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

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Research output: Contribution to journalArticlepeer-review

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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 - 8 Oct 2016

Bibliographical note

Funding Information:
We would like to thank the countless individuals who have contributed to the Global Burden of Disease Study 2015 in various capacities. Data for this research was provided by MEASURE Evaluation, funded by the United States Agency for International Development (USAID). Collection of these data was made possible by the US Agency for International Development (USAID) under the terms of cooperative agreement GPO-A-00-08-000_D3-00. Views expressed do not necessarily reflect those of USAID, the US Government, or MEASURE Evaluation. The following individuals would like to acknowledge various forms of institutional support: Panniyammakal Jeemon is supported by a clinical and public health intermediate fellowship from the Wellcome Trust-DBT India Alliance (2015-2020). Boris Bikbov, Monica Cortinovis, Giuseppe Remuzzi, and Norberto Perico would like to acknowledge that their contribution to this paper has been on behalf of the International Society of Nephrology (ISN) as a follow-up of the activities of the GBD 2010 Genitourinary Diseases Expert Group. Shifalika Goenka is partially supported through a Wellcome Trust Grant (No: 096735/A/11/Z) and The Bernard Lown Scholars in Cardiovascular Health Program, Harvard School of Public Health. Hjalte H Andersen would like to acknowledge funding received from the EliteForsk 2016 travel grant of the Danish Ministry of Higher Education and Science. Amador Goodridge would like to acknowledge funding for me from Sistema Nacional de Investigadores de Panamá-SNI. José das Neves was supported in his contribution to this work by a Fellowship from Fundação para a Ciência e a Tecnologia, Portugal (SFRH/BPD/92934/2013). Beatriz Paulina Ayala Quintanilla would like to acknowledge the Institutional support of PRONABEC (National Program of Scholarship and Educational Loan), provided by the Peruvian Government, while studying for her doctoral course at the Judith Lumley Centre of La Trobe University funded by PRONABEC. Ulrich O Mueller gratefully acknowledges funding by the German National Cohort Consortium (O1ER1511D). Andrea Werdecker gratefully acknowledges funding by the German National Cohort BMBF grant No OIER 1301/22. Charles D A Wolfe would like to acknowledge the following: National Institute for Health Research (NIHR) Program Grant (RP-PG-0407-10184), and the National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' National Health Service (NHS) Foundation Trust and King's College London. No individuals acknowledged received additional compensation for their efforts.

Funding Information:
Simon I Hay is funded by a Senior Research Fellowship from the Wellcome Trust (#095066), and grants from the Bill & Melinda Gates Foundation (OPP1119467, OPP1093011, OPP1106023, and OPP1132415). Itamar S Santos reports grants from FAPESP (Brazilian public agency), outside the submitted work. Carl Abelardo T Antonio reports grants, personal fees and non-financial support from Johnson & Johnson (Philippines), Inc, outside the submitted work. Cyrus Cooper reports other from Alliance for Better Bone Health, other from Amgen, other from Eli Lilly, other from GSK, other from Medtronic, other from Merck, other from Novartis, other from Pfizer, other from Roche, other from Servier, outside the submitted work. Walter Mendoza is currently employed by the Peru Country Office of the United Nations Population Fund, an institution which does not necessarily endorse this study. Katherine B Gibney received the NHMRC Gustav Nossal Postgraduate Scholarship sponsored by CSL in 2012, an award peer reviewed through the standard NHMRC peer review process; CSL does not play any part in the selection of the awardee. Manisha Dubey has received financial support from University Grants Commission, New Delhi, India for pursuing a PhD. Shireen Sindi has received postdoctoral funding from the Fonds de la recherche en santé du Québec (FRSQ), including its renewal. Ashish Awasthi has received financial support from Indian Council of Medical Research, New Delhi, India for pursuing a PhD. Jasvinder A Singh has received research grants from Takeda and Savient and consultant fees from Savient, Takeda, Regeneron, Merz, Iroko, Bioiberica, Crealta and Allergan pharmaceuticals, WebMD, UBM LLC and the American College of Rheumatology; he serves as the principal investigator for an investigator-initiated study funded by Horizon pharmaceuticals through a grant to DINORA, Inc, a 501 (c)(3) entity; is a member of the executive of OMERACT, an organization that develops outcome measures in rheumatology and receives arms-length funding from 36 companies; a member of the American College of Rheumatology's (ACR) Annual Meeting Planning Committee (AMPC); Chair of the ACR Meet-the-Professor, Workshop and Study Group Subcommittee; and a member of the Veterans Affairs Rheumatology Field Advisory Committee. Rafael Tabarés-Seisdedos and Ferrán Catalá-López are supported in part by grant PROMETEOII/2015/021 from Generalitat Valenciana, and Rafael Tabarés-Seisdedos is supported by the national grant PI14/00894 from ISCIII-FEDER. Ai Koyanagi's work is supported by the Miguel Servet contract financed by the CP13/00150 and PI15/00862 projects, integrated into the National R + D + I and funded by the ISCIII - General Branch Evaluation and Promotion of Health Research - and the European Regional Development Fund (ERDF-FEDER). Donal Bisanzio is supported by Bill and Melinda Gates Foundation (#OPP1068048). Kebede Deribe is supported by a Wellcome Trust Fellowship in Public Health and Tropical Medicine (grant number 099876). Thomas Fürst has received financial support from the Swiss National Science Foundation (SNSF; project no. P300P3-154634). Jost B Jonas reports personal fees from Consultant for Mundipharma Co (Cambridge, UK); other from patent application with University of Heidelberg (Heidelberg, Germany) (Title: Agents for use in the therapeutic or prophylactic treatment of myopia or hyperopia; Europäische Patentanmeldung 15 000 771.4), and other from patent holder with Biocompatibles UK Ltd. (Franham, Surrey, UK) (Title: Treatment of eye diseases using encapsulated cells encoding and secreting neuroprotective factor and / or anti-angiogenic factor; Patent number: 20120263794), outside the submitted work. Rodrigo Sarmiento-Suarez has received institutional support from Universidad de Ciencias Aplicadas y Ambientales, UDCA, Bogotá Colombia. Stefanos Tyrovolas's work is supported by the Foundation for Education and European Culture (IPEP), the Sara Borrell postdoctoral programme (reference no. CD15/00019 from the Instituto de Salud Carlos III (ISCIII - Spain) and the Fondos Europeo de Desarrollo Regional (FEDER). Beatriz Paulina Ayala Quintanilla would like to acknowledge the Institutional support of PRONABEC (National Program of Scholarship and Educational Loan), provided by the Peruvian Government, while studying for her doctoral course at the Judith Lumley Centre of La Trobe University funded by PRONABEC. Miia Kivipelto receives research support from the Academy of Finland, the Swedish Research Council, Alzheimerfonden, Alzheimer's Research & Prevention Foundation, Center for Innovative Medicine (CIMED) at Karolinska Institutet South Campus, AXA Research Fund and the Sheika Salama Bint Hamdan Alnahyan Foundation. Juan Jesus Carrero would like to acknowledge the following source of funding: The Swedish Heart and Lung Foundation (grant number 20150497). Charles D A Wolfe's research was funded/supported by the National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. The other authors declare no competing interests.

Publisher Copyright:
© 2016 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY license

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