Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015

Nicholas J. Kassebaum, Ryan M. Barber, Zulfiqar Bhutta, Lalit Dandona, Peter Gething, Simon Hay, Yohannes Kinfu, Heidi Larson, Xiaofeng Liang, Stephen S. Lim, Alan D. Lopez, Rafael Lozano, George Mensah, Ali H. Mokdad, Mohsen Naghavi, Christine Pinho, Joshua A. Salomon, Caitlyn Steiner, Theo Vos, Haidong WangAmanuel Alemu Abajobir, Kalkidan Hassen Abate, Kaja M. Abbas, Foad Abd-Allah, Mahmud A. Abdallat, Abdishakur M. Abdulle, Semaw F. Abera, Victor Aboyans, Ibrahim Abubakar, Niveen Abu-Rmeileh, Tom Achoki, Akindele Olupelumi Adebiyi, Isaac Akinkunmi Adedeji, Ademola Adelekan, Arsène K. 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 S 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, Bedi, Tolesa Bekele, Michelle L. Bell, Derrick A. Bennett, Isabela M. Bensenor, Adugnaw Berhane, Eduardo Bernabe, 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 Bražinová, Nicholas J K Breitborde, Traolach S. Brugha, Zahid A. Butt, Ismael R. Campos-Nonato, Julio C. Campuzano, Rosario Cardenas, Juan Jesus Carrero, Austin Carter, Daniel Casey, Carlos A. Castaneda-Orjuela, Ruben Estanislao Castro, Ferran Catala-Lopez, 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, C. Cooper, Leslie T. 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 Ebel, Christian Lycke Ellingsen, Iqbal Elyazar, Aman Yesuf Endries, Sergey P. Ermakov, Babak Eshrati, Alireza Esteghamati, Emerito Jose A Faraon, Talha A. Farid, Carla Sofia e Sa Farinha, Andre Faro, Maryam S. Farvid, Farshad Farzadfar, Seyed Mohammad Fereshtehnejad, Joao C. Fernandes, Florian Fischer, Joseph Robert Ander Fitchett, Thomas Fleming, Nataliya Foigt, Elisabeth B. França, Richard C. Franklin, Maya S. Fraser, Joseph Friedman, Nancy Fullman, Thomas Fürst, Neal D. Futran, Ketevan Gambashidze, A. Gamkrelidze, Teshome Gebre, Tsegaye Tsewelde Gebrehiwot, Amanuel Tesfay Gebremedhin, Mengistu Gebremedhin, Alemseged Aregay Gebru, Johanna M. Geleijnse, Katherine B. Gibney, Ababi Zergaw Giref, Maurice Giroud, Melkamu Dedefo Gishu, Elizabeth L. Glaser, Shifalika Goenka, Hector Gomez Dantes, Philimon Gona, Amador Goodridge, Sameer Vali Gopalani, Atsushi Goto, Nicholas Graetz, Harish C. Gugnani, Yuming Guo, Rahul Gupta, Rajeev Gupta, Vipin Gupta, Nima Hafezi-Nejad, Alemayehu Desalegne Hailu, Gessessew Bugssa Hailu, Randah R. Hamadeh, Samer Hamidi, Jamie Hancock, Alexis J. Handal, G. 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 M. 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, Andre Karch, Dimitris Karletsos, Amir Kasaeian, Anil Kaul, Norito Kawakami, Jeanne Françoise Kayibanda, Konstantin Kazanjan, Dhruv S. Kazi, Peter Njenga Keiyoro, Laura Kemmer, Andrew H. Kemp, Andrew Pascal Kengne, A. Keren, Maia Kereselidze, Chandrasekharan Nair Kesavachandran, Yousef Saleh Khader, Abdur Rahman Khan, Ejaz Ahmad Khan, Young Ho Khang, Irma Khonelidze, Ardeshir Khosravi, Jagdish Khubchandani, Yunjin Kim, M. Kivipelto, Luke 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 Kutz, Dharmesh Kumar Lal, Ratilal Lalloo, Hilton Lam, Hector Lamadrid-Figueroa, Qing Lan, Anders Larsson, Dennis O. 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, Mohamed Magdy Abd El Razek, Marek Majdan, Azeem Majeed, Reza Malekzadeh, Christopher C. Mapoma, Wagner Marcenes, David J. Margolis, Neal Marquez, Felix Masiye, Melvin B. Marzan, Amanda J. Mason-Jones, Tasara T. Mazorodze, Peter A. Meaney, Alem Mehari, Man Mohan Mehndiratta, Fabiola Mejia-Rodriguez, Alemayehu B. Mekonnen, Yohannes A. Melaku, Ziad 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 C Montanêz 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 G. Murthy, Jean Nachega, Aliya Naheed, Luigi Naldi, Devina Nand, Vinay Nangia, Denis Nash, Subas Neupane, J. Newton, Marie Ng, Frida N. 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 O. Olusanya, Jacob Olusegun Olusanya, John Nelson Opio, Eyal Oren, Erika Ota, Abayomi Samuel Oyekale, Mahesh PA, Amanda W. 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 R. Phillips, Julian David Pillay, Farhad Pishgar, Suzanne Polinder, D. Pope, Farshad Pourmalek, Mostafa Qorbani, Anwar Rafay, Kazem Rahimi, Vafa Rahimi-Movaghar, Mahfuzar Rahman, Mohammad Hifz Ur Rahman, Sajjad U R Rahman, Rajesh Kumar Rai, Usha Ram, Chhabi L. Ranabhat, Thara Rangaswamy, Paturi Vishnupriya Rao, Amany H. Refaat, Giuseppe Remuzzi, Serge Resnikoff, David Rojas-Rueda, Luca Ronfani, Gholamreza Roshandel, Ambuj Roy, George M. 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, S. Seedat, Sadaf G. Sepanlou, Edson E. Servan-Mori, Tesfaye Setegn, Katya 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 D. 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 Tabares-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 A. Towbin, Bach X. Tran, Zacharie Tsala Dimbuene, Abera Kenay Tura, Stefanos Tyrovolas, Kingsley N. Ukwaja, Olalekan A. Uthman, Tommi Vasankari, Narayanaswamy Venketasubramanian, F. S. Violante, Sergey K. Vladimirov, Vasiliy V. Vlassov, Stein Emil Vollset, Joseph Wagner, Linhong Wang, Scott Weichenthal, Elisabete Weiderpass, Robert G. Weintraub, Andrea Werdecker, Ronny Westerman, Tissa Wijeratne, James D. Wilkinson, Charles Shey Wiysonge, Solomon M. Woldeyohannes, Charles D A Wolfe, Timothy M. 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 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

Research output: Contribution to journalArticlepeer-review

Abstract

Background In 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. Methods We 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. Findings Only 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. Interpretation Several 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. Funding Bill & Melinda Gates Foundation.

Original languageEnglish
Pages (from-to)1775-1812
Number of pages38
JournalThe Lancet
Volume388
Issue number10053
DOIs
Publication statusPublished - Oct 8 2016

ASJC Scopus subject areas

  • Medicine(all)

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