2000 to 2017 TRENDS IN MATERNAL MORTALITY Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population DivisionFor more information, please contact: Department of Reproductive Health and Research World Health Organization Avenue Appia 20 CH-1211 Geneva 27 Switzerland Email: reproductivehealth@who.int www.who.int/reproductivehealth Executive summary WHO/RHR/19.23 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). 1Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division EXECUTIVE SUMMARY Background The Sustainable Development Goals (SDGs) were launched on 25 September 2015 and came into force on 1 January 2016 for the 15-year period until 31 December 2030. Among the 17 SDGs, the direct health- related targets come under SDG 3: Ensure healthy lives and promote well-being for all at all ages. With the adoption of the SDGs, the United Nations Member States extended the global commitments they had made in 2000 to the Millennium Development Goals (MDGs), which covered the period until 2015. In anticipation of the launch of the SDGs, the World Health Organization (WHO) released a consensus statement and full strategy paper on ending preventable maternal mortality (EPMM). The EPMM target for reducing the global maternal mortality ratio (MMR) by 2030 was adopted as SDG target 3.1: reduce global MMR to less than 70 per 100 000 live births by 2030. Having targets for mortality reduction is important, but accurate measurement of maternal mortality remains challenging and many deaths still go uncounted. Many countries still lack well functioning civil registration and vital statistics (CRVS) systems, and where such systems do exist, reporting errors – whether incompleteness (unregistered deaths, also known as “missing”) or misclassification of cause of death – continue to pose a major challenge to data accuracy. Methods and interpretation The United Nations Maternal Mortality Estimation Inter- Agency Group (UN MMEIG) – comprising WHO, the United Nations Children (UNICEF), the United Nations Population Fund (UNFPA), the World Bank Group 1 Estimates have been computed to ensure comparability across countries, thus they are not necessarily the same as official statistics of the countries, which may use alternative rigorous methods. 2 Puerto Rico is an Associate Member, and the West Bank and Gaza Strip is a member in the regional committee for the WHO Eastern Mediterranean Region. 3 Available at: www.who.int/reproductivehealth/publications/maternal-mortality-2017/en/. and the United Nations Population Division (UNPD) of the Department of Economic and Social Affairs – has collaborated with external technical experts on a new round of estimates for 2000–2017. To provide increasingly accurate MMR estimates, the previous estimation methods have been refined to optimize use of country-level data. Consultations with countries were carried out during May and June 2019. This process generated additional data for inclusion in the maternal mortality estimation model, demonstrating widespread expansion of in-country efforts to monitor maternal mortality. This report presents internationally comparable global, regional and country-level estimates and trends for maternal mortality between 2000 and 2017.1 Countries and territories included in the analyses are WHO Member States with populations over 100 000 in 2019, plus two territories (Puerto Rico, and the West Bank and Gaza Strip).2 The results described in this summary are the first available estimates for maternal mortality for the SDG reporting period; but since two years (2016 and 2017) is not sufficient to show trends, estimates have been developed and presented covering the period 2000 to 2017. The new estimates presented in this report supersede all previously published estimates for years that fall within the same time period. Care should be taken to use only these estimates for the interpretation of trends in maternal mortality from 2000 to 2017; due to modifications in methodology and data availability, differences between these and previous estimates should not be interpreted as representing time trends. In addition, when interpreting changes in MMRs over time, one should take into consideration that it is easier to reduce the MMR when the level is high than when the MMR level is already low. The full database, country profiles and all model specification codes used are available online.3 2 Trends in maternal mortality: 2000 2017 4 All uncertainty intervals (UIs) reported are 80% UI. The data can be interpreted as meaning that there is an 80% chance that the true value lies within the UI, a 10% chance that the true value lies below the lower limit and a 10% chance that the true value lies above the upper limit. 5 For the purpose of categorization, MMR is considered to be low if it is less than 100, moderate if it is 100–299, high if it is 300–499, very high if it is 500–999 and extremely high if it is equal to or higher than 1000 maternal deaths per 100 000 live births. Global estimates for 2017 and trends for 2000– 2017 The global estimates for the year 2017 indicate that there were 295 000 (UI 279 000 to 340 000)4 maternal deaths; 35% lower than in 2000 when there were an estimated 451 000 (UI 431 000 to 485 000) maternal deaths. The global MMR in 2017 is estimated at 211 (UI 199 to 243) maternal deaths per 100 000 live births, representing a 38% reduction since 2000, when it was estimated at 342. The average annual rate of reduction (ARR) in global MMR during the 2000–2017 period was 2.9%; this means that, on average, the global MMR declined by 2.9% every year between 2000 and 2017. The global lifetime risk of maternal mortality for a 15-year-old girl in 2017 was estimated at 1 in 190; nearly half of the level of risk in 2000: 1 in 100. The overall proportion of deaths to women of reproductive age (15–49 years) that are due to maternal causes (PM) was estimated at 9.2% (UI 8.7% to 10.6%) in 2017 – down by 26.3% since 2000. This means that compared with other causes of death to women of reproductive age, the fraction attributed to maternal causes is decreasing. In addition, the effect of HIV on maternal mortality in 2017 appears to be less pronounced than in earlier years; HIV-related indirect maternal deaths now account for approximately 1% of all maternal deaths compared with 2.5 % in 2005, at the peak of the epidemic. Regional and country-level estimates for 2017 MMR in the world’s least developed countries (LDCs) is high,5 estimated at 415 maternal deaths per 100 000 live births (UI 396 to 477), which is more than 40 times higher than that for MMR in Europe (10; UI 9 to 11), and almost 60 times higher than in Australia and New Zealand (7; UI 6 to 8). In the world’s LDCs, where an estimated 130 000 maternal deaths occurred in 2017, the estimated lifetime risk of maternal death was 1 in 56. Sub-Saharan Africa is the only region with very high MMR for 2017, estimated at 542 (UI 498 to 649), while the lifetime risk of maternal death was 1 in 37, compared with just 1 in 7800 in Australia and New Zealand. Moderate MMR (100–299) was estimated in Northern Africa, Oceania (excluding Australia and New Zealand), Southern Asia, South-Eastern Asia and in small island developing states. Four subregions (Australia and New Zealand, Central Asia, Eastern Asia, Western Asia) and two regions (Latin America and the Caribbean, and Europe and Northern America) have low MMR (< 100 maternal deaths per 100 000 live births) (see Table 1). Sub-Saharan Africa and Southern Asia accounted for approximately 86% (254 000) of the estimated global maternal deaths in 2017 with sub-Saharan Africa alone accounting for roughly 66% (196 000), while Southern Asia accounted for nearly 20% (58 000). South-Eastern Asia, in addition, accounted for over 5% of global maternal deaths (16 000). Three countries are estimated to have had extremely high MMR in 2017 (defined as over 1000 maternal deaths per 100 000 live births): South Sudan (1150; UI 789 to 1710), Chad (1140; UI 847 to 1590) and Sierra Leone (1120; UI 808 to 1620). Sixteen other countries, all also in sub-Saharan Africa except for one (Afghanistan), had very high MMR in 2017 (i.e. estimates ranging between 500 and 999). Only three countries in sub-Saharan Africa had low MMR: Mauritius (61; UI 46 to 85), Cabo Verde (58; UI 45 to 75) and Seychelles (53; UI 26 to 109). Only one country outside the sub-Saharan African region had high MMR: Haiti (480; UI 346 to 718). Ninety countries were estimated to have MMR of 50 or less in 2017. Nigeria and India had the highest estimated numbers of maternal deaths, accounting for approximately one third (35%) of estimated global maternal deaths in 2017, with approximately 67 000 and 35 000 maternal deaths (23% and 12% of global maternal deaths), respectively. Three other countries also had 10 000 maternal deaths or more: the Democratic Republic of the Congo (16 000), Ethiopia (14 000) and the United Republic of Tanzania (11 000). Sixty-one countries were estimated to have had just 10 or fewer maternal deaths in 2017. 3Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division EXECUTIVE SUMMARY Table 1. Estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), number of maternal deaths, lifetime risk and proportion of deaths among women of reproductive age that are due to maternal causes (PM), by United Nations Sustainable Development Goal (SDG) region, subregion and other grouping, 2017 UI: uncertainty interval. a The country groupings are based on the geographic regions defined under the Standard Country or Area Codes for Statistical Use (known as M49) https://unstats.un.org/sdgs/report/2019/regional-groups/. b MMR estimates have been rounded according to the following scheme: < 100 rounded to nearest 1; 100–999 rounded to nearest 1; and ≥ 1000 rounded to nearest 10, and all calculations are based on rounded numbers. c Numbers of maternal deaths have been rounded according to the following scheme: < 100 rounded to nearest 1; 100–999 rounded to nearest 10; 1000–9999 rounded to nearest 100; and ≥ 10 000 rounded to nearest 1000. d Lifetime risk numbers have been rounded according to the following scheme: < 100 rounded to nearest 1; 100–999 rounded to nearest 10; and ≥ 1000 rounded to nearest 100. e The number of maternal deaths in a given time period divided by the total deaths among women aged 15–49 years. SDG regiona MMRa point estimate and range of uncertainty interval (UI: 80%) Number of maternal deathsb Lifetime risk of maternal deathc PMd (%) Lower UI MMR point estimate Upper UI World 199 211 243 295 000 190 9.2 Sub-Saharan Africa 498 542 649 196 000 37 18.2 Northern Africa and Western Asia 73 84 104 9 700 380 5.9 Northern Africa 91 112 145 6 700 260 8.4 Western Asia 45 55 69 3 000 650 3.6 Central and Southern Asia 131 151 181 58 000 260 6.6 Central Asia 21 24 28 390 1 400 1.7 Southern Asia 136 157 189 58 000 250 6.8 Eastern and South-Eastern Asia 61 69 85 21 000 790 3.3 Eastern Asia 22 28 35 5 300 2 200 1.5 South-Eastern Asia 115 137 173 16 000 320 5.5 Latin America and the Caribbean 70 74 81 7 800 630 3.8 Oceania 34 60 120 400 690 4.1 Australia and New Zealand 6 7 8 26 7 800 0.6 Oceania (excl. Australia and New Zealand) 69 129 267 380 210 6.5 Europe and Northern America 12 12 14 1 500 4 800 0.6 Europe 9 10 11 740 6 500 0.5 Northern America 16 18 20 760 3 100 0.9 Landlocked developing countries 378 408 484 65 000 57 17.4 Least developed countries 396 415 477 130 000 56 17.5 Small island developing States 178 210 277 2 600 190 8.5 4 Trends in maternal mortality: 2000 2017 In 2017, according to the Fragile States Index, 15 countries were considered to be “very high alert” or “high alert”6 (from highest to lowest: South Sudan, Somalia, Central African Republic, Yemen, Syrian Arab Republic, Sudan, the Democratic Republic of the Congo, Chad, Afghanistan, Iraq, Haiti, Guinea, Nigeria, Zimbabwe and Ethiopia), and these 15 countries had MMRs in 2017 ranging from 31 (Syrian Arab Republic) to 1150 (South Sudan). Regional and country-level trends, 2000–2017 Between 2000 and 2017, the subregion of Southern Asia achieved the greatest overall percentage reduction in MMR: 59% (from 384 to 157). This equates to an average ARR of 5.3%. Four other subregions roughly halved their MMRs during this period: Central Asia (52%), Eastern Asia (50%), Europe (53%) and Northern Africa (54%). MMR in LDCs also declined by 46%. Despite its very high MMR in 2017, sub-Saharan Africa as a region also achieved a substantial reduction in MMR of roughly 38% since 2000. Notably, one subregion with very low MMR (12) in 2000 – Northern America – had an increase in MMR of almost 52% during this period, rising to 18 in 2017. This is likely related to already low levels of MMR, as well as improvements in data collection, changes in life expectancy and/or changes in disparities between subpopulations. The greatest declines in proportion of deaths among women of reproductive age that are due to maternal causes (PM) occurred in two regions: Central and Southern Asia (56.4%), and Northern Africa and Western Asia (42.6%). Almost no change was seen in PM in Europe and Northern America. The 10 countries with the highest MMRs in 2017 (in order from highest to lowest: South Sudan, Chad, Sierra Leone, Nigeria, Central African Republic, Somalia, Mauritania, Guinea-Bissau, Liberia, Afghanistan) all 0 1,750 3,500875 Kilometres 1−19 20−99 100−299 300−499 500−999 ≥ 1000 Data not available Not applicable © World Health Organization 2019 Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. The designations employed and the presentation of the material in this map do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. Figure 1. Maternal mortality ratios, by country, 2017 6 The Fragile States Index is an assessment of 178 countries based on 12 cohesion, economic, social and political indicators, resulting in a score that indicates their susceptibility to instability. Further information about indicators and methodology is available at: https://fragilestatesindex.org/. At the top of the range (most fragile), the scores are categorized as follows: > 110 = very high alert; 100–110 = high alert. These two categories include the 15 most fragile countries mentioned here. There are 10 other categories ranging from “very sustainable” to “alert”, which include the remaining 163 countries. EXECUTIVE SUMMARY 5Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division have ARRs between 2000 and 2017 of less than 5%. When comparing the ARRs between the year ranges of 2000–2010 and 2010–2017, these 10 countries have also had stagnant or slowing levels of ARR and therefore remain at greatest risk. The impact of interruptions or loss of quality health services must be considered in crisis and other unstable situations. Countries that achieved the highest ARRs between 2000 and 2017 (an average ARR of 7% or above), starting with the highest, were Belarus, Kazakhstan, Timor- Leste, Rwanda, Turkmenistan, Mongolia, Angola and Estonia (see Table 2). In considering the uncertainty intervals around their average ARRs, we can only be very sure about this high level of acceleration in Belarus, Kazakhstan, Timor-Leste and Rwanda. In 13 countries, MMR increased in the same period. In considering the uncertainty around the rate and direction of change, we believe there have been true MMR increases in the United States of America and the Dominican Republic. These findings must be considered in context – as many factors may drive positive and negative trends in maternal mortality. Conclusions The SDGs include a direct emphasis on reducing maternal mortality while also highlighting the importance of moving beyond survival. Despite the ambition to end preventable maternal deaths by 2030, the world will fall short of this target by more than 1 million lives with the current pace of progress. There is a continued urgent need for maternal health and survival to remain high on the global health and development agenda; the state of maternal health interacts with and reflects efforts to improve the accessibility and quality of care. The 2018 Declaration of Astana repositioned primary health care as the most (cost) effective and inclusive means of delivering health services to achieve the SDGs. Primary health care is thereby considered the cornerstone for achieving universal health coverage (UHC), which only exists when all people receive the quality health services they need without suffering financial hardship. Health services that are unavailable, inaccessible or of poor quality, however, will not support the achievement of UHC, as envisioned. Efforts to increase the provision of skilled and competent care to more women, before, during and after childbirth, must also be seen in the context of external forces including but not limited to climate change, migration and humanitarian crises – not only because of the environmental risks presented, but also because of their contribution to health complications. In addition, governments are called upon to establish well functioning CRVS systems with accurate attribution of cause of death. Improvements in measurement must be driven by action at the country level, with governments creating systems to capture data specific to their information needs; systems that must also meet the standards required for international comparability. Globally, standardized methods for preventing errors in CRVS reporting (i.e. incompleteness and misclassification) should be established to enhance international comparability. In consideration of the above, it must be noted that this report on the levels and trends of maternal mortality provides just one critical facet of information, which synthesizes and draws from the available data, to assess one aspect of global progress towards achieving global goals for improved health and sustainable development. In the context of efforts to achieve UHC, improving maternal health is critical to fulfilling the aspiration to reach SDG 3. One can only hope that the global community will not be indifferent to the shortfalls that are expected if we cannot improve the current rate of reduction in maternal mortality. Ultimately, we need to expand horizons beyond a sole focus on mortality, to look at the broader aspects – country and regional situations and trends including health systems, UHC, quality of care, morbidity levels and socioeconomic determinants of women’s empowerment and education – and ensure that appropriate action is taken to support family planning, healthy pregnancy and safe childbirth. 