%0 Journal Article %J Lancet %D 2015 %T Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990-2013: quantifying the epidemiological transition. %A Murray, Christopher J L %A Barber, Ryan M %A Foreman, Kyle J %A Abbasoglu Ozgoren, Ayse %A Abd-Allah, Foad %A Abera, Semaw F %A Aboyans, Victor %A Abraham, Jerry P %A Abubakar, Ibrahim %A Abu-Raddad, Laith J %A Abu-Rmeileh, Niveen M %A Achoki, Tom %A Ackerman, Ilana N %A Ademi, Zanfina %A Adou, Arsène K %A Adsuar, José C %A Afshin, Ashkan %A Agardh, Emilie E %A Alam, Sayed Saidul %A Alasfoor, Deena %A Albittar, Mohammed I %A Alegretti, Miguel A %A Alemu, Zewdie A %A Alfonso-Cristancho, Rafael %A Alhabib, Samia %A Ali, Raghib %A Alla, François %A Allebeck, Peter %A AlMazroa, Mohammad A %A Alsharif, Ubai %A Alvarez, Elena %A Alvis-Guzmán, Nelson %A Amare, Azmeraw T %A Ameh, Emmanuel A %A Amini, Heresh %A Ammar, Walid %A Anderson, H Ross %A Anderson, Benjamin O %A Antonio, Carl Abelardo T %A Anwari, Palwasha %A Arnlöv, Johan %A Arsic Arsenijevic, Valentina S %A Artaman, Al %A Asghar, Rana J %A Assadi, Reza %A Atkins, Lydia S %A Avila, Marco A %A Awuah, Baffour %A Bachman, Victoria F %A Badawi, Alaa %A Bahit, Maria C %A Balakrishnan, Kalpana %A Banerjee, Amitava %A Barker-Collo, Suzanne L %A Barquera, Simon %A Barregard, Lars %A Barrero, Lope H %A Basu, Arindam %A Basu, Sanjay %A Basulaiman, Mohammed O %A Beardsley, Justin %A Bedi, Neeraj %A Beghi, Ettore %A Bekele, Tolesa %A Bell, Michelle L %A Benjet, Corina %A Bennett, Derrick A %A Bensenor, Isabela M %A Benzian, Habib %A Bernabe, Eduardo %A Bertozzi-Villa, Amelia %A Beyene, Tariku J %A Bhala, Neeraj %A Bhalla, Ashish %A Bhutta, Zulfiqar A %A Bienhoff, Kelly %A Bikbov, Boris %A Biryukov, Stan %A Blore, Jed D %A Blosser, Christopher D %A Blyth, Fiona M %A Bohensky, Megan A %A Bolliger, Ian W %A Bora Başara, Berrak %A Bornstein, Natan M %A Bose, Dipan %A Boufous, Soufiane %A Bourne, Rupert R A %A Boyers, Lindsay N %A Brainin, Michael %A Brayne, Carol E %A Brazinova, Alexandra %A Breitborde, Nicholas J K %A Brenner, Hermann %A Briggs, Adam D %A Brooks, Peter M %A Brown, Jonathan C %A Brugha, Traolach S %A Buchbinder, Rachelle %A Buckle, Geoffrey C %A Budke, Christine M %A Bulchis, Anne %A Bulloch, Andrew G %A Campos-Nonato, Ismael R %A Carabin, Hélène %A Carapetis, Jonathan R %A Cárdenas, Rosario %A Carpenter, David O %A Caso, Valeria %A Castañeda-Orjuela, Carlos A %A Castro, Ruben E %A Catalá-López, Ferrán %A Cavalleri, Fiorella %A Cavlin, Alanur %A Chadha, Vineet K %A Chang, Jung-Chen %A Charlson, Fiona J %A Chen, Honglei %A Chen, Wanqing %A Chiang, Peggy P %A Chimed-Ochir, Odgerel %A Chowdhury, Rajiv %A Christensen, Hanne %A Christophi, Costas A %A Cirillo, Massimo %A Coates, Matthew M %A Coffeng, Luc E %A Coggeshall, Megan S %A Colistro, Valentina %A Colquhoun, Samantha M %A Cooke, Graham S %A Cooper, Cyrus %A Cooper, Leslie T %A Coppola, Luis M %A Cortinovis, Monica %A Criqui, Michael H %A Crump, John A %A Cuevas-Nasu, Lucia %A Danawi, Hadi %A Dandona, Lalit %A Dandona, Rakhi %A Dansereau, Emily %A Dargan, Paul I %A Davey, Gail %A Davis, Adrian %A Davitoiu, Dragos V %A Dayama, Anand %A De Leo, Diego %A Degenhardt, Louisa %A del Pozo-Cruz, Borja %A Dellavalle, Robert P %A Deribe, Kebede %A Derrett, Sarah %A Des Jarlais, Don C %A Dessalegn, Muluken %A Dharmaratne, Samath D %A Dherani, Mukesh K %A Diaz-Torné, Cesar %A Dicker, Daniel %A Ding, Eric L %A Dokova, Klara %A Dorsey, E Ray %A Driscoll, Tim R %A Duan, Leilei %A Duber, Herbert C %A Ebel, Beth E %A Edmond, Karen M %A Elshrek, Yousef M %A Endres, Matthias %A Ermakov, Sergey P %A Erskine, Holly E %A Eshrati, Babak %A Esteghamati, Alireza %A Estep, Kara %A Faraon, Emerito Jose A %A Farzadfar, Farshad %A Fay, Derek F %A Feigin, Valery L %A Felson, David T %A Fereshtehnejad, Seyed-Mohammad %A Fernandes, Jefferson G %A Ferrari, Alize J %A Fitzmaurice, Christina %A Flaxman, Abraham D %A Fleming, Thomas D %A Foigt, Nataliya %A Forouzanfar, Mohammad H %A Fowkes, F Gerry R %A Paleo, Urbano Fra %A Franklin, Richard C %A Fürst, Thomas %A Gabbe, Belinda %A Gaffikin, Lynne %A Gankpé, Fortuné G %A Geleijnse, Johanna M %A Gessner, Bradford D %A Gething, Peter %A Gibney, Katherine B %A Giroud, Maurice %A Giussani, Giorgia %A Gomez Dantes, Hector %A Gona, Philimon %A Gonzalez-Medina, Diego %A Gosselin, Richard A %A Gotay, Carolyn C %A Goto, Atsushi %A Gouda, Hebe N %A Graetz, Nicholas %A Gugnani, Harish C %A Gupta, Rahul %A Gupta, Rajeev %A Gutiérrez, Reyna A %A Haagsma, Juanita %A Hafezi-Nejad, Nima %A Hagan, Holly %A Halasa, Yara A %A Hamadeh, Randah R %A Hamavid, Hannah %A Hammami, Mouhanad %A Hancock, Jamie %A Hankey, Graeme J %A Hansen, Gillian M %A Hao, Yuantao %A Harb, Hilda L %A Haro, Josep Maria %A Havmoeller, Rasmus %A Hay, Simon I %A Hay, Roderick J %A Heredia-Pi, Ileana B %A Heuton, Kyle R %A Heydarpour, Pouria %A Higashi, Hideki %A Hijar, Martha %A Hoek, Hans W %A Hoffman, Howard J %A Hosgood, H Dean %A Hossain, Mazeda %A Hotez, Peter J %A Hoy, Damian G %A Hsairi, Mohamed %A Hu, Guoqing %A Huang, Cheng %A Huang, John J %A Husseini, Abdullatif %A Huynh, Chantal %A Iannarone, Marissa L %A Iburg, Kim M %A Innos, Kaire %A Inoue, Manami %A Islami, Farhad %A Jacobsen, Kathryn H %A Jarvis, Deborah L %A Jassal, Simerjot K %A Jee, Sun Ha %A Jeemon, Panniyammakal %A Jensen, Paul N %A Jha, Vivekanand %A Jiang, Guohong %A Jiang, Ying %A Jonas, Jost B %A Juel, Knud %A Kan, Haidong %A Karch, André %A Karema, Corine K %A Karimkhani, Chante %A Karthikeyan, Ganesan %A Kassebaum, Nicholas J %A Kaul, Anil %A Kawakami, Norito %A Kazanjan, Konstantin %A Kemp, Andrew H %A Kengne, Andre P %A Keren, Andre %A Khader, Yousef S %A Khalifa, Shams Eldin A %A Khan, Ejaz A %A Khan, Gulfaraz %A Khang, Young-Ho %A Kieling, Christian %A Kim, Daniel %A Kim, Sungroul %A Kim, Yunjin %A Kinfu, Yohannes %A Kinge, Jonas M %A Kivipelto, Miia %A Knibbs, Luke D %A Knudsen, Ann Kristin %A Kokubo, Yoshihiro %A Kosen, Soewarta %A Krishnaswami, Sanjay %A Kuate Defo, Barthelemy %A Kucuk Bicer, Burcu %A Kuipers, Ernst J %A Kulkarni, Chanda %A Kulkarni, Veena S %A Kumar, G Anil %A Kyu, Hmwe H %A Lai, Taavi %A Lalloo, Ratilal %A Lallukka, Tea %A Lam, Hilton %A Lan, Qing %A Lansingh, Van C %A Larsson, Anders %A Lawrynowicz, Alicia E B %A Leasher, Janet L %A Leigh, James %A Leung, Ricky %A