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Lancet. 2014 Sep 13;384(9947):980-1004. doi: 10.1016/S0140-6736(14)60696-6. Epub 2014 May 2.

Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.

Kassebaum NJ1, Bertozzi-Villa A2, Coggeshall MS2, Shackelford KA2, Steiner C2, Heuton KR2, Gonzalez-Medina D2, Barber R2, Huynh C2, Dicker D2, Templin T2, Wolock TM2, Ozgoren AA3, Abd-Allah F4, Abera SF5, Abubakar I6, Achoki T7, Adelekan A8, Ademi Z9, Adou AK10, Adsuar JC11, Agardh EE12, Akena D13, Alasfoor D14, Alemu ZA15, Alfonso-Cristancho R16, Alhabib S17, Ali R18, Al Kahbouri MJ14, Alla F19, Allen PJ20, AlMazroa MA21, Alsharif U22, Alvarez E23, Alvis-Guzmán N24, Amankwaa AA25, Amare AT26, Amini H27, Ammar W28, Antonio CA29, Anwari P30, Arnlöv J31, Arsenijevic VS32, Artaman A33, Asad MM34, Asghar RJ35, Assadi R36, Atkins LS37, Badawi A38, Balakrishnan K39, Basu A40, Basu S41, Beardsley J42, Bedi N43, Bekele T44, Bell ML45, Bernabe E46, Beyene TJ47, Bhutta Z48, Bin Abdulhak A49, Blore JD9, Basara BB50, Bose D51, Breitborde N52, Cárdenas R53, Castañeda-Orjuela CA54, Castro RE55, Catalá-López F56, Cavlin A3, Chang JC57, Che X58, Christophi CA59, Chugh SS60, Cirillo M61, Colquhoun SM62, Cooper LT63, Cooper C64, da Costa Leite I65, Dandona L66, Dandona R67, Davis A68, Dayama A69, Degenhardt L70, De Leo D71, del Pozo-Cruz B72, Deribe K47, Dessalegn M73, deVeber GA74, Dharmaratne SD75, Dilmen U50, Ding EL76, Dorrington RE77, Driscoll TR78, Ermakov SP79, Esteghamati A80, Faraon EJ29, Farzadfar F81, Felicio MM82, Fereshtehnejad SM83, de Lima GM84, Forouzanfar MH2, França EB85, Gaffikin L86, Gambashidze K87, Gankpé FG88, Garcia AC89, Geleijnse JM90, Gibney KB91, Giroud M92, Glaser EL93, Goginashvili K94, Gona P95, González-Castell D96, Goto A97, Gouda HN98, Gugnani HC99, Gupta R100, Gupta R101, Hafezi-Nejad N80, Hamadeh RR102, Hammami M103, Hankey GJ104, Harb HL28, Havmoeller R83, Hay SI18, Pi IB96, Hoek HW105, Hosgood HD106, Hoy DG107, Husseini A108, Idrisov BT109, Innos K110, Inoue M111, Jacobsen KH112, Jahangir E113, Jee SH114, Jensen PN16, Jha V115, Jiang G116, Jonas JB117, Juel K118, Kabagambe EK119, Kan H120, Karam NE121, Karch A122, Karema CK123, Kaul A124, Kawakami N125, Kazanjan K87, Kazi DS126, Kemp AH127, Kengne AP128, Kereselidze M87, Khader YS129, Khalifa SE130, Khan EA131, Khang YH132, Knibbs L98, Kokubo Y133, Kosen S134, Defo BK135, Kulkarni C136, Kulkarni VS137, Kumar GA67, Kumar K138, Kumar RB139, Kwan G140, Lai T141, Lalloo R142, Lam H143, Lansingh