6 Trends in maternal mortality: 2000 2017 Table 2. Trends in estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), by country and territory, 2000–2017a Country and territory MMR point estimatesa,b Overall change in MMR between 2000 and 2017c (%) Average annual rate of reduction (ARR) point estimate and range of uncertainty interval on ARR between 2000 and 2017 (UI: 80%) (%) 2000 2005 2010 2015 2017 Lower UI Average ARR point estimated Upper UI Afghanistan 1450 1140 954 701 638 56 1.4 4.8 7.3 Albania 23 22 21 15 15 35 -0.1 2.5 5.7 Algeria 161 127 115 114 112 30 -0.5 2.1 4.4 Angola 827 519 326 251 241 71 5.4 7.2 9.3 Antigua and Barbuda 44 40 44 43 42 5 -1.8 0.2 2.4 Argentina 66 59 51 41 39 41 2.1 3.1 4.2 Armenia 43 35 32 28 26 40 1.5 3.0 4.3 Australia 7 5 5 6 6 14 -1.4 0.2 1.7 Austria 6 6 5 5 5 17 -0.5 1.6 3.1 Azerbaijan 47 42 31 27 26 45 2.2 3.5 4.9 Bahamas 75 77 78 74 70 7 -2.4 0.4 2.6 Bahrain 27 19 18 15 14 48 1.6 3.6 5.4 Bangladesh 434 343 258 200 173 60 3.4 5.4 7.1 Barbados 50 42 36 31 27 46 1.9 3.7 6.0 Belarus 22 11 5 3 2 91 9.6 13.0 16.7 Belgium 8 7 6 5 5 38 1.0 2.5 4.1 Belize 89 70 54 43 36 60 3.7 5.3 7.5 Benin 520 500 464 421 397 24 -0.4 1.6 3.2 Bhutan 423 310 247 203 183 57 2.1 4.9 7.0 Bolivia (Plurinational State of) 331 271 212 168 155 53 2.7 4.5 6.2 Bosnia and Herzegovina 17 13 11 10 10 41 1.3 3.3 6.3 Botswana 262 239 179 156 144 45 2.1 3.5 4.7 Brazil 69 71 65 63 60 13 0.7 0.9 1.1 Brunei Darussalam 28 29 28 30 31 -11 -2.5 -0.7 1.6 Bulgaria 19 15 12 10 10 47 1.9 4.0 6.5 Burkina Faso 516 437 385 343 320 38 0.9 2.8 4.9 Burundi 1010 814 665 568 548 46 1.7 3.6 5.5 Cabo Verde 118 86 70 61 58 51 2.5 4.2 5.7 Cambodia 488 351 248 178 160 67 4.6 6.6 8.4 Cameroon 886 692 597 554 529 40 0.8 3.0 4.8 Canada 9 11 11 11 10 -11 -2.5 -0.6 1.2 EXECUTIVE SUMMARY 7Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division Table 2 (continued). Trends in estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), by country and territory, 2000–2017a Country and territory MMR point estimatesa,b Overall change in MMR between 2000 and 2017c (%) Average annual rate of reduction (ARR) point estimate and range of uncertainty interval on ARR between 2000 and 2017 (UI: 80%) (%) 2000 2005 2010 2015 2017 Lower UI Average ARR point estimated Upper UI Central African Republic 1280 1200 1000 912 829 35 0.3 2.6 4.9 Chad 1420 1330 1240 1160 1140 20 -0.7 1.3 2.9 Chile 31 25 20 14 13 58 4.3 5.4 6.7 China 59 44 36 30 29 51 2.9 4.2 6.0 Colombia 94 83 85 85 83 12 -0.4 0.8 1.7 Comoros 444 404 341 285 273 39 0.8 2.9 4.9 Congo 739 677 506 416 378 49 2.0 3.9 5.7 Costa Rica 40 33 32 28 27 33 1.2 2.2 3.4 Côte d’Ivoire 704 704 701 658 617 12 -1.2 0.8 2.7 Croatia 11 10 9 8 8 27 0.0 2.0 3.7 Cuba 46 41 41 38 36 22 0.6 1.4 2.2 Cyprus 14 12 8 7 6 57 2.9 4.9 7.0 Czechia 7 5 4 4 3 57 2.0 4.0 6.3 Democratic People’s Republic of Korea 139 120 106 91 89 36 0.2 2.6 4.9 Democratic Republic of the Congo 760 627 542 490 473 38 0.1 2.8 4.7 Denmark 8 6 5 4 4 50 2.8 4.3 6.2 Djibouti 507 393 283 247 248 51 2.0 4.2 6.5 Dominican Republic 80 83 96 94 95 -19 -1.6 -1.0 -0.5 Ecuador 122 94 78 63 59 52 3.4 4.3 5.2 Egypt 64 52 45 39 37 42 1.7 3.2 5.4 El Salvador 73 62 54 48 46 37 1.3 2.7 4.3 Equatorial Guinea 454 344 308 296 301 34 0.3 2.4 4.5 Eritrea 1280 804 567 518 480 63 3.6 5.8 7.9 Estonia 29 18 11 10 9 69 5.0 7.1 9.6 Eswatini 521 532 450 435 437 16 -1.6 1.0 3.0 Ethiopia 1030 865 597 446 401 61 3.0 5.5 7.4 Fiji 51 46 39 35 34 33 0.8 2.4 4.0 Finland 6 5 4 3 3 50 1.7 3.6 5.2 France 10 9 9 8 8 20 0.2 1.4 2.6 Gabon 380 348 314 261 252 34 0.1 2.4 4.3 8 Trends in maternal mortality: 2000 2017 Table 2 (continued). Trends in estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), by country and territory, 2000–2017a Country and territory MMR point estimatesa,b Overall change in MMR between 2000 and 2017c (%) Average annual rate of reduction (ARR) point estimate and range of uncertainty interval on ARR between 2000 and 2017 (UI: 80%) (%) 2000 2005 2010 2015 2017 Lower UI Average ARR point estimated Upper UI Gambia 932 756 661 625 597 36 0.6 2.6 4.5 Georgia 31 39 32 27 25 19 0.1 1.3 2.5 Germany 7 6 6 5 7 0 -1.3 0.2 1.8 Ghana 484 371 339 320 308 36 0.9 2.7 4.5 Greece 3 3 3 3 3 0 -1.3 0.6 2.7 Grenada 38 33 29 25 25 34 0.4 2.4 4.5 Guatemala 161 142 129 103 95 41 2.5 3.1 3.7 Guinea 1020 920 747 699 576 44 1.6 3.4 4.9 Guinea-Bissau 1210 979 779 694 667 45 1.0 3.5 5.4 Guyana 231 223 179 172 169 27 0.4 1.8 3.3 Haiti 437 459 506 488 480 -10 -2.7 -0.6 1.3 Honduras 85 77 74 67 65 24 0.4 1.6 2.7 Hungary 16 15 13 12 12 25 -0.6 2.0 4.2 Iceland 6 5 5 4 4 33 0.7 2.7 4.9 India 370 286 210 158 145 61 4.2 5.5 7.0 Indonesia 272 252 228 192 177 35 0.5 2.5 4.3 Iran (Islamic Republic of) 48 34 22 17 16 67 5.0 6.3 8.0 Iraq 79 127 70 83 79 0 -1.9 0.0 2.5 Ireland 7 7 6 6 5 29 0.0 2.5 4.3 Israel 7 5 4 3 3 57 3.4 4.9 6.5 Italy 4 3 2 2 2 50 3.3 5.1 6.9 Jamaica 77 80 79 78 80 -4 -1.5 -0.2 0.9 Japan 9 7 6 5 5 44 2.1 3.8 5.7 Jordan 70 62 53 48 46 34 0.6 2.4 4.7 Kazakhstan 61 43 22 12 10 84 9.2 10.9 12.6 Kenya 708 618 432 353 342 52 2.4 4.3 5.9 Kiribati 136 119 112 97 92 32 0.1 2.3 4.7 Kuwait 10 10 10 11 12 -20 -2.8 -0.7 1.2 Kyrgyzstan 79 82 79 66 60 24 0.0 1.6 2.8 Lao People’s Democratic Republic 544 410 292 209 185 66 4.4 6.3 8.0 Latvia 34 30 26 23 19 44 1.6 3.5 5.0 EXECUTIVE SUMMARY 9Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division Table 2 (continued). Trends in estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), by country and territory, 2000–2017a Country and territory MMR point estimatesa,b Overall change in MMR between 2000 and 2017c (%) Average annual rate of reduction (ARR) point estimate and range of uncertainty interval on ARR between 2000 and 2017 (UI: 80%) (%) 2000 2005 2010 2015 2017 Lower UI Average ARR point estimated Upper UI Lebanon 28 24 23 29 29 -4 -2.9 -0.4 1.6 Lesotho 614 679 594 574 544 11 -1.6 0.7 2.5 Liberia 894 816 708 691 661 26 -0.4 1.8 3.5 Lithuania 17 14 10 9 8 53 2.1 4.2 6.5 Luxembourg 10 9 8 5 5 50 2.4 4.5 6.3 Madagascar 559 526 453 363 335 40 1.0 3.0 5.0 Malawi 749 610 444 370 349 53 2.3 4.5 6.5 Malaysia 38 31 30 30 29 24 0.2 1.5 2.7 Maldives 125 75 67 54 53 58 2.1 5.1 7.3 Mali 836 691 660 620 562 33 0.3 2.3 3.9 Malta 9 8 8 7 6 33 0.1 2.3 4.4 Mauritania 834 826 824 785 766 8 -2.0 0.5 2.6 Mauritius 59 53 66 73 61 -3 -2.8 -0.2 1.9 Mexico 55 54 46 36 33 40 2.6 3.0 3.3 Micronesia (Federated States of) 154 133 110 95 88 43 1.0 3.3 5.6 Mongolia 155 98 66 47 45 71 5.8 7.3 8.8 Montenegro 12 9 7 6 6 50 2.1 4.3 6.9 Morocco 188 131 92 74 70 63 4.2 5.8 7.5 Mozambique 798 577 412 318 289 64 3.9 6.0 7.7 Myanmar 340 299 265 246 250 26 -0.7 1.8 4.1 Namibia 348 346 266 217 195 44 1.4 3.4 4.9 Nepal 553 415 305 236 186 66 4.0 6.4 8.4 Netherlands 13 11 7 6 5 62 3.8 5.6 7.5 New Zealand 12 11 11 10 9 25 0.5 1.8 3.3 Nicaragua 162 131 112 101 98 40 1.2 3.0 4.5 Niger 813 755 663 555 509 37 0.8 2.7 4.5 Nigeria 1200 1080 978 931 917 24 -0.8 1.6 3.5 Norway 6 5 4 3 2 67 3.4 5.3 7.8 Oman 20 19 18 19 19 5 -1.0 0.3 1.6 Pakistan 286 237 191 154 140 51 2.0 4.2 6.4 Panama 91 88 79 58 52 43 2.1 3.3 4.7 10 Trends in maternal mortality: 2000 2017 Table 2 (continued). Trends in estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), by country and territory, 2000–2017a Country and territory MMR point estimatesa,b Overall change in MMR between 2000 and 2017c (%) Average annual rate of reduction (ARR) point estimate and range of uncertainty interval on ARR between 2000 and 2017 (UI: 80%) (%) 2000 2005 2010 2015 2017 Lower UI Average ARR point estimated Upper UI Papua New Guinea 249 200 168 151 145 42 0.9 3.2 5.5 Paraguay 162 136 107 89 84 48 2.5 3.9 5.5 Peru 144 118 104 94 88 39 1.5 2.9 4.6 Philippines 160 156 144 127 121 24 -0.3 1.7 3.3 Poland 7 4 3 2 2 71 4.5 6.6 8.9 Portugal 10 9 9 9 8 20 -0.6 1.6 3.3 Puerto Rico 26 23 21 20 21 19 -0.6 1.3 2.7 Qatar 14 12 10 9 9 36 0.5 2.6 4.5 Republic of Korea 17 15 15 12 11 35 1.4 2.4 3.6 Republic of Moldova 44 34 29 22 19 57 3.3 4.9 6.6 Republic of North Macedonia 13 10 8 8 7 46 1.7 3.5 5.8 Romania 54 35 27 21 19 65 4.3 6.3 8.3 Russian Federation 56 42 25 18 17 70 5.0 6.9 8.9 Rwanda 1160 643 373 275 248 79 7.0 9.1 10.7 Saint Lucia 86 83 109 115 117 -36 -4.7 -1.8 0.8 Saint Vincent and the Grenadines 80 59 63 64 68 15 -0.9 0.9 3.1 Samoa 88 72 58 45 43 51 1.7 4.2 6.6 Sao Tome and Principe 179 163 140 130 130 27 -0.1 1.9 4.3 Saudi Arabia 24 22 19 17 17 29 -0.2 2.1 4.5 Senegal 553 519 447 346 315 43 1.4 3.3 4.8 Serbia 13 12 12 13 12 8 -2.0 0.6 2.9 Seychelles 53 55 55 54 53 0 -2.4 0.0 2.4 Sierra Leone 2480 1760 1360 1180 1120 55 2.2 4.7 6.6 Singapore 13 13 10 9 8 38 0.4 2.9 5.3 Slovakia 8 7 6 6 5 38 0.6 2.3 4.0 Slovenia 12 10 8 7 7 42 1.6 3.3 5.0 Solomon Islands 245 188 141 112 104 58 3.0 5.0 7.0 Somalia 1210 1040 985 855 829 31 0.3 2.2 4.6 South Africa 160 201 171 125 119 26 0.1 1.7 3.0 South Sudan 1730 1480 1100 1110 1150 34 0.1 2.4 4.5 EXECUTIVE SUMMARY 11Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division Table 2 (continued). Trends in estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), by country and territory, 2000–2017a Country and territory MMR point estimatesa,b Overall change in MMR between 2000 and 2017c (%) Average annual rate of reduction (ARR) point estimate and range of uncertainty interval on ARR between 2000 and 2017 (UI: 80%) (%) 2000 2005 2010 2015 2017 Lower UI Average ARR point estimated Upper UI Spain 5 5 4 4 4 20 0.0 1.7 3.0 Sri Lanka 56 45 38 36 36 36 1.7 2.7 3.5 State of Libya 70 57 53 70 72 -3 -2.6 -0.2 2.3 Sudan 667 529 408 320 295 56 2.7 4.8 7.1 Suriname 221 164 148 122 120 46 2.3 3.6 5.4 Sweden 5 5 4 4 4 20 -0.2 1.5 2.9 Switzerland 7 7 6 5 5 29 0.4 2.6 4.2 Syrian Arab Republic 26 25 27 30 31 -19 -4.0 -1.1 1.3 Tajikistan 53 32 23 18 17 68 4.3 6.8 9.5 Thailand 43 43 42 38 37 14 -0.5 0.8 2.1 Timor-Leste 745 415 219 160 142 81 7.7 9.8 11.9 Togo 489 492 440 398 396 19 -0.5 1.3 3.1 Tonga 77 66 57 54 52 32 0.0 2.3 4.6 Trinidad and Tobago 81 76 71 68 67 17 -0.6 1.1 2.7 Tunisia 66 51 46 46 43 35 0.7 2.4 4.8 Turkey 42 33 24 19 17 60 3.6 5.3 7.5 Turkmenistan 29 18 10 8 7 76 5.9 8.2 10.5 Uganda 578 491 430 387 375 35 0.5 2.5 4.2 Ukraine 35 33 25 21 19 46 1.6 3.6 5.5 United Arab Emirates 6 5 4 3 3 50 1.9 4.0 6.9 United Kingdom of Great Britain and Northern Ireland 10 11 10 8 7 30 1.9 2.7 3.6 United Republic of Tanzania 854 721 644 556 524 39 0.9 2.9 4.4 United States of America 12 13 15 18 19 -58 -3.3 -2.6 -1.9 Uruguay 26 22 17 18 17 35 1.2 2.4 3.6 Uzbekistan 41 38 31 30 29 29 0.1 2.0 3.6 Vanuatu 140 113 92 76 72 49 1.6 4.0 6.1 Venezuela (Bolivarian Republic of) 119 113 117 115 125 -5 -2.2 -0.3 1.3 12 Trends in maternal mortality: 2000 2017 Table 2 (continued). Trends in estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), by country and territory, 2000–2017a a Estimates have been computed to ensure comparability across countries, thus they are not necessarily the same as official statistics of the countries, which may use alternative rigorous methods. b MMR estimates have been rounded according to the following scheme: < 100 rounded to nearest 1; 100–999 rounded to nearest 1; and ≥ 1000 rounded to nearest 10; and all calculations are based on rounded numbers. c Overall change for the whole period since the first year of the millennium (from 1 January 2000). d Average annual rate of reduction, for the whole period from the first year of the millennium (1 January 2000). e UNICEF, UNPFA, World Bank Group and UNPD refer to this territory as the State of Palestine. Country and territory MMR point estimatesa,b Overall change in MMR between 2000 and 2017c (%) Average annual rate of reduction (ARR) point estimate and range of uncertainty interval on ARR between 2000 and 2017 (UI: 80%) (%) 2000 2005 2010 2015 2017 Lower UI Average ARR point estimated Upper UI Viet Nam 68 54 47 45 43 37 0.5 2.6 4.6 West Bank and Gaza Stripe 70 59 45 32 27 61 3.4 5.6 8.1 Yemen 301 242 192 169 164 46 1.7 3.6 6.1 Zambia 528 421 305 232 213 60 3.7 5.3 6.8 Zimbabwe 579 685 598 480 458 21 0.1 1.4 2.9 2000 to 2017 TRENDS IN MATERNAL MORTALITY Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population DivisionFor more information, please contact: Department of Reproductive Health and Research World Health Organization Avenue Appia 20 CH-1211 Geneva 27 Switzerland Email: reproductivehealth@who.int www.who.int/reproductivehealth Executive summary WHO/RHR/19.23 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).
