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

Collaborators, GBD 2015 Maternal Mortality and Kassebaum, N.J. and Barber, R.M. and Dandona, L. and Hay, S.I. and Larson, H.J. and Lim, S.S. and Lopez, A.D. and Mokdad, A.H. and Naghavi, M. and Pinho, C. and Steiner, C. and Vos, T. and Wang, H. and Achoki, T. and Anderson, G.M. and Arora, M. and Biryukov, S. and Blore, J.D. and Carter, A. and Casey, D.C. and Coates, M.M. and Coggeshall, M. and Dicker, D.J. and Dossou, E. and Fleming, T. and Fraser, M.S. and Friedman, J. and Fullman, N. and Graetz, N. and Hancock, J. and Huynh, C. and Iannarone, M. and Kemmer, L. and Kulikoff, X.R. and Kutz, M.J. and Liu, P.Y. and Marquez, N. and Misganaw, A. and Mooney, M.D. and Moradi-Lakeh, M. and Ng, M. and Nguyen, G. and Pain, A. and Shackelford, K.A. and Silpakit, N. and Sligar, A. and Smith, J.M. and Sorensen, R.J.D. and Vollset, S.E. and Wagner, J.A. and Wolock, T. and Zhao, Y. and Zhou, M. and Murray, C.J.L. and Ebel, B.E. and Futran, N.D. and Harun, K.M. and Bhutta, Z.A. and Nisar, M.I. and Akseer, N. and Jeemon, P. and Dandona, R. and Goenka, S. and Kumar, G.A. and Gething, P.W. and Bisanzio, D. and Deribew, A. and Cooper, C. and Ali, R. and Bennett, D.A. and Jha, V. and Rahimi, K. and Kinfu, Y. and Murthy, G.V.S. and Li, Y. and Liu, S. and Wang, L. and Liang, X. and Yu, S. and Azzopardi, P. and Gibney, K.B. and Meretoja, A. and Szoeke, C.E.I. and Alam, K. and Colquhoun, S.M. and Weintraub, R.G. and Wijeratne, T. and Lozano, R. and Campos-Nonato, I.R. and Campuzano, J.C. and Gomez-Dantes, H. and Lamadrid-Figueroa, H. and Mejia-Rodriguez, F. and Montañez Hernandez, J.C. and Montero, P. and Mensah, G.A. and Salomon, J.A. and Thorne-Lyman, A.L. and Ajala, O.N. and Bärnighausen, T. and Ding, E.L. and Farvid, M.S. and Fitchett, J.R.A. and Abajobir, A.A. and Knibbs, L.D. and Lalloo, R. and Alam, N.K.M. and Guo, Y. and Abate, K.H. and Gebrehiwot, T.T. and Gebremedhin, A.T. and Abbas, K.M. and Abd-Allah, F. and Abdallat, M.A. and Abdulle, A.M. and Abera, S.F. and Melaku, Y.A. and Tesfay, F.H. and Aregay, A.F. and Bayou, T.A. and Betsu, B.D. and Gebremedhin, M. and Gebru, A.A. and Hailu, G.B. and Tekle, T. and Yalew, A.Z. and Yebyo, H.G. and Aboyans, V. and Abubakar, I. and Aldridge, R.W. and Banerjee, A. and AbuRmeileh, N.M. and Adebiyi, A.O. and Adelekan, A.L. and Ojelabi, F.A. and Adedeji, I.A. and Adou, A.K. and Afanvi, K.A. and Badawi, A. and Agarwal, A. and Ahmad Kiadaliri, A. and Akinyemiju, T.F. and Schwebel, D.C. and Singh, J.A. and Al-Aly, Z. and Kemp, A.H. and Leigh, J. and Mekonnen, A.B. and Alasfoor, D. and Aldhahri, S.F. and Terkawi, A.S. and Alhabib, S. and Alkerwi, A. and Alla, F. and Al-Raddadi, R. and Alsharif, U. and Alvarez Martin, E. and Alvis-Guzman, N. and Amare, A.T. and Ciobanu, L.G. and Tessema, G.A. and Setegn, T. and Amberbir, A. and Amegah, A.K. and Kudom, A.A. and Ammar, W. and Harb, H.L. and Amrock, S.M. and Andersen, H.H. and Antoine, R.M. and Antonio, C.A.T. and Faraon, E.J.A. and �rnlöv, J. and Larsson, A. and Arsic Arsenijevic, V.S. and Barac, A. and Artaman, A. and Asayesh, H. and Atique, S. and Avokpaho, E.F.G.A. and Awasthi, A. and Ayala Quintanilla, B.P. and