VC144, Larsson A31, Lee JT145, Leigh J146, Leinsalu M110, Leung R147, Li X148, Li Y149, Li Y150, Liang J151, Liang X152, Lim SS2, Lin HH153, Lipshultz SE154, Liu S149, Liu Y155, Lloyd BK91, London SJ156, Lotufo PA127, Ma J149, Ma S157, Machado VM158, Mainoo NK159, Majdan M160, Mapoma CC161, Marcenes W162, Marzan MB155, Mason-Jones AJ163, Mehndiratta MM164, Mejia-Rodriguez F96, Memish ZA21, Mendoza W165, Miller TR166, Mills EJ167, Mokdad AH2, Mola GL168, Monasta L169, de la Cruz Monis J170, Hernandez JC96, Moore AR171, Moradi-Lakeh M172, Mori R173, Mueller UO174, Mukaigawara M175, Naheed A176, Naidoo KS177, Nand D178, Nangia V179, Nash D180, Nejjari C181, Nelson RG182, Neupane SP183, Newton CR184, Ng M2, Nieuwenhuijsen MJ185, Nisar MI186, Nolte S22, Norheim OF187, Nyakarahuka L13, Oh IH188, Ohkubo T189, Olusanya BO190, Omer SB191, Opio JN192, Orisakwe OE193, Pandian JD194, Papachristou C22, Park JH195, Caicedo AJ196, Patten SB197, Paul VK198, Pavlin BI199, Pearce N200, Pereira DM201, Pesudovs K202, Petzold M203, Poenaru D204, Polanczyk GV127, Polinder S205, Pope D206, Pourmalek F207, Qato D208, Quistberg DA16, Rafay A209, Rahimi K18, Rahimi-Movaghar V210, ur Rahman S211, Raju M212, Rana SM213, Refaat A214, Ronfani L169, Roy N215, Pimienta TG96, Sahraian MA216, Salomon JA217, Sampson U119, Santos IS127, Sawhney M218, Sayinzoga F219, Schneider IJ220, Schumacher A2, Schwebel DC221, Seedat S222, Sepanlou SG223, Servan-Mori EE96, Shakh-Nazarova M87, Sheikhbahaei S80, Shibuya K224, Shin HH225, Shiue I226, Sigfusdottir ID227, Silberberg DH228, Silva AP229, Singh JA221, Skirbekk V230, Sliwa K231, Soshnikov SS232, Sposato LA233, Sreeramareddy CT234, Stroumpoulis K235, Sturua L87, Sykes BL236, Tabb KM237, Talongwa RT238, Tan F239, Teixeira CM82, Tenkorang EY240, Terkawi AS241, Thorne-Lyman AL242, Tirschwell DL243, Towbin JA244, Tran BX245, Tsilimbaris M246, Uchendu US247, Ukwaja KN248, Undurraga EA109, Uzun SB249, Vallely AJ250, van Gool CH251, Vasankari TJ252, Vavilala MS16, Venketasubramanian N253, Villalpando S96, Violante FS254, Vlassov VV255, Vos T2, Waller S256, Wang H2, Wang L149, Wang X257, Wang Y151, Weichenthal S225, Weiderpass E258, Weintraub RG259, Westerman R174, Wilkinson JD260, Woldeyohannes SM261, Wong JQ262, Wordofa MA263, Xu G264, Yang YC265, Yano Y266, Yentur GK50, Yip P267, Yonemoto N268, Yoon SJ145, Younis MZ269, Yu C270, Jin KY271, El Sayed Zaki M272, Zhao Y273, Zheng Y274, Zhou M149, Zhu J151, Zou XN275, Lopez AD9, Naghavi M2, Murray CJ2, Lozano R276.

