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Maternal mortality in developing countries: challenges in scaling-up priority interventions

Prata N, Passano P, Sreenivas A, Gerdts CE

Womens Health (Lond), 2010 Mar;6(2):311-27.
PMID: 20187734 DOI: 10.2217/whe.10.8

Although maternal mortality is a significant global health issue, achievements in mortality decline to date have been inadequate. A review of the interventions targeted at maternal mortality reduction demonstrates that most developing countries face tremendous challenges in the implementation of these interventions, including the availability of unreliable data and the shortage in human and financial resources, as well as limited political commitment. Examples from developing countries, such as Sri Lanka, Malaysia and Honduras, demonstrate that maternal mortality will decline when appropriate strategies are in place. Such achievable strategies need to include redoubled commitments on the part of local, national and global political bodies, concrete investments in high-yield and cost-effective interventions and the delegation of some clinical tasks from higher-level healthcare providers to mid- or lower-level healthcare providers, as well as improved health-management information systems.

Matched MeSH terms: Maternal Mortality/trends*
Poverty and mortality among the elderly: measurement of performance in 33 countries 1960-92

Wang J, Jamison DT, Bos E, Vu MT

Trop Med Int Health, 1997 Oct;2(10):1001-10.
PMID: 9357491

This paper analyses the effect of income and education on life expectancy and mortality rates among the elderly in 33 countries for the period 1960-92 and assesses how that relationship has changed over time as a result of technical progress. Our outcome variables are life expectancy at age 60 and the probability of dying between age 60 and age 80 for both males and females. The data are from vital-registration based life tables published by national statistical offices for several years during this period. We estimate regressions with determinants that include GDP per capita (adjusted for purchasing power), education and time (as a proxy for technical progress). As the available measure of education failed to account for variation in life expectancy or mortality at age 60, our reported analyses focus on a simplified model with only income and time as predictors. The results indicate that, controlling for income, mortality rates among the elderly have declined considerably over the past three decades. We also find that poverty (as measured by low average income levels) explains some of the variation in both life expectancy at age 60 and mortality rates among the elderly across the countries in the sample. The explained amount of variation is more substantial for females than for males. While poverty does adversely affect mortality rates among the elderly (and the strength of this effect is estimated to be increasing over time), technical progress appears far more important in the period following 1960. Predicted female life expectancy (at age 60) in 1960 at the mean income level in 1960 was, for example 18.8 years; income growth to 1992 increased this by an estimated 0.7 years, whereas technical progress increased it by 2.0 years. We then use the estimated regression results to compare country performance on life expectancy of the elderly, controlling for levels of poverty (or income), and to assess how performance has varied over time. High performing countries, on female life expectancy at age 60, for the period around 1990, included Chile (1.0 years longer life expectancy), China (1.7 years longer), France (2.0 years longer), Japan (1.9 years longer), and Switzerland (1.3 years longer). Poorly performing countries included Denmark (1.1 years shorter life expectancy than predicted from income), Hungary (1.4 years shorter), Iceland (1.2 years shorter), Malaysia (1.6 years shorter), and Trinidad and Tobago (3.9 years shorter). Chile and Switzerland registered major improvements in relative performance over this period; Norway, Taiwan and the USA, in contrast showed major declines in performance between 1980 and the early 1990s.

Matched MeSH terms: Mortality/trends*
The use of herbal medicines during pregnancy and perinatal mortality in Tumpat District, Kelantan, Malaysia

Ab Rahman A, Ahmad Z, Naing L, Sulaiman SA, Hamid AM, Daud WN

Southeast Asian J. Trop. Med. Public Health, 2007 Nov;38(6):1150-7.
PMID: 18613559

