Fulltext

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 NJ 1 , Bertozzi-Villa A 2 , Coggeshall MS 2 , Shackelford KA 2 , Steiner C 2 , Heuton KR 2 Show all authors , Gonzalez-Medina D 2 , Barber R 2 , Huynh C 2 , Dicker D 2 , Templin T 2 , Wolock TM 2 , Ozgoren AA 3 , Abd-Allah F 4 , Abera SF 5 , Abubakar I 6 , Achoki T 7 , Adelekan A 8 , Ademi Z 9 , Adou AK 10 , Adsuar JC 11 , Agardh EE 12 , Akena D 13 , Alasfoor D 14 , Alemu ZA 15 , Alfonso-Cristancho R 16 , Alhabib S 17 , Ali R 18 , Al Kahbouri MJ 14 , Alla F 19 , Allen PJ 20 , AlMazroa MA 21 , Alsharif U 22 , Alvarez E 23 , Alvis-Guzmán N 24 , Amankwaa AA 25 , Amare AT 26 , Amini H 27 , Ammar W 28 , Antonio CA 29 , Anwari P 30 , Arnlöv J 31 , Arsenijevic VS 32 , Artaman A 33 , Asad MM 34 , Asghar RJ 35 , Assadi R 36 , Atkins LS 37 , Badawi A 38 , Balakrishnan K 39 , Basu A 40 , Basu S 41 , Beardsley J 42 , Bedi N 43 , Bekele T 44 , Bell ML 45 , Bernabe E 46 , Beyene TJ 47 , Bhutta Z 48 , Bin Abdulhak A 49 , Blore JD 9 , Basara BB 50 , Bose D 51 , Breitborde N 52 , Cárdenas R 53 , Castañeda-Orjuela CA 54 , Castro RE 55 , Catalá-López F 56 , Cavlin A 3 , Chang JC 57 , Che X 58 , Christophi CA 59 , Chugh SS 60 , Cirillo M 61 , Colquhoun SM 62 , Cooper LT 63 , Cooper C 64 , da Costa Leite I 65 , Dandona L 66 , Dandona R 67 , Davis A 68 , Dayama A 69 , Degenhardt L 70 , De Leo D 71 , del Pozo-Cruz B 72 , Deribe K 47 , Dessalegn M 73 , deVeber GA 74 , Dharmaratne SD 75 , Dilmen U 50 , Ding EL 76 , Dorrington RE 77 , Driscoll TR 78 , Ermakov SP 79 , Esteghamati A 80 , Faraon EJ 29 , Farzadfar F 81 , Felicio MM 82 , Fereshtehnejad SM 83 , de Lima GM 84 , Forouzanfar MH 2 , França EB 85 , Gaffikin L 86 , Gambashidze K 87 , Gankpé FG 88 , Garcia AC 89 , Geleijnse JM 90 , Gibney KB 91 , Giroud M 92 , Glaser EL 93 , Goginashvili K 94 , Gona P 95 , González-Castell D 96 , Goto A 97 , Gouda HN 98 , Gugnani HC 99 , Gupta R 100 , Gupta R 101 , Hafezi-Nejad N 80 , Hamadeh RR 102 , Hammami M 103 , Hankey GJ 104 , Harb HL 28 , Havmoeller R 83 , Hay SI 18 , Pi IB 96 , Hoek HW 105 , Hosgood HD 106 , Hoy DG 107 , Husseini A 108 , Idrisov BT 109 , Innos K 110 , Inoue M 111 , Jacobsen KH 112 , Jahangir E 113 , Jee SH 114 , Jensen PN 16 , Jha V 115 , Jiang G 116 , Jonas JB 117 , Juel K 118 , Kabagambe EK 119 , Kan H 120 , Karam NE 121 , Karch A 122 , Karema CK 123 , Kaul A 124 , Kawakami N 125 , Kazanjan K 87 , Kazi DS 126 , Kemp AH 127 , Kengne AP 128 , Kereselidze M 87 , Khader YS 129 , Khalifa SE 130 , Khan EA 131 , Khang YH 132 , Knibbs L 98 , Kokubo Y 133 , Kosen S 134 , Defo BK 135 , Kulkarni C 136 , Kulkarni VS 137 , Kumar GA 67 , Kumar K 138 , Kumar RB 139 , Kwan G 140 , Lai T 141 , Lalloo R 142 , Lam H 143 , Lansingh VC 144 , Larsson A 31 , Lee JT 145 , Leigh J 146 , Leinsalu M 110 , Leung R 147 , Li X 148 , Li Y 149 , Li Y 150 , Liang J 151 , Liang X 152 , Lim SS 2 , Lin HH 153 , Lipshultz SE 154 , Liu S 149 , Liu Y 155 , Lloyd BK 91 , London SJ 156 , Lotufo PA 127 , Ma J 149 , Ma S 157 , Machado VM 158 , Mainoo NK 159 , Majdan M 160 , Mapoma CC 161 , Marcenes W 162 , Marzan MB 155 , Mason-Jones AJ 163 , Mehndiratta MM 164 , Mejia-Rodriguez F 96 , Memish ZA 21 , Mendoza W 165 , Miller TR 166 , Mills EJ 167 , Mokdad AH 2 , Mola GL 168 , Monasta L 169 , de la Cruz Monis J 170 , Hernandez JC 96 , Moore AR 171 , Moradi-Lakeh M 172 , Mori R 173 , Mueller UO 174 , Mukaigawara M 175 , Naheed A 176 , Naidoo KS 177 , Nand D 178 , Nangia V 179 , Nash D 180 , Nejjari C 181 , Nelson RG 182 , Neupane SP 183 , Newton CR 184 , Ng M 2 , Nieuwenhuijsen