Author information

1
Institute for Health Metrics and Evaluation, Seattle, WA, USA; Pediatric Anesthesiology and Pain Medicine, Seattle Children's Hospital, School of Medicine, Seattle, WA, USA. Electronic address: nickjk@uw.edu.
2
Institute for Health Metrics and Evaluation, Seattle, WA, USA.
3
Hacettepe University Institute of Population Studies, Ankara, Turkey.
4
Faculty of Medicine, Cairo University, Cairo, Egypt.
5
School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia.
6
University College London, London, UK.
7
Ministry of Health, Gaborone, Botswana.
8
Public Health Promotion Alliance, Osogbp, Nigeria.
9
University of Melbourne, Melbourne, VIC, Australia.
10
Association Ivoirienne Pour Le Bien Etre Familial, Abidjan, Côte d'Ivoire.
11
University of Extremadura, Cáceres, Spain.
12
Institution of Public Health Sciences, Stockholm, Sweden.
13
Makerere University, Kampala, Uganda.
14
Ministry of Health, Muscat, Oman.
15
Debre Markos University, Debre Markos, Amhara, Ethiopia.
16
University of Washington, Seattle, WA, USA.
17
National Guard Health Affairs, Riyadh, Saudi Arabia.
18
University of Oxford, Oxford, UK.
19
School of Public Health, University of Lorraine, Nancy, France.
20
Ministry of Health, Belmopan, Cayo, Belize.
21
Saudi Ministry of Health, Riyadh, Saudi Arabia.
22
Charité Universitätsmedizin Berlin, Berlin, Germany.
23
Spanish Observatory on Drugs, Government Delegation for the National Plan on Drugs, Madrid, Spain; Ministry of Health, Social Services and Equality, Madrid, Spain.
24
Universidad de Cartagena, Cartagena de Indias, Colombia.
25
Albany State University, Albany, GA, USA.
26
Department of Epidemiology, University of Groningen, Groningen, Netherlands; College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia.
27
Kurdistan Environmental Health Research Centre, Kurdistan University of Medical Sciences, Sanandaj, Kurdistan, Iran.
28
Ministry of Public Health, Beirut, Lebanon.
29
College of Public Health, University of the Philippines Manila, Manila, Philippines.
30
UN Population Fund, Kabul, Afghanistan.
31
Uppsala University, Uppsala, Sweden.
32
Institute of Microbiology and Immunology, School of Medicine, University of Belgrade, Belgrade, Serbia.
33
Median, Windsor, ON, Canada.
34
Ministry of Health, Amman, Jordan.
35
Field Epidemiology and Laboratory Training Program, Islamabad, Pakistan.
36
Mashhad University of Medical Sciences, Mashhad, Iran.
37
Ministry Of Health, Wellness, Human Services and Gender Relations, Sans Souci, Castries, Saint Lucia.
38
Public Health Agency of Canada, Toronto, ON, Canada.
39
Sri Ramachandra University, Chennai, India.
40
School of Health Sciences, University of Canterbury, Christchurch, New Zealand.
41
Stanford University, Stanford, CA, USA.
42
Oxford University, Ho Chi Minh City, Vietnam.
43
College of Public Health and Tropical Medicine, Jazan, Saudi Arabia.
44
Madawalabu University, Bale Goba, Oromia, Ethiopia.
45
Yale University, New Haven, CT, USA.
46
King's College London, London, UK.
47
Addis Ababa University, Debre Zeit, Ethiopia.
48
Aga Khan University Medical Centre, Karachi, Pakistan.
49
University of Missouri-Kansas City, Kansas City, MO, USA.
50
General Directorate of Health Research, Ankara, Turkey.
51
World Bank, Washington, DC, USA.
52
University of Arizona, Tucson, AZ, USA.
53
Universidad Autonoma Metropolitana, Mexico City, Mexico.
54
Colombian National Health Observatory, Instituto Nacional de Salud, Bogota, Colombia.
55
Universidad Diego Portales, Santiago, Chile.
56
Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Medicines and Healthcare Products Agency, Madrid, Spain.
57
National Taiwan University, Taipei, Taiwan.
58
National Institutes of Health, Department of Health and Human Services, Bethesda, MD, USA.
59
Cyprus University of Technology, Limassol, Cyprus.
60
Cedars-Sinai Medical Centre, Los Angeles, CA, USA.
61
University of Salerno, Baronissi, Italy.
62
Centre for International Child Health, Melbourne, VIC, Australia.
63
Mayo Clinic, Rochester, MN, USA.
64
Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK.
65
National School of Public Health (ENSP/Fiocruz), Rio de Janeiro, Brazil.
66
Institute for Health Metrics and Evaluation, Seattle, WA, USA; Public Health Foundation of India, New Delhi, India.
67
Public Health Foundation of India, New Delhi, India.
68
Public Health England, London, UK.
69
School of Medicine, Atlanta, GA, USA.
70
University of New South Wales, Sydney, NSW, Australia.
71
Griffith University, Brisbane, QLD, Australia.
72