The objective of this case-control study was to determine the association between herbal medicine use during pregnancy and perinatal mortality in Tumpat District, Kelantan, Malaysia. Cases were mothers who gave birth from June 2002 to June 2005 with a history of perinatal mortality, while controls were those without a history of perinatal infant mortality. A total of 316 mothers (106 cases and 210 controls) were interviewed. The use of unidentified herbs prepared by traditional midwives and other types of herbal medicines during the first trimester of pregnancy were positively associated with perinatal mortality (OR = 5.24, 95% CI = 1.13; 24.23 and OR = 8.90, 95%, CI = 1.35; 58.53, respectively). The use of unidentified "Orang Asli" herbs and coconut oil during the third trimester of pregnancy were negatively associated with perinatal mortality in Tumpat (OR = 0.10, 95% CI = 0.02; 0.59 and OR = 0.48, 95% CI = 0.25; 0.92, respectively). These findings suggest the use of unidentified "Orang Asli" herbs and coconut oil in late pregnancy are protective against perinatal mortality, while the use of unidentified herbs prepared by traditional midwives and other types of herbal medicines in early pregnancy has an increased risk of perinatal infant mortality. Pharmacological studies to confirm and identify the compounds in these herbs and their effects on the fetus should be conducted in the future.

Matched MeSH terms: Perinatal Mortality/trends*
Environmental problems of the tropical city: a brief overview

Badri MA

Southeast Asian J. Trop. Med. Public Health, 1992;23 Suppl 3:94-109.
PMID: 1342764
Matched MeSH terms: Mortality/trends
Fulltext Maternal deaths due to liver disease in Malaysia

Ravindran J, Jayadev R, Lachmanan SR, Merican I

Med J Malaysia, 2000 Jun;55(2):209-19.
PMID: 19839149

Liver disease is an important and serious condition in pregnancy. The Confidential Enquiries Into Maternal Deaths in Malaysia showed that there were 23 maternal deaths attributed to liver disease between 1991-1994. Over the same period, there were 1066 reported maternal deaths with 929 of them being due to direct and indirect causes. Thus 2.15% of such deaths were due to liver disease in Malaysia. The three main causes of maternal deaths due to liver disease in pregnancy were hepatitis (6 cases), acute fatty liver in pregnancy (6 cases) and septicaemia (4 cases). Liver disease is common at a mean of thirty weeks of gestation with a preponderance to women of low parity. Only two patients in this series had no antenatal care. The majority of cases (45.8%) presented between 28-37 weeks of gestation. All cases delivered by spontaneous vaginal delivery. Remediable factors that were identified included failure to appreciate the severity of disease. Case summaries of all the cases of maternal deaths due to liver disease are discussed and a guideline to management of liver disease in pregnancy presented.

Matched MeSH terms: Maternal Mortality/trends*
Child and Adolescent Mortality Across Malaysia's Epidemiological Transition: A Systematic Analysis of Global Burden of Disease Data

Abdul-Razak S, Azzopardi PS, Patton GC, Mokdad AH, Sawyer SM

J Adolesc Health, 2017 Oct;61(4):424-433.
PMID: 28838752 DOI: 10.1016/j.jadohealth.2017.05.014

PURPOSE: A rapid epidemiological transition in developing countries in Southeast Asia has been accompanied by major shifts in the health status of children and adolescents. In this article, mortality estimates in Malaysian children and adolescents from 1990 to 2013 are used to illustrate these changes.
METHODS: All-cause and cause-specific mortality estimates were obtained from the 2013 Global Burden of Disease Study. Data were extracted from 1990 to 2013 for the developmental age range from 1 to 24 years, for both sexes. Trends in all-cause and cause-specific mortality for the major epidemiological causes were estimated.
RESULTS: From 1990 to 2013, all-cause mortality decreased in all age groups. Reduction of all-cause mortality was greatest in 1- to 4-year-olds (2.4% per year reduction) and least in 20- to 24-year-olds (.9% per year reduction). Accordingly, in 2013, all-cause mortality was highest in 20- to 24-year-old males (129 per 100,000 per year). In 1990, the principal cause of death for 1- to 9-year boys and girls was vaccine preventable diseases. By 2013, neoplasms had become the major cause of death in 1-9 year olds of both sexes. The major cause of death in 10- to 24-year-old females was typhoid in 1990 and neoplasms in 2013, whereas the major cause of death in 10- to 24-year-old males remained road traffic injuries.
CONCLUSIONS: The reduction in mortality across the epidemiological transition in Malaysia has been much less pronounced for adolescents than younger children. The contribution of injuries and noncommunicable diseases to adolescent mortality suggests where public health strategies should focus.

