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

Abstract

Summary 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.

Profile of delivering mothers in Lubumbashi, Democratic Republic of Congo

“…Maternal and perinatal complications at birth are a daily concern for the obstetrician and neonatologist, especially in developing countries, which pay the highest price (99% of these maternal deaths); the main causes are haemorrhage, dystocia, hypertensive disorders of pregnancy and infections [1][2][3][4]. The Democratic Republic of Congo (DRC) is among the countries where the maternal mortality rate is still very high, 846 per 100,000 live births according to the Survey Demographic and Health Survey published in 2014 [5].…”

Intervention or interference? The need for expectant care throughout normal labour

“…The maternal mortality rate in South Sudan is 956.8 per 100,000, very different to the rate of 2.4 in Iceland. 21 In high-income countries, however, healthy women with normal haemoglobin levels do not suffer any ill effects from a PPH of 500mls, which is only slightly more than would be given voluntarily in a routine blood donation. Examining the details of all maternal deaths in the UK in the period 2006-2008 shows that, out of 2.3 million women birthing, only 5 died of PPH.…”

Care of the Critically Ill Pregnant Patient and Perimortem Cesarean Delivery in the Emergency Department

“…Cardiac disease remains the most common cause of death in pregnant women, with myocardial infarction as the leading cause, followed by aortic dissection (10). Deaths from hemorrhage, hypertension, and maternal sepsis have decreased over the past decade according to the Kassebaum et al (2). The highest proportion of maternal deaths are attributable to pregnancy complications in high-income regions like the United States, followed by exacerbation of underlying illness, such as sickle cell anemia, obesity, or chronic kidney disease.…”

“…This represents a concerning rise from 7.2 per 100,000 in 1987. This may be explained by better reporting, higher rates of significant comorbidities, such as diabetes and hypertension, and mothers with previously life-limiting illnesses surviving to adulthood and conceiving (2). Important to note is that this study included postpartum maternal deaths #1 year after birth.…”

“…The recommendations discussed below would not apply postpartum or early antepartum patients. Kassebaum et al address the debate around classifying maternal deaths (2). In their data, only deaths where pregnancy is considered a causal factor are included.…”