Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015
Authors: Nicholas J Kassebaum, Ryan M Barber, Zulfiqar A Bhutta, Lalit Dandona, Peter W Gething, Simon I Hay, Yohannes Kinfu, Heidi J Larson, Xiaofeng Liang, Stephen S Lim, Alan D Lopez, Rafael Lozano, George A Mensah, Ali H Mokdad, Mohsen Naghavi, Christine Pinho, Joshua A Salomon, Caitlyn Steiner, Theo Vos, Haidong Wang, Amanuel Alemu Abajobir, Kalkidan Hassen Abate, Kaja M Abbas, Foad Abd-Allah, Mahmud A Abdallat, Abdishakur M Abdulle, Semaw Ferede Abera, Victor Aboyans, Ibrahim Abubakar, Niveen M E Abu-Rmeileh, Tom Achoki, Akindele Olupelumi Adebiyi, Isaac Akinkunmi Adedeji, Ademola Lukman Adelekan, Arsène Kouablan Adou, Kossivi Agbelenko Afanvi, Arnav Agarwal, Aliasghar Ahmad Kiadaliri, Oluremi N Ajala, Tomi F Akinyemiju, Nadia Akseer, Ziyad Al-Aly, Khurshid Alam, Noore K M Alam, Deena Alasfoor, Saleh Fahed Aldhahri, Robert William Aldridge, Samia Alhabib, Raghib Ali, Ala'a Alkerwi, François Alla, Rajaa Al-Raddadi, Ubai Alsharif, Elena Alvarez Martin, Nelson Alvis-Guzman, Azmeraw T Amare, Alemayehu Amberbir, Adeladza Kofi Amegah, Walid Ammar, Stephen Marc Amrock, Hjalte H Andersen, Gregory M Anderson, Rose Mayerline Antoine, Carl Abelardo T Antonio, Atsede Fantahun Aregay, Johan Ärnlöv, Megha Arora, Valentina S Arsic Arsenijevic, Al Artaman, Hamid Asayesh, Suleman Atique, Euripide Frinel G Arthur Avokpaho, Ashish Awasthi, Beatriz Paulina Ayala Quintanilla, Peter Azzopardi, Umar Bacha, Alaa Badawi, Maria C Bahit, Kalpana Balakrishnan, Amitava Banerjee, Aleksandra Barac, Suzanne L Barker-Collo, Till Bärnighausen, Sanjay Basu, Tigist Assefa Bayou, Yibeltal Tebekaw Bayou, Shahrzad Bazargan-Hejazi, Justin Beardsley, Neeraj Haidong Wang, None Bedi, Tolesa Bekele, Michelle L Bell, Derrick A Bennett, Isabela M Bensenor, Adugnaw Berhane, Eduardo Bernabé, Balem Demtsu Betsu, Addisu Shunu Beyene, Sibhatu Biadgilign, Boris Bikbov, Aref A Bin Abdulhak, Brian J Biroscak, Stan Biryukov, Donal Bisanzio, Espen Bjertness, Jed D Blore, Michael Brainin, Alexandra Brazinova, Nicholas J K Breitborde, Traolach S Brugha, Zahid A Butt, Ismael Ricardo Campos-Nonato, Julio Cesar Campuzano, Rosario Cárdenas, Juan Jesus Carrero, Austin Carter, Daniel C Casey, Carlos A Castañeda-Orjuela, Ruben Estanislao Castro, Ferrán Catalá-López, Fiorella Cavalleri, Hsing-Yi Chang, Jung-Chen Chang, Laxmikant Chavan, Chioma Ezinne Chibueze, Vesper Hichilombwe Chisumpa, Jee-Young Jasmine Choi, Rajiv Chowdhury, Devasahayam Jesudas Christopher, Liliana G Ciobanu, Massimo Cirillo, Matthew M Coates, Megan Coggeshall, Valentina Colistro, Samantha M Colquhoun, Cyrus Cooper, Leslie Trumbull Cooper, Monica Cortinovis, Tukur Dahiru, Albertino Damasceno, Hadi Danawi, Rakhi Dandona, José das Neves, Diego De Leo, Robert P Dellavalle, Kebede Deribe, Amare Deribew, Don C Des Jarlais, Samath D Dharmaratne, Daniel J Dicker, Eric L Ding, Edem Dossou, Manisha Dubey, Beth E Ebel, Christian Lycke Ellingsen, Iqbal Elyazar, Aman Yesuf Endries, Sergey Petrovich Ermakov, Babak Eshrati, Alireza Esteghamati, Emerito Jose Aquino Faraon, Talha A Farid, Carla Sofia e Sa Farinha, André Faro, Maryam S Farvid, Farshad Farzadfar, Seyed-Mohammad Fereshtehnejad, Joao C Fernandes, Florian Fischer, Joseph R A Fitchett, Tom Fleming, Nataliya