Lancet. 2016 Oct 8;388(10053):1775-1812. doi: 10.1016/S0140-6736(16)31470-2.
In transitioning from the Millennium Development Goal to the Sustainable Development Goal era, it is imperative to comprehensively assess progress toward reducing maternal mortality to identify areas of success, remaining challenges, and frame policy discussions. We aimed to quantify maternal mortality throughout the world by underlying cause and age from 1990 to 2015.
We estimated maternal mortality at the global, regional, and national levels from 1990 to 2015 for ages 10-54 years by systematically compiling and processing all available data sources from 186 of 195 countries and territories, 11 of which were analysed at the subnational level. We quantified eight underlying causes of maternal death and four timing categories, improving estimation methods since GBD 2013 for adult all-cause mortality, HIV-related maternal mortality, and late maternal death. Secondary analyses then allowed systematic examination of drivers of trends, including the relation between maternal mortality and coverage of specific reproductive health-care services as well as assessment of observed versus expected maternal mortality as a function of Socio-demographic Index (SDI), a summary indicator derived from measures of income per capita, educational attainment, and fertility.
Only ten countries achieved MDG 5, but 122 of 195 countries have already met SDG 3.1. Geographical disparities widened between 1990 and 2015 and, in 2015, 24 countries still had a maternal mortality ratio greater than 400. The proportion of all maternal deaths occurring in the bottom two SDI quintiles, where haemorrhage is the dominant cause of maternal death, increased from roughly 68% in 1990 to more than 80% in 2015. The middle SDI quintile improved the most from 1990 to 2015, but also has the most complicated causal profile. Maternal mortality in the highest SDI quintile is mostly due to other direct maternal disorders, indirect maternal disorders, and abortion, ectopic pregnancy, and/or miscarriage. Historical patterns suggest achievement of SDG 3.1 will require 91% coverage of one antenatal care visit, 78% of four antenatal care visits, 81% of in-facility delivery, and 87% of skilled birth attendance.
Several challenges to improving reproductive health lie ahead in the SDG era. Countries should establish or renew systems for collection and timely dissemination of health data; expand coverage and improve quality of family planning services, including access to contraception and safe abortion to address high adolescent fertility; invest in improving health system capacity, including coverage of routine reproductive health care and of more advanced obstetric care-including EmOC; adapt health systems and data collection systems to monitor and reverse the increase in indirect, other direct, and late maternal deaths, especially in high SDI locations; and examine their own performance with respect to their SDI level, using that information to formulate strategies to improve performance and ensure optimum reproductive health of their population.
Bill & Melinda Gates Foundation.
在从千年发展目标向可持续发展目标时代过渡的过程中，必须全面评估在降低孕产妇死亡率方面取得的进展，以确定成功领域、尚存挑战并为政策讨论提供框架。我们旨在按潜在原因和年龄对1990年至2015年期间全球的孕产妇死亡率进行量化。
我们通过系统汇编和处理来自195个国家和地区中的186个的所有可用数据源，对1990年至2015年期间10至54岁年龄段的全球、区域和国家层面的孕产妇死亡率进行了估计，其中11个在国家以下层面进行了分析。我们对孕产妇死亡的八个潜在原因和四个时间类别进行了量化，自2013年全球疾病负担研究（GBD）以来改进了成人全因死亡率、与艾滋病毒相关的孕产妇死亡率和晚期孕产妇死亡的估计方法。随后的二次分析允许系统审查趋势驱动因素，包括孕产妇死亡率与特定生殖保健服务覆盖率之间的关系，以及根据社会人口指数（SDI）（一种从人均收入、教育程度和生育率衡量指标得出的汇总指标）评估观察到的与预期的孕产妇死亡率。
只有十个国家实现了千年发展目标5，但195个国家中的122个已经实现了可持续发展目标3.1。1990年至2015年期间地理差距扩大，2015年，24个国家的孕产妇死亡率仍然高于400。在社会人口指数最低的两个五分位数中发生的所有孕产妇死亡比例中，出血是孕产妇死亡的主要原因，从1990年的约68%增加到2015年的80%以上。社会人口指数中间五分位数从1990年到2015年改善最大，但因果关系也最为复杂。社会人口指数最高五分位数的孕产妇死亡主要归因于其他直接孕产妇疾病、间接孕产妇疾病以及流产、异位妊娠和/或流产。历史模式表明，要实现可持续发展目标3.1，需要91%的产妇进行一次产前检查，78%的产妇进行四次产前检查，81%的产妇在医疗机构分娩，87%的产妇由熟练的助产士接生。
在可持续发展目标时代，改善生殖健康面临若干挑战。各国应建立或更新卫生数据收集和及时传播系统；扩大计划生育服务的覆盖范围并提高其质量，包括提供避孕措施和安全堕胎服务以应对高青少年生育率；投资改善卫生系统能力，包括常规生殖保健服务和更先进的产科护理（包括紧急产科护理）的覆盖范围；调整卫生系统和数据收集系统，以监测并扭转间接、其他直接和晚期孕产妇死亡的增加趋势，特别是在社会人口指数较高的地区；并根据其社会人口指数水平审视自身表现，利用这些信息制定战略以提高表现并确保其人口的最佳生殖健康。
比尔及梅琳达·盖茨基金会。
