%0 Journal Article %J Lancet %D 2015 %T Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. %A Forouzanfar, Mohammad H %A Alexander, Lily %A Anderson, H Ross %A Bachman, Victoria F %A Biryukov, Stan %A Brauer, Michael %A Burnett, Richard %A Casey, Daniel %A Coates, Matthew M %A Cohen, Aaron %A Delwiche, Kristen %A Estep, Kara %A Frostad, Joseph J %A Astha, K C %A Kyu, Hmwe H %A Moradi-Lakeh, Maziar %A Ng, Marie %A Slepak, Erica Leigh %A Thomas, Bernadette A %A Wagner, Joseph %A Aasvang, Gunn Marit %A Abbafati, Cristiana %A Abbasoglu Ozgoren, Ayse %A Abd-Allah, Foad %A Abera, Semaw F %A Aboyans, Victor %A Abraham, Biju %A Abraham, Jerry Puthenpurakal %A Abubakar, Ibrahim %A Abu-Rmeileh, Niveen M E %A Aburto, Tania C %A Achoki, Tom %A Adelekan, Ademola %A Adofo, Koranteng %A Adou, Arsène K %A Adsuar, José C %A Afshin, Ashkan %A Agardh, Emilie E %A Al Khabouri, Mazin J %A Al Lami, Faris H %A Alam, Sayed Saidul %A Alasfoor, Deena %A Albittar, Mohammed I %A Alegretti, Miguel A %A Aleman, Alicia V %A Alemu, Zewdie A %A Alfonso-Cristancho, Rafael %A Alhabib, Samia %A Ali, Raghib %A Ali, Mohammed K %A Alla, François %A Allebeck, Peter %A Allen, Peter J %A Alsharif, Ubai %A Alvarez, Elena %A Alvis-Guzmán, Nelson %A Amankwaa, Adansi A %A Amare, Azmeraw T %A Ameh, Emmanuel A %A Ameli, Omid %A Amini, Heresh %A Ammar, Walid %A Anderson, Benjamin O %A Antonio, Carl Abelardo T %A Anwari, Palwasha %A Argeseanu Cunningham, Solveig %A Arnlöv, Johan %A Arsenijevic, Valentina S Arsic %A Artaman, Al %A Asghar, Rana J %A Assadi, Reza %A Atkins, Lydia S %A Atkinson, Charles %A Avila, Marco A %A Awuah, Baffour %A Badawi, Alaa %A Bahit, Maria C %A Bakfalouni, Talal %A Balakrishnan, Kalpana %A Balalla, Shivanthi %A Balu, Ravi Kumar %A Banerjee, Amitava %A Barber, Ryan M %A Barker-Collo, Suzanne L %A Barquera, Simon %A Barregard, Lars %A Barrero, Lope H %A Barrientos-Gutierrez, Tonatiuh %A Basto-Abreu, Ana C %A Basu, Arindam %A Basu, Sanjay %A Basulaiman, Mohammed O %A Batis Ruvalcaba, Carolina %A Beardsley, Justin %A Bedi, Neeraj %A Bekele, Tolesa %A Bell, Michelle L %A Benjet, Corina %A Bennett, Derrick A %A Benzian, Habib %A Bernabe, Eduardo %A Beyene, Tariku J %A Bhala, Neeraj %A Bhalla, Ashish %A Bhutta, Zulfiqar A %A Bikbov, Boris %A Bin Abdulhak, Aref A %A Blore, Jed D %A Blyth, Fiona M %A Bohensky, Megan A %A Bora Başara, Berrak %A Borges, Guilherme %A Bornstein, Natan M %A Bose, Dipan %A Boufous, Soufiane %A Bourne, Rupert R %A Brainin, Michael %A Brazinova, Alexandra %A Breitborde, Nicholas J %A Brenner, Hermann %A Briggs, Adam D M %A Broday, David M %A Brooks, Peter M %A Bruce, Nigel G %A Brugha, Traolach S %A Brunekreef, Bert %A Buchbinder, Rachelle %A Bui, Linh N %A Bukhman, Gene %A Bulloch, Andrew G %A Burch, Michael %A Burney, Peter G J %A Campos-Nonato, Ismael R %A Campuzano, Julio C %A Cantoral, Alejandra J %A Caravanos, Jack %A Cárdenas, Rosario %A Cardis, Elisabeth %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 Chen, Zhengming %A Chiang, Peggy P %A Chimed-Ochir, Odgerel %A Chowdhury, Rajiv %A Christophi, Costas A %A Chuang, Ting-Wu %A Chugh, Sumeet S %A Cirillo, Massimo %A Claßen, Thomas K D %A Colistro, Valentina %A Colomar, Mercedes %A Colquhoun, Samantha M %A Contreras, Alejandra G %A Cooper, Cyrus %A Cooperrider, Kimberly %A Cooper, Leslie T %A Coresh, Josef %A Courville, Karen J %A Criqui, Michael H %A Cuevas-Nasu, Lucia %A Damsere-Derry, James %A Danawi, Hadi %A Dandona, Lalit %A Dandona, Rakhi %A Dargan, Paul I %A Davis, Adrian %A Davitoiu, Dragos V %A Dayama, Anand %A de Castro, E Filipa %A De la Cruz-Góngora, Vanessa %A De Leo, Diego %A de Lima, Graça %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 deVeber, Gabrielle A %A Devries, Karen M %A Dharmaratne, Samath D %A Dherani, Mukesh K %A Dicker, Daniel %A Ding, Eric L %A Dokova, Klara %A Dorsey, E Ray %A Driscoll, Tim R %A Duan, Leilei %A Durrani, Adnan M %A Ebel, Beth E %A Ellenbogen, Richard G %A Elshrek, Yousef M %A Endres, Matthias %A Ermakov, Sergey P %A Erskine, Holly E %A Eshrati, Babak %A Esteghamati, Alireza %A Fahimi, Saman %A Faraon, Emerito Jose A %A Farzadfar, Farshad %A Fay, Derek F J %A Feigin, Valery L %A Feigl, Andrea B %A Fereshtehnejad, Seyed-Mohammad %A Ferrari, Alize J %A Ferri, Cleusa P %A Flaxman, Abraham D %A Fleming, Thomas D %A Foigt, Nataliya %A Foreman, Kyle J %A Paleo, Urbano Fra %A Franklin, Richard C %A Gabbe, Belinda %A Gaffikin, Lynne %A Gakidou, Emmanuela %A Gamkrelidze, Amiran %A Gankpé, Fortuné G %A Gansevoort, Ron T %A García-Guerra, Francisco A %A Gasana, Evariste %A Geleijnse, Johanna M %A Gessner, Bradford D %A Gething, Pete %A Gibney, Katherine B %A Gillum, Richard F %A Ginawi, Ibrahim A M %A Giroud, Maurice %A Giussani, Giorgia %A Goenka, Shifalika %A Goginashvili, Ketevan %A Gomez Dantes, Hector %A Gona, Philimon %A Gonzalez de Cosio, Teresita %A González-Castell, Dinorah %A Gotay, Carolyn C %A Goto, Atsushi %A Gouda, Hebe N %A Guerrant, Richard L %A Gugnani, Harish C %A Guillemin, Francis %A Gunnell, David %A Gupta, Rahul %A Gupta, Rajeev %A Gutiérrez, Reyna A %A Hafezi-Nejad, Nima %A Hagan, Holly %A Hagstromer, Maria %A Halasa, Yara A %A Hamadeh, Randah R %A Hammami, Mouhanad %A Hankey, Graeme J %A Hao, Yuantao %A Harb, Hilda L %A Haregu, Tilahun Nigatu %A Haro, Josep Maria %A Havmoeller, Rasmus %A Hay, Simon I %A Hedayati, Mohammad T %A Heredia-Pi, Ileana B %A Hernandez, Lucia %A Heuton, Kyle R %A Heydarpour, Pouria %A Hijar, Martha %A Hoek, Hans W %A Hoffman, Howard J %A Hornberger, John C %A Hosgood, H Dean %A Hoy, Damian G %A Hsairi, Mohamed %A Hu, Guoqing %A Hu, Howard %A Huang, Cheng %A Huang, John J %A Hubbell, Bryan J %A Huiart, Laetitia %A Husseini, Abdullatif %A Iannarone, Marissa L %A Iburg, Kim M %A Idrisov, Bulat T %A Ikeda, Nayu %A Innos, Kaire %A Inoue, Manami %A Islami, Farhad %A Ismayilova, Samaya %A Jacobsen, Kathryn H %A Jansen, Henrica A %A Jarvis, Deborah L %A Jassal, Simerjot K %A Jauregui, Alejandra %A Jayaraman, Sudha %A Jeemon, Panniyammakal %A Jensen, Paul N %A Jha, Vivekanand %A Jiang, Fan %A Jiang, Guohong %A Jiang, Ying %A Jonas, Jost B %A Juel, Knud %A Kan, Haidong %A Kany Roseline, Sidibe S %A Karam, Nadim E %A Karch, André %A Karema, Corine K %A Karthikeyan, Ganesan %A Kaul, Anil %A Kawakami, Norito %A Kazi, Dhruv S %A Kemp, Andrew H %A Kengne, Andre P %A Keren, Andre %A Khader, Yousef S %A Khalifa, Shams Eldin Ali Hassan %A Khan, Ejaz A %A Khang, Young-Ho %A Khatibzadeh, Shahab %A Khonelidze, Irma %A Kieling, Christian %A Kim, Daniel %A Kim, Sungroul %A Kim, Yunjin %A Kimokoti, Ruth W %A Kinfu, Yohannes %A Kinge, Jonas M %A Kissela, Brett M %A Kivipelto, Miia %A Knibbs, Luke D %A Knudsen, Ann Kristin %A Kokubo, Yoshihiro %A Kose, M Rifat %A Kosen, Soewarta %A Kraemer, Alexander %A Kravchenko, Michael %A Krishnaswami, Sanjay %A Kromhout, Hans %A Ku, Tiffany %A Kuate Defo, Barthelemy %A Kucuk Bicer, Burcu %A Kuipers, Ernst J %A Kulkarni, Chanda %A Kulkarni, Veena S %A Kumar, G Anil %A Kwan, Gene F %A Lai, Taavi %A Lakshmana Balaji, Arjun %A Lalloo, Ratilal %A Lallukka, Tea %A Lam, Hilton %A Lan, Qing %A Lansingh, Van C %A Larson, Heidi J %A Larsson, Anders %A Laryea, Dennis O %A Lavados, Pablo M %A Lawrynowicz, Alicia E %A Leasher, Janet L %A Lee, Jong-Tae %A Leigh, James %A Leung, Ricky %A Levi, Miriam %A Li, Yichong %A Li, Yongmei %A Liang, Juan %A Liang, Xiaofeng %A Lim, Stephen S %A Lindsay, M Patrice %A Lipshultz, Steven E %A Liu, Shiwei %A Liu, Yang %A Lloyd, Belinda K %A Logroscino, Giancarlo %A London, Stephanie J %A Lopez, Nancy %A Lortet-Tieulent, Joannie %A Lotufo, Paulo A %A Lozano, Rafael %A Lunevicius, Raimundas %A Ma, Jixiang %A Ma, Stefan %A Machado, Vasco M P %A MacIntyre, Michael F %A Magis-Rodriguez, Carlos %A Mahdi, Abbas A %A Majdan, Marek %A Malekzadeh, Reza %A Mangalam, Srikanth %A Mapoma, Christopher C %A Marape, Marape %A Marcenes, Wagner %A Margolis, David J %A Margono, Christopher %A Marks, Guy B %A Martin, Randall V %A Marzan, Melvin B %A Mashal, Mohammad T %A Masiye, Felix %A Mason-Jones, Amanda J %A Matsushita, Kunihiro %A Matzopoulos, Richard %A Mayosi, Bongani M %A Mazorodze, Tasara T %A McKay, Abigail C %A McKee, Martin %A McLain, Abigail %A Meaney, Peter A %A Medina, Catalina %A Mehndiratta, Man Mohan %A Mejia-Rodriguez, Fabiola %A Mekonnen, Wubegzier %A Melaku, Yohannes A %A Meltzer, Michele %A Memish, Ziad A %A Mendoza, Walter %A Mensah, George A %A Meretoja, Atte %A Mhimbira, Francis Apolinary %A Micha, Renata %A Miller, Ted R %A Mills, Edward J %A Misganaw, Awoke %A Mishra, Santosh %A Mohamed Ibrahim, Norlinah %A Mohammad, Karzan A %A Mokdad, Ali H %A Mola, Glen L %A Monasta, Lorenzo %A Montañez Hernandez, Julio C %A Montico, Marcella %A Moore, Ami R %A Morawska, Lidia %A Mori, Rintaro %A Moschandreas, Joanna %A Moturi, Wilkister N %A Mozaffarian, Dariush %A Mueller, Ulrich O %A Mukaigawara, Mitsuru %A Mullany, Erin C %A Murthy, Kinnari S %A Naghavi, Mohsen %A Nahas, Ziad %A Naheed, Aliya %A Naidoo, Kovin S %A Naldi, Luigi %A Nand, Devina %A Nangia, Vinay %A Narayan, K M Venkat %A Nash, Denis %A Neal, Bruce %A Nejjari, Chakib %A Neupane, Sudan P %A Newton, Charles R %A Ngalesoni, Frida N %A Ngirabega, Jean de Dieu %A Nguyen, Grant %A Nguyen, Nhung T %A Nieuwenhuijsen, Mark J %A Nisar, Muhammad I %A Nogueira, José R %A Nolla, Joan M %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 Olusanya, Bolajoko O %A Omer, Saad B %A Opio, John Nelson %A Orozco, Ricardo %A Pagcatipunan, Rodolfo S %A Pain, Amanda W %A Pandian, Jeyaraj D %A Panelo, Carlo Irwin A %A Papachristou, Christina %A Park, Eun-Kee %A Parry, Charles D %A Paternina Caicedo, Angel J %A Patten, Scott B %A Paul, Vinod K %A Pavlin, Boris I %A Pearce, Neil %A Pedraza, Lilia S %A Pedroza, Andrea %A Pejin Stokic, Ljiljana %A Pekericli, Ayfer %A Pereira, David M %A Perez-Padilla, Rogelio %A Perez-Ruiz, Fernando %A Perico, Norberto %A Perry, Samuel A L %A Pervaiz, Aslam %A Pesudovs, Konrad %A Peterson, Carrie B %A Petzold, Max %A Phillips, Michael