Matched MeSH terms: Infant Mortality/trends
Regional inequalities of child mortality in peninsular Malaysia with special reference to the differentials between Perlis and Kuala Terengganu

Brehm U

Soc Sci Med, 1993 May;36(10):1331-4.
PMID: 8511619

In Peninsular Malaysia child mortality rates (5q0) vary from 13 to 63 per thousand at district level. The spatial pattern is closely associated with the regional distribution of socio-economic factors. But due to multicollinearity it is difficult to isolate the influence of socio-economic variables from other variables by employing aggregated data. However, individual data collected in a case-control-study that was conducted in Perlis and Kuala Terengganu confirm the important role of socio-economic factors. So it should be possible to achieve a further reduction of child mortality by raising the income and educational level of the under-privileged groups. Apart from that, as the case of Perlis shows, the provision of family planning and preventive medical services may also contribute to lower child mortality independent from socio-economic changes. But, as the comparison with Kuala Terengganu shows, the utilization of family planning and preventive medical services is not only influenced by the accessibility to, but also by the socio-culturally determined acceptability of such services.

Matched MeSH terms: Infant Mortality/trends*; Mortality/trends*
Problems and potential of researching epidemiological transition: examples from Southeast Asia

Phillips DR

Soc Sci Med, 1991;33(4):395-404.
PMID: 1948152

The concept of epidemiological transition is now quite widely recognized, if not so widely accepted. The transition appears to progress at varying speeds and to different extents spatially; it seems that there can be considerable international, regional and local variations in its progress. The paper examines this contention in the case of a number of countries in Southeast Asia, principally Hong Kong, Malaysia and Thailand. Drawing on evidence from this region, the paper highlights the importance when researching epidemiological transition of the time period under consideration; socio-cultural variations; the nature and quality of data, and spatial scale. It makes some suggestions as to the potential of the concept of epidemiological transition in health care planning and development studies.

Matched MeSH terms: Mortality/trends*
[Prognostic evaluations of the medical and demographic processes]

Tishuk EA

Probl Sotsialnoi Gig Zdravookhranenniiai Istor Med, 2003 Sep-Oct.
PMID: 14661406

The medical-and-demographic processes as a starting point for the planning of means and resources for the short- and average-term future are forecasted in the paper on the basis of long-term peculiarities of the natural-science data and with respect for the social-and-economic crisis now underway in the country.

Matched MeSH terms: Mortality/trends*
Fulltext Association between prehospital field to emergency department delta shock index and in-hospital mortality in patients with torso and extremity trauma: A multinational, observational study

Kim DK, Jeong J, Shin SD, Song KJ, Hong KJ, Ro YS, et al.

PLoS One, 2021;16(10):e0258811.
PMID: 34695147 DOI: 10.1371/journal.pone.0258811

Hemorrhage, a main cause of mortality in patients with trauma, affects vital signs such as blood pressure and heart rate. Shock index (SI), calculated as heart rate divided by systolic blood pressure, is widely used to estimate the shock status of patients with hemorrhage. The difference in SI between the emergency department and prehospital field can indirectly reflect urgency after trauma. We aimed to determine the association between delta SI (DSI) and in-hospital mortality in patients with torso or extremity trauma. Patients with DSI >0.1 are expected to be associated with high mortality. This retrospective, observational study used data from the Pan-Asian Trauma Outcomes Study. Patients aged 18-85 years with abdomen, chest, upper extremity, lower extremity, or external injury location were included. Patients from China, Indonesia, Japan, Philippines, Thailand, and Vietnam; those who were transferred from another facility; those who were transferred without the use of emergency medical service; those with prehospital cardiac arrest; those with unknown exposure and outcomes were excluded. The exposure and primary outcome were DSI and in-hospital mortality, respectively. The secondary and tertiary outcome was intensive care unit (ICU) admission and massive transfusion, respectively. Multivariate logistic regression analysis was performed to test the association between DSI and outcome. In total, 21,534 patients were enrolled according to the inclusion and exclusion criteria. There were 3,033 patients with DSI >0.1. The in-hospital mortality rate in the DSI >0.1 and ≤0.1 groups was 2.0% and 0.8%, respectively. In multivariate logistic regression analysis, the DSI ≤0.1 group was considered the reference group. The unadjusted and adjusted odds ratios of in-hospital mortality in the DSI >0.1 group were 2.54 (95% confidence interval [CI] 1.88-3.42) and 2.82 (95% CI 2.08-3.84), respectively. The urgency of traumatic hemorrhage can be determined using DSI, which can help hospital staff to provide proper trauma management, such as early trauma surgery or embolization.