Levitz, Carly E %A Li, Bin %A Li, Yichong %A Li, Yongmei %A Lim, Stephen S %A Lind, Maggie %A Lipshultz, Steven E %A Liu, Shiwei %A Liu, Yang %A Lloyd, Belinda K %A Lofgren, Katherine T %A Logroscino, Giancarlo %A Looker, Katharine J %A Lortet-Tieulent, Joannie %A Lotufo, Paulo A %A Lozano, Rafael %A Lucas, Robyn M %A Lunevicius, Raimundas %A Lyons, Ronan A %A Ma, Stefan %A MacIntyre, Michael F %A Mackay, Mark T %A Majdan, Marek %A Malekzadeh, Reza %A Marcenes, Wagner %A Margolis, David J %A Margono, Christopher %A Marzan, Melvin B %A Masci, Joseph R %A Mashal, Mohammad T %A Matzopoulos, Richard %A Mayosi, Bongani M %A Mazorodze, Tasara T %A Mcgill, Neil W %A McGrath, John J %A McKee, Martin %A McLain, Abigail %A Meaney, Peter A %A Medina, Catalina %A Mehndiratta, Man Mohan %A Mekonnen, Wubegzier %A Melaku, Yohannes A %A Meltzer, Michele %A Memish, Ziad A %A Mensah, George A %A Meretoja, Atte %A Mhimbira, Francis A %A Micha, Renata %A Miller, Ted R %A Mills, Edward J %A Mitchell, Philip B %A Mock, Charles N %A Mohamed Ibrahim, Norlinah %A Mohammad, Karzan A %A Mokdad, Ali H %A Mola, Glen L D %A Monasta, Lorenzo %A Montañez Hernandez, Julio C %A Montico, Marcella %A Montine, Thomas J %A Mooney, Meghan D %A Moore, Ami R %A Moradi-Lakeh, Maziar %A Moran, Andrew E %A Mori, Rintaro %A Moschandreas, Joanna %A Moturi, Wilkister N %A Moyer, Madeline L %A Mozaffarian, Dariush %A Msemburi, William T %A Mueller, Ulrich O %A Mukaigawara, Mitsuru %A Mullany, Erin C %A Murdoch, Michele E %A Murray, Joseph %A Murthy, Kinnari S %A Naghavi, Mohsen %A Naheed, Aliya %A Naidoo, Kovin S %A Naldi, Luigi %A Nand, Devina %A Nangia, Vinay %A Narayan, K M Venkat %A Nejjari, Chakib %A Neupane, Sudan P %A Newton, Charles R %A Ng, Marie %A Ngalesoni, Frida N %A Nguyen, Grant %A Nisar, Muhammad I %A Nolte, Sandra %A Norheim, Ole F %A Norman, Rosana E %A Norrving, Bo %A Nyakarahuka, Luke %A Oh, In-Hwan %A Ohkubo, Takayoshi %A Ohno, Summer L %A Olusanya, Bolajoko O %A Opio, John Nelson %A Ortblad, Katrina %A Ortiz, Alberto %A Pain, Amanda W %A Pandian, Jeyaraj D %A Panelo, Carlo Irwin A %A Papachristou, Christina %A Park, Eun-Kee %A Park, Jae-Hyun %A Patten, Scott B %A Patton, George C %A Paul, Vinod K %A Pavlin, Boris I %A Pearce, Neil %A Pereira, David M %A Perez-Padilla, Rogelio %A Perez-Ruiz, Fernando %A Perico, Norberto %A Pervaiz, Aslam %A Pesudovs, Konrad %A Peterson, Carrie B %A Petzold, Max %A Phillips, Michael R %A Phillips, Bryan K %A Phillips, David E %A Piel, Frédéric B %A Plass, Dietrich %A Poenaru, Dan %A Polinder, Suzanne %A Pope, Daniel %A Popova, Svetlana %A Poulton, Richie G %A Pourmalek, Farshad %A Prabhakaran, Dorairaj %A Prasad, Noela M %A Pullan, Rachel L %A Qato, Dima M %A Quistberg, D Alex %A Rafay, Anwar %A Rahimi, Kazem %A Rahman, Sajjad U %A Raju, Murugesan %A Rana, Saleem M %A Razavi, Homie %A Reddy, K Srinath %A Refaat, Amany %A Remuzzi, Giuseppe %A Resnikoff, Serge %A Ribeiro, Antonio L %A Richardson, Lee %A Richardus, Jan Hendrik %A Roberts, D Allen %A Rojas-Rueda, David %A Ronfani, Luca %A Roth, Gregory A %A Rothenbacher, Dietrich %A Rothstein, David H %A Rowley, Jane T %A Roy, Nobhojit %A