MJ 185 , Nisar MI 186 , Nolte S 22 , Norheim OF 187 , Nyakarahuka L 13 , Oh IH 188 , Ohkubo T 189 , Olusanya BO 190 , Omer SB 191 , Opio JN 192 , Orisakwe OE 193 , Pandian JD 194 , Papachristou C 22 , Park JH 195 , Caicedo AJ 196 , Patten SB 197 , Paul VK 198 , Pavlin BI 199 , Pearce N 200 , Pereira DM 201 , Pesudovs K 202 , Petzold M 203 , Poenaru D 204 , Polanczyk GV 127 , Polinder S 205 , Pope D 206 , Pourmalek F 207 , Qato D 208 , Quistberg DA 16 , Rafay A 209 , Rahimi K 18 , Rahimi-Movaghar V 210 , ur Rahman S 211 , Raju M 212 , Rana SM 213 , Refaat A 214 , Ronfani L 169 , Roy N 215 , Pimienta TG 96 , Sahraian MA 216 , Salomon JA 217 , Sampson U 119 , Santos IS 127 , Sawhney M 218 , Sayinzoga F 219 , Schneider IJ 220 , Schumacher A 2 , Schwebel DC 221 , Seedat S 222 , Sepanlou SG 223 , Servan-Mori EE 96 , Shakh-Nazarova M 87 , Sheikhbahaei S 80 , Shibuya K 224 , Shin HH 225 , Shiue I 226 , Sigfusdottir ID 227 , Silberberg DH 228 , Silva AP 229 , Singh JA 221 , Skirbekk V 230 , Sliwa K 231 , Soshnikov SS 232 , Sposato LA 233 , Sreeramareddy CT 234 , Stroumpoulis K 235 , Sturua L 87 , Sykes BL 236 , Tabb KM 237 , Talongwa RT 238 , Tan F 239 , Teixeira CM 82 , Tenkorang EY 240 , Terkawi AS 241 , Thorne-Lyman AL 242 , Tirschwell DL 243 , Towbin JA 244 , Tran BX 245 , Tsilimbaris M 246 , Uchendu US 247 , Ukwaja KN 248 , Undurraga EA 109 , Uzun SB 249 , Vallely AJ 250 , van Gool CH 251 , Vasankari TJ 252 , Vavilala MS 16 , Venketasubramanian N 253 , Villalpando S 96 , Violante FS 254 , Vlassov VV 255 , Vos T 2 , Waller S 256 , Wang H 2 , Wang L 149 , Wang X 257 , Wang Y 151 , Weichenthal S 225 , Weiderpass E 258 , Weintraub RG 259 , Westerman R 174 , Wilkinson JD 260 , Woldeyohannes SM 261 , Wong JQ 262 , Wordofa MA 263 , Xu G 264 , Yang YC 265 , Yano Y 266 , Yentur GK 50 , Yip P 267 , Yonemoto N 268 , Yoon SJ 145 , Younis MZ 269 , Yu C 270 , Jin KY 271 , El Sayed Zaki M 272 , Zhao Y 273 , Zheng Y 274 , Zhou M 149 , Zhu J 151 , Zou XN 275 , Lopez AD 9 , Naghavi M 2 , Murray CJ 2 , Lozano R 276

Affiliations 

  • 1 Institute for Health Metrics and Evaluation, Seattle, WA, USA; Pediatric Anesthesiology and Pain Medicine, Seattle Children's Hospital, School of Medicine, Seattle, WA, USA. Electronic address: nickjk@uw.edu
  • 2 Institute for Health Metrics and Evaluation, Seattle, WA, USA
  • 3 Hacettepe University Institute of Population Studies, Ankara, Turkey
  • 4 Faculty of Medicine, Cairo University, Cairo, Egypt
  • 5 School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia
  • 6 University College London, London, UK
  • 7 Ministry of Health, Gaborone, Botswana
  • 8 Public Health Promotion Alliance, Osogbp, Nigeria
  • 9 University of Melbourne, Melbourne, VIC, Australia
  • 10 Association Ivoirienne Pour Le Bien Etre Familial, Abidjan, Côte d'Ivoire
  • 11 University of Extremadura, Cáceres, Spain
  • 12 Institution of Public Health Sciences, Stockholm, Sweden
  • 13 Makerere University, Kampala, Uganda
  • 14 Ministry of Health, Muscat, Oman
  • 15 Debre Markos University, Debre Markos, Amhara, Ethiopia
  • 16 University of Washington, Seattle, WA, USA
  • 17 National Guard Health Affairs, Riyadh, Saudi Arabia
  • 18 University of Oxford, Oxford, UK
  • 19 School of Public Health, University of Lorraine, Nancy, France
  • 20 Ministry of Health, Belmopan, Cayo, Belize
  • 21 Saudi Ministry of Health, Riyadh, Saudi Arabia
  • 22 Charité Universitätsmedizin Berlin, Berlin, Germany
  • 23 Spanish Observatory on Drugs, Government Delegation for the National Plan on Drugs, Madrid, Spain; Ministry of Health, Social Services and Equality, Madrid, Spain
