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

doi:10.1016/S0140-6736(14)60696-6

Multicenter Study

. 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

Nicholas J Kassebaum¹, Amelia Bertozzi-Villa², Megan S Coggeshall², Katya A Shackelford², Caitlyn Steiner², Kyle R Heuton², Diego Gonzalez-Medina², Ryan Barber², Chantal Huynh², Daniel Dicker², Tara Templin², Timothy M Wolock², Ayse Abbasoglu Ozgoren³, Foad Abd-Allah⁴, Semaw Ferede Abera⁵, Ibrahim Abubakar⁶, Tom Achoki⁷, Ademola Adelekan⁸, Zanfina Ademi⁹, Arsène Kouablan Adou¹⁰, José C Adsuar¹¹, Emilie E Agardh¹², Dickens Akena¹³, Deena Alasfoor¹⁴, Zewdie Aderaw Alemu¹⁵, Rafael Alfonso-Cristancho¹⁶, Samia Alhabib¹⁷, Raghib Ali¹⁸, Mazin J Al Kahbouri¹⁴, François Alla¹⁹, Peter J Allen²⁰, Mohammad A AlMazroa²¹, Ubai Alsharif²², Elena Alvarez²³, Nelson Alvis-Guzmán²⁴, Adansi A Amankwaa²⁵, Azmeraw T Amare²⁶, Hassan Amini²⁷, Walid Ammar²⁸, Carl A T Antonio²⁹, Palwasha Anwari³⁰, Johan Arnlöv³¹, Valentina S Arsic Arsenijevic³², Ali Artaman³³, Majed Masoud Asad³⁴, Rana J Asghar³⁵, Reza Assadi³⁶, Lydia S Atkins³⁷, Alaa Badawi³⁸, Kalpana Balakrishnan³⁹, Arindam Basu⁴⁰, Sanjay Basu⁴¹, Justin Beardsley⁴², Neeraj Bedi⁴³, Tolesa Bekele⁴⁴, Michelle L Bell⁴⁵, Eduardo Bernabe⁴⁶, Tariku J Beyene⁴⁷, Zulfiqar Bhutta⁴⁸, Aref Bin Abdulhak⁴⁹, Jed D Blore⁹, Berrak Bora Basara⁵⁰, Dipan Bose⁵¹, Nicholas Breitborde⁵², Rosario Cárdenas⁵³, Carlos A Castañeda-Orjuela⁵⁴, Ruben Estanislao Castro⁵⁵, Ferrán Catalá-López⁵⁶, Alanur Cavlin³, Jung-Chen Chang⁵⁷, Xuan Che⁵⁸, Costas A Christophi⁵⁹, Sumeet S Chugh⁶⁰, Massimo Cirillo⁶¹, Samantha M Colquhoun⁶², Leslie Trumbull Cooper⁶³, Cyrus Cooper⁶⁴, Iuri da Costa Leite⁶⁵, Lalit Dandona⁶⁶, Rakhi Dandona⁶⁷, Adrian Davis⁶⁸, Anand Dayama⁶⁹, Louisa Degenhardt⁷⁰, Diego De Leo⁷¹, Borja del Pozo-Cruz⁷², Kebede Deribe⁴⁷, Muluken Dessalegn⁷³, Gabrielle A deVeber⁷⁴, Samath D Dharmaratne⁷⁵, Uğur Dilmen⁵⁰, Eric L Ding⁷⁶, Rob E Dorrington⁷⁷, Tim R Driscoll⁷⁸, Sergei Petrovich Ermakov⁷⁹, Alireza Esteghamati⁸⁰, Emerito Jose A Faraon²⁹, Farshad Farzadfar⁸¹, Manuela Mendonca Felicio⁸², Seyed-Mohammad Fereshtehnejad⁸³, Graça Maria Ferreira de Lima⁸⁴, Mohammad H Forouzanfar², Elisabeth B França⁸⁵, Lynne Gaffikin⁸⁶, Ketevan Gambashidze⁸⁷, Fortuné Gbètoho Gankpé⁸⁸, Ana C Garcia⁸⁹, Johanna M Geleijnse⁹⁰, Katherine B Gibney⁹¹, Maurice Giroud⁹², Elizabeth L Glaser⁹³, Ketevan Goginashvili⁹⁴, Philimon