AU - Innos, Kaire
AU - Inoue, Manami
AU - Jacobsen, Kathryn
AU - Jahangir, Eiman
AU - Jee, Sunha
AU - Jensen, Paul
AU - Jha, Vivekanand
AU - Jiang, Guohong
AU - Jonas, Jost
AU - Juel, Knud
AU - Kabagambe, Edmond
AU - Kan, Haidong
AU - Karam, Nadim
AU - Karch, Andre
AU - Karema, Corine
AU - Kaul, Anil
AU - Kawakami, Norito
AU - Kazanjan, Konstantin
AU - Kazi, Dhruv
AU - Kemp, Andrew
AU - Kengne, Andre
AU - Kereselidze, Maia
AU - Khader, Yousef
AU - Khalifa, Shams
AU - Khan, Ejaz
AU - Khang, Young-Ho
AU - Knibbs, Luke
AU - Kokubo, Yoshihiro
AU - Kosen, Soewarta
AU - Defo, Barthelemy
AU - Kulkarni, Chanda
AU - Kulkarni, Veena
AU - Kumar, Gautam
AU - Kumar, Kaushalendra
AU - Kumar, Ravi
AU - Kwan, Gene
AU - Lai, Taavi
AU - Lalloo, Ratilal
AU - Lam, Hilton
AU - Van, Lansingh
AU - Larsson, Anders
AU - Lee, Jongtae
AU - Leigh, James
AU - Leinsalu, Mall
AU - Leung, Ricky
AU - Li, Xiaohong
AU - Li, Yichong
AU - Li, Yongmei
AU - Liang, Juan
AU - Liang, Xiaofeng
AU - Lim, Stephen
AU - Lin, Hsien-Ho
AU - Lipshultz, Steven
AU - Liu, Shiwei
AU - Liu, Yang
AU - Lloyd, Belinda
AU - London, Stephanie
AU - Lotufo, Paulo
AU - Ma, Jixiang
AU - Ma, Stefan
AU - Machado, Vasco
AU - Mainoo, Nana
AU - Majdan, Marek
AU - Mapoma, Christopher
AU - Marcenes, Wagner
AU - Marzan, Melvin
AU - Mason-Jones, Amanda
AU - Mehndiratta, Man
AU - Mejia-Rodriguez, Fabiola
AU - Memish, Z
AU - Mendoza, Walter
AU - Miller, Ted
AU - Mills, Edward
AU - Mokdad, Ali
AU - Mola, Glen
AU - Monasta, Lorenzo
AU - De La Cruz Monis, Jonathan
AU - Hernandez, Julio
AU - Moore, Ami
AU - Moradi-Lakeh, Mazier
AU - Mori, Rintaro
AU - Mueller, Ulrich
AU - Mukaigawara, Mitsuru
AU - Naheed, Aliya
AU - Naidoo, Kovin
AU - Nand, Devina
AU - Nangia, Vinay
AU - Nash, Denis
AU - Nejjari, Chakib
AU - Nelson, Robert
AU - Neupane, Sudan
AU - Newton, Charles
AU - Ng, Marie
AU - Nieuwenhuijsen, Mark
AU - Nisar, Muhammad
AU - Nolte, Sandra
AU - Norheim, Ole
AU - Nyakarahuka, Luke
AU - Oh, Inhwan
AU - Ohkubo, Takayoshi
AU - Olusanya, Bolajoko
AU - Omer, Saad
AU - Opio, John
AU - Orisakwe, Orish
AU - Pandian, Jeyaraj
AU - Papachristou, Christina
AU - Park, Jaehyun
AU - Caicedo, Angel
AU - Patten, Scott
AU - Paul, Vinod
AU - Pavlin, Boris
AU - Pearce, Neil
AU - Pereira, David
AU - Pesudovs, Konrad
AU - Petzold, Max
AU - Poenaru, Dan
AU - Polanczyk, Guilherme
AU - Polinder, Suzanne
AU - Pope, Dan
AU - Pourmalek, Farshad
AU - Qato, Dima
AU - Quistberg, Duane
AU - Rafay, Anwar
AU - Rahimi, Kazem
AU - Rahimi-Movaghar, Vafa
AU - Rahman, Sajjad