  • 24 Universidad de Cartagena, Cartagena de Indias, Colombia
  • 25 Albany State University, Albany, GA, USA
  • 26 Department of Epidemiology, University of Groningen, Groningen, Netherlands; College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
  • 27 Kurdistan Environmental Health Research Centre, Kurdistan University of Medical Sciences, Sanandaj, Kurdistan, Iran
  • 28 Ministry of Public Health, Beirut, Lebanon
  • 29 College of Public Health, University of the Philippines Manila, Manila, Philippines
  • 30 UN Population Fund, Kabul, Afghanistan
  • 31 Uppsala University, Uppsala, Sweden
  • 32 Institute of Microbiology and Immunology, School of Medicine, University of Belgrade, Belgrade, Serbia
  • 33 Median, Windsor, ON, Canada
  • 34 Ministry of Health, Amman, Jordan
  • 35 Field Epidemiology and Laboratory Training Program, Islamabad, Pakistan
  • 36 Mashhad University of Medical Sciences, Mashhad, Iran
  • 37 Ministry Of Health, Wellness, Human Services and Gender Relations, Sans Souci, Castries, Saint Lucia
  • 38 Public Health Agency of Canada, Toronto, ON, Canada
  • 39 Sri Ramachandra University, Chennai, India
  • 40 School of Health Sciences, University of Canterbury, Christchurch, New Zealand
  • 41 Stanford University, Stanford, CA, USA
  • 42 Oxford University, Ho Chi Minh City, Vietnam
  • 43 College of Public Health and Tropical Medicine, Jazan, Saudi Arabia
  • 44 Madawalabu University, Bale Goba, Oromia, Ethiopia
  • 45 Yale University, New Haven, CT, USA
  • 46 King's College London, London, UK
  • 47 Addis Ababa University, Debre Zeit, Ethiopia
  • 48 Aga Khan University Medical Centre, Karachi, Pakistan
  • 49 University of Missouri-Kansas City, Kansas City, MO, USA
  • 50 General Directorate of Health Research, Ankara, Turkey
  • 51 World Bank, Washington, DC, USA
  • 52 University of Arizona, Tucson, AZ, USA
  • 53 Universidad Autonoma Metropolitana, Mexico City, Mexico
  • 54 Colombian National Health Observatory, Instituto Nacional de Salud, Bogota, Colombia
  • 55 Universidad Diego Portales, Santiago, Chile
  • 56 Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Medicines and Healthcare Products Agency, Madrid, Spain
  • 57 National Taiwan University, Taipei, Taiwan
  • 58 National Institutes of Health, Department of Health and Human Services, Bethesda, MD, USA
  • 59 Cyprus University of Technology, Limassol, Cyprus
  • 60 Cedars-Sinai Medical Centre, Los Angeles, CA, USA
  • 61 University of Salerno, Baronissi, Italy
  • 62 Centre for International Child Health, Melbourne, VIC, Australia
  • 63 Mayo Clinic, Rochester, MN, USA
  • 64 Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
  • 65 National School of Public Health (ENSP/Fiocruz), Rio de Janeiro, Brazil
  • 66 Institute for Health Metrics and Evaluation, Seattle, WA, USA; Public Health Foundation of India, New Delhi, India
  • 67 Public Health Foundation of India, New Delhi, India
  • 68 Public Health England, London, UK
  • 69 School of Medicine, Atlanta, GA, USA
  • 70 University of New South Wales, Sydney, NSW, Australia
  • 71 Griffith University, Brisbane, QLD, Australia
  • 72 University of Auckland, Auckland, New Zealand
  • 73 Africa Medical and Research Foundation in Ethiopia, Addis Ababa, Ethiopia
  • 74 Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
  • 75 University of Peradeniya, Peradeniya, Sri Lanka
  • 76 Harvard School of Public Health, Boston, MA, USA
