Comparative trends in maternal mortality around the world
The 2014 WHO et al review of maternal mortality trends showed a global decline in maternal deaths of 45% between 1990 and 2013. The global maternal mortality ratio (MMR) fell to 210 maternal deaths per 100,000 live births in 2013, compared to 380 to 100,000 in 1990. The MMR in developing regions (230) was 14 times higher than in developed regions (16). Sub-Saharan Africa has the highest regional MMR (510) and accounts for the largest proportion of global deaths at 62% (179,000), followed by southern Asia at 24% (69,000). India and Nigeria accounted for 17% and 14% of global deaths respectively.
It is important to note that mortality estimates can be generated using different data sources and methodologies. Generally, estimates from different sources show similar trends. This strengthens the evidence for an overall reduction in maternal mortality, but variations may occur due to factors such as data sources, including civil registration systems or health management information systems, which may not be fully functional or accurate: WHO et al (2014) estimate that less than 40% of countries have a complete civil registration system with good attribution of cause of death. This will have an impact on the accuracy of mortality estimates. Similarly different data sources and methodologies prevent direct comparison of some estimates.
For example, Figure 1.11 compares data provided by IHME and WHO in 2014 for Latin America and the Caribbean (LAC) region. In a blog for the Maternal Health Task Force, Affette McCaw-Binns (2014) notes that ‘When one compares and contrasts both papers (WHO, for 2003-2009; IHME, representing 2013) the relative rankings and number of deaths for LAC emerge below. They disagree on the relative burden of the three leading causes, with better agreement on less common causes. Where they vary widely is on the numbers, albeit for different periods. WHO estimated almost twice as many haemmorhage deaths and 18 times as many HIV deaths as IHME.‘
Figure 1.12 provides a country level comparison of estimates of maternal mortality from the Institute for Health Metrics and Evaluation (IHME) and the Maternal Mortality Estimation Inter-agency Group (MMEIG) using Nepal as an example.
Comparative trends in neonatal mortality (including stillbirths)
Newborn mortality data are generally captured in population based surveys such as the DHS. As with all mortality estimates the accuracy is dependent on the data sources and the classification of deaths; in particular the distinction between early, late and post-natal deaths (see definitions, below). In 2013 neonatal deaths constituted an estimated 41.6% (approximately 2.6 million) of all deaths for under-fives. This compared with 37·4% in 1990 (Wang et al 2014).
Figures 1.13 and 1.14 show that the rates of stillbirths appear to have reduced from 1995 to 2009. However a recent review found that “the number of annual stillbirths remains unchanged since 2011 and is unacceptably high: an estimated 2·6 million in 2015. Failure to consistently include global targets or indicators for stillbirth in post-2015 initiatives shows that stillbirths are hidden in the worldwide agenda”(de Bernis, Luc et al. 2016).
The rates of early neonatal deaths and late neonatal deaths appear to have reduced during this time, but early neonatal deaths are more than double the rate of late neonatal deaths. Early neonatal deaths tend to be more closely associated with pregnancy related factors and maternal health, whereas late neonatal deaths are associated more with factors in the newborn’s environment.
- World Health Organization (WHO), (Website) MDG 5: Maternal and Reproductive Health
- Affette McCaw-Binns, (2014) Commentary: WHO and IHME estimates – global, regional and national causes of maternal death
- Kassebaum, N. J. et al, (2014) Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013
- Say, L. Chou, D. Gemmill, A. Tuncalp, O. Moller, A. Daniels, J. Gulmezoglu, M. Temmerman, M. Alkema, L., (2014) Global causes of maternal death: a WHO systematic analysis
- Maternal Mortality Estimation Inter-agency Group (MMEIG), (Website) Maternal mortality estimates and related data
- Institute for Health Metrics and Evaluation (IHME), (Website) Maternal Mortality Estimates by Country 1990-2011
- Wang, H., Liddell, C., Coates, M., Moobey, M., Levitz, C et al, (2014) Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990 – 2013: A systematic analysis for the Global Burden of Disease Study 2013
- de Bernis, Luc et al., (2016) Stillbirths: ending preventable deaths by 2030