Ruhago, George M %A Saeedi, Mohammad Y %A Saha, Sukanta %A Sahraian, Mohammad Ali %A Sampson, Uchechukwu K A %A Sanabria, Juan R %A Sandar, Logan %A Santos, Itamar S %A Satpathy, Maheswar %A Sawhney, Monika %A Scarborough, Peter %A Schneider, Ione J %A Schöttker, Ben %A Schumacher, Austin E %A Schwebel, David C %A Scott, James G %A Seedat, Soraya %A Sepanlou, Sadaf G %A Serina, Peter T %A Servan-Mori, Edson E %A Shackelford, Katya A %A Shaheen, Amira %A Shahraz, Saeid %A Shamah Levy, Teresa %A Shangguan, Siyi %A She, Jun %A Sheikhbahaei, Sara %A Shi, Peilin %A Shibuya, Kenji %A Shinohara, Yukito %A Shiri, Rahman %A Shishani, Kawkab %A Shiue, Ivy %A Shrime, Mark G %A Sigfusdottir, Inga D %A Silberberg, Donald H %A Simard, Edgar P %A Sindi, Shireen %A Singh, Abhishek %A Singh, Jasvinder A %A Singh, Lavanya %A Skirbekk, Vegard %A Slepak, Erica Leigh %A Sliwa, Karen %A Soneji, Samir %A Søreide, Kjetil %A Soshnikov, Sergey %A Sposato, Luciano A %A Sreeramareddy, Chandrashekhar T %A Stanaway, Jeffrey D %A Stathopoulou, Vasiliki %A Stein, Dan J %A Stein, Murray B %A Steiner, Caitlyn %A Steiner, Timothy J %A Stevens, Antony %A Stewart, Andrea %A Stovner, Lars J %A Stroumpoulis, Konstantinos %A Sunguya, Bruno F %A Swaminathan, Soumya %A Swaroop, Mamta %A Sykes, Bryan L %A Tabb, Karen M %A Takahashi, Ken %A Tandon, Nikhil %A Tanne, David %A Tanner, Marcel %A Tavakkoli, Mohammad %A Taylor, Hugh R %A Te Ao, Braden J %A Tediosi, Fabrizio %A Temesgen, Awoke M %A Templin, Tara %A Ten Have, Margreet %A Tenkorang, Eric Y %A Terkawi, Abdullah S %A Thomson, Blake %A Thorne-Lyman, Andrew L %A Thrift, Amanda G %A Thurston, George D %A Tillmann, Taavi %A Tonelli, Marcello %A Topouzis, Fotis %A Toyoshima, Hideaki %A Traebert, Jefferson %A Tran, Bach X %A Trillini, Matias %A Truelsen, Thomas %A Tsilimbaris, Miltiadis %A Tuzcu, Emin M %A Uchendu, Uche S %A Ukwaja, Kingsley N %A Undurraga, Eduardo A %A Uzun, Selen B %A Van Brakel, Wim H %A van de Vijver, Steven %A van Gool, Coen H %A van Os, Jim %A Vasankari, Tommi J %A Venketasubramanian, N %A Violante, Francesco S %A Vlassov, Vasiliy V %A Vollset, Stein Emil %A Wagner, Gregory R %A Wagner, Joseph %A Waller, Stephen G %A Wan, Xia %A Wang, Haidong %A Wang, JianLi %A Wang, Linhong %A Warouw, Tati S %A Weichenthal, Scott %A Weiderpass, Elisabete %A Weintraub, Robert G %A Wenzhi, Wang %A Werdecker, Andrea %A Westerman, Ronny %A Whiteford, Harvey A %A Wilkinson, James D %A Williams, Thomas N %A Wolfe, Charles D %A Wolock, Timothy M %A Woolf, Anthony D %A Wulf, Sarah %A Wurtz, Brittany %A Xu, Gelin %A Yan, Lijing L %A Yano, Yuichiro %A Ye, Pengpeng %A Yentür, Gökalp K %A Yip, Paul %A Yonemoto, Naohiro %A Yoon, Seok-Jun %A Younis, Mustafa Z %A Yu, Chuanhua %A Zaki, Maysaa E %A Zhao, Yong %A Zheng, Yingfeng %A Zonies, David %A Zou, Xiaonong %A Salomon, Joshua A %A Lopez, Alan D %A Vos, Theo %K Aged %K Chronic Disease %K Communicable Diseases %K Female %K Global Health %K Health Transition %K Humans %K Life Expectancy %K Male %K Middle Aged %K Mortality, Premature %K Quality-Adjusted Life Years %K Socioeconomic Factors %K Wounds and Injuries %X