Bacha, U. and Bahit, M.C. and Balakrishnan, K. and Barker-Collo, S.L. and Mohammed, S. and Basu, S. and Bayou, Y.T. and Bazargan-Hejazi, S. and Beardsley, J. and Bedi, N. and Bekele, T. and Bell, M.L. and Biroscak, B.J. and Huang, J.J. and Santos, I.S. and Bensenor, I.M. and Lotufo, P.A. and Berhane, A. and Wolfe, C.D. and Bernabé, E. and Beyene, A.S. and Biadgilign, S. and Bikbov, B. and Bin Abdulhak, A.A. and Bjertness, E. and Htet, A.S. and Brainin, M. and Brazinova, A. and Majdan, M. and Shen, J. and Breitborde, N.J.K. and Brugha, T.S. and Butt, Z.A. and Cárdenas, R. and Fereshtehnejad, S. and Kivipelto, M. and Weiderpass, E. and Havmoeller, R. and Sindi, S. and Castañeda-Orjuela, C.A. and CastañedaOrjuela, C.A. and Castro, R.E. and Catalá-López, F. and Cavalleri, F. and Colistro, V. and Chang, H. and Chang, J. and Chavan, L. and Chibueze, C.E. and Chisumpa, V.H. and Mapoma, C.C. and Masiye, F. and Choi, J.J. and Chowdhury, R. and Christopher, D.J. and Cirillo, M. and Cooper, L.T. and Dahiru, T. and Damasceno, A. and Danawi, H. and Refaat, A.H. and das Neves, J. and Santos, J.V. and De Leo, D. and Dellavalle, R.P. and Deribe, K. and Hailu, A.D. and Tefera, W. and Giref, A.Z. and Jibat, T. and Temam Shifa, G. and Des Jarlais, D.C. and Dharmaratne, S.D. and Dubey, M. and Rahman, M.H.U. and Ram, U. and Singh, A. and Yadav, A.K. and Vollset, S.E. and Ellingsen, C.L. and Savic, M. and Skirbekk, V. and Elyazar, I. and Ermakov, S.P. and Soshnikov, S. and Eshrati, B. and Farzadfar, F. and Kasaeian, A. and Pishgar, F. and Esteghamati, A. and Hafezi-Nejad, N. and Sheikhbahaei, S. and Khosravi, A. and Malekzadeh, R. and Roshandel, G. and Sepanlou, S.G. and Rahimi-Movaghar, V. and Farid, T.A. and Khan, A.R. and Farinha, C.S.E.S. and Faro, A. and Fernandes, J.C. and Fischer, F. and Foigt, N. and Franca, E.B. and Franklin, R.C. and Fürst, T. and Majeed, A. and Gambashidze, K. and Kazanjan, K. and Kereselidze, M. and Khonelidze, I. and Shakh-Nazarova, M. and Sturua, L. and Gamkrelidze, A. and Gebre, T. and Geleijnse, J.M. and Giroud, M. and Gishu, M.D. and Tura, A.K. and Glaser, E. and Gona, P. and Goodridge, A. and Gopalani, S.V. and Goto, A. and Gugnani, H.C. and Gupta, R. and Gupta, R. and Gupta, V. and Norheim, O.F. and Hamadeh, R.R. and Hamidi, S. and Handal, A.J. and Hankey, G.J. and Harikrishnan, S. and Hoek, H.W. and Horino, M. and Horita, N. and Hosgood, H.D. and Hoy, D.G. and Hu, G. and Huang, H. and Huybrechts, I. and Iburg, K.M. and Idrisov, B.T. and Iyer, V.J. and Jacobsen, K.H. and Jahanmehr, N. and Jakovljevic, M.B. and Javanbakht, M. and Jayatilleke, A.U. and Jee, S.H. and Lal, D.K. and Zodpey, S. and Jiang, G. and Jiang, Y. and Jonas, J.B. and Kabir, Z. and Kamal, R. and Kesavachandran, C.N. and She, J. and Kan, H. and Karch, A. and Karletsos, D. and Kaul, A. and Kawakami, N. and Shibuya, K. and Kayibanda, J.F. and Kazi, D.S. and Keiyoro, P.N. and Kengne, A.P. and Wiysonge, C.S. and Sliwa, K. and Keren, A. and Khader, Y.S. and Khan, E.A. and Khang, Y.H. and Won, S. and Khubchandani, J. and Kim, Y.J. and Kokubo, Y. and Kosen, S. and Koul, P.A. and Koyanagi, A. and Krishnaswami, S. and Kuate Defo, B. and Kucuk Bicer, B. and Lam, H. and