ArticlesGlobal, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013
Introduction
Since the 1980s, the global health community has focused on reducing maternal mortality through a sequence of initiatives, beginning with the Safe Motherhood movement in 1987, to the creation of the Partnership for Maternal, Newborn and Child Health in 2005.1, 2 The priority accorded to reductions in maternal mortality is shown by its choice as one of the eight Millennium Development Goals (MDGs). Despite these efforts and visibility, there was broad concern that little or no progress was being made, which prompted intensified efforts by the UN Secretary General through the launch of Every Woman Every Child in 2010, and the subsequent creation of the Commission on Information and Accountability for Women's and Children's Health.2, 3 In 2010, a comprehensive assessment of global trends in maternal mortality suggested that the maternal mortality ratio (MMR; number of maternal deaths per 100 000 livebirths) had decreased by 1·3% per year since 1990.4 Subsequent revisions of the historical estimates have shown even larger worldwide rates of change, from −1·9% to −3·1% per year.5, 6 This evidence collectively suggests that, although concerns about the rate of change of maternal mortality might have been too pessimistic, there is substantial uncertainty about how rapid the decrease has been and about the actual numbers of deaths in several large populations. If policy debates about acceleration of maternal mortality reductions are to be usefully informed, goals established, and targets set for reproductive health, up-to-date monitoring of the levels and trends in maternal mortality is essential.7
Compared with child mortality, maternal mortality has been more difficult to track over time at the national level.8 Several major challenges have to be addressed in any measurement effort: misclassification of maternal deaths to other causes in countries with complete vital registration and medical certification of causes of death; substantial sampling error in measurements that depend on survey recall because few maternal deaths are reported; large non-sampling error in survey and census measurements as demonstrated in settings with repeated overlapping measurements; variation in the demographic assessment of reproductive-age mortality from all causes, particularly in the 1990s; and the need for models to synthesise data from several studies or generate estimates when data are sparse.9, 10, 11 The substantial differences between global modelling efforts, which are at times substantial, emphasise the influence of each of the analytical steps used to estimate maternal mortality.12 Political attention to how countries are progressing towards MDG 5 targets is intensifying.1, 13 Donors, global health partners, and national programme managers are understandably frustrated by the wide uncertainty intervals and the variability of estimates from different analysts.8
Here, we use the systematic approach of the Global Burden of Diseases, Injuries, and Risk Factors Study 2013 (GBD 2013) to measure levels and track trends in maternal mortality, the key causes contributing to maternal death, and the timing of maternal deaths. In GBD 2013, with application of rigorous statistical methods to critically appraise and synthesise data from different sources to estimate levels and causes of death in each age and sex group, a consistent and holistic approach to the challenges of maternal mortality measurement is used that enables comparisons across time, country, and other important causes of death in women of reproductive age. Algorithms for cause of death reclassification are applied consistently across all causes and modelling strategies use methods with clearly quantified out-of-sample predictive validity.14 On the basis of recent trends in MMR, we also project an MMR scenario for 2030 to inform policy debates by identifying which countries are in greatest need of intensified focus.
Section snippets
Data
We used the GBD 2013 cause of death database, which extends from 1980 to 2013, to estimate maternal mortality. Although we report estimates for the MDG period 1990–2013, data for 1980–90 are included in the analysis to improve the robustness of the time trend estimation. Naghavi and colleagues15 provide substantial detail about the inclusion criteria and data processing of studies across all causes. Briefly, building on previous analyses, we identified data from 180 of 188 GBD countries,
Results
The total annual number of maternal deaths decreased from 376 034 (95% UI 343 483– 407 574) in 1990, to 292 982 (261 017–327 792) in 2013 (figure 3A, table 1). The reduction accelerated steadily from 1990 to 2013 (figure 3B), with corresponding decreases in MMR (table 1). Between 2003 and 2013, the annual rate of change in MMR was greater than −1%, reaching −3·3% for 2012–13 (figure 3B).
MMR was highest in the oldest age groups and lowest in women aged 20–29 years in both 1990 and 2013 (figure 4
Discussion
On the basis of recent data and a refined understanding of the association between HIV and maternal mortality, we have shown that worldwide maternal mortality has decreased by 1·3% per year since 1990. Despite reductions in the number of maternal deaths—from about 376 000 in 1990 to about 293 000 in 2013—only 16 countries, seven of which are developing countries, are expected to achieve the MDG 5 target of a 75% reduction in the MMR by 2015. We noted two different patterns in developing
References (74)
- et al.
Generation of political priority for global health initiatives: a framework and case study of maternal mortality
Lancet
(2007) - et al.
From safe motherhood, newborn, and child survival partnerships to the continuum of care and accountability: moving fast forward to 2015
Int J Gynaecol Obstet
(2012) - et al.
Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5
Lancet
(2010) - et al.
Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis
Lancet
(2011) - et al.
Countdown to 2015 decade report (2000–10): taking stock of maternal, newborn, and child survival
Lancet
(2010) - et al.
Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010
Lancet
(2012) - et al.
Maternal mortality: who, when, where, and why
Lancet
(2006) - et al.
HIV infection in critically ill obstetrical patients
Int J Gynaecol Obstet
(2003) - et al.
The association between maternal HIV-1 infection and pregnancy outcomes in Dar es Salaam, Tanzania
BJOG
(2001) - et al.
Effect of HIV infection on pregnancy-related mortality in sub-Saharan Africa: secondary analyses of pooled community-based data from the network for Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA)
Lancet
(2013)
Impact of maternal HIV-1 infection on perinatal outcome
Int J Gynaecol Obstet
Global health 2035: a world converging within a generation
Lancet
Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost?
Lancet
What works? Interventions for maternal and child undernutrition and survival
Lancet
Maternal sepsis
Obstet Gynecol Clin North Am
Effect of active prenatal management on pregnancy outcome in sickle cell disease in an African setting
Blood
Incidence, mortality, and racial differences in peripartum cardiomyopathy
Am J Cardiol
Clinical profile and predictors of complications in peripartum cardiomyopathy
J Card Fail
Peripartum cardiomyopathy
Lancet
Age-specific and sex-specific mortality in 187 countries, 1970–2010: a systematic analysis for the Global Burden of Disease Study 2010
Lancet
Injury-related deaths among women aged 10–50 years in Bangladesh, 1996–97
Lancet
Estimates of maternal mortality worldwide between 1990 and 2005: an assessment of available data
Lancet
Keeping promises, measuring results
Trends in maternal mortality: 1990 to 2010
Towards elimination of maternal deaths: maternal deaths surveillance and response
Reprod Health
Measuring differential maternal mortality using census data in developing countries
Popul Space Place
Misclassification of pregnancy-related deaths in adult mortality surveys: case study in Senegal
Trop Med Int Health
What you count is what you target: the implications of maternal death classification for tracking progress towards reducing maternal mortality in developing countries
Bull World Health Organ
Reflections on the maternal mortality Millennium Goal
Birth
Scaling up in international health: what are the key issues?
Health Policy Plan
Algorithms for enhancing public health utility of national causes-of-death data
Popul Health Metr
International statistical classification of diseases and related health problems: tenth revision, volume 2
Why mothers die: 2000–2002
Indicators for monitoring the Millennium Development Goals: definitions, rationale, concepts, and sources
Death by survey: estimating adult mortality without selection bias from sibling survival data
Demography
The contribution of HIV to pregnancy-related mortality: a systematic review and meta-analysis
AIDS
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