Matched MeSH terms: Hospital Mortality/trends*
Fulltext C-reactive protein/albumin ratio is a prognostic indicator for predicting surgical intervention and mortality in neonates with necrotizing enterocolitis

Mohd Amin AT, Zaki RA, Friedmacher F, Sharif SP

Pediatr Surg Int, 2021 Jul;37(7):881-886.
PMID: 33779823 DOI: 10.1007/s00383-021-04879-1

PURPOSE: The role of hypoalbuminemia and raised C-reactive protein (CRP) levels in predicting critical prognosis has been described extensively in adult literature. However, there are limited studies in pediatrics, particularly neonates. The CRP/albumin (CRP/ALB) ratio is often associated with higher mortality, organ failure and prolonged hospital stay. We hypothesized that the serum CRP/ALB ratio has a prognostic value in predicting surgery and mortality in neonates with necrotizing enterocolitis (NEC).
METHODS: Retrospective review of all neonates with clinical and radiological evidence of non-perforated NEC that were treated in a tertiary-level referral hospital between 2009 and 2018. General patient demographics, laboratory parameters and outcomes were recorded. Receiver operating characteristics analysis was performed to evaluated optimal cut-offs and area under the curve (AUC) with 95% confidence intervals (CI).
RESULTS: A total of 191 neonates were identified. Of these, 103 (53.9%) were born at ≤ 28 weeks of gestation and 101 (52.9%) had a birth weight of ≤ 1000 g. Eighty-four (44.0%) patients underwent surgical intervention for NEC. The overall survival rate was 161/191 (84.3%). A CRP/ALB ratio of ≥ 3 on day 2 of NEC diagnosis was associated with a statistically significant higher likelihood for surgery [AUC 0.71 (95% CI 0.63-0.79); p

Matched MeSH terms: Infant Mortality/trends
Fulltext Does the granting of legal privileges as an indigenous people help to reduce health disparities? Evidence from New Zealand and Malaysia

Phua KL

Pac Health Dialog, 2009 Nov;15(2):117-27.
PMID: 20443525

Both the Maori of New Zealand and the Orang Asli of Malaysia are indigenous peoples who have been subjected to prejudice, discrimination and displacement in its various forms by other ethnic groups in their respective countries. However, owing to changes in the socio-political climate, they have been granted rights (including legal privileges) in more recent times. Data pertaining to the health and socio-economic status of the Maori and the Orang Asli are analysed to see if the granting of legal privileges has made any difference for the two communities. One conclusion is that legal privileges (and the granting of special status) do not appear to work well in terms of reducing health and socio-economic gaps.

Matched MeSH terms: Mortality/trends
Impact and Challenges of Early Continuous Positive Airway Pressure Therapy for Very Low Birth Weight Neonates in a Developing Country

