Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5.
Maternal mortality remains a major challenge to health systems worldwide. Reliable information about the rates and trends in maternal mortality is essential for resource mobilisation, and for planning and assessment of progress towards Millennium Development Goal 5 (MDG 5), the target for which is a 75% reduction in the maternal mortality ratio (MMR) from 1990 to 2015. The authors assessed levels and trends in maternal mortality for 181 countries. They constructed a database of 2651 observations of maternal mortality for 181 countries for 1980-2008, from vital registration data, censuses, surveys, and verbal autopsy studies. They used robust analytical methods to generate estimates of maternal deaths and the maternal mortality ratio for each year between 1980 and 2008. They explored the sensitivity of their data to model specification and show the out-of-sample predictive validity of their methods. They estimated that there were 342 900 (uncertainty interval 302 100-394 300) maternal deaths worldwide in 2008, down from 526 300 (446 400-629 600) in 1980. The global maternal mortality ratio decreased from 422 (358-505) in 1980 to 320 (272-388) in 1990, and was 251 (221-289) per 100 000 live births in 2008. The yearly rate of decline of the global maternal mortality ratio since 1990 was 1.3% (1.0-1.5). During 1990-2008, rates of yearly decline in the maternal mortality ratio varied between countries, from 8.8% (8.7-14.1) in the Maldives to an increase of 5.5% (5.2-5.6) in Zimbabwe. More than 50% of all maternal deaths were in only six countries in 2008 (India, Nigeria, Pakistan, Afghanistan, Ethiopia, and the Democratic Republic of the Congo). In the absence of HIV, there would have been 281 500 (243 900-327 900) maternal deaths worldwide in 2008. Substantial, albeit varied, progress has been made towards MDG 5. Although only 23 countries are on track to achieve a 75% decrease in maternal mortality ratio by 2015, countries such as Egypt, China, Ecuador, and Bolivia have been achieving accelerated progress.
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Editors’ Note: Both early maternal mortality defined as the death of women during pregnancy, childbirth, or in the 42 days after delivery, and late maternal mortality in the period from 43 days to 1 year post-delivery are notoriously difficult to measure accurately. This study drew on every available data source, tried to correct for misclassification, and ran predictive validity tests on their modelling approach. Late maternal mortality and mortality due to Incidental causes such as motor vehicle accidents, drowning, etc. are not included in the calculation of the maternal mortality ratio (MMR). Thus the MMR includes early maternal deaths due to direct obstetric causes, indirect causes (aggravated by pregnancy), and HIV infection causes, and is calculated as the number of maternal deaths per 100,000 live births. The target for Millennium Development Goal (MDG) 5 is a 75% reduction in the MMR between 1990 and 2015 which would require a 5.5% annual decline in the MMR when it has fallen 1.8% per year from 1980 to 2008. We need to speed up the decline to get on target. This stocktaking analysis has striking findings. Analysis of the 1.5% annual rate of decline in the number of maternal deaths from 1980 to 2008 reveals a disturbing trend. The decline was 1.8% annually between 1980 and 1990, dropping to 1.4% from 1990 to 2008. In fact, had there been no HIV epidemic, the decline overall would have been 2.2% per year, not 1.5%. With the proportion of global maternal deaths occurring in sub-Saharan Africa having increased from 23% in 1990 to 52% in 2008, as the HIV epidemic in the region deepened, it is clear that initiating antiretroviral therapy for pregnant women with HIV infection worldwide, but particularly in sub-Saharan Africa, could help get us on track. At the same time, we need to continue to address factors that influence maternal mortality and HIV such as education for girls - it rose from 1.5 years in 1980 to 4.4 years in 2008 in sub-Saharan Africa. Continued reductions in the total fertility rate, which fell from 3.7 in 1980 to 2.6 in 2008, acceleration in the slow increases in the coverage of skilled birth attendance, and specific tracking of HIV-related maternal mortality are top priorities. Preventing HIV infection in women, preventing unintended pregnancy in women who have HIV infection, and putting pregnant women with HIV infection on antiretroviral therapy for their own health would have rapid and sustained effects on maternal mortality in high HIV prevalence settings.
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