Lan, Q. and Laryea, D.O. and Leung, R. and Li, Y. and Lipshultz, S.E. and Wilkinson, J.D. and Simard, E.P. and Liu, Y. and Phillips, M.R. and Xiao, Q. and Lloyd, B.K. and Lunevicius, R. and Pope, D. and Ma, S. and Magdy Abd El Razek, H. and Magdy Abd El Razek, M. and Marcenes, W. and Meaney, P.A. and Margolis, D.J. and Marzan, M.B. and Mason-Jones, A.J. and Mazorodze, T.T. and Mehari, A. and Mehndiratta, M.M. and Woldeyohannes, S.M. and Tedla, B.A. and Memish, Z.A. and Mendoza, W. and Meretoja, T.J. and Mhimbira, F.A. and Miller, T.R. and Mills, E.J. and Mohamed Ibrahim, N. and Mohammad, K.A. and Mohammadi, A. and Mola, G.L.D. and Monasta, L. and Montico, M. and Ronfani, L. and Monis, J.D. and Moore, A.R. and MoradiLakeh, M. and Morawska, L. and Norman, R.E. and Mori, R. and Werdecker, A. and Mueller, U.O. and Westerman, R. and Murthy, S. and Pourmalek, F. and Nachega, J.B. and Paternina Caicedo, A.J. and Seedat, S. and Tran, B.X. and Naheed, A. and Naldi, L. and Remuzzi, G. and Nand, D. and Nangia, V. and Nash, D. and Neupane, S. and Newton, J.N. and Ngalesoni, F.N. and Nguhiu, P. and Nguyen, Q.L. and Nomura, M. and Nyakarahuka, L. and Obermeyer, C.M. and Ogbo, F.A. and Oh, I. and Olivares, P.R. and Olusanya, B.O. and Olusanya, J.O. and Opio, J.N. and Oren, E. and Ota, E. and Oyekale, A.S. and Mahesh, P.A. and Papantoniou, N. and Stathopoulou, V. and Park, E. and Park, H. and Patten, S.B. and Paul, V.K. and Roy, A. and Sagar, R. and Satpathy, M. and Pereira, D.M. and Cortinovis, M. and Perico, N. and Pesudovs, K. and Petzold, M. and Pillay, J.D. and Polinder, S. and Qorbani, M. and Rafay, A. and Rahman, M. and Rahman, S.U. and Rai, R.K. and Ranabhat, C.L. and Rangaswamy, T. and Rao, P.V. and Resnikoff, S. and Rojas-Rueda, D. and Ruhago, G.M. and Sunguya, B.F. and Saleh, M.M. and Sanabria, J.R. and Sanchez-Niño, M.D. and Sarmiento-Suarez, R. and Sartorius, B. and Sawhney, M. and Saylan, M.I. and Schneider, I.J.C. and Silva, D.A.S. and Servan-Mori, E.E. and Shaikh, M.A. and Sharma, R. and Shin, M. and Yoon, S. and Shiri, R. and Shishani, K. and Shiue, I. and Sigfusdottir, I.D. and Silveira, D.G.A. and Silverberg, J.I. and Yano, Y. and Singh, O.P. and Singh, P.K. and Singh, V. and Soneji, S. and Soriano, J.B. and Sposato, L.A. and Sreeramareddy, C.T. and Stroumpoulis, K. and Swaminathan, S. and Sykes, B.L. and Tabarés-Seisdedos, R. and Tabb, K.M. and Talongwa, R.T. and Tavakkoli, M. and Taye, B. and Endries, A.Y. and Thomson, A.J. and Tobe-Gai, R. and Topor-Madry, R. and Towbin, J.A. and Tsala Dimbuene, Z. and Tyrovolas, S. and Ukwaja, K.N. and Uthman, O.A. and Vasankari, T. and Venketasubramanian, N. and Violante, F.S. and Vladimirov, S.K. and Vlassov, V.V. and Weichenthal, S. and Wubshet, M. and Xu, G. and Yakob, B. and Yip, P. and Yonemoto, N. and Younis, M.Z. and Yu, C. and Zaidi, Z. and Zaki, M.E. and Zeeb, H. and Zhao, Y. and Zuhlke, L.J. Global, regional, and national levels of maternal mortality, 1990�2015: a systematic analysis for the Global Burden of Disease Study 2015. This online publication has been corrected..

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

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