Global, regional, and national levels and trends in maternal mortality, progress towards the Sustainable Development Goals, and mortality from COVID-19 infection in pregnant women, 1990–2023: a systematic analysis for the GBD Study 2023

Abstract

Background 

Maternal mortality has decreased globally in the past three decades; however, mortality remains high in some locations and progress has plateaued or reversed in others. Updated comprehensive assessments of maternal mortality for countries and territories, including subcauses of maternal mortality, are essential to understand progress toward meeting the Sustainable Development Goal (SDG) 3.1 target for maternal mortality ratio (MMR) of fewer than 70 deaths per 100 000 livebirths and to inform ongoing and future efforts to improve maternal health. Our study aim was to assess maternal mortality levels and trends globally and for regions, countries, and territories, to report progress toward meeting SDG 3.1, and to assess pandemic-year trends in maternal mortality.

Methods 

In this systematic analysis for the Global Burden of Diseases, Injuries, and Risk Factors Study 2023, we used Cause of Death Ensemble modelling (CODEm) to estimate maternal mortality rates up to 1 year postpartum using data from vital registration, verbal autopsies, household surveys, censuses, surveillance systems, and maternal mortality audits. These estimates were combined with age-specific all-cause mortality, population, and fertility estimates to calculate maternal deaths, maternal cause fraction, and MMR (maternal deaths per 100 000 livebirths) from 1990 to 2023, by 5-year age groups from 10 years to 54 years, and for 204 countries and territories. We also estimated MMR for each of ten maternal subcauses. We assessed progress toward meeting the SDG 3.1 target by calculating MMR for women and girls aged 10–54 years, determining which countries and territories are currently meeting or close to meeting the target, assessing annualised rates of change in MMR, and identifying locations that have stagnated or reversed trends in MMR. Estimates for 2020 to 2023 capture the effects of the peak of the COVID-19 pandemic and subsequent recovery; however, pandemic effects are difficult to estimate in locations in which timely or high-quality data for pandemic years are scarce. We explored and separately reported three alternative (non-CODEm) methods of estimating COVID-19 effects for these locations: two population attributable fraction (PAF) approaches and an excess mortality approach.

Findings

In 2023, there were 240 000 (95% uncertainty interval [UI] 208 000–280 000) total maternal deaths globally, which equates to a global MMR of 190·5 (95% UI 165·1–222·5) maternal deaths per 100 000 livebirths. Maternal deaths account for 5·5% (95% UI 4·7–6·3) of all deaths among women and girls aged 10–54 years. Global MMR has decreased substantially from 1990 (321·0 [281·0–374·0]), but 104 of 204 countries and territories have yet to meet the SDG 3.1 target of MMR of less than 70. Of these 104 countries and territories, 15 had an MMR in the range of 70 to 100, 16 had an MMR between 100 and 140, and 73 had an MMR higher than 140. Most countries and territories (120 out of 204) had slower or reversed annualised rates of change in MMR during the early SDG period of 2015–23 compared with the Millennium Development Goals period of 2000–15. In some regions of the world, including the Caribbean, Latin America, high-income North America, central Asia, and central and eastern Europe, maternal deaths rose in 2020 and 2021, a departure appreciable using standard data collection and modelling methods. Using the experimental COVID-19 PAF, maternal PAF, and excess mortality approaches in locations lacking timely or high-quality data, we estimated approximately 1740 (95% UI –3380 to 8180), 23 100 (–14 900 to 90 800), and 22 900 (17 800 to 29 300) total additional maternal deaths due to the COVID-19 pandemic, respectively, for 2020 and 2021 combined.

Interpretation 

Global progress on maternal mortality slowed during the early SDG period of 2015–23 and mortality remains high in many locations. We found that 104 of 204 countries and territories have yet to meet the SDG goal of fewer than 70 maternal deaths per 100 000 livebirths. The COVID-19 pandemic increased maternal mortality in the peak pandemic years of 2020 and 2021 in many locations with high COVID-19 mortality. High-quality and timely data are essential for monitoring progress toward meeting the SDG 3.1 target, and efforts should prioritise identifying data gaps and focusing data collection in areas where data are sparse or less timely. Efforts should also continue to focus on providing high-quality, accessible, and adaptable care to prevent and manage well known obstetric complications, while also assessing and responding to health threats such as COVID-19 in 2020 and 2021.

Funding 

The Gates Foundation.