BACKGROUND: The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age-sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development.

METHODS: We used the published GBD 2013 data for age-specific mortality, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) to calculate DALYs and HALE for 1990, 1995, 2000, 2005, 2010, and 2013 for 188 countries. We calculated HALE using the Sullivan method; 95% uncertainty intervals (UIs) represent uncertainty in age-specific death rates and YLDs per person for each country, age, sex, and year. We estimated DALYs for 306 causes for each country as the sum of YLLs and YLDs; 95% UIs represent uncertainty in YLL and YLD rates. We quantified patterns of the epidemiological transition with a composite indicator of sociodemographic status, which we constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population. We applied hierarchical regression to DALY rates by cause across countries to decompose variance related to the sociodemographic status variable, country, and time.

FINDINGS: Worldwide, from 1990 to 2013, life expectancy at birth rose by 6·2 years (95% UI 5·6-6·6), from 65·3 years (65·0-65·6) in 1990 to 71·5 years (71·0-71·9) in 2013, HALE at birth rose by 5·4 years (4·9-5·8), from 56·9 years (54·5-59·1) to 62·3 years (59·7-64·8), total DALYs fell by 3·6% (0·3-7·4), and age-standardised DALY rates per 100 000 people fell by 26·7% (24·6-29·1). For communicable, maternal, neonatal, and nutritional disorders, global DALY numbers, crude rates, and age-standardised rates have all declined between 1990 and 2013, whereas for non-communicable diseases, global DALYs have been increasing, DALY rates have remained nearly constant, and age-standardised DALY rates declined during the same period. From 2005 to 2013, the number of DALYs increased for most specific non-communicable diseases, including cardiovascular diseases and neoplasms, in addition to dengue, food-borne trematodes, and leishmaniasis; DALYs decreased for nearly all other causes. By 2013, the five leading causes of DALYs were ischaemic heart disease, lower respiratory infections, cerebrovascular disease, low back and neck pain, and road injuries. Sociodemographic status explained more than 50% of the variance between countries and over time for diarrhoea, lower respiratory infections, and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable, maternal, neonatal, and nutritional diseases; musculoskeletal disorders; and other non-communicable diseases. However, sociodemographic status explained less than 10% of the variance in DALY rates for cardiovascular diseases; chronic respiratory diseases; cirrhosis; diabetes, urogenital, blood, and endocrine diseases; unintentional injuries; and self-harm and interpersonal violence. Predictably, increased sociodemographic status was associated with a shift in burden from YLLs to YLDs, driven by declines in YLLs and increases in YLDs from musculoskeletal disorders, neurological disorders, and mental and substance use disorders. In most country-specific estimates, the increase in life expectancy was greater than that in HALE. Leading causes of DALYs are highly variable across countries.