Gona⁹⁵, Dinorah González-Castell⁹⁶, Atsushi Goto⁹⁷, Hebe N Gouda⁹⁸, Harish Chander Gugnani⁹⁹, Rahul Gupta¹⁰⁰, Rajeev Gupta¹⁰¹, Nima Hafezi-Nejad⁸⁰, Randah Ribhi Hamadeh¹⁰², Mouhanad Hammami¹⁰³, Graeme J Hankey¹⁰⁴, Hilda L Harb²⁸, Rasmus Havmoeller⁸³, Simon I Hay¹⁸, Ileana B Heredia Pi⁹⁶, Hans W Hoek¹⁰⁵, H Dean Hosgood¹⁰⁶, Damian G Hoy¹⁰⁷, Abdullatif Husseini¹⁰⁸, Bulat T Idrisov¹⁰⁹, Kaire Innos¹¹⁰, Manami Inoue¹¹¹, Kathryn H Jacobsen¹¹², Eiman Jahangir¹¹³, Sun Ha Jee¹¹⁴, Paul N Jensen¹⁶, Vivekanand Jha¹¹⁵, Guohong Jiang¹¹⁶, Jost B Jonas¹¹⁷, Knud Juel¹¹⁸, Edmond Kato Kabagambe¹¹⁹, Haidong Kan¹²⁰, Nadim E Karam¹²¹, André Karch¹²², Corine Kakizi Karema¹²³, Anil Kaul¹²⁴, Norito Kawakami¹²⁵, Konstantin Kazanjan⁸⁷, Dhruv S Kazi¹²⁶, Andrew H Kemp¹²⁷, Andre Pascal Kengne¹²⁸, Maia Kereselidze⁸⁷, Yousef Saleh Khader¹²⁹, Shams Eldin Ali Hassan Khalifa¹³⁰, Ejaz Ahmed Khan¹³¹, Young-Ho Khang¹³², Luke Knibbs⁹⁸, Yoshihiro Kokubo¹³³, Soewarta Kosen¹³⁴, Barthelemy Kuate Defo¹³⁵, Chanda Kulkarni¹³⁶, Veena S Kulkarni¹³⁷, G Anil Kumar⁶⁷, Kaushalendra Kumar¹³⁸, Ravi B Kumar¹³⁹, Gene Kwan¹⁴⁰, Taavi Lai¹⁴¹, Ratilal Lalloo¹⁴², Hilton Lam¹⁴³, Van C Lansingh¹⁴⁴, Anders Larsson³¹, Jong-Tae Lee¹⁴⁵, James Leigh¹⁴⁶, Mall Leinsalu¹¹⁰, Ricky Leung¹⁴⁷, Xiaohong Li¹⁴⁸, Yichong Li¹⁴⁹, Yongmei Li¹⁵⁰, Juan Liang¹⁵¹, Xiaofeng Liang¹⁵², Stephen S Lim², Hsien-Ho Lin¹⁵³, Steven E Lipshultz¹⁵⁴, Shiwei Liu¹⁴⁹, Yang Liu¹⁵⁵, Belinda K Lloyd⁹¹, Stephanie J London¹⁵⁶, Paulo A Lotufo¹²⁷, Jixiang Ma¹⁴⁹, Stefan Ma¹⁵⁷, Vasco Manuel Pedro Machado¹⁵⁸, Nana Kwaku Mainoo¹⁵⁹, Marek Majdan¹⁶⁰, Christopher Chabila Mapoma¹⁶¹, Wagner Marcenes¹⁶², Melvin Barrientos Marzan¹⁵⁵, Amanda J Mason-Jones¹⁶³, Man Mohan Mehndiratta¹⁶⁴, Fabiola Mejia-Rodriguez⁹⁶, Ziad A Memish²¹, Walter Mendoza¹⁶⁵, Ted R Miller¹⁶⁶, Edward J Mills¹⁶⁷, Ali H Mokdad², Glen Liddell Mola¹⁶⁸, Lorenzo Monasta¹⁶⁹, Jonathan de la Cruz Monis¹⁷⁰, Julio Cesar Montañez Hernandez⁹⁶, Ami R Moore¹⁷¹, Maziar Moradi-Lakeh¹⁷², Rintaro Mori¹⁷³, Ulrich O Mueller¹⁷⁴, Mitsuru Mukaigawara¹⁷⁵, Aliya Naheed¹⁷⁶, Kovin S Naidoo¹⁷⁷, Devina Nand¹⁷⁸, Vinay Nangia¹⁷⁹, Denis Nash¹⁸⁰, Chakib Nejjari¹⁸¹, Robert G Nelson¹⁸², Sudan Prasad Neupane¹⁸³, Charles R Newton¹⁸⁴, Marie Ng², Mark J Nieuwenhuijsen¹⁸⁵, Muhammad Imran Nisar¹⁸⁶, Sandra Nolte²², Ole F Norheim¹⁸⁷, Luke Nyakarahuka¹³, In-Hwan Oh¹⁸⁸, Takayoshi Ohkubo¹⁸⁹, Bolajoko O Olusanya¹⁹⁰, Saad B Omer¹⁹¹, John Nelson