2000 to 2017 TRENDS IN MATERNAL MORTALITY Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population DivisionFor more information, please contact: Department of Reproductive Health and Research World Health Organization Avenue Appia 20 CH-1211 Geneva 27 Switzerland Email: reproductivehealth@who.int www.who.int/reproductivehealth Executive summary WHO/RHR/19.23 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Cover.indd 1 22.11.19 13:06 1Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division EXECUTIVE SUMMARY Background The Sustainable Development Goals (SDGs) were launched on 25 September 2015 and came into force on 1 January 2016 for the 15-year period until 31 December 2030. Among the 17 SDGs, the direct health- related targets come under SDG 3: Ensure healthy lives and promote well-being for all at all ages. With the adoption of the SDGs, the United Nations Member States extended the global commitments they had made in 2000 to the Millennium Development Goals (MDGs), which covered the period until 2015. In anticipation of the launch of the SDGs, the World Health Organization (WHO) and partners released a consensus statement and full strategy paper on ending preventable maternal mortality (EPMM). The EPMM target for reducing the global maternal mortality ratio (MMR) by 2030 was adopted as SDG target 3.1: reduce global MMR to less than 70 per 100 000 live births by 2030. Having targets for mortality reduction is important, but accurate measurement of maternal mortality remains challenging and many deaths still go uncounted. Many countries still lack well functioning civil registration and vital statistics (CRVS) systems, and where such systems do exist, reporting errors – whether incompleteness (unregistered deaths, also known as “missing”) or misclassification of cause of death – continue to pose a major challenge to data accuracy. Methods and interpretation The United Nations Maternal Mortality Estimation Inter-Agency Group (UN MMEIG) – comprising WHO, the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA), the World 1 Estimates have been computed to ensure comparability across countries, thus they are not necessarily the same as official statistics of the countries, which may use alternative rigorous methods. 2 Puerto Rico is an Associate Member, and the West Bank and Gaza Strip is a member in the regional committee for the WHO Eastern Mediterranean Region. 3 Available at: www.who.int/reproductivehealth/publications/maternal-mortality-2017/en/. Bank Group and the United Nations Population Division (UNPD) of the Department of Economic and Social Affairs – has collaborated with external technical experts on a new round of estimates for 2000–2017. To provide increasingly accurate MMR estimates, the previous estimation methods have been refined to optimize use of country-level data. Consultations with countries were carried out during May and June 2019. This process generated additional data for inclusion in the maternal mortality estimation model, demonstrating widespread expansion of in-country efforts to monitor maternal mortality. This report presents internationally comparable global, regional and country-level estimates and trends for maternal mortality between 2000 and 2017.1 Countries and territories included in the analyses are WHO Member States with populations over 100 000, plus two territories (Puerto Rico, and the West Bank and Gaza Strip)2. The results described in this report include the first available estimates for maternal mortality in the SDG reporting period; but since two years (2016 and 2017) is not sufficient to show trends, estimates have been developed and presented covering the period 2000 to 2017. The new estimates presented in this report supersede all previously published estimates for years that fall within the same time period. Care should be taken to use only these estimates for the interpretation of trends in maternal mortality from 2000 to 2017; due to modifications in methodology and data availability, differences between these and previous estimates should not be interpreted as representing time trends. In addition, when interpreting changes in MMRs over time, one should take into consideration that it is easier to reduce the MMR when the level is high than when the MMR level is already low. The full database, country profiles and all model specification codes used are available online.3 2 Trends in maternal mortality 2000 to 2017 4 All uncertainty intervals (UIs) reported are 80% UI. The data can be interpreted as meaning that there is an 80% chance that the true value lies within the UI, a 10% chance that the true value lies below the lower limit and a 10% chance that the true value lies above the upper limit. 5 For the purpose of categorization, MMR is considered to be low if it is less than 100, moderate if it is 100–299, high if it is 300–499, very high if it is 500–999 and extremely high if it is equal to or higher than 1000 maternal deaths per 100 000 live births. Global estimates for 2017 and trends for 2000– 2017 The global estimates for the year 2017 indicate that there were 295 000 (UI 279 000 to 340 000)4 maternal deaths; 35% lower than in 2000 when there were an estimated 451 000 (UI 431 000 to 485 000) maternal deaths. The global MMR in 2017 is estimated at 211 (UI 99 to 243) maternal deaths per 100 000 live births, representing a 38% reduction since 2000, when it was estimated at 342. The average annual rate of reduction (ARR) in global MMR during the 2000–2017 period was 2.9%; this means that, on average, the global MMR declined by 2.9% every year between 2000 and 2017. The global lifetime risk of maternal mortality for a 15-year-old girl in 2017 was estimated at 1 in 190; nearly half of the level of risk in 2000: 1 in 100. The overall proportion of deaths to women of reproductive age (15–49 years) that are due to maternal causes (PM) was estimated at 9.2% (UI 8.7% to 10.6%) in 2017 – down by 26.3% since 2000. This means that compared with other causes of death to women of reproductive age, the fraction attributed to maternal causes is decreasing. In addition, the effect of HIV on maternal mortality in 2017 appears to be less pronounced than in earlier years; HIV-related indirect maternal deaths now account for approximately 1% of all maternal deaths compared with 2.5% in 2005, at the peak of the epidemic. Regional and country-level estimates for 2017 MMR in the world’s least developed countries (LDCs) is high,5 estimated at 415 (UI 396 to 477) maternal deaths per 100 000 live births, which is more than 40 times higher than MMR in Europe (10; UI 9 to 11), and almost 60 times higher than in Australia and New Zealand (7; UI 6 to 8). In the world’s LDCs, where an estimated 130 000 maternal deaths occurred in 2017, the estimated lifetime risk of maternal death was 1 in 56. Sub-Saharan Africa is the only region with very high MMR for 2017, estimated at 542 (UI 498 to 649), while the lifetime risk of maternal death was 1 in 37, compared with just 1 in 7800 in Australia and New Zealand. Moderate MMR (100–299) was estimated in Northern Africa, Oceania (excluding Australia and New Zealand), Southern Asia, South-Eastern Asia and in small island developing States. Four subregions (Australia and New Zealand, Central Asia, Eastern Asia and Western Asia) and two regions (Latin America and the Caribbean, and Europe and Northern America) have low MMR (< 100 maternal deaths per 100 000 live births). Sub-Saharan Africa and Southern Asia accounted for approximately 86% (254 000) of the estimated global maternal deaths in 2017, with sub-Saharan Africa alone accounting for roughly 66% (196 000), while Southern Asia accounted for nearly 20% (58 000). South-Eastern Asia, in addition, accounted for over 5% of global maternal deaths (16 000). Three countries are estimated to have had extremely high MMR in 2017 (defined as over 1000 maternal deaths per 100 000 live births): South Sudan (1150; UI 789 to 1710), Chad (1140; UI 847 to 1590) and Sierra Leone (1120; UI 808 to 1620). Sixteen other countries, all also in sub-Saharan Africa except for one (Afghanistan), had very high MMR in 2017 (i.e. estimates ranging between 500 and 999). Only three countries in sub-Saharan Africa had low MMR: Mauritius (61; UI 46 to 85), Cabo Verde (58; UI 45 to 75) and Seychelles (53; UI 26 to 109). Only one country outside the sub-Saharan African region had high MMR: Haiti (480; UI 346 to 718). Ninety countries were estimated to have MMR of 50 or less in 2017. Nigeria and India had the highest estimated numbers of maternal deaths, accounting for approximately one third (35%) of estimated global maternal deaths in 2017, with approximately 67 000 and 35 000 maternal deaths (23% and 12% of global maternal deaths), respectively. Three other countries also had 10 000 maternal deaths or more: the Democratic Republic of the Congo (16 000), Ethiopia (14 000) and the United Republic of Tanzania (11 000). Sixty-one countries were estimated to have had just 10 or fewer maternal deaths in 2017. 3Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division EXECUTIVE SUMMARY Table 1. Estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), number of maternal deaths, lifetime risk and proportion of deaths among women of reproductive age that are due to maternal causes (PM), by United Nations Sustainable Development Goal (SDG) region, subregion and other grouping, 2017 UI: uncertainty interval. a MMR estimates have been rounded according to the following scheme: < 100 rounded to nearest 1; 100–999 rounded to nearest 1; and ≥ 1000 rounded to nearest 10. b Numbers of maternal deaths have been rounded according to the following scheme: < 100 rounded to nearest 1; 100–999 rounded to nearest 10; 1000– 9999 rounded to nearest 100; and ≥ 10 000 rounded to nearest 1000. c Lifetime risk numbers have been rounded according to the following scheme: < 100 rounded to nearest 1; 100–999 rounded to nearest 10; and ≥ 1000 rounded to nearest 100. d The number of maternal deaths in a given time period divided by the total deaths among women aged 15–49 years. e Angola, Benin, Botswana, Burkina Faso, Burundi, Cabo Verde, Cameroon, Central African Republic, Chad, Comoros, Congo, Côte d’Ivoire, Democratic Republic of the Congo, Djibouti, Equatorial Guinea, Eritrea, Eswatini, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mauritius, Mozambique, Namibia, Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Seychelles, Sierra Leone, Somalia, South Africa, South Sudan, Togo, Uganda, United Republic of Tanzania, Zambia, Zimbabwe. f Algeria, Egypt, Morocco, State of Libya, Sudan, Tunisia. g Armenia, Azerbaijan, Bahrain, Cyprus, Georgia, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Syrian Arab Republic, Turkey, United Arab Emirates, West Bank and Gaza Strip, Yemen. h Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, Uzbekistan. i Afghanistan, Bangladesh, Bhutan, India, Iran (Islamic Republic of), Maldives, Nepal, Pakistan, Sri Lanka. j China, Democratic People’s Republic of Korea, Japan, Mongolia, Republic of Korea. SDG region MMRa point estimate and range of uncertainty interval (UI: 80%) Number of maternal deathsb Lifetime risk of maternal deathc PMd (%) Lower UI MMR point estimate Upper UI World 199 211 243 295 000 190 9.2 Sub-Saharan Africae 498 542 649 196 000 37 18.2 Northern Africa and Western Asia 73 84 104 9 700 380 5.9 Northern Africaf 91 112 145 6 700 260 8.4 Western Asiag 45 55 69 3 000 650 3.6 Central and Southern Asia 131 151 181 58 000 260 6.6 Central Asiah 21 24 28 390 1 400 1.7 Southern Asiai 136 157 189 58 000 250 6.8 Eastern and South-Eastern Asia 61 69 85 21 000 790 3.3 Eastern Asiaj 22 28 35 5 300 2 200 1.5 South-Eastern Asiak 115 137 173 16 000 320 5.5 Latin America and the Caribbeanl 69 73 80 7 700 640 3.8 Oceania 34 60 120 400 690 4.1 Australia and New Zealand 6 7 8 26 7 800 0.6 Oceania (excl. Australia and New Zealand)m 69 129 267 380 210 6.5 Europe and Northern America 12 12 14 1 500 4 800 0.6 Europen 9 10 11 740 6 500 0.5 Northern Americao 16 18 20 760 3 100 0.9 Landlocked developing countriesp 377 407 483 64 000 57 17.4 Least developed countriesq 396 415 477 130 000 56 17.5 Small island developing Statesr 178 210 277 2 600 190 8.5 4 Trends in maternal mortality 2000 to 2017 In 2017, according to the Fragile States Index, 15 countries were considered to be “very high alert” or “high alert” (from highest to lowest: South Sudan, Somalia, Central African Republic, Yemen, Syrian Arab Republic, Sudan, the Democratic Republic of the Congo, Chad, Afghanistan, Iraq, Haiti, Guinea, Nigeria, Zimbabwe and Ethiopia), and these 15 countries had MMRs in 2017 ranging from 31 (Syrian Arab Republic) to 1150 (South Sudan). Regional and country-level trends: 2000–2017 Between 2000 and 2017, the subregion of Southern Asia achieved the greatest overall percentage reduction in MMR: 59% (from 384 to 157). This equates to an average ARR of 5.3%. Four other subregions roughly halved their MMRs during this period: Central Asia (52%), Eastern Asia (50%), Europe (53%) and Northern Africa (54%). MMR in LDCs also declined by 46%. Despite its very high MMR in 2017, sub-Saharan Africa as a region also achieved a substantial reduction in MMR of roughly 38% since 2000. Notably, one subregion with very low MMR (12) in 2000 – Northern America – had an increase in MMR of almost 52% during this period, rising to 18 in 2017. This is likely related to already low levels of MMR, as well as improvements in data collection, changes in life expectancy and/or changes in disparities between subpopulations. The greatest declines in proportion of deaths among women of reproductive age that are due to maternal causes (PM) occurred in two regions: Central and Southern Asia (56.4%), and Northern Africa and Western Asia (42.6%). Almost no change was seen in PM in Europe and Northern America. The 10 countries with the highest MMRs in 2017 (in order from highest to lowest: South Sudan, Chad, Sierra Leone, Nigeria, Central African Republic, Somalia, Mauritania, Guinea-Bissau, Liberia, Afghanistan) all Figure 1. Maternal mortality ratios, by country, 2017 6 The Fragile States Index is an assessment of 178 countries based on 12 cohesion, economic, social and political indicators, resulting in a score that indicates their susceptibility to instability. Further information about indicators and methodology is available at: https://fragilestatesindex.org/. At the top of the range (most fragile), the scores are categorized as follows: > 110 = very high alert; 100–110 = high alert. These two categories include the 15 most fragile countries mentioned here. There are 10 other categories ranging from “very sustainable” to “alert”, which include the remaining 163 countries. 0 1,750 3,500875 Kilometres 1−19 20−99 100−299 300−499 500−999 ≥ 1000 Data not available Not applicable © World Health Organization 2019 Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. The designations employed and the presentation of the material in this map do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. EXECUTIVE SUMMARY 5Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division have ARRs between 2000 and 2017 of less than 5%. When comparing the ARRs between the year ranges of 2000–2010 and 2010–2017, these 10 countries have also had stagnant or slowing levels of ARR and therefore remain at greatest risk. The impact of interruptions or loss of quality health services must be considered in crisis and other unstable situations. Countries that achieved the highest ARRs between 2000 and 2017 (an average ARR of 7% or above), starting with the highest, were Belarus, Kazakhstan, Timor-Leste, Rwanda, Turkmenistan, Mongolia, Angola and Estonia. In considering the uncertainty intervals around their average ARRs, we can only be very sure about this high level of acceleration in Belarus, Kazakhstan, Timor- Leste and Rwanda. In 13 countries, MMR increased in the same period. In considering the uncertainty around the rate and direction of change, we believe there have been true MMR increases in the United States of America and the Dominican Republic. These findings must be considered in context – as many factors may drive positive and negative trends in maternal mortality. Conclusions The SDGs include a direct emphasis on reducing maternal mortality while also highlighting the importance of moving beyond survival. Despite the ambition to end preventable maternal deaths by 2030, the world will fall short of this target by more than 1 million lives with the current pace of progress. There is a continued urgent need for maternal health and survival to remain high on the global health and development agenda; the state of maternal health interacts with and reflects efforts to improve the accessibility and quality of care. The 2018 Declaration of Astana repositioned primary health care as the most (cost) effective and inclusive means of delivering health services to achieve the SDGs. Primary health care is thereby considered the cornerstone for achieving universal health coverage (UHC), which only exists when all people receive the quality health services they need without suffering financial hardship. Health services that are unavailable/ inaccessible or of poor quality, however, will not support the achievement of UHC, as envisioned. Efforts to increase the provision of skilled and competent care to more women, before, during and after childbirth, must also be seen in the context of external forces including but not limited to climate change, migration and humanitarian crises. In addition, governments are called upon to establish well functioning CRVS systems with accurate attribution of cause of death. Improvements in measurement must be driven by action at the country level, with governments creating systems to capture data specific to their information needs; systems that must also meet the standards required for international comparability. Globally, standardized methods for preventing errors in CRVS reporting (i.e. incompleteness and misclassification) should be established to enhance international comparability. In consideration of the above, it must be noted that this report on the levels and trends of maternal mortality provides just one critical facet of information, which synthesizes and draws from the available data, to assess progress in reducing maternal mortality towards achieving SDG target 3.1. The results so far show good but uneven progress across the world in reducing maternal deaths between 2000 and 2017. The global community should accelerate efforts, because if we only continue with the same rate of progress as achieved during this period, it will not be possible to reach the global SDG target of less than 70 maternal deaths per 100 000 live births by 2030. Ultimately, we need to expand horizons beyond a sole focus on mortality, to look at the broader aspects – country and regional situations and trends including health systems, UHC, quality of care, morbidity levels and socioeconomic determinants of women’s empowerment and education – and ensure that appropriate action is taken to support family planning, healthy pregnancy and safe childbirth. 