  • 77 University of Cape Town, Cape Town, South Africa
  • 78 Sydney School of Public Health, NSW, Australia
  • 79 The Institute of Social and Economic Studies of Population at the Russian Academy of Sciences, Moscow, Russia
  • 80 Endocrinology and Metabolism Research Centre, Tehran University of Medical Sciences, Tehran, Iran
  • 81 Non-Communicable Diseases Research Centre, Tehran University of Medical Sciences, Tehran, Iran
  • 82 Departamento de Saúde Pública, ARS Norte IP, Porto, Portugal
  • 83 Karolinska Institutet, Stockholm, Sweden
  • 84 Public Health Department, Unidade Local de Saúde de Matosinhos, Porto, Portugal
  • 85 Federal University of Minas Gerais, Belo Horizonte, Brazil
  • 86 School of Medicine, Stanford, CA, USA
  • 87 National Centre for Disease Control and Public Health of Georgia, Tbilisi, Georgia
  • 88 Clinique Coopérative de Parakou, Parakou, Borgou, Benin
  • 89 Public Health Unit of Primary Health Care Group of Almada-Seixal, Almada, Setúbal, Portugal
  • 90 Division of Human Nutrition, Wageningen University, Wageningen, Netherlands
  • 91 Monash University, Melbourne, VIC, Australia
  • 92 University Hospital of Dijon, Dijon, France
  • 93 Heller School for Social Policy and Management, Waltham, MA, USA
  • 94 Ministry of Labour, Health and Social Affairs, Tbilisi, Georgia
  • 95 University of Massachusetts Medical School, Worcester, MA, USA
  • 96 National Institute of Public Health, Cuernavaca, Mexico
  • 97 Department of Diabetes Research, National Centre for Global Health and Medicine, Tokyo, Japan
  • 98 University of Queensland, Brisbane, QLD, Australia
  • 99 Saint James School of Medicine, Kralendijk, Bonaire, Netherlands
  • 100 Kanawha Charleston Health Department, Charleston, WV, USA
  • 101 Fortis Escorts Hospital, Jaipur, India
  • 102 Arabian Gulf University, Manama, Bahrain
  • 103 Wayne County Department of Health and Human Services, Detroit, MI, USA
  • 104 School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
  • 105 Parnassia Psychiatric Institute, The Hague, Netherlands
  • 106 Albert Einstein College of Medicine, Bronx, NY, USA
  • 107 School of Population Health, QLD, Australia; Public Health Division, Secretariat of the Pacific Community, Noumea, New Caledonia
  • 108 Birzeit University, Birzeit, Ramallah, Palestine
  • 109 Brandeis University, Waltham, MA, USA
  • 110 National Institute for Health Development, Tallinn, Estonia
  • 111 Graduate School of Medicine, Tokyo, Japan
  • 112 George Mason University, Fairfax, VA, USA
  • 113 Ochsner Medical Centre, New Orleans, LA, USA
  • 114 Graduate School of Public Health, Yonsei University, Seoul, South Korea
  • 115 Postgraduate Institute of Medical Education and Research, Chandigarh, India
  • 116 Tianjin Centres for Diseases Control and Prevention, Tianjin, China
  • 117 Department of Ophthalmology, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
  • 118 National Institute of Public Health, Copenhagen, Denmark
  • 119 Vanderbilt University, Nashville, TN, USA
  • 120 Fudan University, Shanghai, China
  • 121 University of Balamand, Beirut, Lebanon
  • 122 Helmholtz Centre for Infection Research, Braunschweig, Germany
  • 123 Malaria and Other Parasitic Diseases Division, Kigali, Rwanda
  • 124 Oklahoma State University, Tulsa, OK, USA
  • 125 School of Public Health, Tokyo, Japan
  • 126 University of California San Francisco, San Francisco, CA, USA
  • 127 University of São Paulo, São Paulo, Brazil
  • 128 South African Medical Research Council, Cape Town, South Africa