Opio¹⁹², Orish Ebere Orisakwe¹⁹³, Jeyaraj D Pandian¹⁹⁴, Christina Papachristou²², Jae-Hyun Park¹⁹⁵, Angel J Paternina Caicedo¹⁹⁶, Scott B Patten¹⁹⁷, Vinod K Paul¹⁹⁸, Boris Igor Pavlin¹⁹⁹, Neil Pearce²⁰⁰, David M Pereira²⁰¹, Konrad Pesudovs²⁰², Max Petzold²⁰³, Dan Poenaru²⁰⁴, Guilherme V Polanczyk¹²⁷, Suzanne Polinder²⁰⁵, Dan Pope²⁰⁶, Farshad Pourmalek²⁰⁷, Dima Qato²⁰⁸, D Alex Quistberg¹⁶, Anwar Rafay²⁰⁹, Kazem Rahimi¹⁸, Vafa Rahimi-Movaghar²¹⁰, Sajjad ur Rahman²¹¹, Murugesan Raju²¹², Saleem M Rana²¹³, Amany Refaat²¹⁴, Luca Ronfani¹⁶⁹, Nobhojit Roy²¹⁵, Tania Georgina Sánchez Pimienta⁹⁶, Mohammad Ali Sahraian²¹⁶, Joshua A Salomon²¹⁷, Uchechukwu Sampson¹¹⁹, Itamar S Santos¹²⁷, Monika Sawhney²¹⁸, Felix Sayinzoga²¹⁹, Ione J C Schneider²²⁰, Austin Schumacher², David C Schwebel²²¹, Soraya Seedat²²², Sadaf G Sepanlou²²³, Edson E Servan-Mori⁹⁶, Marina Shakh-Nazarova⁸⁷, Sara Sheikhbahaei⁸⁰, Kenji Shibuya²²⁴, Hwashin Hyun Shin²²⁵, Ivy Shiue²²⁶, Inga Dora Sigfusdottir²²⁷, Donald H Silberberg²²⁸, Andrea P Silva²²⁹, Jasvinder A Singh²²¹, Vegard Skirbekk²³⁰, Karen Sliwa²³¹, Sergey S Soshnikov²³², Luciano A Sposato²³³, Chandrashekhar T Sreeramareddy²³⁴, Konstantinos Stroumpoulis²³⁵, Lela Sturua⁸⁷, Bryan L Sykes²³⁶, Karen M Tabb²³⁷, Roberto Tchio Talongwa²³⁸, Feng Tan²³⁹, Carolina Maria Teixeira⁸², Eric Yeboah Tenkorang²⁴⁰, Abdullah Sulieman Terkawi²⁴¹, Andrew L Thorne-Lyman²⁴², David L Tirschwell²⁴³, Jeffrey A Towbin²⁴⁴, Bach X Tran²⁴⁵, Miltiadis Tsilimbaris²⁴⁶, Uche S Uchendu²⁴⁷, Kingsley N Ukwaja²⁴⁸, Eduardo A Undurraga¹⁰⁹, Selen Begüm Uzun²⁴⁹, Andrew J Vallely²⁵⁰, Coen H van Gool²⁵¹, Tommi J Vasankari²⁵², Monica S Vavilala¹⁶, N Venketasubramanian²⁵³, Salvador Villalpando⁹⁶, Francesco S Violante²⁵⁴, Vasiliy Victorovich Vlassov²⁵⁵, Theo Vos², Stephen Waller²⁵⁶, Haidong Wang², Linhong Wang¹⁴⁹, XiaoRong Wang²⁵⁷, Yanping Wang¹⁵¹, Scott Weichenthal²²⁵, Elisabete Weiderpass²⁵⁸, Robert G Weintraub²⁵⁹, Ronny Westerman¹⁷⁴, James D Wilkinson²⁶⁰, Solomon Meseret Woldeyohannes²⁶¹, John Q Wong²⁶², Muluemebet Abera Wordofa²⁶³, Gelin Xu²⁶⁴, Yang C Yang²⁶⁵, Yuichiro Yano²⁶⁶, Gokalp Kadri Yentur⁵⁰, Paul Yip²⁶⁷, Naohiro Yonemoto²⁶⁸, Seok-Jun Yoon¹⁴⁵, Mustafa Z Younis²⁶⁹, Chuanhua Yu²⁷⁰, Kim Yun Jin²⁷¹, Maysaa El Sayed Zaki²⁷², Yong Zhao²⁷³, Yingfeng Zheng²⁷⁴, Maigeng Zhou¹⁴⁹, Jun Zhu¹⁵¹, Xiao Nong Zou²⁷⁵, Alan D Lopez⁹, Mohsen Naghavi², Christopher J L Murray², Rafael Lozano²⁷⁶

