Dataset Information

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

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 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.

SUBMITTER: Kassebaum NJ

PROVIDER: S-EPMC4255481 | biostudies-literature | 2014 Sep

REPOSITORIES: biostudies-literature

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Publications

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

Lancet (London, England) 20140502 9947

<h4>Background</h4>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.<h4>Methods</h4>We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to analyse a ...[more]

PMID: 24797575

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Project description:BackgroundIn transitioning from the Millennium Development Goal to the Sustainable Development Goal era, it is imperative to comprehensively assess progress toward reducing maternal mortality to identify areas of success, remaining challenges, and frame policy discussions. We aimed to quantify maternal mortality throughout the world by underlying cause and age from 1990 to 2015.MethodsWe estimated maternal mortality at the global, regional, and national levels from 1990 to 2015 for ages 10-54 years by systematically compiling and processing all available data sources from 186 of 195 countries and territories, 11 of which were analysed at the subnational level. We quantified eight underlying causes of maternal death and four timing categories, improving estimation methods since GBD 2013 for adult all-cause mortality, HIV-related maternal mortality, and late maternal death. Secondary analyses then allowed systematic examination of drivers of trends, including the relation between maternal mortality and coverage of specific reproductive health-care services as well as assessment of observed versus expected maternal mortality as a function of Socio-demographic Index (SDI), a summary indicator derived from measures of income per capita, educational attainment, and fertility.FindingsOnly ten countries achieved MDG 5, but 122 of 195 countries have already met SDG 3.1. Geographical disparities widened between 1990 and 2015 and, in 2015, 24 countries still had a maternal mortality ratio greater than 400. The proportion of all maternal deaths occurring in the bottom two SDI quintiles, where haemorrhage is the dominant cause of maternal death, increased from roughly 68% in 1990 to more than 80% in 2015. The middle SDI quintile improved the most from 1990 to 2015, but also has the most complicated causal profile. Maternal mortality in the highest SDI quintile is mostly due to other direct maternal disorders, indirect maternal disorders, and abortion, ectopic pregnancy, and/or miscarriage. Historical patterns suggest achievement of SDG 3.1 will require 91% coverage of one antenatal care visit, 78% of four antenatal care visits, 81% of in-facility delivery, and 87% of skilled birth attendance.InterpretationSeveral challenges to improving reproductive health lie ahead in the SDG era. Countries should establish or renew systems for collection and timely dissemination of health data; expand coverage and improve quality of family planning services, including access to contraception and safe abortion to address high adolescent fertility; invest in improving health system capacity, including coverage of routine reproductive health care and of more advanced obstetric care-including EmOC; adapt health systems and data collection systems to monitor and reverse the increase in indirect, other direct, and late maternal deaths, especially in high SDI locations; and examine their own performance with respect to their SDI level, using that information to formulate strategies to improve performance and ensure optimum reproductive health of their population.FundingBill & Melinda Gates Foundation.

Project description:BackgroundRemarkable financial and political efforts have been focused on the reduction of child mortality during the past few decades. Timely measurements of levels and trends in under-5 mortality are important to assess progress towards the Millennium Development Goal 4 (MDG 4) target of reduction of child mortality by two thirds from 1990 to 2015, and to identify models of success.MethodsWe generated updated estimates of child mortality in early neonatal (age 0-6 days), late neonatal (7-28 days), postneonatal (29-364 days), childhood (1-4 years), and under-5 (0-4 years) age groups for 188 countries from 1970 to 2013, with more than 29,000 survey, census, vital registration, and sample registration datapoints. We used Gaussian process regression with adjustments for bias and non-sampling error to synthesise the data for under-5 mortality for each country, and a separate model to estimate mortality for more detailed age groups. We used explanatory mixed effects regression models to assess the association between under-5 mortality and income per person, maternal education, HIV child death rates, secular shifts, and other factors. To quantify the contribution of these different factors and birth numbers to the change in numbers of deaths in under-5 age groups from 1990 to 2013, we used Shapley decomposition. We used estimated rates of change between 2000 and 2013 to construct under-5 mortality rate scenarios out to 2030.FindingsWe estimated that 6·3 million (95% UI 6·0-6·6) children under-5 died in 2013, a 64% reduction from 17·6 million (17·1-18·1) in 1970. In 2013, child mortality rates ranged from 152·5 per 1000 livebirths (130·6-177·4) in Guinea-Bissau to 2·3 (1·8-2·9) per 1000 in Singapore. The annualised rates of change from 1990 to 2013 ranged from -6·8% to 0·1%. 99 of 188 countries, including 43 of 48 countries in sub-Saharan Africa, had faster decreases in child mortality during 2000-13 than during 1990-2000. In 2013, neonatal deaths accounted for 41·6% of under-5 deaths compared with 37·4% in 1990. Compared with 1990, in 2013, rising numbers of births, especially in sub-Saharan Africa, led to 1·4 million more child deaths, and rising income per person and maternal education led to 0·9 million and 2·2 million fewer deaths, respectively. Changes in secular trends led to 4·2 million fewer deaths. Unexplained factors accounted for only -1% of the change in child deaths. In 30 developing countries, decreases since 2000 have been faster than predicted attributable to income, education, and secular shift alone.InterpretationOnly 27 developing countries are expected to achieve MDG 4. Decreases since 2000 in under-5 mortality rates are accelerating in many developing countries, especially in sub-Saharan Africa. The Millennium Declaration and increased development assistance for health might have been a factor in faster decreases in some developing countries. Without further accelerated progress, many countries in west and central Africa will still have high levels of under-5 mortality in 2030.FundingBill & Melinda Gates Foundation, US Agency for International Development.

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Dataset Information

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

Background

Methods

Findings

Interpretation

Funding

Publications

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

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