  • 129 Jordan University of Science and Technology, Al-Ramtha, Jordan
  • 130 Supreme Council of Health, Doha, Qatar
  • 131 Health Services Academy, Islamabad, Pakistan
  • 132 Institute of Health Policy and Management, Seoul National University College of Medicine, Seoul, South Korea
  • 133 Department of Preventive Cardiology, Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Centre, Suita, Japan
  • 134 Centre for Community Empowerment, Health Policy and Humanities, National Institute of Health Research and Development, Jakarta, Indonesia
  • 135 University of Montreal, Montreal, QC, Canada
  • 136 Rajrajeshwari Medical College and Hospital, Bangalore, India
  • 137 Arkansas State University, Jonesboro, AR, USA
  • 138 International Institute for Population Sciences, Mumbai, India
  • 139 Indian Institute of Public Health, Public Health Foundation of India, Gurgaon, India
  • 140 Boston Medical Centre, Boston, MA, USA
  • 141 Fourth View Consulting, Tallinn, Estonia
  • 142 Australian Research Centre for Population Oral Health (ARCPOH), School of Dentistry, University of Adelaide, Adelaide, SA, Australia
  • 143 Institute of Health Policy and Development Studies, National Institutes of Health, Manila, Philippines
  • 144 International Agency for the Prevention of Blindness and Vision 2020, Weston, FL, USA
  • 145 Korea University, Seoul, South Korea
  • 146 University of Sydney, NSW, Australia
  • 147 University at Albany, Rensselaer, NY, USA
  • 148 National Centre for Birth Defects Monitoring of China, Chengdu, China
  • 149 National Centre for Chronic and Non-Communicable Disease Control and Prevention, Beijing, China
  • 150 Genentech, South San Francisco, CA, USA
  • 151 National Office for Maternal and Child Health Surveillance, West China Second University Hospital, Sichuan University, Chengdu, China
  • 152 Chinese Centre for Disease Control and Prevention, Beijing, China
  • 153 College of Public Health, Taipei, Taiwan
  • 154 Wayne State University, Miami, FL, USA
  • 155 University of the East Ramon Magsaysay Memorial Medical Centre, Quezon City, Philippines
  • 156 National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA
  • 157 Ministry of Health Singapore, Singapore, Singapore
  • 158 Northern Region Health Administration, Porto, Portugal
  • 159 Xpharmconsult, Kumasi, Ghana
  • 160 Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovakia
  • 161 University of Zambia, Lusaka, Zambia
  • 162 Queen Mary University of London, London, UK
  • 163 University of York, York, UK
  • 164 Janakpuri Super Specialty Hospital, New Delhi, India
  • 165 UN Population Fund, Lima, Peru
  • 166 Pacific Institute for Research and Evaluation, Calverton, MD, USA
  • 167 University of Ottawa, Ottawa, ON, Canada
  • 168 University of Papua New Guinea, Port Moresby, Papua New Guinea
  • 169 Institute for Maternal and Child Health Istituto di Ricovero e Cura a Carattere Scientifico Burlo Garofolo, Trieste, Italy
  • 170 Bureau of International Health Cooperation, Manila City, Philippines
  • 171 University of North Texas, Denton, TX, USA
  • 172 Institute for Health Metrics and Evaluation, Seattle, WA, USA; Iran University of Medical Sciences, Department of Community Medicine, Tehran, Iran
  • 173 National Centre for Child Health and Development, Setagaya, Tokyo, Japan
  • 174 Philipps-University Marburg, Marburg, Germany
  • 175 Tokyo Medical and Dental University, Tokyo, Japan
  • 176 International Centre for Diarrhoeal Diseases Research, Dhaka, Bangladesh