Affiliations

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.

PMID: 24797575
PMCID: PMC4255481
DOI: 10.1016/S0140-6736(14)60696-6

Multicenter Study

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

Nicholas J Kassebaum et al. Lancet. 2014.

. 2014 Sep 13;384(9947):980-1004.

doi: 10.1016/S0140-6736(14)60696-6. Epub 2014 May 2.

Authors

Affiliations

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.

PMID: 24797575
PMCID: PMC4255481
DOI: 10.1016/S0140-6736(14)60696-6

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.

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Figures

**Figure 1. Definitions of maternal death**
ICD-10=International Classification of Diseases, version 10. *During labour and up to 24 h after delivery. †Between 24 h and 6 weeks after delivery. ‡Between 6 weeks and 1 year after delivery.

**Figure 2. Forest plot of the relative risk of death during pregnancy for women with HIV infection compared with women without HIV infection**
Weights are from random effects analysis. Size of the triangles is proportional to the weighting of each study in the meta-analysis. UI=uncertainty interval.

**Figure 3. Global maternal deaths (A) and annualised rate of change in maternal mortality ratio (B), 1990–2013**
Shaded areas show 95% uncertainty intervals.

**Figure 4. Global maternal mortality ratio in 1990 and 2013, by age**
Shaded areas show 95% uncertainty intervals.

**Figure 5. Change in MMR between 1990 and 2013, by region**
MMR=maternal mortality ratio.

**Figure 6. Causes of maternal death**
(A) Mean proportion (left) and total number (right) of maternal deaths due to different causes in 1990 and 2013. Error bars show 95% uncertainty intervals. (B) Proportion of maternal deaths due to different causes in 2013, by region.

**Figure 7. Maternal mortality ratio in 2013**
ATG=Antigua and Barbuda. VCT=Saint Vincent and the Grenadines. Isl=Islands. FSM=Federated States of Micronesia. LCA=Saint Lucia. TTO=Trinidad and Tobago. TLS=Timor-Leste.

**Figure 8. Annualised rate of change in maternal mortality ratio in 1990–2003 and 2003–13**
Countries are grouped by Global Burden of Disease super-region. Countries are labelled when at or near the MDG5 achievement rate, or if they had large increases in either period. MDG=Millennium Development Goal. RO U=Romania. POL=Poland. MDV=Maldives. MAR=Morocco. ALB=Albania. CZE=Czech Republic. ARE=United Arab Emirates. EST=Estonia. LBN=Lebanon. LVA=Latvia. CHN=China. LTU=Lithuania. HUN=Hungary. SLV=El Salvador. BLR=Belarus. GRC=Greece. RWA=Rwanda. KHM=Cambodia. BLZ=Belize. AFG=Afghanistan. MWI=Malawi. KEN=Kenya. NAM=Namibia. THA=Thailand. SWZ=Swaziland. ZAF=South Africa. LSO=Lesotho. ZWE=Zimbabwe. BWA=Botswana.

**Figure 9. Projected maternal mortality ratio in 2030**
ATG=Antigua and Barbuda. VCT=Saint Vincent and the Grenadines. Isl=Islands. FSM=Federated States of Micronesia. LCA=Saint Lucia. TTO=Trinidad and Tobago. TLS=Timor-Leste.

**Figure 10. Comparison of all-cause reproductive-age mortality envelopes between 1990 and 2010**
WPP=World Population Prospects. GBD=Global Burden of Disease Study.