Boo NY, Cheah IG, Neoh SH, Chee SC, Malaysian National Neonatal Registry

Neonatology, 2016;110(2):116-24.
PMID: 27074004 DOI: 10.1159/000444316

BACKGROUND: Early nasal continuous positive airway pressure (EnCPAP) therapy after birth for very low birth weight (VLBW; <1,500 g) neonates has been reported to be beneficial in developed countries. Its benefits in developing countries, such as Malaysia, are unknown.
OBJECTIVES: This study aimed to determine EnCPAP rates in 36 neonatal intensive care units of the Malaysian National Neonatal Registry (MNNR) in 2013, to compare the outcomes of VLBW neonates with and without EnCPAP, and to determine whether the availability of CPAP facilities and unit policies played a significant role in EnCPAP rates.
METHODS: First, a retrospective cohort study was conducted of VLBW neonates born in the hospitals participating in the study without major congenital abnormalities in the MNNR. This was followed by a questionnaire survey of these hospitals focussed on CPAP facilities and unit policies.
RESULTS: Of the 2,823 neonates, 963 (34.1%) received EnCPAP. Amongst EnCPAP neonates significantly fewer deaths were recorded (10.9 vs. 21.7%; p < 0.001), less bronchopulmonary dysplasia was observed (BPD; 8.0 vs. 11.7%; p = 0.002) and fewer mechanical ventilation days were necessary (p < 0.001) than in non-EnCPAP neonates. Logistic regression analysis showed that EnCPAP was significantly associated with a lower mortality (adjusted OR 0.623; 95% CI 0.472, 0.824; p = 0.001) and BPD among survivors (adjusted OR 0.585; 95% CI 0.427, 0.802; p = 0.001). The median EnCPAP rate of the 36 hospitals was 28.4% (IQR 14.3-38.7). Hospitals with CPAP facilities in the delivery suites (p = 0.001) and during transport (p = 0.001) and a policy for EnCPAP (p = 0.036) had significantly higher EnCPAP rates.
CONCLUSION: EnCPAP reduced mortality and BPD in Malaysian VLBW neonates. Resource-strapped developing countries should prioritise the use of this low-cost therapy.

Matched MeSH terms: Infant Mortality/trends*
Fulltext Mapping 123 million neonatal, infant and child deaths between 2000 and 2017

Burstein R, Henry NJ, Collison ML, Marczak LB, Sligar A, Watson S, et al.

Nature, 2019 Oct;574(7778):353-358.
PMID: 31619795 DOI: 10.1038/s41586-019-1545-0

Since 2000, many countries have achieved considerable success in improving child survival, but localized progress remains unclear. To inform efforts towards United Nations Sustainable Development Goal 3.2-to end preventable child deaths by 2030-we need consistently estimated data at the subnational level regarding child mortality rates and trends. Here we quantified, for the period 2000-2017, the subnational variation in mortality rates and number of deaths of neonates, infants and children under 5 years of age within 99 low- and middle-income countries using a geostatistical survival model. We estimated that 32% of children under 5 in these countries lived in districts that had attained rates of 25 or fewer child deaths per 1,000 live births by 2017, and that 58% of child deaths between 2000 and 2017 in these countries could have been averted in the absence of geographical inequality. This study enables the identification of high-mortality clusters, patterns of progress and geographical inequalities to inform appropriate investments and implementations that will help to improve the health of all populations.

Matched MeSH terms: Infant Mortality/trends*; Child Mortality/trends*
Fulltext Association of non-alcoholic fatty liver disease and all-cause mortality in hospitalized cardiovascular disease patients: A systematic review and meta-analysis

Saokaew S, Kanchanasurakit S, Thawichai K, Duangprom P, Wannasri M, Khankham S, et al.

Medicine (Baltimore), 2021 Feb 05;100(5):e24557.
PMID: 33592910 DOI: 10.1097/MD.0000000000024557

BACKGROUND: Controversy remains concerning the association of the all-cause mortality risk of hospitalized cardiovascular disease (CVD) patients with non-alcoholic fatty liver disease (NAFLD). This study investigated the risks of all-cause mortality among hospitalized CVD patients with NAFLD.
METHODS: We used related keywords to search for studies in 3 electronic databases: PubMed, EMBASE, and Cochrane Library. All eligible studies published up to April 2020 were reviewed. The findings of those studies reporting the mortality outcomes of hospitalized CVD patients with and without NAFLD were examined, and the various study results were pooled and analyzed using a random-effects model. A quality assessment using the Newcastle-Ottawa scale was performed on the studies selected for inclusion in a meta-analysis.
RESULTS: A total of 2135 studies were found, of which 3 were included in this meta-analysis. All studies were considered good quality. The mean age of the patients in the analysis was 73 years, and about half of them were men. The comorbidities reported were hypertension, diabetes mellitus, and dyslipidemia. The results showed that hospitalized CVD patients with NAFLD were at a significantly higher risk of all-cause mortality than non-NAFLD patients (adjusted hazard ratio of 2.08 [95% confidence interval, 1.56-2.59], P