  • 177 University of KwaZulu-Natal, Durban, South Africa
  • 178 Ministry of Health Fiji, Suva, Fiji
  • 179 Suraj Eye Institute, Nagpur, India
  • 180 School of Public Health, State University of New York, New York, NY, USA
  • 181 Faculty of Medicine, Fez, Morocco
  • 182 National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, AZ, USA
  • 183 Norwegian Centre for Addiction Research (SERAF), University of Oslo, Oslo, Norway
  • 184 Kenya Medical Research Institute Wellcome Trust Programme, Kilifi, Kenya
  • 185 Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain
  • 186 Aga Khan University, Karachi, Pakistan
  • 187 University of Bergen, Bergen, Norway
  • 188 Kyung Hee Unversity, Seoul, South Korea
  • 189 Teikyo University School of Medicine, Tokyo, Japan
  • 190 Centre for Healthy Start Initiative, Lagos, Nigeria
  • 191 Emory University, Atlanta, GA, USA
  • 192 Lira District Local Government, Lira Municipal Council, Lira, Uganda
  • 193 Toxicology Unit, Faculty of Pharmacy, University of Port Harcourt, Port Harcourt, Nigeria
  • 194 Christian Medical College Ludhiana, Ludhiana, India
  • 195 Sungkyunkwan University School of Medicine, Suwon, South Korea
  • 196 Universidad de Cartagena, Cartagena, Colombia
  • 197 University of Calgary, Calgary, AB, Canada
  • 198 All India Institute of Medical Sciences (AIIMS), New Delhi, India
  • 199 WHO, Waigani, Papua New Guinea
  • 200 London School of Hygiene & Tropical Medicine, London, UK
  • 201 3B's Research Group in Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, and ICVS/3B's PT Government Associate Laboratory, Braga Portugal
  • 202 Flinders University, Adelaide, SA, Australia
  • 203 Centre for Applied Biostatistics, Sahlgrenska Academy, University of Gothenburg, Sweden
  • 204 McMaster University, Hamilton, ON, Canada
  • 205 Erasmus Medical Center, Department of Public Health, Rotterdam, Netherlands
  • 206 University of Liverpool, Liverpool, UK
  • 207 University of British Columbia, Vancouver, BC, Canada
  • 208 College of Pharmacy, Chicago, IL, USA
  • 209 Contech International, Lahore, Pakistan
  • 210 Sina Trauma and Surgery Research Centre, Tehran University of Medical Sciences, Tehran, Iran
  • 211 Hamad Medical Corporation, Doha, Qatar
  • 212 University of Missouri, Columbia, MO, USA
  • 213 Department of Public Health, University of the Punjab, Lahore, Pakistan
  • 214 Walden University, Minneapolis, MN, USA
  • 215 Bhaba Atomic Research Center Hospital, Mumbai, India
  • 216 MS Research Centre, Tehran University of Medical Sciences, Tehran, Iran
  • 217 Harvard University, Boston, MA, USA
  • 218 Marshall University, Huntington, WV, USA
  • 219 Ministry of Health, Kigali, Rwanda
  • 220 Federal University of Santa Catarina, Florianópolis, Brazil
  • 221 University of Alabama at Birmingham, Birmingham, AL, USA
  • 222 Stellenbosch University, Cape Town, South Africa
  • 223 Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
  • 224 University of Tokyo, Tokyo, Japan
  • 225 Health Canada, Ottawa, ON, Canada
  • 226 Heriot-Watt University, Edinburgh, UK
  • 227 Reykjavik University, Reykjavik, Iceland
  • 228 University of Pennsylvania, Philadelphia, PA, USA
  • 229 Instituto Nacional de Epidemiología Dr Juan H Jara, Mar del Plata, Buenos Aires, Argentina
  • 230 Norwegian Institute of Public Health, Oslo, Norway
  • 231 Hatter Institute for Cardiovascular Research in Africa, Faculty of Health Sciences, Cape Town, South Africa
  • 232 Federal Research Institute for Health Organisation and Informatics of Ministry of Health of the Russian Federation, Moscow, Russia
