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Abstract

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 live births) 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 7,065 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 metaregression. 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. 2,070 (1,290–2,866) 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 (685.1–1,262.8) 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.

Citation: 

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, Abbasoglu Ozgoren A*, Abd-Allah F*, Abera SF*, 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-Guzmán N*, Amankwaa AA*, Amare AT*, Amini H*, Ammar W*, Antonio CAT*, Anwari P*, Ärnlöv J*, Arsenijevic VSA*, 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*, Abdulhak AB*, Blore J*, Bora Basara B*, Bose D*, Breitborde N*, Cárdenas R*, Castañeda-Orjuela CA*, Castro RE*, Catalá-López F*, Cavlin A*, Chang J*, 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 EJA*, Farzadfar F*, Felicio MM*, Seyed-Mohammad Fereshtehnejad*, Graça Maria Ferreira de Lima*, Forouzanfar MH*, França EB*, Gaffikin L*, Gambashidze K*, Gankpé FG*, Garcia AC*, Geleijnse JM*, Gibney KB*, Giroud M*, Glaser EL*, Goginashvili K*, Gona P*, González-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 S*, Heredia 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*, Juel K*, Kabagambe EK*, Kan H*, Karam NE*, Karch A*, Karema CK*, Kaul A*, Kawakami N*, Kazanjan K*, Kazi DS*, Kemp AG*, Kengne AP*, Kereselidze M*, Khader YS*, Khalifa SEAH*, Khan EA*, Khang Y*, Knibbs L*, Kokubo Y*, Kosen S*, Kuate Defo B*, Kulkarni C*, Kulkarni VS*, Kumar GA*, Kumar K*, Kumar RB*, Kwan G*, Lai T*, Lalloo R*, Lam H*, Lansingh VC*, Larsson A*, Lee J*, Leigh J*, Leinsalu M*, Leung R*, Li X*, Li Y*, Li Y*, Liang J*, Liang X*, Lim SS*, Lin H*, Lipshultz SE*, Liu S*, Liu Y*, Lloyd BK*, London SJ*, Lotufo PA*, Ma J*, Ma S*, Machado VMP*, 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*, Monis JC*, Montañez Hernandez JC*, Moore AR*, 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 I*, Ohkubo T*, Olusanya BO*, Omer SB*, Opio JN*, Orisakwe OE*, Pandian JD*, Papachristou C*, Park J*, Paternina 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*, Rahman S*, Raju M*, Rana SM*, Refaat A*, Ronfani L*, Roy N*, Sánchez Pimienta TG*, Sahraian MA*, Salomon J*, Sampson U*, Santos IS*, Sawhney M*, Sayinzoga F*, Schneider IJC*, Schumacher A*, Schwebel DC*, Seedat S*, Sepanlou SG*, Servan-Mori EE*, Shakh-Nazarova M*, Sheikhbahaei S*, Shibuya K*, Shin HH*, Ivy Shiue*, 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 CE*, Vasankari TJ*, Vavilala MS*, Venketasubramanian N*, Villalpando S*, Violante FS*, Vlassov VV*, Vos T*, Waller S*, Wang H*, Wang L*, Wang SX*, 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 S*, Younis MZ*, Yu C*, Jin KY*, Zaki MES*, Zhao Y*, Zheng Y*, Zhou M*, Zhu J*, Zou XN*, Lopez AD†, Naghavi M†, Murray CJL†, Lozano R†. Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013The Lancet. 2014 May 2. doi: 10.1016/S0140-6736(14)60696-6.

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