Matched MeSH terms: Mortality/trends*
Integrating health interventions for women, newborn babies, and children: a framework for action

Ekman B, Pathmanathan I, Liljestrand J

Lancet, 2008 Sep 13;372(9642):990-1000.
PMID: 18790321 DOI: 10.1016/S0140-6736(08)61408-7

For women and children, especially those who are poor and disadvantaged, to benefit from primary health care, they need to access and use cost-effective interventions for maternal, newborn, and child health. The challenge facing weak health systems is how to deliver such packages. Experiences from countries such as Iran, Malaysia, Sri Lanka, and China, and from projects in countries like Tanzania and India, show that outcomes in maternal, newborn, and child health can be improved through integrated packages of cost-effective health-care interventions that are implemented incrementally in accordance with the capacity of health systems. Such packages should include community-based interventions that act in combination with social protection and intersectoral action in education, infrastructure, and poverty reduction. Interventions need to be planned and implemented at the district level, which requires strengthening of district planning and management skills. Furthermore, districts need to be supported by national strategies and policies, and, in the case of the least developed countries, also by international donors and other partners. If packages for maternal, newborn and child health care can be integrated within a gradually strengthened primary health-care system, continuity of care will be improved, including access to basic referral care before and during pregnancy, birth, the postpartum period, and throughout childhood.

Matched MeSH terms: Maternal Mortality/trends
Variations in common diseases, hospital admissions, and deaths in middle-aged adults in 21 countries from five continents (PURE): a prospective cohort study

Dagenais GR, Leong DP, Rangarajan S, Lanas F, Lopez-Jaramillo P, Gupta R, et al.

Lancet, 2020 03 07;395(10226):785-794.
PMID: 31492501 DOI: 10.1016/S0140-6736(19)32007-0

BACKGROUND: To our knowledge, no previous study has prospectively documented the incidence of common diseases and related mortality in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) with standardised approaches. Such information is key to developing global and context-specific health strategies. In our analysis of the Prospective Urban Rural Epidemiology (PURE) study, we aimed to evaluate differences in the incidence of common diseases, related hospital admissions, and related mortality in a large contemporary cohort of adults from 21 HICs, MICs, and LICs across five continents by use of standardised approaches.
METHODS: The PURE study is a prospective, population-based cohort study of individuals aged 35-70 years who have been enrolled from 21 countries across five continents. The key outcomes were the incidence of fatal and non-fatal cardiovascular diseases, cancers, injuries, respiratory diseases, and hospital admissions, and we calculated the age-standardised and sex-standardised incidence of these events per 1000 person-years.
FINDINGS: This analysis assesses the incidence of events in 162 534 participants who were enrolled in the first two phases of the PURE core study, between Jan 6, 2005, and Dec 4, 2016, and who were assessed for a median of 9·5 years (IQR 8·5-10·9). During follow-up, 11 307 (7·0%) participants died, 9329 (5·7%) participants had cardiovascular disease, 5151 (3·2%) participants had a cancer, 4386 (2·7%) participants had injuries requiring hospital admission, 2911 (1·8%) participants had pneumonia, and 1830 (1·1%) participants had chronic obstructive pulmonary disease (COPD). Cardiovascular disease occurred more often in LICs (7·1 cases per 1000 person-years) and in MICs (6·8 cases per 1000 person-years) than in HICs (4·3 cases per 1000 person-years). However, incident cancers, injuries, COPD, and pneumonia were most common in HICs and least common in LICs. Overall mortality rates in LICs (13·3 deaths per 1000 person-years) were double those in MICs (6·9 deaths per 1000 person-years) and four times higher than in HICs (3·4 deaths per 1000 person-years). This pattern of the highest mortality in LICs and the lowest in HICs was observed for all causes of death except cancer, where mortality was similar across country income levels. Cardiovascular disease was the most common cause of deaths overall (40%) but accounted for only 23% of deaths in HICs (vs 41% in MICs and 43% in LICs), despite more cardiovascular disease risk factors (as judged by INTERHEART risk scores) in HICs and the fewest such risk factors in LICs. The ratio of deaths from cardiovascular disease to those from cancer was 0·4 in HICs, 1·3 in MICs, and 3·0 in LICs, and four upper-MICs (Argentina, Chile, Turkey, and Poland) showed ratios similar to the HICs. Rates of first hospital admission and cardiovascular disease medication use were lowest in LICs and highest in HICs.
INTERPRETATION: Among adults aged 35-70 years, cardiovascular disease is the major cause of mortality globally. However, in HICs and some upper-MICs, deaths from cancer are now more common than those from cardiovascular disease, indicating a transition in the predominant causes of deaths in middle-age. As cardiovascular disease decreases in many countries, mortality from cancer will probably become the leading cause of death. The high mortality in poorer countries is not related to risk factors, but it might be related to poorer access to health care.
FUNDING: Full funding sources are listed at the end of the paper (see Acknowledgments).