  • 233 Department of Clinical Neurological Sciences, Western University, London, ON, Canada
  • 234 University Tunku Abdul Rahman, Kajang, Malaysia
  • 235 Hellenic Centre for Disease Control and Prevention (KEELPNO) Greece, Athens, Greece
  • 236 Department of Criminology, Law and Society (and Sociology), University of California Irvine, Irvine, CA, USA
  • 237 University of Illinois, Chicago, IL, USA
  • 238 Ministry of Public Health, Yaounde, Cameroon
  • 239 National Institute of Occupational Health and Poison Control, Beijing, China
  • 240 Memorial University, St John's, NL, Canada
  • 241 Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA; Department of Anesthesiology, King Fahad Medical City, Riyadh, Saudi Arabia
  • 242 The Earth Institute, Columbia University, New York, NY, USA
  • 243 Department of Neurology, Seattle, WA, USA
  • 244 Cincinnati Children's Hospital Medical Centre, Cincinnati, OH, USA
  • 245 Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
  • 246 Department of Medicine, University of Crete, Heraklion, Greece
  • 247 Department of Veterans Affairs, Washington, DC, USA
  • 248 Department of Internal Medicine, Federal Teaching Hospital Abakaliki, Abakaliki, Nigeria
  • 249 Ministry of Health, Ankara, Turkey
  • 250 The Kirby Institute, Sydney, NSW, Australia
  • 251 National Institute for Public Health and the Environment, Bilthoven, Netherlands
  • 252 UKK Institute for Health Promotion Research, Tampere, Finland
  • 253 Neuroscience Centre, Raffles Hospital, Singapore
  • 254 University of Bologna, Bologna, Italy
  • 255 Higher School of Economics, Moscow, Russia
  • 256 Uniformed Services University of Health Sciences, Bethesda, MD, USA
  • 257 Shandong University Affiliated Jinan Central Hospital, Jinan, China
  • 258 Department of Medical Epidemiology and Biostatistics, Stockholm, Sweden
  • 259 University of Melbourne, Melbourne, VIC, Australia; Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, VIC, Australia
  • 260 University of Miami, Miami, FL, USA
  • 261 Institute of Public Health, University of Gondar, Gondar, Ethiopia
  • 262 Ateneo School of Medicine and Public Health, City of Pasig, Manila, Philippines
  • 263 Jimma University, Jimma, Ethiopia
  • 264 Nanjing University School of Medicine, Jinling Hospital, Nanjing, China
  • 265 University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
  • 266 Division of Cardiovascular Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan
  • 267 University of Hong Kong, Hong Kong Special Administrative Region, China
  • 268 National Centre of Neurology and Psychiatry, Kodaira, Japan
  • 269 Jackson State University, Jackson, MS, USA
  • 270 Department of Epidemiology and Biostatistics, Global Health Institute, School of Public Health, Wuhan University, Wuhan, China
  • 271 TCM Medical Tk, Nusajaya, Johor Bahru, Malaysia
  • 272 Mansoura Faculty of Medicine, Mansoura, Egypt
  • 273 Chongqing Medical University, Chongqing, China
  • 274 Zhongshan Ophthalmic Centre, Sun Yat-sen University, Guangzhou, China
  • 275 Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, China
  • 276 Institute for Health Metrics and Evaluation, Seattle, WA, USA; National Institute of Public Health, Cuernavaca, Mexico
Lancet, 2014 Sep 13;384(9947):980-1004.
PMID: 24797575 DOI: 10.1016/S0140-6736(14)60696-6

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.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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