University of Auckland, Auckland, New Zealand.
73
Africa Medical and Research Foundation in Ethiopia, Addis Ababa, Ethiopia.
74
Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
75
University of Peradeniya, Peradeniya, Sri Lanka.
76
Harvard School of Public Health, Boston, MA, USA.
77
University of Cape Town, Cape Town, South Africa.
78
Sydney School of Public Health, NSW, Australia.
79
The Institute of Social and Economic Studies of Population at the Russian Academy of Sciences, Moscow, Russia.
80
Endocrinology and Metabolism Research Centre, Tehran University of Medical Sciences, Tehran, Iran.
81
Non-Communicable Diseases Research Centre, Tehran University of Medical Sciences, Tehran, Iran.
82
Departamento de Saúde Pública, ARS Norte IP, Porto, Portugal.
83
Karolinska Institutet, Stockholm, Sweden.
84
Public Health Department, Unidade Local de Saúde de Matosinhos, Porto, Portugal.
85
Federal University of Minas Gerais, Belo Horizonte, Brazil.
86
School of Medicine, Stanford, CA, USA.
87
National Centre for Disease Control and Public Health of Georgia, Tbilisi, Georgia.
88
Clinique Coopérative de Parakou, Parakou, Borgou, Benin.
89
Public Health Unit of Primary Health Care Group of Almada-Seixal, Almada, Setúbal, Portugal.
90
Division of Human Nutrition, Wageningen University, Wageningen, Netherlands.
91
Monash University, Melbourne, VIC, Australia.
92
University Hospital of Dijon, Dijon, France.
93
Heller School for Social Policy and Management, Waltham, MA, USA.
94
Ministry of Labour, Health and Social Affairs, Tbilisi, Georgia.
95
University of Massachusetts Medical School, Worcester, MA, USA.
96
National Institute of Public Health, Cuernavaca, Mexico.
97
Department of Diabetes Research, National Centre for Global Health and Medicine, Tokyo, Japan.
98
University of Queensland, Brisbane, QLD, Australia.
99
Saint James School of Medicine, Kralendijk, Bonaire, Netherlands.
100
Kanawha Charleston Health Department, Charleston, WV, USA.
101
Fortis Escorts Hospital, Jaipur, India.
102
Arabian Gulf University, Manama, Bahrain.
103
Wayne County Department of Health and Human Services, Detroit, MI, USA.
104
School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia.
105
Parnassia Psychiatric Institute, The Hague, Netherlands.
106
Albert Einstein College of Medicine, Bronx, NY, USA.
107
School of Population Health, QLD, Australia; Public Health Division, Secretariat of the Pacific Community, Noumea, New Caledonia.
108
Birzeit University, Birzeit, Ramallah, Palestine.
109
Brandeis University, Waltham, MA, USA.
110
National Institute for Health Development, Tallinn, Estonia.
111
Graduate School of Medicine, Tokyo, Japan.
112
George Mason University, Fairfax, VA, USA.
113
Ochsner Medical Centre, New Orleans, LA, USA.
114
Graduate School of Public Health, Yonsei University, Seoul, South Korea.
115
Postgraduate Institute of Medical Education and Research, Chandigarh, India.
116
Tianjin Centres for Diseases Control and Prevention, Tianjin, China.
117
Department of Ophthalmology, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany.
118
National Institute of Public Health, Copenhagen, Denmark.
119
Vanderbilt University, Nashville, TN, USA.
120
Fudan University, Shanghai, China.
121
University of Balamand, Beirut, Lebanon.
122
Helmholtz Centre for Infection Research, Braunschweig, Germany.
123
Malaria and Other Parasitic Diseases Division, Kigali, Rwanda.
124
Oklahoma State University, Tulsa, OK, USA.
125
School of Public Health, Tokyo, Japan.
126
University of California San Francisco, San Francisco, CA, USA.
127
University of São Paulo, São Paulo, Brazil.
128
South African Medical Research Council, Cape Town, South Africa.
129
Jordan University of Science and Technology, Al-Ramtha, Jordan.
130
Supreme Council of Health, Doha, Qatar.
131
Health Services Academy, Islamabad, Pakistan.
132
Institute of Health Policy and Management, Seoul National University College of Medicine, Seoul, South Korea.
133
Department of Preventive Cardiology, Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Centre, Suita, Japan.
134
Centre for Community Empowerment, Health Policy and Humanities, National Institute of Health Research and Development, Jakarta, Indonesia.
135
University of Montreal, Montreal, QC, Canada.
136
Rajrajeshwari Medical College and Hospital, Bangalore, India.
137
Arkansas State University, Jonesboro, AR, USA.
138
International Institute for Population Sciences, Mumbai, India.
139
Indian Institute of Public Health, Public Health Foundation of India, Gurgaon, India.
140