Foigt, Elisabeth Barboza Franca, Richard C Franklin, Maya S Fraser, Joseph Friedman, Nancy Fullman, Thomas Fürst, Neal D Futran, Ketevan Gambashidze, Amiran Gamkrelidze, Teshome Gebre, Tsegaye Tewelde Gebrehiwot, Amanuel Tesfay Gebremedhin, Mengistu Gebremedhin, Alemseged Aregay Gebru, Johanna M Geleijnse, Katherine B Gibney, Ababi Zergaw Giref, Maurice Giroud, Melkamu Dedefo Gishu, Elizabeth Glaser, Shifalika Goenka, Hector Gomez-Dantes, Philimon Gona, Amador Goodridge, Sameer Vali Gopalani, Atsushi Goto, Nicholas Graetz, Harish Chander Gugnani, Yuming Guo, Rahul Gupta, Rajeev Gupta, Vipin Gupta, Nima Hafezi-Nejad, Alemayehu Desalegne Hailu, Gessessew Bugssa Hailu, Randah Ribhi Hamadeh, Samer Hamidi, Jamie Hancock, Alexis J Handal, Graeme J Hankey, Hilda L Harb, Sivadasanpillai Harikrishnan, Kimani M Harun, Rasmus Havmoeller, Hans W Hoek, Masako Horino, Nobuyuki Horita, H Dean Hosgood, Damian G Hoy, Aung Soe Htet, Guoqing Hu, Hsiang Huang, John J Huang, Inge Huybrechts, Chantal Huynh, Marissa Iannarone, Kim Moesgaard Iburg, Bulat T Idrisov, Veena J Iyer, Kathryn H Jacobsen, Nader Jahanmehr, Mihajlo B Jakovljevic, Mehdi Javanbakht, Achala Upendra Jayatilleke, Sun Ha Jee, Panniyammakal Jeemon, Vivekanand Jha, Guohong Jiang, Ying Jiang, Tariku Jibat, Jost B Jonas, Zubair Kabir, Ritul Kamal, Haidong Kan, André Karch, Dimitris Karletsos, Amir Kasaeian, Anil Kaul, Norito Kawakami, Jeanne Françoise Kayibanda, Konstantin Kazanjan, Dhruv S Kazi, Peter Njenga Keiyoro, Laura Kemmer, Andrew Haddon Kemp, Andre Pascal Kengne, Andre Keren, Maia Kereselidze, Chandrasekharan Nair Kesavachandran, Yousef Saleh Khader, Abdur Rahman Khan, Ejaz Ahmad Khan, Young-Ho Khang, Irma Khonelidze, Ardeshir Khosravi, Jagdish Khubchandani, Yun Jin Kim, Miia Kivipelto, Luke D Knibbs, Yoshihiro Kokubo, Soewarta Kosen, Parvaiz A Koul, Ai Koyanagi, Sanjay Krishnaswami, Barthelemy Kuate Defo, Burcu Kucuk Bicer, Andreas A Kudom, Xie Rachel Kulikoff, Chanda Kulkarni, G Anil Kumar, Michael J Kutz, Dharmesh Kumar Lal, Ratilal Lalloo, Hilton Lam, Hector Lamadrid-Figueroa, Qing Lan, Anders Larsson, Dennis Odai Laryea, James Leigh, Ricky Leung, Yichong Li, Yongmei Li, Steven E Lipshultz, Patrick Y Liu, Shiwei Liu, Yang Liu, Belinda K Lloyd, Paulo A Lotufo, Raimundas Lunevicius, Stefan Ma, Hassan Magdy Abd El Razek, Mohammed Magdy Abd El Razek, Marek Majdan, Azeem Majeed, Reza Malekzadeh, Chabila C Mapoma, Wagner Marcenes, David Joel Margolis, Neal Marquez, Felix Masiye, Melvin Barrientos Marzan, Amanda J Mason-Jones, Tasara T Mazorodze, Peter A Meaney, Alem Mehari, Man Mohan Mehndiratta, Fabiola Mejia-Rodriguez, Alemayehu B Mekonnen, Yohannes Adama Melaku, Ziad A Memish, Walter Mendoza, Atte Meretoja, Tuomo J Meretoja, Francis Apolinary Mhimbira, Ted R Miller, Edward J Mills, Mojde Mirarefin, Awoke Misganaw, Norlinah Mohamed Ibrahim, Karzan Abdulmuhsin Mohammad, Alireza Mohammadi, Shafiu Mohammed, Glen Liddell D Mola, Lorenzo Monasta, Jonathan de la Cruz Monis, Julio Cesar Montañez Hernandez, Pablo Montero, Marcella Montico, Meghan D Mooney, Ami R Moore, Maziar Moradi-Lakeh, Lidia Morawska, Rintaro Mori, Ulrich O Mueller, Gudlavalleti Venkata Satyanarayana Murthy, Srinivas Murthy, Jean B Nachega, Aliya Naheed, Luigi Naldi, Devina Nand, Vinay Nangia, Denis