R %A Phua, Hwee Pin %A Plass, Dietrich %A Poenaru, Dan %A Polanczyk, Guilherme V %A Polinder, Suzanne %A Pond, Constance D %A Pope, C Arden %A Pope, Daniel %A Popova, Svetlana %A Pourmalek, Farshad %A Powles, John %A Prabhakaran, Dorairaj %A Prasad, Noela M %A Qato, Dima M %A Quezada, Amado D %A Quistberg, D Alex A %A Racapé, Lionel %A Rafay, Anwar %A Rahimi, Kazem %A Rahimi-Movaghar, Vafa %A Rahman, Sajjad Ur %A Raju, Murugesan %A Rakovac, Ivo %A 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Shaddick, Gavin %A Shahraz, Saeid %A Levy, Teresa Shamah %A Shangguan, Siyi %A She, Jun %A Sheikhbahaei, Sara %A Shibuya, Kenji %A Shin, Hwashin H %A Shinohara, Yukito %A Shiri, Rahman %A Shishani, Kawkab %A Shiue, Ivy %A Sigfusdottir, Inga D %A Silberberg, Donald H %A Simard, Edgar P %A Sindi, Shireen %A Singh, Abhishek %A Singh, Gitanjali M %A Singh, Jasvinder A %A Skirbekk, Vegard %A Sliwa, Karen %A Soljak, Michael %A Soneji, Samir %A Søreide, Kjetil %A Soshnikov, Sergey %A Sposato, Luciano A %A Sreeramareddy, Chandrashekhar T %A Stapelberg, Nicolas J C %A Stathopoulou, Vasiliki %A Steckling, Nadine %A Stein, Dan J %A Stein, Murray B %A Stephens, Natalie %A Stöckl, Heidi %A Straif, Kurt %A Stroumpoulis, Konstantinos %A Sturua, Lela %A Sunguya, Bruno F %A Swaminathan, Soumya %A Swaroop, Mamta %A Sykes, Bryan L %A Tabb, Karen M %A Takahashi, Ken %A Talongwa, Roberto T %A Tandon, Nikhil %A Tanne, David %A Tanner, Marcel %A Tavakkoli, Mohammad %A Te Ao, Braden J %A Teixeira, Carolina M 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%A Wang, Haidong %A Wang, JianLi %A Wang, Linhong %A Wang, Wenzhi %A Wang, Yanping %A Warouw, Tati S %A Watts, Charlotte H %A Weichenthal, Scott %A Weiderpass, Elisabete %A Weintraub, Robert G %A Werdecker, Andrea %A Wessells, K Ryan %A Westerman, Ronny %A Whiteford, Harvey A %A Wilkinson, James D %A Williams, Hywel C %A Williams, Thomas N %A Woldeyohannes, Solomon M %A Wolfe, Charles D A %A Wong, John Q %A Woolf, Anthony D %A Wright, Jonathan L %A Wurtz, Brittany %A Xu, Gelin %A Yan, Lijing L %A Yang, Gonghuan %A Yano, Yuichiro %A Ye, Pengpeng %A Yenesew, Muluken %A Yentür, Gökalp K %A Yip, Paul %A Yonemoto, Naohiro %A Yoon, Seok-Jun %A Younis, Mustafa Z %A Younoussi, Zourkaleini %A Yu, Chuanhua %A Zaki, Maysaa E %A Zhao, Yong %A Zheng, Yingfeng %A Zhou, Maigeng %A Zhu, Jun %A Zhu, Shankuan %A Zou, Xiaonong %A Zunt, Joseph R %A Lopez, Alan D %A Vos, Theo %A Murray, Christopher J %X

BACKGROUND: The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution.

METHODS: Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk-outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990-2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian meta-regression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol.

FINDINGS: All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8-58·5) of deaths and 41·6% (40·1-43·0) of DALYs. Risks quantified account for 87·9% (86·5-89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa.

INTERPRETATION: Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks.

FUNDING: Bill & Melinda Gates Foundation.

%B Lancet %V 386 %P 2287-323 %8 2015 Dec 5 %G eng %N 10010 %1 http://www.ncbi.nlm.nih.gov/pubmed/26364544?dopt=Abstract %R 10.1016/S0140-6736(15)00128-2 %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