Boston Medical Centre, Boston, MA, USA.
141
Fourth View Consulting, Tallinn, Estonia.
142
Australian Research Centre for Population Oral Health (ARCPOH), School of Dentistry, University of Adelaide, Adelaide, SA, Australia.
143
Institute of Health Policy and Development Studies, National Institutes of Health, Manila, Philippines.
144
International Agency for the Prevention of Blindness and Vision 2020, Weston, FL, USA.
145
Korea University, Seoul, South Korea.
146
University of Sydney, NSW, Australia.
147
University at Albany, Rensselaer, NY, USA.
148
National Centre for Birth Defects Monitoring of China, Chengdu, China.
149
National Centre for Chronic and Non-Communicable Disease Control and Prevention, Beijing, China.
150
Genentech, South San Francisco, CA, USA.
151
National Office for Maternal and Child Health Surveillance, West China Second University Hospital, Sichuan University, Chengdu, China.
152
Chinese Centre for Disease Control and Prevention, Beijing, China.
153
College of Public Health, Taipei, Taiwan.
154
Wayne State University, Miami, FL, USA.
155
University of the East Ramon Magsaysay Memorial Medical Centre, Quezon City, Philippines.
156
National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA.
157
Ministry of Health Singapore, Singapore, Singapore.
158
Northern Region Health Administration, Porto, Portugal.
159
Xpharmconsult, Kumasi, Ghana.
160
Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovakia.
161
University of Zambia, Lusaka, Zambia.
162
Queen Mary University of London, London, UK.
163
University of York, York, UK.
164
Janakpuri Super Specialty Hospital, New Delhi, India.
165
UN Population Fund, Lima, Peru.
166
Pacific Institute for Research and Evaluation, Calverton, MD, USA.
167
University of Ottawa, Ottawa, ON, Canada.
168
University of Papua New Guinea, Port Moresby, Papua New Guinea.
169
Institute for Maternal and Child Health Istituto di Ricovero e Cura a Carattere Scientifico Burlo Garofolo, Trieste, Italy.
170
Bureau of International Health Cooperation, Manila City, Philippines.
171
University of North Texas, Denton, TX, USA.
172
Institute for Health Metrics and Evaluation, Seattle, WA, USA; Iran University of Medical Sciences, Department of Community Medicine, Tehran, Iran.
173
National Centre for Child Health and Development, Setagaya, Tokyo, Japan.
174
Philipps-University Marburg, Marburg, Germany.
175
Tokyo Medical and Dental University, Tokyo, Japan.
176
International Centre for Diarrhoeal Diseases Research, Dhaka, Bangladesh.
177
University of KwaZulu-Natal, Durban, South Africa.
178
Ministry of Health Fiji, Suva, Fiji.
179
Suraj Eye Institute, Nagpur, India.
180
School of Public Health, State University of New York, New York, NY, USA.
181
Faculty of Medicine, Fez, Morocco.
182
National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, AZ, USA.
183
Norwegian Centre for Addiction Research (SERAF), University of Oslo, Oslo, Norway.
184
Kenya Medical Research Institute Wellcome Trust Programme, Kilifi, Kenya.
185
Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain.
186
Aga Khan University, Karachi, Pakistan.
187
University of Bergen, Bergen, Norway.
188
Kyung Hee Unversity, Seoul, South Korea.
189
Teikyo University School of Medicine, Tokyo, Japan.
190
Centre for Healthy Start Initiative, Lagos, Nigeria.
191
Emory University, Atlanta, GA, USA.
192
Lira District Local Government, Lira Municipal Council, Lira, Uganda.
193
Toxicology Unit, Faculty of Pharmacy, University of Port Harcourt, Port Harcourt, Nigeria.
194
Christian Medical College Ludhiana, Ludhiana, India.
195
Sungkyunkwan University School of Medicine, Suwon, South Korea.
196
Universidad de Cartagena, Cartagena, Colombia.
197
University of Calgary, Calgary, AB, Canada.
198
All India Institute of Medical Sciences (AIIMS), New Delhi, India.
199
WHO, Waigani, Papua New Guinea.
200
London School of Hygiene & Tropical Medicine, London, UK.
201
3B's Research Group in Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, and ICVS/3B's PT Government Associate Laboratory, Braga Portugal.
202
Flinders University, Adelaide, SA, Australia.
203
Centre for Applied Biostatistics, Sahlgrenska Academy, University of Gothenburg, Sweden.
204
McMaster University, Hamilton, ON, Canada.
205
Erasmus Medical Center, Department of Public Health, Rotterdam, Netherlands.
206
University of Liverpool, Liverpool, UK.
207
University of British Columbia, Vancouver, BC, Canada.
208
College of Pharmacy, Chicago, IL, USA.
209
Contech International, Lahore, Pakistan.
210