6 Trends in maternal mortality 2000 to 2017 Table 2. Trends in estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), by country and territory, 2000–2017a Country and territory MMR point estimatesa,b Overall change in MMR between 2000 and 2017c (%) Average annual rate of reduction (ARR) point estimate and range of uncertainty interval on ARR between 2000 and 2017 (UI: 80%) (%) 2000 2005 2010 2015 2017 Lower UI Average ARR point estimated Upper UI Afghanistan 1450 1140 954 701 638 56 1.4 4.8 7.3 Albania 23 22 21 15 15 35 -0.1 2.5 5.7 Algeria 161 127 115 114 112 30 -0.5 2.1 4.4 Angola 827 519 326 251 241 71 5.4 7.2 9.3 Antigua and Barbuda 44 40 44 43 42 5 -1.8 0.2 2.4 Argentina 66 59 51 41 39 41 2.1 3.1 4.2 Armenia 43 35 32 28 26 40 1.5 3.0 4.3 Australia 7 5 5 6 6 14 -1.4 0.2 1.7 Austria 6 6 5 5 5 17 -0.5 1.6 3.1 Azerbaijan 47 42 31 27 26 45 2.2 3.5 4.9 Bahamas 75 77 78 74 70 7 -2.4 0.4 2.6 Bahrain 27 19 18 15 14 48 1.6 3.6 5.4 Bangladesh 434 343 258 200 173 60 3.4 5.4 7.1 Barbados 50 42 36 31 27 46 1.9 3.7 6.0 Belarus 22 11 5 3 2 91 9.6 13.0 16.7 Belgium 8 7 6 5 5 38 1.0 2.5 4.1 Belize 89 70 54 43 36 60 3.7 5.3 7.5 Benin 520 500 464 421 397 24 -0.4 1.6 3.2 Bhutan 423 310 247 203 183 57 2.1 4.9 7.0 Bolivia (Plurinational State of) 331 271 212 168 155 53 2.7 4.5 6.2 Bosnia and Herzegovina 17 13 11 10 10 41 1.3 3.3 6.3 Botswana 262 239 179 156 144 45 2.1 3.5 4.7 Brazil 69 71 65 63 60 13 0.7 0.9 1.1 Brunei Darussalam 28 29 28 30 31 -11 -2.5 -0.7 1.6 Bulgaria 19 15 12 10 10 47 1.9 4.0 6.5 Burkina Faso 516 437 385 343 320 38 0.9 2.8 4.9 Burundi 1010 814 665 568 548 46 1.7 3.6 5.5 Cabo Verde 118 86 70 61 58 51 2.5 4.2 5.7 Cambodia 488 351 248 178 160 67 4.6 6.6 8.4 Cameroon 886 692 597 554 529 40 0.8 3.0 4.8 Canada 9 11 11 11 10 -11 -2.5 -0.6 1.2 EXECUTIVE SUMMARY 7Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division Table 2 (continued). Trends in estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), by country and territory, 2000–2017a Country and territory MMR point estimatesa,b Overall change in MMR between 2000 and 2017c (%) Average annual rate of reduction (ARR) point estimate and range of uncertainty interval on ARR between 2000 and 2017 (UI: 80%) (%) 2000 2005 2010 2015 2017 Lower UI Average ARR point estimated Upper UI Central African Republic 1280 1200 1000 912 829 35 0.3 2.6 4.9 Chad 1420 1330 1240 1160 1140 20 -0.7 1.3 2.9 Chile 31 25 20 14 13 58 4.3 5.4 6.7 China 59 44 36 30 29 51 2.9 4.2 6.0 Colombia 94 83 85 85 83 12 -0.4 0.8 1.7 Comoros 444 404 341 285 273 39 0.8 2.9 4.9 Congo 739 677 506 416 378 49 2.0 3.9 5.7 Costa Rica 40 33 32 28 27 33 1.2 2.2 3.4 Côte d’Ivoire 704 704 701 658 617 12 -1.2 0.8 2.7 Croatia 11 10 9 8 8 27 0.0 2.0 3.7 Cuba 46 41 41 38 36 22 0.6 1.4 2.2 Cyprus 14 12 8 7 6 57 2.9 4.9 7.0 Czechia 7 5 4 4 3 57 2.0 4.0 6.3 Democratic People’s Republic of Korea 139 120 106 91 89 36 0.2 2.6 4.9 Democratic Republic of the Congo 760 627 542 490 473 38 0.1 2.8 4.7 Denmark 8 6 5 4 4 50 2.8 4.3 6.2 Djibouti 507 393 283 247 248 51 2.0 4.2 6.5 Dominican Republic 80 83 96 94 95 -19 -1.6 -1.0 -0.5 Ecuador 122 94 78 63 59 52 3.4 4.3 5.2 Egypt 64 52 45 39 37 42 1.7 3.2 5.4 El Salvador 73 62 54 48 46 37 1.3 2.7 4.3 Equatorial Guinea 454 344 308 296 301 34 0.3 2.4 4.5 Eritrea 1280 804 567 518 480 63 3.6 5.8 7.9 Estonia 29 18 11 10 9 69 5.0 7.1 9.6 Eswatini 521 532 450 435 437 16 -1.6 1.0 3.0 Ethiopia 1030 865 597 446 401 61 3.0 5.5 7.4 Fiji 51 46 39 35 34 33 0.8 2.4 4.0 Finland 6 5 4 3 3 50 1.7 3.6 5.2 France 10 9 9 8 8 20 0.2 1.4 2.6 Gabon 380 348 314 261 252 34 0.1 2.4 4.3 8 Trends in maternal mortality 2000 to 2017 Table 2 (continued). Trends in estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), by country and territory, 2000–2017a Country and territory MMR point estimatesa,b Overall change in MMR between 2000 and 2017c (%) Average annual rate of reduction (ARR) point estimate and range of uncertainty interval on ARR between 2000 and 2017 (UI: 80%) (%) 2000 2005 2010 2015 2017 Lower UI Average ARR point estimated Upper UI Gambia 932 756 661 625 597 36 0.6 2.6 4.5 Georgia 31 39 32 27 25 19 0.1 1.3 2.5 Germany 7 6 6 5 7 0 -1.3 0.2 1.8 Ghana 484 371 339 320 308 36 0.9 2.7 4.5 Greece 3 3 3 3 3 0 -1.3 0.6 2.7 Grenada 38 33 29 25 25 34 0.4 2.4 4.5 Guatemala 161 142 129 103 95 41 2.5 3.1 3.7 Guinea 1020 920 747 699 576 44 1.6 3.4 4.9 Guinea-Bissau 1210 979 779 694 667 45 1.0 3.5 5.4 Guyana 231 223 179 172 169 27 0.4 1.8 3.3 Haiti 437 459 506 488 480 -10 -2.7 -0.6 1.3 Honduras 85 77 74 67 65 24 0.4 1.6 2.7 Hungary 16 15 13 12 12 25 -0.6 2.0 4.2 Iceland 6 5 5 4 4 33 0.7 2.7 4.9 India 370 286 210 158 145 61 4.2 5.5 7.0 Indonesia 272 252 228 192 177 35 0.5 2.5 4.3 Iran (Islamic Republic of) 48 34 22 17 16 67 5.0 6.3 8.0 Iraq 79 127 70 83 79 0 -1.9 0.0 2.5 Ireland 7 7 6 6 5 29 0.0 2.5 4.3 Israel 7 5 4 3 3 57 3.4 4.9 6.5 Italy 4 3 2 2 2 50 3.3 5.1 6.9 Jamaica 77 80 79 78 80 -4 -1.5 -0.2 0.9 Japan 9 7 6 5 5 44 2.1 3.8 5.7 Jordan 70 62 53 48 46 34 0.6 2.4 4.7 Kazakhstan 61 43 22 12 10 84 9.2 10.9 12.6 Kenya 708 618 432 353 342 52 2.4 4.3 5.9 Kiribati 136 119 112 97 92 32 0.1 2.3 4.7 Kuwait 10 10 10 11 12 -20 -2.8 -0.7 1.2 Kyrgyzstan 79 82 79 66 60 24 0.0 1.6 2.8 Lao People’s Democratic Republic 544 410 292 209 185 66 4.4 6.3 8.0 Latvia 34 30 26 23 19 44 1.6 3.5 5.0 EXECUTIVE SUMMARY 9Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division Table 2 (continued). Trends in estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), by country and territory, 2000–2017a Country and territory MMR point estimatesa,b Overall change in MMR between 2000 and 2017c (%) Average annual rate of reduction (ARR) point estimate and range of uncertainty interval on ARR between 2000 and 2017 (UI: 80%) (%) 2000 2005 2010 2015 2017 Lower UI Average ARR point estimated Upper UI Lebanon 28 24 23 29 29 -4 -2.9 -0.4 1.6 Lesotho 614 679 594 574 544 11 -1.6 0.7 2.5 Liberia 894 816 708 691 661 26 -0.4 1.8 3.5 Lithuania 17 14 10 9 8 53 2.1 4.2 6.5 Luxembourg 10 9 8 5 5 50 2.4 4.5 6.3 Madagascar 559 526 453 363 335 40 1.0 3.0 5.0 Malawi 749 610 444 370 349 53 2.3 4.5 6.5 Malaysia 38 31 30 30 29 24 0.2 1.5 2.7 Maldives 125 75 67 54 53 58 2.1 5.1 7.3 Mali 836 691 660 620 562 33 0.3 2.3 3.9 Malta 9 8 8 7 6 33 0.1 2.3 4.4 Mauritania 834 826 824 785 766 8 -2.0 0.5 2.6 Mauritius 59 53 66 73 61 -3 -2.8 -0.2 1.9 Mexico 55 54 46 36 33 40 2.6 3.0 3.3 Micronesia (Federated States of) 154 133 110 95 88 43 1.0 3.3 5.6 Mongolia 155 98 66 47 45 71 5.8 7.3 8.8 Montenegro 12 9 7 6 6 50 2.1 4.3 6.9 Morocco 188 131 92 74 70 63 4.2 5.8 7.5 Mozambique 798 577 412 318 289 64 3.9 6.0 7.7 Myanmar 340 299 265 246 250 26 -0.7 1.8 4.1 Namibia 348 346 266 217 195 44 1.4 3.4 4.9 Nepal 553 415 305 236 186 66 4.0 6.4 8.4 Netherlands 13 11 7 6 5 62 3.8 5.6 7.5 New Zealand 12 11 11 10 9 25 0.5 1.8 3.3 Nicaragua 162 131 112 101 98 40 1.2 3.0 4.5 Niger 813 755 663 555 509 37 0.8 2.7 4.5 Nigeria 1200 1080 978 931 917 24 -0.8 1.6 3.5 Norway 6 5 4 3 2 67 3.4 5.3 7.8 Oman 20 19 18 19 19 5 -1.0 0.3 1.6 Pakistan 286 237 191 154 140 51 2.0 4.2 6.4 Panama 91 88 79 58 52 43 2.1 3.3 4.7 10 Trends in maternal mortality 2000 to 2017 Table 2 (continued). Trends in estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), by country and territory, 2000–2017a Country and territory MMR point estimatesa,b Overall change in MMR between 2000 and 2017c (%) Average annual rate of reduction (ARR) point estimate and range of uncertainty interval on ARR between 2000 and 2017 (UI: 80%) (%) 2000 2005 2010 2015 2017 Lower UI Average ARR point estimated Upper UI Papua New Guinea 249 200 168 151 145 42 0.9 3.2 5.5 Paraguay 165 137 108 88 84 49 2.6 4.0 5.6 Peru 144 118 104 94 88 39 1.5 2.9 4.6 Philippines 160 156 144 127 121 24 -0.3 1.7 3.3 Poland 7 4 3 2 2 71 4.5 6.6 8.9 Portugal 10 9 9 9 8 20 -0.6 1.6 3.3 Puerto Rico 26 23 21 20 21 19 -0.6 1.3 2.7 Qatar 14 12 10 9 9 36 0.5 2.6 4.5 Republic of Korea 17 15 15 12 11 35 1.4 2.4 3.6 Republic of Moldova 44 34 29 22 19 57 3.3 4.9 6.6 Republic of North Macedonia 13 10 8 8 7 46 1.7 3.5 5.8 Romania 54 35 27 21 19 65 4.3 6.3 8.3 Russian Federation 56 42 25 18 17 70 5.0 6.9 8.9 Rwanda 1160 643 373 275 248 79 7.0 9.1 10.7 Saint Lucia 86 83 109 115 117 -36 -4.7 -1.8 0.8 Saint Vincent and the Grenadines 80 59 63 64 68 15 -0.9 0.9 3.1 Samoa 88 72 58 45 43 51 1.7 4.2 6.6 Sao Tome and Principe 179 163 140 130 130 27 -0.1 1.9 4.3 Saudi Arabia 24 22 19 17 17 29 -0.2 2.1 4.5 Senegal 553 519 447 346 315 43 1.4 3.3 4.8 Serbia 13 12 12 13 12 8 -2.0 0.6 2.9 Seychelles 53 55 55 54 53 0 -2.4 0.0 2.4 Sierra Leone 2480 1760 1360 1180 1120 55 2.2 4.7 6.6 Singapore 13 13 10 9 8 38 0.4 2.9 5.3 Slovakia 8 7 6 6 5 38 0.6 2.3 4.0 Slovenia 12 10 8 7 7 42 1.6 3.3 5.0 Solomon Islands 245 188 141 112 104 58 3.0 5.0 7.0 Somalia 1210 1040 985 855 829 31 0.3 2.2 4.6 South Africa 160 201 171 125 119 26 0.1 1.7 3.0 South Sudan 1730 1480 1100 1110 1150 34 0.1 2.4 4.5 EXECUTIVE SUMMARY 11Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division Table 2 (continued). Trends in estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), by country and territory, 2000–2017a Country and territory MMR point estimatesa,b Overall change in MMR between 2000 and 2017c (%) Average annual rate of reduction (ARR) point estimate and range of uncertainty interval on ARR between 2000 and 2017 (UI: 80%) (%) 2000 2005 2010 2015 2017 Lower UI Average ARR point estimated Upper UI Spain 5 5 4 4 4 20 0.0 1.7 3.0 Sri Lanka 56 45 38 36 36 36 1.7 2.7 3.5 State of Libya 70 57 53 70 72 -3 -2.6 -0.2 2.3 Sudan 667 529 408 320 295 56 2.7 4.8 7.1 Suriname 221 164 148 122 120 46 2.3 3.6 5.4 Sweden 5 5 4 4 4 20 -0.2 1.5 2.9 Switzerland 7 7 6 5 5 29 0.4 2.6 4.2 Syrian Arab Republic 26 25 27 30 31 -19 -4.0 -1.1 1.3 Tajikistan 53 32 23 18 17 68 4.3 6.8 9.5 Thailand 43 43 42 38 37 14 -0.5 0.8 2.1 Timor-Leste 745 415 219 160 142 81 7.7 9.8 11.9 Togo 489 492 440 398 396 19 -0.5 1.3 3.1 Tonga 77 66 57 54 52 32 0.0 2.3 4.6 Trinidad and Tobago 81 76 71 68 67 17 -0.6 1.1 2.7 Tunisia 66 51 46 46 43 35 0.7 2.4 4.8 Turkey 42 33 24 19 17 60 3.6 5.3 7.5 Turkmenistan 29 18 10 8 7 76 5.9 8.2 10.5 Uganda 578 491 430 387 375 35 0.5 2.5 4.2 Ukraine 35 33 25 21 19 46 1.6 3.6 5.5 United Arab Emirates 6 5 4 3 3 50 1.9 4.0 6.9 United Kingdom of Great Britain and Northern Ireland 10 11 10 8 7 30 1.9 2.7 3.6 United Republic of Tanzania 854 721 644 556 524 39 0.9 2.9 4.4 United States of America 12 13 15 18 19 -58 -3.3 -2.6 -1.9 Uruguay 26 22 17 18 17 35 1.2 2.4 3.6 Uzbekistan 41 38 31 30 29 29 0.1 2.0 3.6 Vanuatu 140 113 92 76 72 49 1.6 4.0 6.1 Venezuela (Bolivarian Republic of) 119 113 117 115 125 -5 -2.2 -0.3 1.3 12 Trends in maternal mortality 2000 to 2017 Table 2 (continued). Trends in estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), by country and territory, 2000–2017a a Estimates have been computed to ensure comparability across countries, thus they are not necessarily the same as official statistics of the countries, which may use alternative rigorous methods. b MMR estimates have been rounded according to the following scheme: < 100 rounded to nearest 1; 100–999 rounded to nearest 1; and ≥ 1000 rounded to nearest 10; and all calculations are based on rounded numbers. c Overall change for the whole period since the first year of the millennium (from 1 January 2000). d Average annual rate of reduction, for the whole period from the first year of the millennium (1 January 2000). e UNICEF, UNPFA, World Bank Group and UNPD refer to this territory as the State of Palestine. Country and territory MMR point estimatesa,b Overall change in MMR between 2000 and 2017c (%) Average annual rate of reduction (ARR) point estimate and range of uncertainty interval on ARR between 2000 and 2017 (UI: 80%) (%) 2000 2005 2010 2015 2017 Lower UI Average ARR point estimated Upper UI Viet Nam 68 54 47 45 43 37 0.5 2.6 4.6 West Bank and Gaza Stripe 70 59 45 32 27 61 3.4 5.6 8.1 Yemen 301 242 192 169 164 46 1.7 3.6 6.1 Zambia 528 421 305 232 213 60 3.7 5.3 6.8 Zimbabwe 579 685 598 480 458 21 0.1 1.4 2.9 2000 to 2017 TRENDS IN MATERNAL MORTALITY Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population DivisionFor more information, please contact: Department of Reproductive Health and Research World Health Organization Avenue Appia 20 CH-1211 Geneva 27 Switzerland Email: reproductivehealth@who.int www.who.int/reproductivehealth Executive summary WHO/RHR/19.23 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Cover.indd 1 22.11.19 13:06
2000 to 2017 TRENDS IN MATERNAL MORTALITY Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population DivisionFor more information, please contact: Department of Reproductive Health and Research World Health Organization Avenue Appia 20 CH-1211 Geneva 27 Switzerland Email: reproductivehealth@who.int www.who.int/reproductivehealth Executive summary WHO/RHR/19.23 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Cover.indd 1 22.11.19 13:06 1Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division EXECUTIVE SUMMARY Background The Sustainable Development Goals (SDGs) were launched on 25 September 2015 and came into force on 1 January 2016 for the 15-year period until 31 December 2030. Among the 17 SDGs, the direct health- related targets come under SDG 3: Ensure healthy lives and promote well-being for all at all ages. With the adoption of the SDGs, the United Nations Member States extended the global commitments they had made in 2000 to the Millennium Development Goals (MDGs), which covered the period until 2015. In anticipation of the launch of the SDGs, the World Health Organization (WHO) and partners released a consensus statement and full strategy paper on ending preventable maternal mortality (EPMM). The EPMM target for reducing the global maternal mortality ratio (MMR) by 2030 was adopted as SDG target 3.1: reduce global MMR to less than 70 per 100 000 live births by 2030. Having targets for mortality reduction is important, but accurate measurement of maternal mortality remains challenging and many deaths still go uncounted. Many countries still lack well functioning civil registration and vital statistics (CRVS) systems, and where such systems do exist, reporting errors – whether incompleteness (unregistered deaths, also known as “missing”) or misclassification of cause of death – continue to pose a major challenge to data accuracy. Methods and interpretation The United Nations Maternal Mortality Estimation Inter-Agency Group (UN MMEIG) – comprising WHO, the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA), the World 1 Estimates have been computed to ensure comparability across countries, thus they are not necessarily the same as official statistics of the countries, which may use alternative rigorous methods. 2 Puerto Rico is an Associate Member, and the West Bank and Gaza Strip is a member in the regional committee for the WHO Eastern Mediterranean Region. 