Matched MeSH terms: Mortality/trends
Fulltext Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015

GBD 2015 Mortality and Causes of Death Collaborators

Lancet, 2016 Oct 08;388(10053):1459-1544.
PMID: 27733281 DOI: 10.1016/S0140-6736(16)31012-1

BACKGROUND: Improving survival and extending the longevity of life for all populations requires timely, robust evidence on local mortality levels and trends. The Global Burden of Disease 2015 Study (GBD 2015) provides a comprehensive assessment of all-cause and cause-specific mortality for 249 causes in 195 countries and territories from 1980 to 2015. These results informed an in-depth investigation of observed and expected mortality patterns based on sociodemographic measures.
METHODS: We estimated all-cause mortality by age, sex, geography, and year using an improved analytical approach originally developed for GBD 2013 and GBD 2010. Improvements included refinements to the estimation of child and adult mortality and corresponding uncertainty, parameter selection for under-5 mortality synthesis by spatiotemporal Gaussian process regression, and sibling history data processing. We also expanded the database of vital registration, survey, and census data to 14 294 geography-year datapoints. For GBD 2015, eight causes, including Ebola virus disease, were added to the previous GBD cause list for mortality. We used six modelling approaches to assess cause-specific mortality, with the Cause of Death Ensemble Model (CODEm) generating estimates for most causes. We used a series of novel analyses to systematically quantify the drivers of trends in mortality across geographies. First, we assessed observed and expected levels and trends of cause-specific mortality as they relate to the Socio-demographic Index (SDI), a summary indicator derived from measures of income per capita, educational attainment, and fertility. Second, we examined factors affecting total mortality patterns through a series of counterfactual scenarios, testing the magnitude by which population growth, population age structures, and epidemiological changes contributed to shifts in mortality. Finally, we attributed changes in life expectancy to changes in cause of death. We documented each step of the GBD 2015 estimation processes, as well as data sources, in accordance with Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER).
FINDINGS: Globally, life expectancy from birth increased from 61·7 years (95% uncertainty interval 61·4-61·9) in 1980 to 71·8 years (71·5-72·2) in 2015. Several countries in sub-Saharan Africa had very large gains in life expectancy from 2005 to 2015, rebounding from an era of exceedingly high loss of life due to HIV/AIDS. At the same time, many geographies saw life expectancy stagnate or decline, particularly for men and in countries with rising mortality from war or interpersonal violence. From 2005 to 2015, male life expectancy in Syria dropped by 11·3 years (3·7-17·4), to 62·6 years (56·5-70·2). Total deaths increased by 4·1% (2·6-5·6) from 2005 to 2015, rising to 55·8 million (54·9 million to 56·6 million) in 2015, but age-standardised death rates fell by 17·0% (15·8-18·1) during this time, underscoring changes in population growth and shifts in global age structures. The result was similar for non-communicable diseases (NCDs), with total deaths from these causes increasing by 14·1% (12·6-16·0) to 39·8 million (39·2 million to 40·5 million) in 2015, whereas age-standardised rates decreased by 13·1% (11·9-14·3). Globally, this mortality pattern emerged for several NCDs, including several types of cancer, ischaemic heart disease, cirrhosis, and Alzheimer's disease and other dementias. By contrast, both total deaths and age-standardised death rates due to communicable, maternal, neonatal, and