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

Authors:
Dr. Luke Nyakarahuka, DVM, MPH, PhD
Dr. Luke Nyakarahuka, DVM, MPH, PhD
Makerere University
Lecturer
Epidemiology
Kampala, Uganda | Uganda
Corine Karema, MD, MSc
Corine Karema, MD, MSc
Quality and Equity Health care
Independent Malaria, Infectious diseases, HSS and Global Health consultant and Senior technical advisor
Malaria & infectious diseases- Neglected Tropical Diseases, Malaria control and Elimination, Global Health
Kigali, Kigali City | Rwanda
Xuan Che
Xuan Che
National Institute of Health
United States
Deena Alasfoor
Deena Alasfoor
Ministry of Health
Oman
Dr Muhammad Imran Nisar, MBBS MSc
Dr Muhammad Imran Nisar, MBBS MSc
Aga Khan University
Senior Instructor
Maternal and Child Health , Vaccination, Epidemiology and Biostatistics
Karachi, Sindh | Pakistan
Mr. Gokalp Kadri Yentur
Mr. Gokalp Kadri Yentur
Applied Statistics, Biostatistics
Ankara | Turkey
Kyle R Heuton
Kyle R Heuton
Institute for Health Metrics and Evaluation
United States
Dr. Lorenzo Monasta, DSc Epidemiology, MSc Health Sciences, MSc+BSc Statistics & Demography
Dr. Lorenzo Monasta, DSc Epidemiology, MSc Health Sciences, MSc+BSc Statistics & Demography
Institute for Maternal and Child Health -
Epidemiology and Biostatistics
Trieste, TS | Italy
Dr.  Berrak Bora Basara, MD, PhD
Dr. Berrak Bora Basara, MD, PhD
Ministry of Health of Turkey
Head of Department of Health Statistics
Ankara | Turkey
Dr Ademola Adelekan, DrPH
Dr Ademola Adelekan, DrPH
Public Health
Ibadan
Chuanhua Yu, PhD
Chuanhua Yu, PhD
Wuhan University
Prof.
Wuhan, Hubei | China
Nicholas J Kassebaum Amelia Bertozzi-Villa Megan S Coggeshall Katya A Shackelford Caitlyn Steiner 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 Zanfina Ademi Arsène Kouablan Adou José C Adsuar Emilie E Agardh Dickens Akena 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 Arnlöv 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 Dipan Bose Nicholas Breitborde Rosario Cárdenas Carlos A Castañeda-Orjuela Ruben Estanislao Castro Ferrán Catalá-López Alanur Cavlin Jung-Chen Chang 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 Uğur 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 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 Sandra Nolte Ole F Norheim 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 XiaoRong 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 Paul Yip Naohiro Yonemoto Seok-Jun Yoon Mustafa Z Younis 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

Lancet 2014 Sep 2;384(9947):980-1004. Epub 2014 May 2.

Institute for Health Metrics and Evaluation, Seattle, WA, USA; National Institute of Public Health, Cuernavaca, Mexico.

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.

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Source
http://dx.doi.org/10.1016/S0140-6736(14)60696-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4255481PMC
September 2014
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292 Citations
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