3 Available at: www.who.int/reproductivehealth/publications/maternal-mortality-2017/en/. Bank Group and the United Nations Population Division (UNPD) of the Department of Economic and Social Affairs – has collaborated with external technical experts on a new round of estimates for 2000–2017. To provide increasingly accurate MMR estimates, the previous estimation methods have been refined to optimize use of country-level data. Consultations with countries were carried out during May and June 2019. This process generated additional data for inclusion in the maternal mortality estimation model, demonstrating widespread expansion of in-country efforts to monitor maternal mortality. This report presents internationally comparable global, regional and country-level estimates and trends for maternal mortality between 2000 and 2017.1 Countries and territories included in the analyses are WHO Member States with populations over 100 000, plus two territories (Puerto Rico, and the West Bank and Gaza Strip)2. The results described in this report include the first available estimates for maternal mortality in the SDG reporting period; but since two years (2016 and 2017) is not sufficient to show trends, estimates have been developed and presented covering the period 2000 to 2017. The new estimates presented in this report supersede all previously published estimates for years that fall within the same time period. Care should be taken to use only these estimates for the interpretation of trends in maternal mortality from 2000 to 2017; due to modifications in methodology and data availability, differences between these and previous estimates should not be interpreted as representing time trends. In addition, when interpreting changes in MMRs over time, one should take into consideration that it is easier to reduce the MMR when the level is high than when the MMR level is already low. The full database, country profiles and all model specification codes used are available online.3 2 Trends in maternal mortality 2000 to 2017 4 All uncertainty intervals (UIs) reported are 80% UI. The data can be interpreted as meaning that there is an 80% chance that the true value lies within the UI, a 10% chance that the true value lies below the lower limit and a 10% chance that the true value lies above the upper limit. 5 For the purpose of categorization, MMR is considered to be low if it is less than 100, moderate if it is 100–299, high if it is 300–499, very high if it is 500–999 and extremely high if it is equal to or higher than 1000 maternal deaths per 100 000 live births. Global estimates for 2017 and trends for 2000– 2017 The global estimates for the year 2017 indicate that there were 295 000 (UI 279 000 to 340 000)4 maternal deaths; 35% lower than in 2000 when there were an estimated 451 000 (UI 431 000 to 485 000) maternal deaths. The global MMR in 2017 is estimated at 211 (UI 99 to 243) maternal deaths per 100 000 live births, representing a 38% reduction since 2000, when it was estimated at 342. The average annual rate of reduction (ARR) in global MMR during the 2000–2017 period was 2.9%; this means that, on average, the global MMR declined by 2.9% every year between 2000 and 2017. The global lifetime risk of maternal mortality for a 15-year-old girl in 2017 was estimated at 1 in 190; nearly half of the level of risk in 2000: 1 in 100. The overall proportion of deaths to women of reproductive age (15–49 years) that are due to maternal causes (PM) was estimated at 9.2% (UI 8.7% to 10.6%) in 2017 – down by 26.3% since 2000. This means that compared with other causes of death to women of reproductive age, the fraction attributed to maternal causes is decreasing. In addition, the effect of HIV on maternal mortality in 2017 appears to be less pronounced than in earlier years; HIV-related indirect maternal deaths now account for approximately 1% of all maternal deaths compared with 2.5% in 2005, at the peak of the epidemic. Regional and country-level estimates for 2017 MMR in the world’s least developed countries (LDCs) is high,5 estimated at 415 (UI 396 to 477) maternal deaths per 100 000 live births, which is more than 40 times higher than MMR in Europe (10; UI 9 to 11), and almost 60 times higher than in Australia and New Zealand (7; UI 6 to 8). In the world’s LDCs, where an estimated 130 000 maternal deaths occurred in 2017, the estimated lifetime risk of maternal death was 1 in 56. Sub-Saharan Africa is the only region with very high MMR for 2017, estimated at 542 (UI 498 to 649), while the lifetime risk of maternal death was 1 in 37, compared with just 1 in 7800 in Australia and New Zealand. Moderate MMR (100–299) was estimated in Northern Africa, Oceania (excluding Australia and New Zealand), Southern Asia, South-Eastern Asia and in small island developing States. Four subregions (Australia and New Zealand, Central Asia, Eastern Asia and Western Asia) and two regions (Latin America and the Caribbean, and Europe and Northern America) have low MMR (< 100 maternal deaths per 100 000 live births). Sub-Saharan Africa and Southern Asia accounted for approximately 86% (254 000) of the estimated global maternal deaths in 2017, with sub-Saharan Africa alone accounting for roughly 66% (196 000), while Southern Asia accounted for nearly 20% (58 000). South-Eastern Asia, in addition, accounted for over 5% of global maternal deaths (16 000). Three countries are estimated to have had extremely high MMR in 2017 (defined as over 1000 maternal deaths per 100 000 live births): South Sudan (1150; UI 789 to 1710), Chad (1140; UI 847 to 1590) and Sierra Leone (1120; UI 808 to 1620). Sixteen other countries, all also in sub-Saharan Africa except for one (Afghanistan), had very high MMR in 2017 (i.e. estimates ranging between 500 and 999). Only three countries in sub-Saharan Africa had low MMR: Mauritius (61; UI 46 to 85), Cabo Verde (58; UI 45 to 75) and Seychelles (53; UI 26 to 109). Only one country outside the sub-Saharan African region had high MMR: Haiti (480; UI 346 to 718). Ninety countries were estimated to have MMR of 50 or less in 2017. Nigeria and India had the highest estimated numbers of maternal deaths, accounting for approximately one third (35%) of estimated global maternal deaths in 2017, with approximately 67 000 and 35 000 maternal deaths (23% and 12% of global maternal deaths), respectively. Three other countries also had 10 000 maternal deaths or more: the Democratic Republic of the Congo (16 000), Ethiopia (14 000) and the United Republic of Tanzania (11 000). Sixty-one countries were estimated to have had just 10 or fewer maternal deaths in 2017. 3Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division EXECUTIVE SUMMARY Table 1. Estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), number of maternal deaths, lifetime risk and proportion of deaths among women of reproductive age that are due to maternal causes (PM), by United Nations Sustainable Development Goal (SDG) region, subregion and other grouping, 2017 UI: uncertainty interval. a The country groupings are based on the geographic regions defined under the Standard Country or Area Codes for Statistical Use (known as M49) https://unstats.un.org/sdgs/report/2019/regional-groups/. b MMR estimates have been rounded according to the following scheme: < 100 rounded to nearest 1; 100–999 rounded to nearest 1; and ≥ 1000 rounded to nearest 10. c Numbers of maternal deaths have been rounded according to the following scheme: < 100 rounded to nearest 1; 100–999 rounded to nearest 10; 1000– 9999 rounded to nearest 100; and ≥ 10 000 rounded to nearest 1000. d Lifetime risk numbers have been rounded according to the following scheme: < 100 rounded to nearest 1; 100–999 rounded to nearest 10; and ≥ 1000 rounded to nearest 100. e The number of maternal deaths in a given time period divided by the total deaths among women aged 15–49 years. SDG regiona MMRb point estimate and range of uncertainty interval (UI: 80%) Number of maternal deathsc Lifetime risk of maternal deathd PMe (%) Lower UI MMR point estimate Upper UI World 199 211 243 295 000 190 9.2 Sub-Saharan Africa 498 542 649 196 000 37 18.2 Northern Africa and Western Asia 73 84 104 9 700 380 5.9 Northern Africa 91 112 145 6 700 260 8.4 Western Asia 45 55 69 3 000 650 3.6 Central and Southern Asia 131 151 181 58 000 260 6.6 Central Asia 21 24 28 390 1 400 1.7 Southern Asia 136 157 189 58 000 250 6.8 Eastern and South-Eastern Asia 61 69 85 21 000 790 3.3 Eastern Asia 22 28 35 5 300 2 200 1.5 South-Eastern Asia 115 137 173 16 000 320 5.5 Latin America and the Caribbean 69 73 80 7 700 640 3.8 Oceania 34 60 120 400 690 4.1 Australia and New Zealand 6 7 8 26 7 800 0.6 Oceania (excl. Australia and New Zealand) 69 129 267 380 210 6.5 Europe and Northern America 12 12 14 1 500 4 800 0.6 Europe 9 10 11 740 6 500 0.5 Northern America 16 18 20 760 3 100 0.9 Landlocked developing countries 377 407 483 64 000 57 17.4 Least developed countries 396 415 477 130 000 56 17.5 Small island developing States 178 210 277 2 600 190 8.5 4 Trends in maternal mortality 2000 to 2017 In 2017, according to the Fragile States Index, 15 countries were considered to be “very high alert” or “high alert” (from highest to lowest: South Sudan, Somalia, Central African Republic, Yemen, Syrian Arab Republic, Sudan, the Democratic Republic of the Congo, Chad, Afghanistan, Iraq, Haiti, Guinea, Nigeria, Zimbabwe and Ethiopia), and these 15 countries had MMRs in 2017 ranging from 31 (Syrian Arab Republic) to 1150 (South Sudan). Regional and country-level trends: 2000–2017 Between 2000 and 2017, the subregion of Southern Asia achieved the greatest overall percentage reduction in MMR: 59% (from 384 to 157). This equates to an average ARR of 5.3%. Four other subregions roughly halved their MMRs during this period: Central Asia (52%), Eastern Asia (50%), Europe (53%) and Northern Africa (54%). MMR in LDCs also declined by 46%. Despite its very high MMR in 2017, sub-Saharan Africa as a region also achieved a substantial reduction in MMR of roughly 38% since 2000. Notably, one subregion with very low MMR (12) in 2000 – Northern America – had an increase in MMR of almost 52% during this period, rising to 18 in 2017. This is likely related to already low levels of MMR, as well as improvements in data collection, changes in life expectancy and/or changes in disparities between subpopulations. The greatest declines in proportion of deaths among women of reproductive age that are due to maternal causes (PM) occurred in two regions: Central and Southern Asia (56.4%), and Northern Africa and Western Asia (42.6%). Almost no change was seen in PM in Europe and Northern America. The 10 countries with the highest MMRs in 2017 (in order from highest to lowest: South Sudan, Chad, Sierra Leone, Nigeria, Central African Republic, Somalia, Mauritania, Guinea-Bissau, Liberia, Afghanistan) all Figure 1. Maternal mortality ratios, by country, 2017 6 The Fragile States Index is an assessment of 178 countries based on 12 cohesion, economic, social and political indicators, resulting in a score that indicates their susceptibility to instability. Further information about indicators and methodology is available at: https://fragilestatesindex.org/. At the top of the range (most fragile), the scores are categorized as follows: > 110 = very high alert; 100–110 = high alert. These two categories include the 15 most fragile countries mentioned here. There are 10 other categories ranging from “very sustainable” to “alert”, which include the remaining 163 countries. 0 1,750 3,500875 Kilometres 1−19 20−99 100−299 300−499 500−999 ≥ 1000 Data not available Not applicable © World Health Organization 2019 Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. The designations employed and the presentation of the material in this map do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. EXECUTIVE SUMMARY 5Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division have ARRs between 2000 and 2017 of less than 5%. When comparing the ARRs between the year ranges of 2000–2010 and 2010–2017, these 10 countries have also had stagnant or slowing levels of ARR and therefore remain at greatest risk. The impact of interruptions or loss of quality health services must be considered in crisis and other unstable situations. Countries that achieved the highest ARRs between 2000 and 2017 (an average ARR of 7% or above), starting with the highest, were Belarus, Kazakhstan, Timor-Leste, Rwanda, Turkmenistan, Mongolia, Angola and Estonia. In considering the uncertainty intervals around their average ARRs, we can only be very sure about this high level of acceleration in Belarus, Kazakhstan, Timor- Leste and Rwanda. In 13 countries, MMR increased in the same period. In considering the uncertainty around the rate and direction of change, we believe there have been true MMR increases in the United States of America and the Dominican Republic. These findings must be considered in context – as many factors may drive positive and negative trends in maternal mortality. Conclusions The SDGs include a direct emphasis on reducing maternal mortality while also highlighting the importance of moving beyond survival. Despite the ambition to end preventable maternal deaths by 2030, the world will fall short of this target by more than 1 million lives with the current pace of progress. There is a continued urgent need for maternal health and survival to remain high on the global health and development agenda; the state of maternal health interacts with and reflects efforts to improve the accessibility and quality of care. The 2018 Declaration of Astana repositioned primary health care as the most (cost) effective and inclusive means of delivering health services to achieve the SDGs. Primary health care is thereby considered the cornerstone for achieving universal health coverage (UHC), which only exists when all people receive the quality health services they need without suffering financial hardship. Health services that are unavailable/ inaccessible or of poor quality, however, will not support the achievement of UHC, as envisioned. Efforts to increase the provision of skilled and competent care to more women, before, during and after childbirth, must also be seen in the context of external forces including but not limited to climate change, migration and humanitarian crises. In addition, governments are called upon to establish well functioning CRVS systems with accurate attribution of cause of death. Improvements in measurement must be driven by action at the country level, with governments creating systems to capture data specific to their information needs; systems that must also meet the standards required for international comparability. Globally, standardized methods for preventing errors in CRVS reporting (i.e. incompleteness and misclassification) should be established to enhance international comparability. In consideration of the above, it must be noted that this report on the levels and trends of maternal mortality provides just one critical facet of information, which synthesizes and draws from the available data, to assess progress in reducing maternal mortality towards achieving SDG target 3.1. The results so far show good but uneven progress across the world in reducing maternal deaths between 2000 and 2017. The global community should accelerate efforts, because if we only continue with the same rate of progress as achieved during this period, it will not be possible to reach the global SDG target of less than 70 maternal deaths per 100 000 live births by 2030. Ultimately, we need to expand horizons beyond a sole focus on mortality, to look at the broader aspects – country and regional situations and trends including health systems, UHC, quality of care, morbidity levels and socioeconomic determinants of women’s empowerment and education – and ensure that appropriate action is taken to support family planning, healthy pregnancy and safe childbirth. 