INTERPRETATION: Global health is improving. Population growth and ageing have driven up numbers of DALYs, but crude rates have remained relatively constant, showing that progress in health does not mean fewer demands on health systems. The notion of an epidemiological transition--in which increasing sociodemographic status brings structured change in disease burden--is useful, but there is tremendous variation in burden of disease that is not associated with sociodemographic status. This further underscores the need for country-specific assessments of DALYs and HALE to appropriately inform health policy decisions and attendant actions.

FUNDING: Bill & Melinda Gates Foundation.

%B Lancet %V 386 %P 2145-91 %8 2015 Nov 28 %G eng %N 10009 %1 http://www.ncbi.nlm.nih.gov/pubmed/26321261?dopt=Abstract %R 10.1016/S0140-6736(15)61340-X %0 Journal Article %J Lancet %D 2014 %T Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. %A Kassebaum, Nicholas J %A Bertozzi-Villa, Amelia %A Coggeshall, Megan S %A Shackelford, Katya A %A Steiner, Caitlyn %A Heuton, Kyle R %A Gonzalez-Medina, Diego %A Barber, Ryan %A Huynh, Chantal %A Dicker, Daniel %A Templin, Tara %A Wolock, Timothy M %A Ozgoren, Ayse Abbasoglu %A Abd-Allah, Foad %A Abera, Semaw Ferede %A Abubakar, Ibrahim %A Achoki, Tom %A Adelekan, Ademola %A Ademi, Zanfina %A Adou, Arsène Kouablan %A Adsuar, José C %A Agardh, Emilie E %A Akena, Dickens %A Alasfoor, Deena %A Alemu, Zewdie Aderaw %A Alfonso-Cristancho, Rafael %A Alhabib, Samia %A Ali, Raghib %A Al Kahbouri, Mazin J %A Alla, François %A Allen, Peter J %A AlMazroa, Mohammad A %A Alsharif, Ubai %A Alvarez, Elena %A Alvis-Guzmán, Nelson %A Amankwaa, Adansi A %A Amare, Azmeraw T %A Amini, Hassan %A Ammar, Walid %A Antonio, Carl A T %A Anwari, Palwasha %A Arnlöv, Johan %A Arsenijevic, Valentina S Arsic %A Artaman, Ali %A Asad, Majed Masoud %A Asghar, Rana J %A Assadi, Reza %A Atkins, Lydia S %A Badawi, Alaa %A Balakrishnan, Kalpana %A Basu, Arindam %A Basu, Sanjay %A Beardsley, Justin %A Bedi, Neeraj %A Bekele, Tolesa %A Bell, Michelle L %A Bernabe, Eduardo %A Beyene, Tariku J %A Bhutta, Zulfiqar %A Bin Abdulhak, Aref %A Blore, Jed D %A Basara, Berrak Bora %A Bose, Dipan %A Breitborde, Nicholas %A Cárdenas, Rosario %A Castañeda-Orjuela, Carlos A %A Castro, Ruben Estanislao %A Catalá-López, Ferrán %A Cavlin, Alanur %A Chang, Jung-Chen %A Che, Xuan %A Christophi, Costas A %A Chugh, Sumeet S %A Cirillo, Massimo %A Colquhoun, Samantha M %A Cooper, Leslie Trumbull %A Cooper, Cyrus %A da Costa Leite, Iuri %A Dandona, Lalit %A Dandona, Rakhi %A Davis, Adrian %A Dayama, Anand %A Degenhardt, Louisa %A De Leo, Diego %A del Pozo-Cruz, Borja %A Deribe, Kebede %A Dessalegn, Muluken %A deVeber, Gabrielle A %A Dharmaratne, Samath D %A Dilmen, Uğur %A Ding, Eric L %A Dorrington, Rob E %A Driscoll, Tim R %A Ermakov, Sergei Petrovich %A