Maternal Mortality for 181 Countries, 1980−2008: A Systematic Analysis of Progress Toward Millennium Development Goal 5

Maternal mortality is still a major challenge for health systems throughout the world. TheMillenniumDevelopment Goal 5 (MDG 5) is a 75% reduction in the maternal mortality ratio (MMR) from 1990 to 2015. To make progress toward this goal, information on the rates and trends in maternal mortality is critical for resource mobilization and planning.This studyassesseddata todetermine levels and trends in maternal mortality from 1980 to 2008 for 181 countries. Early maternal deaths were those occurring during pregnancy or <42 days after termination of pregnancy; late deaths were those that occurred 42 days up to 1 year after the end of pregnancy. Causes were classified as direct obstetric causes, causes aggravated by pregnancy (ie, indirect), HIV infection, and incidental causes unrelated to pregnancy. Data sources were: vital registration information; sibling history data from household surveys; censuses and surveys for deaths in the household; and published population-based studies of maternal mortality, both national and subnational. The final database included 2651 site years of observations of maternal mortality for the 181 countries. Analytical methods generated estimates of maternal deaths and the MMR for each year from 1980 through 2008. In 2008, 342,900 maternal deaths (uncertainty interval 302,100-394,300) occurred compared with 526,300 (446,400629,600) in 1980, for a yearly rate of decline of 1.5%. Excluding HIV as a cause, the deaths are 281,500 (243,900 to 327,900) in 2008 compared with 526,200 (444,500 to 633,900) in 1980, a yearly rate of decline of 2.2%. With the start of the HIV epidemic in the early 1990s, the rate of decline in global maternal deaths slowed from 1.8% between 1980 and 1990 to 1.4% from 1990 to 2008. The MMR was 251/100,000 live births in 2008, reduced from 320 in 1990 and 422 in 1980 for a yearly rate of decline of 1.8%. To reach the MDG target of a 75% reduction inMMR from 1990 to 2015, a yearly rate of decline of 5.5%will be required. The changes in regional composition of maternal deaths included a shift toward sub-Saharan Africa, with this region’s proportion of global maternal deaths increasing from 23% in 1980 to 52% in 2008. In 2008, the following regions had MMRs <20/ 100,000: Australasia, western Europe, Asia-Pacific high-income, central Europe, and North America high-income. MMRs <60/100,000 were found in eastern Europe, east Asia, southern Latin America, central Asia, tropical Latin America, and central Latin America in 2008. The following regions showed consistent declines in mortality with MMRs <280/100,000 in 2008: North Africa, theMiddle East, Latin America Andean, Southeast Asia, Oceania, and the Caribbean. In all parts of sub-Saharan Africa, MMR increased during the 1990s and was >280/100,000 in 2008. When deaths fromHIV infection are excluded, however, a decrease did occur between 1980 and 2008. South Asia also had an MMR >280/100,000 in 2008 but a significant decline has occurred since 1980. In analyzing individual countries, an apparent rise in MMR was found in the USA, Canada, and Norway although the investigators thought this could be explained in part by a revision in the International Classification of Disease that occurred during the study period which added a specific code for late maternal deaths. The data show a substantial decline in maternal mortality from 1980 to 2008; more progress would have been made had the HIV epidemic not occurred. Powerful factors contributing to the decline in maternal mortality include the decline in the global total fertility rate (3.70 in 1980 to 3.26 in 1990 and 2.56 in 2008), which has kept the size of the global birth cohort stable; rising income leading to improved nutritional status of mothers and access to health care; increase in the level of maternal education; and a rise in the presence of skilled birth attendants at delivery. Although progress has been made toward reaching MDG 5 and 23 countries are on track to achieve a 75% decrease in MMR by 2015, many countries have not shown substantial reductions in maternal deaths. Progress must be accelerated in countries where reductions in maternal deaths can be achieved with effective health care reform.All countriesmust aim toprovide the care necessary for women to survive pregnancy.