6 Trends in maternal mortality 2000 to 2017 Table 2. Trends in estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), by country and territory, 2000–2017a Country and territory MMR point estimatesa,b Overall change in MMR between 2000 and 2017c (%) Average annual rate of reduction (ARR) point estimate and range of uncertainty interval on ARR between 2000 and 2017 (UI: 80%) (%) 2000 2005 2010 2015 2017 Lower UI Average ARR point estimated Upper UI Afghanistan 1450 1140 954 701 638 56 1.4 4.8 7.3 Albania 23 22 21 15 15 35 -0.1 2.5 5.7 Algeria 161 127 115 114 112 30 -0.5 2.1 4.4 Angola 827 519 326 251 241 71 5.4 7.2 9.3 Antigua and Barbuda 44 40 44 43 42 5 -1.8 0.2 2.4 Argentina 66 59 51 41 39 41 2.1 3.1 4.2 Armenia 43 35 32 28 26 40 1.5 3.0 4.3 Australia 7 5 5 6 6 14 -1.4 0.2 1.7 Austria 6 6 5 5 5 17 -0.5 1.6 3.1 Azerbaijan 47 42 31 27 26 45 2.2 3.5 4.9 Bahamas 75 77 78 74 70 7 -2.4 0.4 2.6 Bahrain 27 19 18 15 14 48 1.6 3.6 5.4 Bangladesh 434 343 258 200 173 60 3.4 5.4 7.1 Barbados 50 42 36 31 27 46 1.9 3.7 6.0 Belarus 22 11 5 3 2 91 9.6 13.0 16.7 Belgium 8 7 6 5 5 38 1.0 2.5 4.1 Belize 89 70 54 43 36 60 3.7 5.3 7.5 Benin 520 500 464 421 397 24 -0.4 1.6 3.2 Bhutan 423 310 247 203 183 57 2.1 4.9 7.0 Bolivia (Plurinational State of) 331 271 212 168 155 53 2.7 4.5 6.2 Bosnia and Herzegovina 17 13 11 10 10 41 1.3 3.3 6.3 Botswana 262 239 179 156 144 45 2.1 3.5 4.7 Brazil 69 71 65 63 60 13 0.7 0.9 1.1 Brunei Darussalam 28 29 28 30 31 -11 -2.5 -0.7 1.6 Bulgaria 19 15 12 10 10 47 1.9 4.0 6.5 Burkina Faso 516 437 385 343 320 38 0.9 2.8 4.9 Burundi 1010 814 665 568 548 46 1.7 3.6 5.5 Cabo Verde 118 86 70 61 58 51 2.5 4.2 5.7 Cambodia 488 351 248 178 160 67 4.6 6.6 8.4 Cameroon 886 692 597 554 529 40 0.8 3.0 4.8 Canada 9 11 11 11 10 -11 -2.5 -0.6 1.2 EXECUTIVE SUMMARY 7Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division Table 2 (continued). Trends in estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), by country and territory, 2000–2017a Country and territory MMR point estimatesa,b Overall change in MMR between 2000 and 2017c (%) Average annual rate of reduction (ARR) point estimate and range of uncertainty interval on ARR between 2000 and 2017 (UI: 80%) (%) 2000 2005 2010 2015 2017 Lower UI Average ARR point estimated Upper UI Central African Republic 1280 1200 1000 912 829 35 0.3 2.6 4.9 Chad 1420 1330 1240 1160 1140 20 -0.7 1.3 2.9 Chile 31 25 20 14 13 58 4.3 5.4 6.7 China 59 44 36 30 29 51 2.9 4.2 6.0 Colombia 94 83 85 85 83 12 -0.4 0.8 1.7 Comoros 444 404 341 285 273 39 0.8 2.9 4.9 Congo 739 677 506 416 378 49 2.0 3.9 5.7 Costa Rica 40 33 32 28 27 33 1.2 2.2 3.4 Côte d’Ivoire 704 704 701 658 617 12 -1.2 0.8 2.7 Croatia 11 10 9 8 8 27 0.0 2.0 3.7 Cuba 46 41 41 38 36 22 0.6 1.4 2.2 Cyprus 14 12 8 7 6 57 2.9 4.9 7.0 Czechia 7 5 4 4 3 57 2.0 4.0 6.3 Democratic People’s Republic of Korea 139 120 106 91 89 36 0.2 2.6 4.9 Democratic Republic of the Congo 760 627 542 490 473 38 0.1 2.8 4.7 Denmark 8 6 5 4 4 50 2.8 4.3 6.2 Djibouti 507 393 283 247 248 51 2.0 4.2 6.5 Dominican Republic 80 83 96 94 95 -19 -1.6 -1.0 -0.5 Ecuador 122 94 78 63 59 52 3.4 4.3 5.2 Egypt 64 52 45 39 37 42 1.7 3.2 5.4 El Salvador 73 62 54 48 46 37 1.3 2.7 4.3 Equatorial Guinea 454 344 308 296 301 34 0.3 2.4 4.5 Eritrea 1280 804 567 518 480 63 3.6 5.8 7.9 Estonia 29 18 11 10 9 69 5.0 7.1 9.6 Eswatini 521 532 450 435 437 16 -1.6 1.0 3.0 Ethiopia 1030 865 597 446 401 61 3.0 5.5 7.4 Fiji 51 46 39 35 34 33 0.8 2.4 4.0 Finland 6 5 4 3 3 50 1.7 3.6 5.2 France 10 9 9 8 8 20 0.2 1.4 2.6 Gabon 380 348 314 261 252 34 0.1 2.4 4.3 8 Trends in maternal mortality 2000 to 2017 Table 2 (continued). Trends in estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), by country and territory, 2000–2017a Country and territory MMR point estimatesa,b Overall change in MMR between 2000 and 2017c (%) Average annual rate of reduction (ARR) point estimate and range of uncertainty interval on ARR between 2000 and 2017 (UI: 80%) (%) 2000 2005 2010 2015 2017 Lower UI Average ARR point estimated Upper UI Gambia 932 756 661 625 597 36 0.6 2.6 4.5 Georgia 31 39 32 27 25 19 0.1 1.3 2.5 Germany 7 6 6 5 7 0 -1.3 0.2 1.8 Ghana 484 371 339 320 308 36 0.9 2.7 4.5 Greece 3 3 3 3 3 0 -1.3 0.6 2.7 Grenada 38 33 29 25 25 34 0.4 2.4 4.5 Guatemala 161 142 129 103 95 41 2.5 3.1 3.7 Guinea 1020 920 747 699 576 44 1.6 3.4 4.9 Guinea-Bissau 1210 979 779 694 667 45 1.0 3.5 5.4 Guyana 231 223 179 172 169 27 0.4 1.8 3.3 Haiti 437 459 506 488 480 -10 -2.7 -0.6 1.3 Honduras 85 77 74 67 65 24 0.4 1.6 2.7 Hungary 16 15 13 12 12 25 -0.6 2.0 4.2 Iceland 6 5 5 4 4 33 0.7 2.7 4.9 India 370 286 210 158 145 61 4.2 5.5 7.0 Indonesia 272 252 228 192 177 35 0.5 2.5 4.3 Iran (Islamic Republic of) 48 34 22 17 16 67 5.0 6.3 8.0 Iraq 79 127 70 83 79 0 -1.9 0.0 2.5 Ireland 7 7 6 6 5 29 0.0 2.5 4.3 Israel 7 5 4 3 3 57 3.4 4.9 6.5 Italy 4 3 2 2 2 50 3.3 5.1 6.9 Jamaica 77 80 79 78 80 -4 -1.5 -0.2 0.9 Japan 9 7 6 5 5 44 2.1 3.8 5.7 Jordan 70 62 53 48 46 34 0.6 2.4 4.7 Kazakhstan 61 43 22 12 10 84 9.2 10.9 12.6 Kenya 708 618 432 353 342 52 2.4 4.3 5.9 Kiribati 136 119 112 97 92 32 0.1 2.3 4.7 Kuwait 10 10 10 11 12 -20 -2.8 -0.7 1.2 Kyrgyzstan 79 82 79 66 60 24 0.0 1.6 2.8 Lao People’s Democratic Republic 544 410 292 209 185 66 4.4 6.3 8.0 Latvia 34 30 26 23 19 44 1.6 3.5 5.0 EXECUTIVE SUMMARY 9Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division Table 2 (continued). Trends in estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), by country and territory, 2000–2017a Country and territory MMR point estimatesa,b Overall change in MMR between 2000 and 2017c (%) Average annual rate of reduction (ARR) point estimate and range of uncertainty interval on ARR between 2000 and 2017 (UI: 80%) (%) 2000 2005 2010 2015 2017 Lower UI Average ARR point estimated Upper UI Lebanon 28 24 23 29 29 -4 -2.9 -0.4 1.6 Lesotho 614 679 594 574 544 11 -1.6 0.7 2.5 Liberia 894 816 708 691 661 26 -0.4 1.8 3.5 Lithuania 17 14 10 9 8 53 2.1 4.2 6.5 Luxembourg 10 9 8 5 5 50 2.4 4.5 6.3 Madagascar 559 526 453 363 335 40 1.0 3.0 5.0 Malawi 749 610 444 370 349 53 2.3 4.5 6.5 Malaysia 38 31 30 30 29 24 0.2 1.5 2.7 Maldives 125 75 67 54 53 58 2.1 5.1 7.3 Mali 836 691 660 620 562 33 0.3 2.3 3.9 Malta 9 8 8 7 6 33 0.1 2.3 4.4 Mauritania 834 826 824 785 766 8 -2.0 0.5 2.6 Mauritius 59 53 66 73 61 -3 -2.8 -0.2 1.9 Mexico 55 54 46 36 33 40 2.6 3.0 3.3 Micronesia (Federated States of) 154 133 110 95 88 43 1.0 3.3 5.6 Mongolia 155 98 66 47 45 71 5.8 7.3 8.8 Montenegro 12 9 7 6 6 50 2.1 4.3 6.9 Morocco 188 131 92 74 70 63 4.2 5.8 7.5 Mozambique 798 577 412 318 289 64 3.9 6.0 7.7 Myanmar 340 299 265 246 250 26 -0.7 1.8 4.1 Namibia 348 346 266 217 195 44 1.4 3.4 4.9 Nepal 553 415 305 236 186 66 4.0 6.4 8.4 Netherlands 13 11 7 6 5 62 3.8 5.6 7.5 New Zealand 12 11 11 10 9 25 0.5 1.8 3.3 Nicaragua 162 131 112 101 98 40 1.2 3.0 4.5 Niger 813 755 663 555 509 37 0.8 2.7 4.5 Nigeria 1200 1080 978 931 917 24 -0.8 1.6 3.5 Norway 6 5 4 3 2 67 3.4 5.3 7.8 Oman 20 19 18 19 19 5 -1.0 0.3 1.6 Pakistan 286 237 191 154 140 51 2.0 4.2 6.4 Panama 91 88 79 58 52 43 2.1 3.3 4.7 10 Trends in maternal mortality 2000 to 2017 Table 2 (continued). Trends in estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), by country and territory, 2000–2017a Country and territory MMR point estimatesa,b Overall change in MMR between 2000 and 2017c (%) Average annual rate of reduction (ARR) point estimate and range of uncertainty interval on ARR between 2000 and 2017 (UI: 80%) (%) 2000 2005 2010 2015 2017 Lower UI Average ARR point estimated Upper UI Papua New Guinea 249 200 168 151 145 42 0.9 3.2 5.5 Paraguay 165 137 108 88 84 49 2.6 4.0 5.6 Peru 144 118 104 94 88 39 1.5 2.9 4.6 Philippines 160 156 144 127 121 24 -0.3 1.7 3.3 Poland 7 4 3 2 2 71 4.5 6.6 8.9 Portugal 10 9 9 9 8 20 -0.6 1.6 3.3 Puerto Rico 26 23 21 20 21 19 -0.6 1.3 2.7 Qatar 14 12 10 9 9 36 0.5 2.6 4.5 Republic of Korea 17 15 15 12 11 35 1.4 2.4 3.6 Republic of Moldova 44 34 29 22 19 57 3.3 4.9 6.6 Republic of North Macedonia 13 10 8 8 7 46 1.7 3.5 5.8 Romania 54 35 27 21 19 65 4.3 6.3 8.3 Russian Federation 56 42 25 18 17 70 5.0 6.9 8.9 Rwanda 1160 643 373 275 248 79 7.0 9.1 10.7 Saint Lucia 86 83 109 115 117 -36 -4.7 -1.8 0.8 Saint Vincent and the Grenadines 80 59 63 64 68 15 -0.9 0.9 3.1 Samoa 88 72 58 45 43 51 1.7 4.2 6.6 Sao Tome and Principe 179 163 140 130 130 27 -0.1 1.9 4.3 Saudi Arabia 24 22 19 17 17 29 -0.2 2.1 4.5 Senegal 553 519 447 346 315 43 1.4 3.3 4.8 Serbia 13 12 12 13 12 8 -2.0 0.6 2.9 Seychelles 53 55 55 54 53 0 -2.4 0.0 2.4 Sierra Leone 2480 1760 1360 1180 1120 55 2.2 4.7 6.6 Singapore 13 13 10 9 8 38 0.4 2.9 5.3 Slovakia 8 7 6 6 5 38 0.6 2.3 4.0 Slovenia 12 10 8 7 7 42 1.6 3.3 5.0 Solomon Islands 245 188 141 112 104 58 3.0 5.0 7.0 Somalia 1210 1040 985 855 829 31 0.3 2.2 4.6 South Africa 160 201 171 125 119 26 0.1 1.7 3.0 South Sudan 1730 1480 1100 1110 1150 34 0.1 2.4 4.5 EXECUTIVE SUMMARY 11Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division Table 2 (continued). Trends in estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), by country and territory, 2000–2017a Country and territory MMR point estimatesa,b Overall change in MMR between 2000 and 2017c (%) Average annual rate of reduction (ARR) point estimate and range of uncertainty interval on ARR between 2000 and 2017 (UI: 80%) (%) 2000 2005 2010 2015 2017 Lower UI Average ARR point estimated Upper UI Spain 5 5 4 4 4 20 0.0 1.7 3.0 Sri Lanka 56 45 38 36 36 36 1.7 2.7 3.5 State of Libya 70 57 53 70 72 -3 -2.6 -0.2 2.3 Sudan 667 529 408 320 295 56 2.7 4.8 7.1 Suriname 221 164 148 122 120 46 2.3 3.6 5.4 Sweden 5 5 4 4 4 20 -0.2 1.5 2.9 Switzerland 7 7 6 5 5 29 0.4 2.6 4.2 Syrian Arab Republic 26 25 27 30 31 -19 -4.0 -1.1 1.3 Tajikistan 53 32 23 18 17 68 4.3 6.8 9.5 Thailand 43 43 42 38 37 14 -0.5 0.8 2.1 Timor-Leste 745 415 219 160 142 81 7.7 9.8 11.9 Togo 489 492 440 398 396 19 -0.5 1.3 3.1 Tonga 77 66 57 54 52 32 0.0 2.3 4.6 Trinidad and Tobago 81 76 71 68 67 17 -0.6 1.1 2.7 Tunisia 66 51 46 46 43 35 0.7 2.4 4.8 Turkey 42 33 24 19 17 60 3.6 5.3 7.5 Turkmenistan 29 18 10 8 7 76 5.9 8.2 10.5 Uganda 578 491 430 387 375 35 0.5 2.5 4.2 Ukraine 35 33 25 21 19 46 1.6 3.6 5.5 United Arab Emirates 6 5 4 3 3 50 1.9 4.0 6.9 United Kingdom of Great Britain and Northern Ireland 10 11 10 8 7 30 1.9 2.7 3.6 United Republic of Tanzania 854 721 644 556 524 39 0.9 2.9 4.4 United States of America 12 13 15 18 19 -58 -3.3 -2.6 -1.9 Uruguay 26 22 17 18 17 35 1.2 2.4 3.6 Uzbekistan 41 38 31 30 29 29 0.1 2.0 3.6 Vanuatu 140 113 92 76 72 49 1.6 4.0 6.1 Venezuela (Bolivarian Republic of) 119 113 117 115 125 -5 -2.2 -0.3 1.3 12 Trends in maternal mortality 2000 to 2017 Table 2 (continued). Trends in estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), by country and territory, 2000–2017a a Estimates have been computed to ensure comparability across countries, thus they are not necessarily the same as official statistics of the countries, which may use alternative rigorous methods. b MMR estimates have been rounded according to the following scheme: < 100 rounded to nearest 1; 100–999 rounded to nearest 1; and ≥ 1000 rounded to nearest 10; and all calculations are based on rounded numbers. c Overall change for the whole period since the first year of the millennium (from 1 January 2000). d Average annual rate of reduction, for the whole period from the first year of the millennium (1 January 2000). e UNICEF, UNPFA, World Bank Group and UNPD refer to this territory as the State of Palestine. Country and territory MMR point estimatesa,b Overall change in MMR between 2000 and 2017c (%) Average annual rate of reduction (ARR) point estimate and range of uncertainty interval on ARR between 2000 and 2017 (UI: 80%) (%) 2000 2005 2010 2015 2017 Lower UI Average ARR point estimated Upper UI Viet Nam 68 54 47 45 43 37 0.5 2.6 4.6 West Bank and Gaza Stripe 70 59 45 32 27 61 3.4 5.6 8.1 Yemen 301 242 192 169 164 46 1.7 3.6 6.1 Zambia 528 421 305 232 213 60 3.7 5.3 6.8 Zimbabwe 579 685 598 480 458 21 0.1 1.4 2.9 2000 to 2017 TRENDS IN MATERNAL MORTALITY Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population DivisionFor more information, please contact: Department of Reproductive Health and Research World Health Organization Avenue Appia 20 CH-1211 Geneva 27 Switzerland Email: reproductivehealth@who.int www.who.int/reproductivehealth Executive summary WHO/RHR/19.23 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Cover.indd 1 22.11.19 13:06
2000 to 2017 TRENDS IN MATERNAL MORTALITY Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population DivisionFor more information, please contact: Department of Reproductive Health and Research World Health Organization Avenue Appia 20 CH-1211 Geneva 27 Switzerland Email: reproductivehealth@who.int www.who.int/reproductivehealth Executive summary WHO/RHR/19.23 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Cover.indd 1 22.11.19 13:06 1Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division EXECUTIVE SUMMARY Background The Sustainable Development Goals (SDGs) were launched on 25 September 2015 and came into force on 1 January 2016 for the 15-year period until 31 December 2030. Among the 17 SDGs, the direct health- related targets come under SDG 3: Ensure healthy lives and promote well-being for all at all ages. With the adoption of the SDGs, the United Nations Member States extended the global commitments they had made in 2000 to the Millennium Development Goals (MDGs), which covered the period until 2015. In anticipation of the launch of the SDGs, the World Health Organization (WHO) and partners released a consensus statement and full strategy paper on ending preventable maternal mortality (EPMM). The EPMM target for reducing the global maternal mortality ratio (MMR) by 2030 was adopted as SDG target 3.1: reduce global MMR to less than 70 per 100 000 live births by 2030. Having targets for mortality reduction is important, but accurate measurement of maternal mortality remains challenging and many deaths still go uncounted. Many countries still lack well functioning civil registration and vital statistics (CRVS) systems, and where such systems do exist, reporting errors – whether incompleteness (unregistered deaths, also known as “missing”) or misclassification of cause of death – continue to pose a major challenge to data accuracy. Methods and interpretation The United Nations Maternal Mortality Estimation Inter-Agency Group (UN MMEIG) – comprising WHO, the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA), the World 1 Estimates have been computed to ensure comparability across countries, thus they are not necessarily the same as official statistics of the countries, which may use alternative rigorous methods. 2 Puerto Rico is an Associate Member, and the West Bank and Gaza Strip is a member in the regional committee for the WHO Eastern Mediterranean Region. 3 Available at: www.who.int/reproductivehealth/publications/maternal-mortality-2017/en/. Bank Group and the United Nations Population Division (UNPD) of the Department of Economic and Social Affairs – has collaborated with external technical experts on a new round of estimates for 2000–2017. To provide increasingly accurate MMR estimates, the previous estimation methods have been refined to optimize use of country-level data. Consultations with countries were carried out during May and June 2019. This process generated additional data for inclusion in the maternal mortality estimation model, demonstrating widespread expansion of in-country efforts to monitor maternal mortality. This report presents internationally comparable global, regional and country-level estimates and trends for maternal mortality between 2000 and 2017.1 Countries and territories included in the analyses are WHO Member States with populations over 100 000, plus two territories (Puerto Rico, and the West Bank and Gaza Strip)2. The results described in this report include the first available estimates for maternal mortality in the SDG reporting period; but since two years (2016 and 2017) is not sufficient to show trends, estimates have been developed and presented covering the period 2000 to 2017. The new estimates presented in this report supersede all previously published estimates for years that fall within the same time period. Care should be taken to use only these estimates for the interpretation of trends in maternal mortality from 2000 to 2017; due to modifications in methodology and data availability, differences between these and previous estimates should not be interpreted as representing time trends. In addition, when interpreting changes in MMRs over time, one should take into consideration that it is easier to reduce the MMR when the level is high than when the MMR level is already low. The full database, country profiles and all model specification codes used are available online.3 2 Trends in maternal mortality 2000 to 2017 4 All uncertainty intervals (UIs) reported are 80% UI. The data can be interpreted as meaning that there is an 80% chance that the true value lies within the UI, a 10% chance that the true value lies below the lower limit and a 10% chance that the true value lies above the upper limit. 