AU - Raju, Murugesan
AU - Rana, Saleem
AU - Refaat, Amany
AU - Ronfani, Luca
AU - Roy, Nobhojit
AU - Pimienta, Tania
AU - Sahraian, Mohammad
AU - Salomon, Joshua
AU - Sampson, Uchechukwu
AU - Santos, Itamar
AU - Sawhney, Monika
AU - Sayinzoga, Felix
AU - Schneider, Ione
AU - Schumacher, Austin
AU - Schwebel, David
AU - Seedat, Soraya
AU - Sepanlou, Sadaf
AU - Servan-Mori, Edson
AU - Shakh-Nazarova, Marina
AU - Sheikhbahaei, Sara
AU - Shibuya, Kenji
AU - Shin, Hwashin
AU - Shiue, Ivy
AU - Sigfusdottir, Inga
AU - Silberberg, Donald
AU - Silva, Andrea
AU - Singh, Jasvinder
AU - Skirbekk, Vegard
AU - Sliwa, Karen
AU - Soshnikov, Sergey
AU - Sposato, Luciano
AU - Sreeramareddy, Chandrashekhar
AU - Stroumpoulis, Konstantinos
AU - Sturua, Lela
AU - Sykes, Bryan
AU - Tabb, Karen
AU - Talongwa, Robert
AU - Tan, Feng
AU - Teixeira, Carolina
AU - Tenkorang, Eric
AU - Terkawi, Abdullah
AU - Thorne-Lyman, Andrew
AU - Tirschwell, David
AU - Towbin, Jeffrey
AU - Tran, Bach
AU - Tsilimbaris, Miltiadis
AU - Uchendu, Uche
AU - Ukwaja, Kingsley
AU - Undurraga, Eduardo
AU - Uzun, Selen
AU - Vallely, Andrew
AU - Van Gool, Coen
AU - Vasankari, Tommi
AU - Vavilala, Monica
AU - Venketasubramanian, N
AU - Villalpando, Salvador
AU - Violante, Francesco
AU - Vlassov, Vasiliy
AU - Vos, Theo
AU - Waller, Stephen
AU - Wang, Haidong
AU - Wang, Linhong
AU - Wang, Sharon
AU - Wang, Yanping
AU - Weichenthal, Scott
AU - Weiderpass, Elisabete
AU - Weintraub, Robert
AU - Westerman, Ronny
AU - Wilkinson, James
AU - Woldeyohannes, Solomon
AU - Wong, John
AU - Wordofa, Muluemebet
AU - Xu, Gelin
AU - Yang, Claire
AU - Yano, Yuichiro
AU - Yentur, Gokalp
AU - Yip, Paul
AU - Yonemoto, Naohiro
AU - Yoon, Seokjun
AU - Younis, Mustafa
AU - Yu, Chuanhua
AU - Jin, Kimyun
AU - El Sayed Zaki, Maysaa
AU - Zhao, Yong
AU - Zheng, Yingfeng
AU - Zhou, Maigeng
AU - Zhu, Jun
AU - Zou, Xiaonong
AU - Lopez, Alan
AU - Naghavi, Mohsen
AU - Murray, Christopher
AU - Lozano, Rafael
AU - De Leo, Diego
AU - Del Pozo-Cruz, Borja
AU - Deribe, Kebede
AU - deVeber, Gabrielle
AU - Dharmaratne, Samath
AU - Dilmen, Ugur
AU - Ding, Eric
AU - Dorrington, Rob
AU - Driscoll, T
AU - Ermakov, Sergei
AU - Esteghamati, Alireza
PY - 2014
Y1 - 2014
N2 - 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.
AB - 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.
U2 - 10.1016/S0140-6736(14)60696-6
DO - 10.1016/S0140-6736(14)60696-6
M3 - Article
VL - 384
SP - 980
EP - 1004
JO - Lancet
JF - Lancet
SN - 0140-6736
IS - 9947
ER -