Nash, Subas Neupane, John N Newton, Marie Ng, Frida Namnyak Ngalesoni, Peter Nguhiu, Grant Nguyen, Quyen Le Nguyen, Muhammad Imran Nisar, Marika Nomura, Ole F Norheim, Rosana E Norman, Luke Nyakarahuka, Carla Makhlouf Obermeyer, Felix Akpojene Ogbo, In-Hwan Oh, Foluke Adetola Ojelabi, Pedro R Olivares, Bolajoko Olubukunola Olusanya, Jacob Olusegun Olusanya, John Nelson Opio, Eyal Oren, Erika Ota, Abayomi Samuel Oyekale, Mahesh PA, Amanda Pain, Nikolaos Papantoniou, Eun-Kee Park, Hye-Youn Park, Angel J Paternina Caicedo, Scott B Patten, Vinod K Paul, David M Pereira, Norberto Perico, Konrad Pesudovs, Max Petzold, Michael Robert Phillips, Julian David Pillay, Farhad Pishgar, Suzanne Polinder, Daniel Pope, Farshad Pourmalek, Mostafa Qorbani, Anwar Rafay, Kazem Rahimi, Vafa Rahimi-Movaghar, Mahfuzar Rahman, Mohammad Hifz Ur Rahman, Sajjad Ur Rahman, Rajesh Kumar Rai, Usha Ram, Chhabi Lal Ranabhat, Thara Rangaswamy, Paturi Vishnupriya Rao, Amany H Refaat, Giuseppe Remuzzi, Serge Resnikoff, David Rojas-Rueda, Luca Ronfani, Gholamreza Roshandel, Ambuj Roy, George Mugambage Ruhago, Rajesh Sagar, Muhammad Muhammad Saleh, Juan R Sanabria, Maria Dolores Sanchez-Niño, Itamar S Santos, Joao Vascos Santos, Rodrigo Sarmiento-Suarez, Benn Sartorius, Maheswar Satpathy, Miloje Savic, Monika Sawhney, Mete I Saylan, Ione J C Schneider, David C Schwebel, Soraya Seedat, Sadaf G Sepanlou, Edson E Servan-Mori, Tesfaye Setegn, Katya A Shackelford, Masood Ali Shaikh, Marina Shakh-Nazarova, Rajesh Sharma, Jun She, Sara Sheikhbahaei, Jiabin Shen, Kenji Shibuya, Min-Jeong Shin, Rahman Shiri, Kawkab Shishani, Ivy Shiue, Inga Dora Sigfusdottir, Naris Silpakit, Diego Augusto Santos Silva, Dayane Gabriele Alves Silveira, Jonathan I Silverberg, Edgar P Simard, Shireen Sindi, Abhishek Singh, Jasvinder A Singh, Om Prakash Singh, Prashant Kumar Singh, Virendra Singh, Vegard Skirbekk, Amber Sligar, Karen Sliwa, Jessica M Smith, Samir Soneji, Reed J D Sorensen, Joan B Soriano, Sergey Soshnikov, Luciano A Sposato, Chandrashekhar T Sreeramareddy, Vasiliki Stathopoulou, Konstantinos Stroumpoulis, Lela Sturua, Bruno F Sunguya, Soumya Swaminathan, Bryan L Sykes, Cassandra E I Szoeke, Rafael Tabarés-Seisdedos, Karen M Tabb, Roberto Tchio Talongwa, Mohammad Tavakkoli, Bineyam Taye, Bemnet Amare Tedla, Worku Mekonnen Tefera, Tesfaye Tekle, Girma Temam Shifa, Abdullah Sulieman Terkawi, Fisaha Haile Tesfay, Gizachew Assefa Tessema, Alan J Thomson, Andrew L Thorne-Lyman, Ruoyan Tobe-Gai, Roman Topor-Madry, Jeffrey Allen Towbin, Bach Xuan Tran, Zacharie Tsala Dimbuene, Abera Kenay Tura, Stefanos Tyrovolas, Kingsley N Ukwaja, Olalekan A Uthman, Tommi Vasankari, Narayanaswamy Venketasubramanian, Francesco S Violante, Sergey K Vladimirov, Vasiliy Victorovich Vlassov, Stein Emil Vollset, Joseph A Wagner, Linhong Wang, Scott Weichenthal, Elisabete Weiderpass, Robert G Weintraub, Andrea Werdecker, Ronny Westerman, Tissa Wijeratne, James D Wilkinson, Charles Shey Wiysonge, Solomon Meseret Woldeyohannes, Charles D A Wolfe, Timothy Wolock, Sungho Won, Mamo Wubshet, Qingyang Xiao, Gelin Xu, Ajit Kumar Yadav, Bereket Yakob, Ayalnesh Zemene Yalew, Yuichiro Yano, Henock Gebremedhin Yebyo, Paul Yip, Naohiro Yonemoto, Seok-Jun Yoon, Mustafa Z Younis, Chuanhua Yu, Shicheng Yu, Zoubida Zaidi, Maysaa El Sayed Zaki, Hajo Zeeb, Yi Zhao, Yong Zhao, Maigeng Zhou, Sanjay Zodpey, Liesl Joanna Zuhlke, Christopher J L Murray