5 For the purpose of categorization, MMR is considered to be low if it is less than 100, moderate if it is 100–299, high if it is 300–499, very high if it is 500–999 and extremely high if it is equal to or higher than 1000 maternal deaths per 100 000 live births. Global estimates for 2017 and trends for 2000– 2017 The global estimates for the year 2017 indicate that there were 295 000 (UI 279 000 to 340 000)4 maternal deaths; 35% lower than in 2000 when there were an estimated 451 000 (UI 431 000 to 485 000) maternal deaths. The global MMR in 2017 is estimated at 211 (UI 99 to 243) maternal deaths per 100 000 live births, representing a 38% reduction since 2000, when it was estimated at 342. The average annual rate of reduction (ARR) in global MMR during the 2000–2017 period was 2.9%; this means that, on average, the global MMR declined by 2.9% every year between 2000 and 2017. The global lifetime risk of maternal mortality for a 15-year-old girl in 2017 was estimated at 1 in 190; nearly half of the level of risk in 2000: 1 in 100. The overall proportion of deaths to women of reproductive age (15–49 years) that are due to maternal causes (PM) was estimated at 9.2% (UI 8.7% to 10.6%) in 2017 – down by 26.3% since 2000. This means that compared with other causes of death to women of reproductive age, the fraction attributed to maternal causes is decreasing. In addition, the effect of HIV on maternal mortality in 2017 appears to be less pronounced than in earlier years; HIV-related indirect maternal deaths now account for approximately 1% of all maternal deaths compared with 2.5% in 2005, at the peak of the epidemic. Regional and country-level estimates for 2017 MMR in the world’s least developed countries (LDCs) is high,5 estimated at 415 (UI 396 to 477) maternal deaths per 100 000 live births, which is more than 40 times higher than MMR in Europe (10; UI 9 to 11), and almost 60 times higher than in Australia and New Zealand (7; UI 6 to 8). In the world’s LDCs, where an estimated 130 000 maternal deaths occurred in 2017, the estimated lifetime risk of maternal death was 1 in 56. Sub-Saharan Africa is the only region with very high MMR for 2017, estimated at 542 (UI 498 to 649), while the lifetime risk of maternal death was 1 in 37, compared with just 1 in 7800 in Australia and New Zealand. Moderate MMR (100–299) was estimated in Northern Africa, Oceania (excluding Australia and New Zealand), Southern Asia, South-Eastern Asia and in small island developing States. Four subregions (Australia and New Zealand, Central Asia, Eastern Asia and Western Asia) and two regions (Latin America and the Caribbean, and Europe and Northern America) have low MMR (< 100 maternal deaths per 100 000 live births). Sub-Saharan Africa and Southern Asia accounted for approximately 86% (254 000) of the estimated global maternal deaths in 2017, with sub-Saharan Africa alone accounting for roughly 66% (196 000), while Southern Asia accounted for nearly 20% (58 000). South-Eastern Asia, in addition, accounted for over 5% of global maternal deaths (16 000). Three countries are estimated to have had extremely high MMR in 2017 (defined as over 1000 maternal deaths per 100 000 live births): South Sudan (1150; UI 789 to 1710), Chad (1140; UI 847 to 1590) and Sierra Leone (1120; UI 808 to 1620). Sixteen other countries, all also in sub-Saharan Africa except for one (Afghanistan), had very high MMR in 2017 (i.e. estimates ranging between 500 and 999). Only three countries in sub-Saharan Africa had low MMR: Mauritius (61; UI 46 to 85), Cabo Verde (58; UI 45 to 75) and Seychelles (53; UI 26 to 109). Only one country outside the sub-Saharan African region had high MMR: Haiti (480; UI 346 to 718). Ninety countries were estimated to have MMR of 50 or less in 2017. Nigeria and India had the highest estimated numbers of maternal deaths, accounting for approximately one third (35%) of estimated global maternal deaths in 2017, with approximately 67 000 and 35 000 maternal deaths (23% and 12% of global maternal deaths), respectively. Three other countries also had 10 000 maternal deaths or more: the Democratic Republic of the Congo (16 000), Ethiopia (14 000) and the United Republic of Tanzania (11 000). Sixty-one countries were estimated to have had just 10 or fewer maternal deaths in 2017. 3Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division EXECUTIVE SUMMARY Table 1. Estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), number of maternal deaths, lifetime risk and proportion of deaths among women of reproductive age that are due to maternal causes (PM), by United Nations Sustainable Development Goal (SDG) region, subregion and other grouping, 2017 UI: uncertainty interval. a The country groupings are based on the geographic regions defined under the Standard Country or Area Codes for Statistical Use (known as M49) https://unstats.un.org/sdgs/report/2019/regional-groups/. b MMR estimates have been rounded according to the following scheme: < 100 rounded to nearest 1; 100–999 rounded to nearest 1; and ≥ 1000 rounded to nearest 10. c Numbers of maternal deaths have been rounded according to the following scheme: < 100 rounded to nearest 1; 100–999 rounded to nearest 10; 1000– 9999 rounded to nearest 100; and ≥ 10 000 rounded to nearest 1000. d Lifetime risk numbers have been rounded according to the following scheme: < 100 rounded to nearest 1; 100–999 rounded to nearest 10; and ≥ 1000 rounded to nearest 100. e The number of maternal deaths in a given time period divided by the total deaths among women aged 15–49 years. SDG regiona MMRb point estimate and range of uncertainty interval (UI: 80%) Number of maternal deathsc Lifetime risk of maternal deathd PMe (%) Lower UI MMR point estimate Upper UI World 199 211 243 295 000 190 9.2 Sub-Saharan Africa 498 542 649 196 000 37 18.2 Northern Africa and Western Asia 73 84 104 9 700 380 5.9 Northern Africa 91 112 145 6 700 260 8.4 Western Asia 45 55 69 3 000 650 3.6 Central and Southern Asia 131 151 181 58 000 260 6.6 Central Asia 21 24 28 390 1 400 1.7 Southern Asia 136 157 189 58 000 250 6.8 Eastern and South-Eastern Asia 61 69 85 21 000 790 3.3 Eastern Asia 22 28 35 5 300 2 200 1.5 South-Eastern Asia 115 137 173 16 000 320 5.5 Latin America and the Caribbean 69 73 80 7 700 640 3.8 Oceania 34 60 120 400 690 4.1 Australia and New Zealand 6 7 8 26 7 800 0.6 Oceania (excl. Australia and New Zealand) 69 129 267 380 210 6.5 Europe and Northern America 12 12 14 1 500 4 800 0.6 Europe 9 10 11 740 6 500 0.5 Northern America 16 18 20 760 3 100 0.9 Landlocked developing countries 377 407 483 64 000 57 17.4 Least developed countries 396 415 477 130 000 56 17.5 Small island developing States 178 210 277 2 600 190 8.5 4 Trends in maternal mortality 2000 to 2017 In 2017, according to the Fragile States Index, 15 countries were considered to be “very high alert” or “high alert” (from highest to lowest: South Sudan, Somalia, Central African Republic, Yemen, Syrian Arab Republic, Sudan, the Democratic Republic of the Congo, Chad, Afghanistan, Iraq, Haiti, Guinea, Nigeria, Zimbabwe and Ethiopia), and these 15 countries had MMRs in 2017 ranging from 31 (Syrian Arab Republic) to 1150 (South Sudan). Regional and country-level trends: 2000–2017 Between 2000 and 2017, the subregion of Southern Asia achieved the greatest overall percentage reduction in MMR: 59% (from 384 to 157). This equates to an average ARR of 5.3%. Four other subregions roughly halved their MMRs during this period: Central Asia (52%), Eastern Asia (50%), Europe (53%) and Northern Africa (54%). MMR in LDCs also declined by 46%. Despite its very high MMR in 2017, sub-Saharan Africa as a region also achieved a substantial reduction in MMR of roughly 38% since 2000. Notably, one subregion with very low MMR (12) in 2000 – Northern America – had an increase in MMR of almost 52% during this period, rising to 18 in 2017. This is likely related to already low levels of MMR, as well as improvements in data collection, changes in life expectancy and/or changes in disparities between subpopulations. The greatest declines in proportion of deaths among women of reproductive age that are due to maternal causes (PM) occurred in two regions: Central and Southern Asia (56.4%), and Northern Africa and Western Asia (42.6%). Almost no change was seen in PM in Europe and Northern America. The 10 countries with the highest MMRs in 2017 (in order from highest to lowest: South Sudan, Chad, Sierra Leone, Nigeria, Central African Republic, Somalia, Mauritania, Guinea-Bissau, Liberia, Afghanistan) all Figure 1. Maternal mortality ratios, by country, 2017 6 The Fragile States Index is an assessment of 178 countries based on 12 cohesion, economic, social and political indicators, resulting in a score that indicates their susceptibility to instability. Further information about indicators and methodology is available at: https://fragilestatesindex.org/. At the top of the range (most fragile), the scores are categorized as follows: > 110 = very high alert; 100–110 = high alert. These two categories include the 15 most fragile countries mentioned here. There are 10 other categories ranging from “very sustainable” to “alert”, which include the remaining 163 countries. 0 1,750 3,500875 Kilometres 1−19 20−99 100−299 300−499 500−999 ≥ 1000 Data not available Not applicable © World Health Organization 2019 Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. The designations employed and the presentation of the material in this map do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. EXECUTIVE SUMMARY 5Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division have ARRs between 2000 and 2017 of less than 5%. When comparing the ARRs between the year ranges of 2000–2010 and 2010–2017, these 10 countries have also had stagnant or slowing levels of ARR and therefore remain at greatest risk. The impact of interruptions or loss of quality health services must be considered in crisis and other unstable situations. Countries that achieved the highest ARRs between 2000 and 2017 (an average ARR of 7% or above), starting with the highest, were Belarus, Kazakhstan, Timor-Leste, Rwanda, Turkmenistan, Mongolia, Angola and Estonia. In considering the uncertainty intervals around their average ARRs, we can only be very sure about this high level of acceleration in Belarus, Kazakhstan, Timor- Leste and Rwanda. In 13 countries, MMR increased in the same period. In considering the uncertainty around the rate and direction of change, we believe there have been true MMR increases in the United States of America and the Dominican Republic. These findings must be considered in context – as many factors may drive positive and negative trends in maternal mortality. Conclusions The SDGs include a direct emphasis on reducing maternal mortality while also highlighting the importance of moving beyond survival. Despite the ambition to end preventable maternal deaths by 2030, the world will fall short of this target by more than 1 million lives with the current pace of progress. There is a continued urgent need for maternal health and survival to remain high on the global health and development agenda; the state of maternal health interacts with and reflects efforts to improve the accessibility and quality of care. The 2018 Declaration of Astana repositioned primary health care as the most (cost) effective and inclusive means of delivering health services to achieve the SDGs. Primary health care is thereby considered the cornerstone for achieving universal health coverage (UHC), which only exists when all people receive the quality health services they need without suffering financial hardship. Health services that are unavailable/ inaccessible or of poor quality, however, will not support the achievement of UHC, as envisioned. Efforts to increase the provision of skilled and competent care to more women, before, during and after childbirth, must also be seen in the context of external forces including but not limited to climate change, migration and humanitarian crises. In addition, governments are called upon to establish well functioning CRVS systems with accurate attribution of cause of death. Improvements in measurement must be driven by action at the country level, with governments creating systems to capture data specific to their information needs; systems that must also meet the standards required for international comparability. Globally, standardized methods for preventing errors in CRVS reporting (i.e. incompleteness and misclassification) should be established to enhance international comparability. In consideration of the above, it must be noted that this report on the levels and trends of maternal mortality provides just one critical facet of information, which synthesizes and draws from the available data, to assess progress in reducing maternal mortality towards achieving SDG target 3.1. The results so far show good but uneven progress across the world in reducing maternal deaths between 2000 and 2017. The global community should accelerate efforts, because if we only continue with the same rate of progress as achieved during this period, it will not be possible to reach the global SDG target of less than 70 maternal deaths per 100 000 live births by 2030. Ultimately, we need to expand horizons beyond a sole focus on mortality, to look at the broader aspects – country and regional situations and trends including health systems, UHC, quality of care, morbidity levels and socioeconomic determinants of women’s empowerment and education – and ensure that appropriate action is taken to support family planning, healthy pregnancy and safe childbirth. 6 Trends in maternal mortality 2000 to 2017 Table 2. Trends in estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), by country and territory, 2000–2017a Country and territory MMR point estimatesa,b Overall change in MMR between 2000 and 2017c (%) Average annual rate of reduction (ARR) point estimate and range of uncertainty interval on ARR between 2000 and 2017 (UI: 80%) (%) 2000 2005 2010 2015 2017 Lower UI Average ARR point estimated Upper UI Afghanistan 1450 1140 954 701 638 56 1.4 4.8 7.3 Albania 23 22 21 15 15 35 -0.1 2.5 5.7 Algeria 161 127 115 114 112 30 -0.5 2.1 4.4 Angola 827 519 326 251 241 71 5.4 7.2 9.3 Antigua and Barbuda 44 40 44 43 42 5 -1.8 0.2 2.4 Argentina 66 59 51 41 39 41 2.1 3.1 4.2 Armenia 43 35 32 28 26 40 1.5 3.0 4.3 Australia 7 5 5 6 6 14 -1.4 0.2 1.7 Austria 6 6 5 5 5 17 -0.5 1.6 3.1 Azerbaijan 47 42 31 27 26 45 2.2 3.5 4.9 Bahamas 75 77 78 74 70 7 -2.4 0.4 2.6 Bahrain 27 19 18 15 14 48 1.6 3.6 5.4 Bangladesh 434 343 258 200 173 60 3.4 5.4 7.1 Barbados 50 42 36 31 27 46 1.9 3.7 6.0 Belarus 22 11 5 3 2 91 9.6 13.0 16.7 Belgium 8 7 6 5 5 38 1.0 2.5 4.1 Belize 89 70 54 43 36 60 3.7 5.3 7.5 Benin 520 500 464 421 397 24 -0.4 1.6 3.2 Bhutan 423 310 247 203 183 57 2.1 4.9 7.0 Bolivia (Plurinational State of) 331 271 212 168 155 53 2.7 4.5 6.2 Bosnia and Herzegovina 17 13 11 10 10 41 1.3 3.3 6.3 Botswana 262 239 179 156 144 45 2.1 3.5 4.7 Brazil 69 71 65 63 60 13 0.7 0.9 1.1 Brunei Darussalam 28 29 28 30 31 -11 -2.5 -0.7 1.6 Bulgaria 19 15 12 10 10 47 1.9 4.0 6.5 Burkina Faso 516 437 385 343 320 38 0.9 2.8 4.9 Burundi 1010 814 665 568 548 46 1.7 3.6 5.5 Cabo Verde 118 86 70 61 58 51 2.5 4.2 5.7 Cambodia 488 351 248 178 160 67 4.6 6.6 8.4 Cameroon 886 692 597 554 529 40 0.8 3.0 4.8 Canada 9 11 11 11 10 -11 -2.5 -0.6 1.2 EXECUTIVE SUMMARY 7Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division Table 2 (continued). Trends in estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), by country and territory, 2000–2017a Country and territory MMR point estimatesa,b Overall change in MMR between 2000 and 2017c (%) Average annual rate of reduction (ARR) point estimate and range of uncertainty interval on ARR between 2000 and 2017 (UI: 80%) (%) 2000 2005 2010 2015 2017 Lower UI Average ARR point estimated Upper UI Central African Republic 1280 1200 1000 912 829 35 0.3 2.6 4.9 Chad 1420 1330 1240 1160 1140 20 -0.7 1.3 2.9 Chile 31 25 20 14 13 58 4.3 5.4 6.7 China 59 44 36 30 29 51 2.9 4.2 6.0 Colombia 94 83 85 85 83 12 -0.4 0.8 1.7 Comoros 444 404 341 285 273 39 0.8 2.9 4.9 Congo 739 677 506 416 378 49 2.0 3.9 5.7 Costa Rica 40 33 32 28 27 33 1.2 2.2 3.4 Côte d’Ivoire 704 704 701 658 617 12 -1.2 0.8 2.7 Croatia 11 10 9 8 8 27 0.0 2.0 3.7 Cuba 46 41 41 38 36 22 0.6 1.4 2.2 Cyprus 14 