Esteghamati, Alireza %A Faraon, Emerito Jose A %A Farzadfar, Farshad %A Felicio, Manuela Mendonca %A Fereshtehnejad, Seyed-Mohammad %A de Lima, Graça Maria Ferreira %A Forouzanfar, Mohammad H %A França, Elisabeth B %A Gaffikin, Lynne %A Gambashidze, Ketevan %A Gankpé, Fortuné Gbètoho %A Garcia, Ana C %A Geleijnse, Johanna M %A Gibney, Katherine B %A Giroud, Maurice %A Glaser, Elizabeth L %A Goginashvili, Ketevan %A Gona, Philimon %A González-Castell, Dinorah %A Goto, Atsushi %A Gouda, Hebe N %A Gugnani, Harish Chander %A Gupta, Rahul %A Gupta, Rajeev %A Hafezi-Nejad, Nima %A Hamadeh, Randah Ribhi %A Hammami, Mouhanad %A Hankey, Graeme J %A Harb, Hilda L %A Havmoeller, Rasmus %A Hay, Simon I %A Pi, Ileana B Heredia %A Hoek, Hans W %A Hosgood, H Dean %A Hoy, Damian G %A Husseini, Abdullatif %A Idrisov, Bulat T %A Innos, Kaire %A Inoue, Manami %A Jacobsen, Kathryn H %A Jahangir, Eiman %A Jee, Sun Ha %A Jensen, Paul N %A Jha, Vivekanand %A Jiang, Guohong %A Jonas, Jost B %A Juel, Knud %A Kabagambe, Edmond Kato %A Kan, Haidong %A Karam, Nadim E %A Karch, André %A Karema, Corine Kakizi %A Kaul, Anil %A Kawakami, Norito %A Kazanjan, Konstantin %A Kazi, Dhruv S %A Kemp, Andrew H %A Kengne, Andre Pascal %A Kereselidze, Maia %A Khader, Yousef Saleh %A Khalifa, Shams Eldin Ali Hassan %A Khan, Ejaz Ahmed %A Khang, Young-Ho %A Knibbs, Luke %A Kokubo, Yoshihiro %A Kosen, Soewarta %A Defo, Barthelemy Kuate %A Kulkarni, Chanda %A Kulkarni, Veena S %A Kumar, G Anil %A Kumar, Kaushalendra %A Kumar, Ravi B %A Kwan, Gene %A Lai, Taavi %A Lalloo, Ratilal %A Lam, Hilton %A Lansingh, Van C %A Larsson, Anders %A Lee, Jong-Tae %A Leigh, James %A Leinsalu, Mall %A Leung, Ricky %A Li, Xiaohong %A Li, Yichong %A Li, Yongmei %A Liang, Juan %A Liang, Xiaofeng %A Lim, Stephen S %A Lin, Hsien-Ho %A Lipshultz, Steven E %A Liu, Shiwei %A Liu, Yang %A Lloyd, Belinda K %A London, Stephanie J %A Lotufo, Paulo A %A Ma, Jixiang %A Ma, Stefan %A Machado, Vasco Manuel Pedro %A Mainoo, Nana Kwaku %A Majdan, Marek %A Mapoma, Christopher Chabila %A Marcenes, Wagner %A Marzan, Melvin Barrientos %A Mason-Jones, Amanda J %A Mehndiratta, Man Mohan %A Mejia-Rodriguez, Fabiola %A Memish, Ziad A %A Mendoza, Walter %A Miller, Ted R %A Mills, Edward J %A Mokdad, Ali H %A Mola, Glen Liddell %A Monasta, Lorenzo %A de la Cruz Monis, Jonathan %A Hernandez, Julio Cesar Montañez %A Moore, Ami R %A Moradi-Lakeh, Maziar %A Mori, Rintaro %A Mueller, Ulrich O %A Mukaigawara, Mitsuru %A Naheed, Aliya %A Naidoo, Kovin S %A Nand, Devina %A Nangia, Vinay %A Nash, Denis %A Nejjari, Chakib %A Nelson, Robert G %A Neupane, Sudan Prasad %A Newton, Charles R %A Ng, Marie %A Nieuwenhuijsen, Mark J %A Nisar, Muhammad Imran %A Nolte, Sandra %A Norheim, Ole F %A Nyakarahuka, Luke %A Oh, In-Hwan %A Ohkubo, Takayoshi %A Olusanya, Bolajoko O %A Omer, Saad B %A Opio, John Nelson %A Orisakwe, Orish Ebere %A Pandian, Jeyaraj D %A Papachristou, Christina %A Park, Jae-Hyun %A Caicedo, Angel J Paternina %A Patten, Scott B %A Paul, Vinod K %A Pavlin, Boris Igor %A Pearce, Neil %A Pereira, David M %A Pesudovs, Konrad %A Petzold, Max %A Poenaru, Dan %A Polanczyk, Guilherme V %A Polinder, Suzanne %A Pope, Dan %A Pourmalek, Farshad %A Qato, Dima %A Quistberg, D Alex %A Rafay, Anwar %A Rahimi, Kazem %A Rahimi-Movaghar, Vafa %A ur Rahman, Sajjad %A Raju, Murugesan %A Rana, Saleem M %A Refaat, Amany %A Ronfani, Luca %A Roy, Nobhojit %A Pimienta, Tania Georgina Sánchez %A Sahraian, Mohammad Ali %A Salomon, Joshua A %A Sampson, Uchechukwu %A Santos, Itamar S %A Sawhney, Monika %A Sayinzoga, Felix %A Schneider, Ione J C %A Schumacher, Austin %A Schwebel, David C %A Seedat, Soraya %A Sepanlou, Sadaf G %A Servan-Mori, Edson E %A Shakh-Nazarova, Marina %A Sheikhbahaei, Sara %A Shibuya, Kenji %A Shin, Hwashin Hyun %A Shiue, Ivy %A Sigfusdottir, Inga Dora %A Silberberg, Donald H %A Silva, Andrea P %A Singh, Jasvinder A %A Skirbekk, Vegard %A Sliwa, Karen %A Soshnikov, Sergey S %A Sposato, Luciano A %A Sreeramareddy, Chandrashekhar T %A Stroumpoulis, Konstantinos %A Sturua, Lela %A Sykes, Bryan L %A Tabb, Karen M %A Talongwa, Roberto Tchio %A Tan, Feng %A Teixeira, Carolina Maria %A Tenkorang, Eric Yeboah %A Terkawi, Abdullah Sulieman %A Thorne-Lyman, Andrew L %A Tirschwell, David L %A Towbin, Jeffrey A %A Tran, Bach X %A Tsilimbaris, Miltiadis %A Uchendu, Uche S %A Ukwaja, Kingsley N %A Undurraga, Eduardo A %A Uzun, Selen Begüm %A Vallely, Andrew J %A van Gool, Coen H %A Vasankari, Tommi J %A Vavilala, Monica S %A Venketasubramanian, N %A Villalpando, Salvador %A Violante, Francesco S %A Vlassov, Vasiliy Victorovich %A Vos, Theo %A Waller, Stephen %A Wang, Haidong %A Wang, Linhong %A Wang, XiaoRong %A Wang, Yanping %A Weichenthal, Scott %A Weiderpass, Elisabete %A Weintraub, Robert G %A Westerman, Ronny %A Wilkinson, James D %A Woldeyohannes, Solomon Meseret %A Wong, John Q %A Wordofa, Muluemebet Abera %A Xu, Gelin %A Yang, Yang C %A Yano, Yuichiro %A Yentur, Gokalp Kadri %A Yip, Paul %A Yonemoto, Naohiro %A Yoon, Seok-Jun %A Younis, Mustafa Z %A Yu, Chuanhua %A Jin, Kim Yun %A El Sayed Zaki, Maysaa %A Zhao, Yong %A Zheng, Yingfeng %A Zhou, Maigeng %A Zhu, Jun %A Zou, Xiao Nong %A Lopez, Alan D %A Naghavi, Mohsen %A Murray, Christopher J L %A Lozano, Rafael %K Age Distribution %K Cause of Death %K Female %K Global Health %K HIV Infections %K Humans %K Maternal Mortality %K Models, Statistical %K Organizational Objectives %K Pregnancy %K Pregnancy Complications, Infectious %K Risk Factors %K Socioeconomic Factors %K Time Factors %X

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.

%B Lancet %V 384 %P 980-1004 %8 2014 Sep 13 %G eng %N 9947 %1 http://www.ncbi.nlm.nih.gov/pubmed/24797575?dopt=Abstract %R 10.1016/S0140-6736(14)60696-6