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Comment in

Counting what counts for maternal mortality.
Graham WJ, Witter S. Graham WJ, et al. Lancet. 2014 Sep 13;384(9947):933-5. doi: 10.1016/S0140-6736(14)61604-4. Lancet. 2014. PMID: 25220960 No abstract available.
Maternal mortality estimates.
Donati S. Donati S. Lancet. 2014 Dec 20;384(9961):2210. doi: 10.1016/S0140-6736(14)62422-3. Epub 2014 Dec 19. Lancet. 2014. PMID: 25625394 No abstract available.
Maternal mortality estimates.
Vrachnis N, Vlachadis N. Vrachnis N, et al. Lancet. 2014 Dec 20;384(9961):2210. doi: 10.1016/S0140-6736(14)62423-5. Epub 2014 Dec 19. Lancet. 2014. PMID: 25625395 No abstract available.
Maternal mortality estimates.
Gerland P, Masquelier B, Helleringer S, Hogan D, Mathers CD. Gerland P, et al. Lancet. 2014 Dec 20;384(9961):2211. doi: 10.1016/S0140-6736(14)62424-7. Epub 2014 Dec 19. Lancet. 2014. PMID: 25625396 No abstract available.
Maternal mortality estimates - Authors' reply.
Kassebaum NJ, Wang H, Lopez AD, Murray CJ, Lozano R. Kassebaum NJ, et al. Lancet. 2014 Dec 20;384(9961):2211-2. doi: 10.1016/S0140-6736(14)62425-9. Epub 2014 Dec 19. Lancet. 2014. PMID: 25625397 No abstract available.
In-country data will illuminate under-5 mortality disparities.
Moyer CA, Waiswa P. Moyer CA, et al. Lancet. 2021 Sep 4;398(10303):821-822. doi: 10.1016/S0140-6736(21)01110-7. Epub 2021 Aug 17. Lancet. 2021. PMID: 34416194 No abstract available.

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References

1. Shiffman J, Smith S. Generation of political priority for global health initiatives: a framework and case study of maternal mortality. Lancet. 2007;370:1370–79. - PubMed
1. Bustreo F, Requejo JH, Merialdi M, Presern C, Songane F. From safe motherhood, newborn, and child survival partnerships to the continuum of care and accountability: moving fast forward to 2015. Int J Gynaecol Obstet. 2012;119(suppl 1):S6–8. - PubMed
1. Commission on Information and Accountability for Women’s and Children’s Health [accessed January 29, 2014];Keeping promises, measuring results. 2011 http://www.everywomaneverychild.org/images/content/files/accountability_....
1. Hogan MC, Foreman KJ, Naghavi M, et al. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet. 2010;375:1609–23. - PubMed
1. Lozano R, Wang H, Foreman KJ, et al. Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis. Lancet. 2011;378:1139–65. - PubMed

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[1] Shiffman J, Smith S. Generation of political priority for global health initiatives: a framework and case study of maternal mortality. Lancet. 2007;370:1370–79. - PubMed

[2] Shiffman J, Smith S. Generation of political priority for global health initiatives: a framework and case study of maternal mortality. Lancet. 2007;370:1370–79. - PubMed

[3] Bustreo F, Requejo JH, Merialdi M, Presern C, Songane F. From safe motherhood, newborn, and child survival partnerships to the continuum of care and accountability: moving fast forward to 2015. Int J Gynaecol Obstet. 2012;119(suppl 1):S6–8. - PubMed

[4] Bustreo F, Requejo JH, Merialdi M, Presern C, Songane F. From safe motherhood, newborn, and child survival partnerships to the continuum of care and accountability: moving fast forward to 2015. Int J Gynaecol Obstet. 2012;119(suppl 1):S6–8. - PubMed

[5] Commission on Information and Accountability for Women’s and Children’s Health [accessed January 29, 2014];Keeping promises, measuring results. 2011 http://www.everywomaneverychild.org/images/content/files/accountability_....

[6] Commission on Information and Accountability for Women’s and Children’s Health [accessed January 29, 2014];Keeping promises, measuring results. 2011 http://www.everywomaneverychild.org/images/content/files/accountability_....

[7] Hogan MC, Foreman KJ, Naghavi M, et al. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet. 2010;375:1609–23. - PubMed

[8] Hogan MC, Foreman KJ, Naghavi M, et al. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet. 2010;375:1609–23. - PubMed

[9] Lozano R, Wang H, Foreman KJ, et al. Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis. Lancet. 2011;378:1139–65. - PubMed

[10] Lozano R, Wang H, Foreman KJ, et al. Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis. Lancet. 2011;378:1139–65. - PubMed

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

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

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