Sina Trauma and Surgery Research Centre, Tehran University of Medical Sciences, Tehran, Iran.
211
Hamad Medical Corporation, Doha, Qatar.
212
University of Missouri, Columbia, MO, USA.
213
Department of Public Health, University of the Punjab, Lahore, Pakistan.
214
Walden University, Minneapolis, MN, USA.
215
Bhaba Atomic Research Center Hospital, Mumbai, India.
216
MS Research Centre, Tehran University of Medical Sciences, Tehran, Iran.
217
Harvard University, Boston, MA, USA.
218
Marshall University, Huntington, WV, USA.
219
Ministry of Health, Kigali, Rwanda.
220
Federal University of Santa Catarina, Florianópolis, Brazil.
221
University of Alabama at Birmingham, Birmingham, AL, USA.
222
Stellenbosch University, Cape Town, South Africa.
223
Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.
224
University of Tokyo, Tokyo, Japan.
225
Health Canada, Ottawa, ON, Canada.
226
Heriot-Watt University, Edinburgh, UK.
227
Reykjavik University, Reykjavik, Iceland.
228
University of Pennsylvania, Philadelphia, PA, USA.
229
Instituto Nacional de Epidemiología Dr Juan H Jara, Mar del Plata, Buenos Aires, Argentina.
230
Norwegian Institute of Public Health, Oslo, Norway.
231
Hatter Institute for Cardiovascular Research in Africa, Faculty of Health Sciences, Cape Town, South Africa.
232
Federal Research Institute for Health Organisation and Informatics of Ministry of Health of the Russian Federation, Moscow, Russia.
233
Department of Clinical Neurological Sciences, Western University, London, ON, Canada.
234
University Tunku Abdul Rahman, Kajang, Malaysia.
235
Hellenic Centre for Disease Control and Prevention (KEELPNO) Greece, Athens, Greece.
236
Department of Criminology, Law and Society (and Sociology), University of California Irvine, Irvine, CA, USA.
237
University of Illinois, Chicago, IL, USA.
238
Ministry of Public Health, Yaounde, Cameroon.
239
National Institute of Occupational Health and Poison Control, Beijing, China.
240
Memorial University, St John's, NL, Canada.
241
Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA; Department of Anesthesiology, King Fahad Medical City, Riyadh, Saudi Arabia.
242
The Earth Institute, Columbia University, New York, NY, USA.
243
Department of Neurology, Seattle, WA, USA.
244
Cincinnati Children's Hospital Medical Centre, Cincinnati, OH, USA.
245
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
246
Department of Medicine, University of Crete, Heraklion, Greece.
247
Department of Veterans Affairs, Washington, DC, USA.
248
Department of Internal Medicine, Federal Teaching Hospital Abakaliki, Abakaliki, Nigeria.
249
Ministry of Health, Ankara, Turkey.
250
The Kirby Institute, Sydney, NSW, Australia.
251
National Institute for Public Health and the Environment, Bilthoven, Netherlands.
252
UKK Institute for Health Promotion Research, Tampere, Finland.
253
Neuroscience Centre, Raffles Hospital, Singapore.
254
University of Bologna, Bologna, Italy.
255
Higher School of Economics, Moscow, Russia.
256
Uniformed Services University of Health Sciences, Bethesda, MD, USA.
257
Shandong University Affiliated Jinan Central Hospital, Jinan, China.
258
Department of Medical Epidemiology and Biostatistics, Stockholm, Sweden.
259
University of Melbourne, Melbourne, VIC, Australia; Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, VIC, Australia.
260
University of Miami, Miami, FL, USA.
261
Institute of Public Health, University of Gondar, Gondar, Ethiopia.
262
Ateneo School of Medicine and Public Health, City of Pasig, Manila, Philippines.
263
Jimma University, Jimma, Ethiopia.
264
Nanjing University School of Medicine, Jinling Hospital, Nanjing, China.
265
University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
266
Division of Cardiovascular Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan.
267
University of Hong Kong, Hong Kong Special Administrative Region, China.
268
National Centre of Neurology and Psychiatry, Kodaira, Japan.
269
Jackson State University, Jackson, MS, USA.
270
Department of Epidemiology and Biostatistics, Global Health Institute, School of Public Health, Wuhan University, Wuhan, China.
271
TCM Medical Tk, Nusajaya, Johor Bahru, Malaysia.
272
Mansoura Faculty of Medicine, Mansoura, Egypt.
273
Chongqing Medical University, Chongqing, China.
274
Zhongshan Ophthalmic Centre, Sun Yat-sen University, Guangzhou, China.
275
Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, China.
276
Institute for Health Metrics and Evaluation, Seattle, WA, USA; National Institute of Public Health, Cuernavaca, Mexico.