nutritional conditions significantly declined from 2005 to 2015, gains largely attributable to decreases in mortality rates due to HIV/AIDS (42·1%, 39·1-44·6), malaria (43·1%, 34·7-51·8), neonatal preterm birth complications (29·8%, 24·8-34·9), and maternal disorders (29·1%, 19·3-37·1). Progress was slower for several causes, such as lower respiratory infections and nutritional deficiencies, whereas deaths increased for others, including dengue and drug use disorders. Age-standardised death rates due to injuries significantly declined from 2005 to 2015, yet interpersonal violence and war claimed increasingly more lives in some regions, particularly in the Middle East. In 2015, rotaviral enteritis (rotavirus) was the leading cause of under-5 deaths due to diarrhoea (146 000 deaths, 118 000-183 000) and pneumococcal pneumonia was the leading cause of under-5 deaths due to lower respiratory infections (393 000 deaths, 228 000-532 000), although pathogen-specific mortality varied by region. Globally, the effects of population growth, ageing, and changes in age-standardised death rates substantially differed by cause. Our analyses on the expected associations between cause-specific mortality and SDI show the regular shifts in cause of death composition and population age structure with rising SDI. Country patterns of premature mortality (measured as years of life lost [YLLs]) and how they differ from the level expected on the basis of SDI alone revealed distinct but highly heterogeneous patterns by region and country or territory. Ischaemic heart disease, stroke, and diabetes were among the leading causes of YLLs in most regions, but in many cases, intraregional results sharply diverged for ratios of observed and expected YLLs based on SDI. Communicable, maternal, neonatal, and nutritional diseases caused the most YLLs throughout sub-Saharan Africa, with observed YLLs far exceeding expected YLLs for countries in which malaria or HIV/AIDS remained the leading causes of early death.
INTERPRETATION: At the global scale, age-specific mortality has steadily improved over the past 35 years; this pattern of general progress continued in the past decade. Progress has been faster in most countries than expected on the basis of development measured by the SDI. Against this background of progress, some countries have seen falls in life expectancy, and age-standardised death rates for some causes are increasing. Despite progress in reducing age-standardised death rates, population growth and ageing mean that the number of deaths from most non-communicable causes are increasing in most countries, putting increased demands on health systems.
FUNDING: Bill & Melinda Gates Foundation.
Malaysian collaborators: Southern University College, Skudai, Malaysia (Y J Kim PhD); School of Medical Sciences, University of Science Malaysia, Kubang Kerian, Malaysia (K I Musa MD); Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia (R Sahathevan PhD); Department of Community Medicine, International Medical University, Kuala Lumpur, Malaysia (C T Sreeramareddy MD); WorldFish, Penang, Malaysia (A L Thorne-Lyman ScD)

Matched MeSH terms: Mortality/trends
Inequities in adolescent and young adult deaths

Ameratunga S, George A

Lancet, 2021 10 30;398(10311):1545-1547.
PMID: 34755617 DOI: 10.1016/S0140-6736(21)01603-2
Matched MeSH terms: Mortality/trends*
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, Bertozzi-Villa A, Coggeshall MS, Shackelford KA, Steiner C, Heuton KR, et al.

Lancet, 2014 Sep 13;384(9947):980-1004.
PMID: 24797575 DOI: 10.1016/S0140-6736(14)60696-6

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.

Matched MeSH terms: Maternal Mortality/trends*

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