Elsevier

The Lancet

Volume 375, Issue 9726, 8–14 May 2010, Pages 1609-1623
The Lancet

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Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5

https://doi.org/10.1016/S0140-6736(10)60518-1Get rights and content

Summary

Background

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. We assessed levels and trends in maternal mortality for 181 countries.

Methods

We 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. We used robust analytical methods to generate estimates of maternal deaths and the MMR for each year between 1980 and 2008. We explored the sensitivity of our data to model specification and show the out-of-sample predictive validity of our methods.

Findings

We 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 MMR decreased from 422 (358–505) in 1980 to 320 (272–388) in 1990, and was 251 (221–289) per 100 000 livebirths in 2008. The yearly rate of decline of the global MMR since 1990 was 1·3% (1·0–1·5). During 1990–2008, rates of yearly decline in the MMR 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.

Interpretation

Substantial, albeit varied, progress has been made towards MDG 5. Although only 23 countries are on track to achieve a 75% decrease in MMR by 2015, countries such as Egypt, China, Ecuador, and Bolivia have been achieving accelerated progress.

Funding

Bill & Melinda Gates Foundation.

Introduction

Maternal mortality—the death of women during pregnancy, childbirth, or in the 42 days after delivery—remains a major challenge to health systems worldwide. Global initiatives to intensify policy intervention for maternal mortality began with the Safe Motherhood Initiative in 1987,1 a response to growing recognition that primary health-care programmes in many developing countries were not adequately focused on maternal health.2 The 1994 International Conference on Population and Development strengthened international commitment to reproductive health.3, 4 The focus on maternal mortality was sharpened when reduction in maternal mortality became one of eight goals for development in the Millennium Declaration (Millennium Development Goal [MDG] 5).5 The target for MDG 5 is to reduce the maternal mortality ratio (MMR) by three-quarters from 1990 to 2015.6 There is a widespread perception that progress in maternal mortality has been slow, and in many places non-existent.7, 8, 9 Acceleration of progress in maternal mortality has received renewed policy attention in the USA through the Obama administration's proposed Global Health Initiative,10 and high-profile civil society groups such as the White Ribbon Alliance continue to bring further attention.

The need for accurate monitoring of maternal mortality has long been recognised, both to advocate for resources and policy attention and to track progress.11, 12, 13 Maternal mortality, however, is considered very difficult to measure.14, 15, 16, 17 Several efforts have been made over nearly three decades to improve the quality of information about maternal mortality, including the incorporation of sibling history modules in the Demographic and Health Surveys (DHS) and similar surveys;18, 19 the inclusion of questions about whether recent deaths were related to pregnancy in censuses;20, 21 and the use of record linkage or confidential enquiry to identify under-registration of maternal deaths in vital registration systems.22, 23

Beginning in 1996, WHO sponsored the development of country estimates of maternal mortality for 1990, 1995, 2000, and 2005.24, 25, 26, 27 The most recent assessment of maternal mortality, which was jointly sponsored by WHO, UNICEF, UNFPA, and the World Bank, reported 576 300 maternal deaths globally in 1990, and 535 900 maternal deaths in 2005—a 0·48% yearly rate of decline.7 The corresponding decrease in the global MMR (the number of maternal deaths per 100 000 livebirths) was 0·37% per year. As a separate analysis, Hill and colleagues7 estimated a rate of decline of 2·5% per year for a subset of 125 countries with more than one observation. For the two results to be consistent, a substantial proportion of the countries without multiple observations must have had increases in the MMR.

In view of the continued prominence of maternal mortality as a health and development goal, global rates and trends in maternal mortality need to be reassessed. Recent developments provide an opportunity for substantially improved estimates of maternal mortality. First, the Global Burden of Disease (GBD) study28 has undertaken a detailed analysis of vital registration data to identify misclassified deaths from causes such as maternal mortality. Second, methodological advances allow for the correction of known biases in survey sibling history data, including whether sibling deaths are from maternal causes.29 Third, population-based verbal autopsy studies have been done that measure maternal mortality both nationally and subnationally. Fourth, a systematic assessment of data sources for adult female mortality has provided estimates of mortality for women of reproductive age (15–49 years) from 1970 to 2010.30 Finally, methodological developments in other areas have provided improved methods for estimation. In this study, we used all available data to assess levels and trends in maternal mortality from 1980 to 2008 for 181 countries.

Section snippets

Definitions

Table 1 classifies, by timing and cause, the types of maternal deaths among pregnant or recently pregnant (up to 1 year) women that can be captured by different data systems. Deaths during pregnancy or less than 42 days after termination of pregnancy were defined as early, and those after 42 days up to 1 year were defined as late. Four groups of causes were identified: direct obstetric causes, causes aggravated by pregnancy (often called indirect), HIV infection, and incidental causes unrelated

Results

Table 2 shows the source of the 2651 observations included in the dataset. Vital registration data were the dominant source, accounting for 2186 (82%) of the total observations. Other sources contributed 465 observations. 21 countries had no empirical observations during 1980–2008 (webappendix p 10), the largest of which were Angola and Saudi Arabia in terms of births; together these countries accounted for 2·2% of global births. As a region, north Africa and the Middle East was particularly

Discussion

Our analysis of all available data for maternal mortality from 1980 to 2008 for 181 countries has shown a substantial decline in maternal deaths. Progress overall would have been greater if the HIV epidemic had not contributed to substantial increases in maternal mortality in eastern and southern Africa. Global progress to reduce the MMR has been similar to progress to reduce maternal deaths, since the size of the global birth cohort has changed little during this period. Across countries,

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