Erratum in

  • Lancet. 2014 Sep 13;384(9947):956.

Abstract

BACKGROUND:

The fifth Millennium Development Goal (MDG 5) established the goal of a 75% reduction in the maternal mortality ratio (MMR; number of maternal deaths per 100,000 livebirths) between 1990 and 2015. We aimed to measure levels and track trends in maternal mortality, the key causes contributing to maternal death, and timing of maternal death with respect to delivery.

METHODS:

We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to analyse a database of data for 7065 site-years and estimate the number of maternal deaths from all causes in 188 countries between 1990 and 2013. We estimated the number of pregnancy-related deaths caused by HIV on the basis of a systematic review of the relative risk of dying during pregnancy for HIV-positive women compared with HIV-negative women. We also estimated the fraction of these deaths aggravated by pregnancy on the basis of a systematic review. To estimate the numbers of maternal deaths due to nine different causes, we identified 61 sources from a systematic review and 943 site-years of vital registration data. We also did a systematic review of reports about the timing of maternal death, identifying 142 sources to use in our analysis. We developed estimates for each country for 1990-2013 using Bayesian meta-regression. We estimated 95% uncertainty intervals (UIs) for all values.

FINDINGS:

292,982 (95% UI 261,017-327,792) maternal deaths occurred in 2013, compared with 376,034 (343,483-407,574) in 1990. The global annual rate of change in the MMR was -0·3% (-1·1 to 0·6) from 1990 to 2003, and -2·7% (-3·9 to -1·5) from 2003 to 2013, with evidence of continued acceleration. MMRs reduced consistently in south, east, and southeast Asia between 1990 and 2013, but maternal deaths increased in much of sub-Saharan Africa during the 1990s. 2070 (1290-2866) maternal deaths were related to HIV in 2013, 0·4% (0·2-0·6) of the global total. MMR was highest in the oldest age groups in both 1990 and 2013. In 2013, most deaths occurred intrapartum or postpartum. Causes varied by region and between 1990 and 2013. We recorded substantial variation in the MMR by country in 2013, from 956·8 (685·1-1262·8) in South Sudan to 2·4 (1·6-3·6) in Iceland.

INTERPRETATION:

Global rates of change suggest that only 16 countries will achieve the MDG 5 target by 2015. Accelerated reductions since the Millennium Declaration in 2000 coincide with increased development assistance for maternal, newborn, and child health. Setting of targets and associated interventions for after 2015 will need careful consideration of regions that are making slow progress, such as west and central Africa.

FUNDING:

Bill & Melinda Gates Foundation.

PMID:
24797575
PMCID:
PMC4255481
DOI:
10.1016/S0140-6736(14)60696-6
[Indexed for MEDLINE]
Free PMC Article
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