Journal: The Lancet (2016)

BackgroundIn transitioning from the Millennium Development Goal to the Sustainable Development Goal era, it is imperative to comprehensively assess progress toward reducing maternal mortality to identify areas of success, remaining challenges, and frame policy discussions. We aimed to quantify maternal mortality throughout the world by underlying cause and age from 1990 to 2015.MethodsWe estimated maternal mortality at the global, regional, and national levels from 1990 to 2015 for ages 10–54 years by systematically compiling and processing all available data sources from 186 of 195 countries and territories, 11 of which were analysed at the subnational level. We quantified eight underlying causes of maternal death and four timing categories, improving estimation methods since GBD 2013 for adult all-cause mortality, HIV-related maternal mortality, and late maternal death. Secondary analyses then allowed systematic examination of drivers of trends, including the relation between maternal mortality and coverage of specific reproductive health-care services as well as assessment of observed versus expected maternal mortality as a function of Socio-demographic Index (SDI), a summary indicator derived from measures of income per capita, educational attainment, and fertility.FindingsOnly ten countries achieved MDG 5, but 122 of 195 countries have already met SDG 3.1. Geographical disparities widened between 1990 and 2015 and, in 2015, 24 countries still had a maternal mortality ratio greater than 400. The proportion of all maternal deaths occurring in the bottom two SDI quintiles, where haemorrhage is the dominant cause of maternal death, increased from roughly 68% in 1990 to more than 80% in 2015. The middle SDI quintile improved the most from 1990 to 2015, but also has the most complicated causal profile. Maternal mortality in the highest SDI quintile is mostly due to other direct maternal disorders, indirect maternal disorders, and abortion, ectopic pregnancy, and/or miscarriage. Historical patterns suggest achievement of SDG 3.1 will require 91% coverage of one antenatal care visit, 78% of four antenatal care visits, 81% of in-facility delivery, and 87% of skilled birth attendance.InterpretationSeveral challenges to improving reproductive health lie ahead in the SDG era. Countries should establish or renew systems for collection and timely dissemination of health data; expand coverage and improve quality of family planning services, including access to contraception and safe abortion to address high adolescent fertility; invest in improving health system capacity, including coverage of routine reproductive health care and of more advanced obstetric care—including EmOC; adapt health systems and data collection systems to monitor and reverse the increase in indirect, other direct, and late maternal deaths, especially in high SDI locations; and examine their own performance with respect to their SDI level, using that information to formulate strategies to improve performance and ensure optimum reproductive health of their population.FundingBill & Melinda Gates Foundation.