12 8 7 6 57 2.9 4.9 7.0 Czechia 7 5 4 4 3 57 2.0 4.0 6.3 Democratic People’s Republic of Korea 139 120 106 91 89 36 0.2 2.6 4.9 Democratic Republic of the Congo 760 627 542 490 473 38 0.1 2.8 4.7 Denmark 8 6 5 4 4 50 2.8 4.3 6.2 Djibouti 507 393 283 247 248 51 2.0 4.2 6.5 Dominican Republic 80 83 96 94 95 -19 -1.6 -1.0 -0.5 Ecuador 122 94 78 63 59 52 3.4 4.3 5.2 Egypt 64 52 45 39 37 42 1.7 3.2 5.4 El Salvador 73 62 54 48 46 37 1.3 2.7 4.3 Equatorial Guinea 454 344 308 296 301 34 0.3 2.4 4.5 Eritrea 1280 804 567 518 480 63 3.6 5.8 7.9 Estonia 29 18 11 10 9 69 5.0 7.1 9.6 Eswatini 521 532 450 435 437 16 -1.6 1.0 3.0 Ethiopia 1030 865 597 446 401 61 3.0 5.5 7.4 Fiji 51 46 39 35 34 33 0.8 2.4 4.0 Finland 6 5 4 3 3 50 1.7 3.6 5.2 France 10 9 9 8 8 20 0.2 1.4 2.6 Gabon 380 348 314 261 252 34 0.1 2.4 4.3 8 Trends in maternal mortality 2000 to 2017 Table 2 (continued). Trends in estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), by country and territory, 2000–2017a Country and territory MMR point estimatesa,b Overall change in MMR between 2000 and 2017c (%) Average annual rate of reduction (ARR) point estimate and range of uncertainty interval on ARR between 2000 and 2017 (UI: 80%) (%) 2000 2005 2010 2015 2017 Lower UI Average ARR point estimated Upper UI Gambia 932 756 661 625 597 36 0.6 2.6 4.5 Georgia 31 39 32 27 25 19 0.1 1.3 2.5 Germany 7 6 6 5 7 0 -1.3 0.2 1.8 Ghana 484 371 339 320 308 36 0.9 2.7 4.5 Greece 3 3 3 3 3 0 -1.3 0.6 2.7 Grenada 38 33 29 25 25 34 0.4 2.4 4.5 Guatemala 161 142 129 103 95 41 2.5 3.1 3.7 Guinea 1020 920 747 699 576 44 1.6 3.4 4.9 Guinea-Bissau 1210 979 779 694 667 45 1.0 3.5 5.4 Guyana 231 223 179 172 169 27 0.4 1.8 3.3 Haiti 437 459 506 488 480 -10 -2.7 -0.6 1.3 Honduras 85 77 74 67 65 24 0.4 1.6 2.7 Hungary 16 15 13 12 12 25 -0.6 2.0 4.2 Iceland 6 5 5 4 4 33 0.7 2.7 4.9 India 370 286 210 158 145 61 4.2 5.5 7.0 Indonesia 272 252 228 192 177 35 0.5 2.5 4.3 Iran (Islamic Republic of) 48 34 22 17 16 67 5.0 6.3 8.0 Iraq 79 127 70 83 79 0 -1.9 0.0 2.5 Ireland 7 7 6 6 5 29 0.0 2.5 4.3 Israel 7 5 4 3 3 57 3.4 4.9 6.5 Italy 4 3 2 2 2 50 3.3 5.1 6.9 Jamaica 77 80 79 78 80 -4 -1.5 -0.2 0.9 Japan 9 7 6 5 5 44 2.1 3.8 5.7 Jordan 70 62 53 48 46 34 0.6 2.4 4.7 Kazakhstan 61 43 22 12 10 84 9.2 10.9 12.6 Kenya 708 618 432 353 342 52 2.4 4.3 5.9 Kiribati 136 119 112 97 92 32 0.1 2.3 4.7 Kuwait 10 10 10 11 12 -20 -2.8 -0.7 1.2 Kyrgyzstan 79 82 79 66 60 24 0.0 1.6 2.8 Lao People’s Democratic Republic 544 410 292 209 185 66 4.4 6.3 8.0 Latvia 34 30 26 23 19 44 1.6 3.5 5.0 EXECUTIVE SUMMARY 9Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division Table 2 (continued). Trends in estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), by country and territory, 2000–2017a Country and territory MMR point estimatesa,b Overall change in MMR between 2000 and 2017c (%) Average annual rate of reduction (ARR) point estimate and range of uncertainty interval on ARR between 2000 and 2017 (UI: 80%) (%) 2000 2005 2010 2015 2017 Lower UI Average ARR point estimated Upper UI Lebanon 28 24 23 29 29 -4 -2.9 -0.4 1.6 Lesotho 614 679 594 574 544 11 -1.6 0.7 2.5 Liberia 894 816 708 691 661 26 -0.4 1.8 3.5 Lithuania 17 14 10 9 8 53 2.1 4.2 6.5 Luxembourg 10 9 8 5 5 50 2.4 4.5 6.3 Madagascar 559 526 453 363 335 40 1.0 3.0 5.0 Malawi 749 610 444 370 349 53 2.3 4.5 6.5 Malaysia 38 31 30 30 29 24 0.2 1.5 2.7 Maldives 125 75 67 54 53 58 2.1 5.1 7.3 Mali 836 691 660 620 562 33 0.3 2.3 3.9 Malta 9 8 8 7 6 33 0.1 2.3 4.4 Mauritania 834 826 824 785 766 8 -2.0 0.5 2.6 Mauritius 59 53 66 73 61 -3 -2.8 -0.2 1.9 Mexico 55 54 46 36 33 40 2.6 3.0 3.3 Micronesia (Federated States of) 154 133 110 95 88 43 1.0 3.3 5.6 Mongolia 155 98 66 47 45 71 5.8 7.3 8.8 Montenegro 12 9 7 6 6 50 2.1 4.3 6.9 Morocco 188 131 92 74 70 63 4.2 5.8 7.5 Mozambique 798 577 412 318 289 64 3.9 6.0 7.7 Myanmar 340 299 265 246 250 26 -0.7 1.8 4.1 Namibia 348 346 266 217 195 44 1.4 3.4 4.9 Nepal 553 415 305 236 186 66 4.0 6.4 8.4 Netherlands 13 11 7 6 5 62 3.8 5.6 7.5 New Zealand 12 11 11 10 9 25 0.5 1.8 3.3 Nicaragua 162 131 112 101 98 40 1.2 3.0 4.5 Niger 813 755 663 555 509 37 0.8 2.7 4.5 Nigeria 1200 1080 978 931 917 24 -0.8 1.6 3.5 Norway 6 5 4 3 2 67 3.4 5.3 7.8 Oman 20 19 18 19 19 5 -1.0 0.3 1.6 Pakistan 286 237 191 154 140 51 2.0 4.2 6.4 Panama 91 88 79 58 52 43 2.1 3.3 4.7 10 Trends in maternal mortality 2000 to 2017 Table 2 (continued). Trends in estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), by country and territory, 2000–2017a Country and territory MMR point estimatesa,b Overall change in MMR between 2000 and 2017c (%) Average annual rate of reduction (ARR) point estimate and range of uncertainty interval on ARR between 2000 and 2017 (UI: 80%) (%) 2000 2005 2010 2015 2017 Lower UI Average ARR point estimated Upper UI Papua New Guinea 249 200 168 151 145 42 0.9 3.2 5.5 Paraguay 165 137 108 88 84 49 2.6 4.0 5.6 Peru 144 118 104 94 88 39 1.5 2.9 4.6 Philippines 160 156 144 127 121 24 -0.3 1.7 3.3 Poland 7 4 3 2 2 71 4.5 6.6 8.9 Portugal 10 9 9 9 8 20 -0.6 1.6 3.3 Puerto Rico 26 23 21 20 21 19 -0.6 1.3 2.7 Qatar 14 12 10 9 9 36 0.5 2.6 4.5 Republic of Korea 17 15 15 12 11 35 1.4 2.4 3.6 Republic of Moldova 44 34 29 22 19 57 3.3 4.9 6.6 Republic of North Macedonia 13 10 8 8 7 46 1.7 3.5 5.8 Romania 54 35 27 21 19 65 4.3 6.3 8.3 Russian Federation 56 42 25 18 17 70 5.0 6.9 8.9 Rwanda 1160 643 373 275 248 79 7.0 9.1 10.7 Saint Lucia 86 83 109 115 117 -36 -4.7 -1.8 0.8 Saint Vincent and the Grenadines 80 59 63 64 68 15 -0.9 0.9 3.1 Samoa 88 72 58 45 43 51 1.7 4.2 6.6 Sao Tome and Principe 179 163 140 130 130 27 -0.1 1.9 4.3 Saudi Arabia 24 22 19 17 17 29 -0.2 2.1 4.5 Senegal 553 519 447 346 315 43 1.4 3.3 4.8 Serbia 13 12 12 13 12 8 -2.0 0.6 2.9 Seychelles 53 55 55 54 53 0 -2.4 0.0 2.4 Sierra Leone 2480 1760 1360 1180 1120 55 2.2 4.7 6.6 Singapore 13 13 10 9 8 38 0.4 2.9 5.3 Slovakia 8 7 6 6 5 38 0.6 2.3 4.0 Slovenia 12 10 8 7 7 42 1.6 3.3 5.0 Solomon Islands 245 188 141 112 104 58 3.0 5.0 7.0 Somalia 1210 1040 985 855 829 31 0.3 2.2 4.6 South Africa 160 201 171 125 119 26 0.1 1.7 3.0 South Sudan 1730 1480 1100 1110 1150 34 0.1 2.4 4.5 EXECUTIVE SUMMARY 11Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division Table 2 (continued). Trends in estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), by country and territory, 2000–2017a Country and territory MMR point estimatesa,b Overall change in MMR between 2000 and 2017c (%) Average annual rate of reduction (ARR) point estimate and range of uncertainty interval on ARR between 2000 and 2017 (UI: 80%) (%) 2000 2005 2010 2015 2017 Lower UI Average ARR point estimated Upper UI Spain 5 5 4 4 4 20 0.0 1.7 3.0 Sri Lanka 56 45 38 36 36 36 1.7 2.7 3.5 State of Libya 70 57 53 70 72 -3 -2.6 -0.2 2.3 Sudan 667 529 408 320 295 56 2.7 4.8 7.1 Suriname 221 164 148 122 120 46 2.3 3.6 5.4 Sweden 5 5 4 4 4 20 -0.2 1.5 2.9 Switzerland 7 7 6 5 5 29 0.4 2.6 4.2 Syrian Arab Republic 26 25 27 30 31 -19 -4.0 -1.1 1.3 Tajikistan 53 32 23 18 17 68 4.3 6.8 9.5 Thailand 43 43 42 38 37 14 -0.5 0.8 2.1 Timor-Leste 745 415 219 160 142 81 7.7 9.8 11.9 Togo 489 492 440 398 396 19 -0.5 1.3 3.1 Tonga 77 66 57 54 52 32 0.0 2.3 4.6 Trinidad and Tobago 81 76 71 68 67 17 -0.6 1.1 2.7 Tunisia 66 51 46 46 43 35 0.7 2.4 4.8 Turkey 42 33 24 19 17 60 3.6 5.3 7.5 Turkmenistan 29 18 10 8 7 76 5.9 8.2 10.5 Uganda 578 491 430 387 375 35 0.5 2.5 4.2 Ukraine 35 33 25 21 19 46 1.6 3.6 5.5 United Arab Emirates 6 5 4 3 3 50 1.9 4.0 6.9 United Kingdom of Great Britain and Northern Ireland 10 11 10 8 7 30 1.9 2.7 3.6 United Republic of Tanzania 854 721 644 556 524 39 0.9 2.9 4.4 United States of America 12 13 15 18 19 -58 -3.3 -2.6 -1.9 Uruguay 26 22 17 18 17 35 1.2 2.4 3.6 Uzbekistan 41 38 31 30 29 29 0.1 2.0 3.6 Vanuatu 140 113 92 76 72 49 1.6 4.0 6.1 Venezuela (Bolivarian Republic of) 119 113 117 115 125 -5 -2.2 -0.3 1.3 12 Trends in maternal mortality 2000 to 2017 Table 2 (continued). Trends in estimates of maternal mortality ratio (MMR, maternal deaths per 100 000 live births), by country and territory, 2000–2017a a Estimates have been computed to ensure comparability across countries, thus they are not necessarily the same as official statistics of the countries, which may use alternative rigorous methods. b MMR estimates have been rounded according to the following scheme: < 100 rounded to nearest 1; 100–999 rounded to nearest 1; and ≥ 1000 rounded to nearest 10; and all calculations are based on rounded numbers. c Overall change for the whole period since the first year of the millennium (from 1 January 2000). d Average annual rate of reduction, for the whole period from the first year of the millennium (1 January 2000). e UNICEF, UNPFA, World Bank Group and UNPD refer to this territory as the State of Palestine. Country and territory MMR point estimatesa,b Overall change in MMR between 2000 and 2017c (%) Average annual rate of reduction (ARR) point estimate and range of uncertainty interval on ARR between 2000 and 2017 (UI: 80%) (%) 2000 2005 2010 2015 2017 Lower UI Average ARR point estimated Upper UI Viet Nam 68 54 47 45 43 37 0.5 2.6 4.6 West Bank and Gaza Stripe 70 59 45 32 27 61 3.4 5.6 8.1 Yemen 301 242 192 169 164 46 1.7 3.6 6.1 Zambia 528 421 305 232 213 60 3.7 5.3 6.8 Zimbabwe 579 685 598 480 458 21 0.1 1.4 2.9 2000 to 2017 TRENDS IN MATERNAL MORTALITY Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population DivisionFor more information, please contact: Department of Reproductive Health and Research World Health Organization Avenue Appia 20 CH-1211 Geneva 27 Switzerland Email: reproductivehealth@who.int www.who.int/reproductivehealth Executive summary WHO/RHR/19.23 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Cover.indd 1 22.11.19 13:06
2000–2017 гг. ТЕНДЕНЦИИ МАТЕРИНСКОЙ СМЕРТНОСТИ Оценки ВОЗ, ЮНИТЭЙД, ЮНФПА, Группы Всемирного банка и Отдела народонаселения Организации Объединенных НацийЗа дополнительной информацией обращайтесь: Департамент репродуктивного здоровья и научных исследований Всемирной организации здравоохранения Avenue Appia 20 CH-1211 Geneva 27 Switzerland Электронная почта: reproductivehealth@who.int www.who.int/reproductivehealth Резюме WHO/RHR/19.23 © Всемирная организация здравоохранения, 2019 Некоторые права защищены. Данная работа распространяется на условиях лицензии Creative Commons. «С указанием авторства — На некоммерческих условиях — Распространение на тех же условиях» 3.0 IGO (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/ licenses/by-nc-sa/3.0/igo/). Russian-Cover-MMR_ES_FINAL_April2020_AML.indd 1 17.06.20 18:16 1Оценки ВОЗ, ЮНИТЭЙД, ЮНФПА, Группы Всемирного банка и Отдела народонаселения Организации Объединенных Наций РЕЗЮМЕ Справочная информация Цели в области устойчивого развития (ЦУР) были приняты 25 сентября 2015 г. и вступили в действие 1 января 2016 г. на 15 летний период до 31 декабря 2030 г. Из 17 ЦУР к здравоохранению непосредственно относятся задачи в рамках ЦУР 3 «Обеспечение здорового образа жизни и содействие благополучию для всех в любом возрасте». ЦУР были приняты государствами-членами Организации Объединенных Наций в развитие глобальных обязательств, провозглашенных ими в 2000 г. с принятием Целей в области развития, сформулированных в Декларации тысячелетия (ЦРДТ) и охватывающих период до 2015 г. В преддверии принятия ЦУР Всемирная организация здравоохранения (ВОЗ) совместно с партнерами выпустила согласованное заявление и документ о полномасштабной стратегии по ликвидации предотвратимой материнской смертности (ЛПМС). Целевой показатель ЛПМС по сокращению к 2030 г. коэффициента материнской смертности (КМС) во всем мире был принят в качестве задачи 3.1 ЦУР: к 2030 г. снизить глобальный коэффициент материнской смертности до менее 70 случаев на 100 000 живорождений. При всей важности наличия целевого показателя сокращения смертности нельзя не отметить, что точная оценка материнской смертности все еще сопряжена с трудностями и многие случаи смерти до сих пор не учитываются. Во многих странах до сих пор отсутствует налаженная система регистрации актов гражданского состояния и демографической статистики (РГСДС), а там, где такие системы существуют, точность данных все еще нередко страдает из-за ошибок в отчетности, связанных с неполной регистрацией случаев (нерегистрацией или «недоучетом» случаев смерти) или неправильной классификацией их причин. Использованные методы и интерпретация результатов В ходе нового раунда оценок за период 2000–2017 гг. Межведомственная группа по оценке материнской 1 Оценки рассчитывались таким образом, чтобы обеспечить сопоставимость между странами, и поэтому могут отличаться от официальных статистических данных по странам, при расчете которых могли быть использованы альтернативные методы точного анализа. 2 Пуэрто-Рико является ассоциированным членом, а Западный берег реки Иордан и сектор Газа представлены в региональном комитете Региона Восточного Средиземноморья ВОЗ. смертности Организации Объединенных Наций (MMEIG), в которую входят ВОЗ, Детский фонд Организации Объединенных Наций (ЮНИСЕФ), Фонд Организации Объединенных Наций в области народонаселения (ЮНФПА), Группа Всемирного банка и Отдел народонаселения Организации Объединенных Наций Департамента по экономическим и социальным вопросам, взаимодействовала с внешними техническими экспертами. Для получения более точных оценок КМС, ранее применявшиеся методы оценки были усовершенствованы в целях оптимизации использования данных по странам. В мае июне 2019 г. были проведены консультации со странами. В ходе этого процесса, в подтверждение широкомасштабного расширения национальных усилий по мониторингу материнской смертности были получены дополнительные данные для включения в модель оценки. В настоящем докладе представлены сопоставимые на международном уровне глобальные, региональные и страновые оценки и тенденции материнской смертности с 2000 по 2017 г.1 Анализ охватывает страны и территории с населением свыше 100 000 человек, входящие в число государств-членов ВОЗ, а также две территории (Пуэрто-Рико и Западный берег реки Иордан и сектор Газа)2. В представленных в настоящем докладе итоговых данных учтены первые имеющиеся оценки материнской смертности за отчетный период, предусмотренный ЦУР; однако поскольку первых двух лет (2016 и 2017 гг.) недостаточно для выявления тенденций, выполненные и представленные оценки охватывают период с 2000 по 2017 г. Представленные в настоящем докладе новые оценки заменяют собой все ранее опубликованные оценки за годы, относящиеся к тому же периоду времени. При интерпретации тенденций в области материнской смертности с 2000 по 2017 г. данные оценки следует использовать с осторожностью; поскольку в силу изменений методологии и доступности данных различия между этими и предыдущими оценками не следует толковать как проявление временной динамики. Кроме того, при интерпретации изменений КМС во времени следует учитывать, что высокий уровень КМС легче поддается сокращению, чем изначально низкий КМС. Полная база данных, сводки данных по странам и все 2 Тенденции материнской смертности, 2000–2017 гг. 3 Имеется по адресу www.who.int/reproductivehealth/publications/maternal-mortality-2017/en/. 4 Значение интервала неопределенности (ИН) для всех представленных расчетных значений составляет 80%. В целях интерпретации данных это означает, что истинное значение с вероятностью 80% находится в пределах ИН, с вероятностью 10% не превышает нижней границы и с вероятностью 10% превышает верхнюю границу. 5 В целях распределения по категориям считается, что низкий КМС составляет менее 100, средний 100–299, высокий 300–499, очень высокий 500–999, а экстремально высокий — 1000 или более случаев смерти матерей на 100 000 живорождений. использованные в описании модели коды имеются в онлайновом доступе.3 Глобальные оценки за 2017 г. и тенденции в 2000–2017 гг. Согласно глобальным оценкам, в 2017 г. произошло 295 000 случаев материнской смерти (ИН 279 000–340 000)4; это на 35% меньше, чем в 2000 г., когда расчетное количество случаев материнской смерти составило 451 000 (ИН 431 000–485 000). Глобальный показатель КМС за 2017 г. оценивается на уровне 211 (ИН 99–243) случаев материнской смертности на 100 000 живорождений, что на 38% меньше по сравнению с 2000 г., когда он оценивался на уровне 342 случаев. Среднегодовые темпы сокращения глобального КМС составили в 2000–2017 гг. 2,9%; то есть, с 2000 по 2017 г. КМС ежегодно снижался на 2,9%. В 2017 г. общемировое значение риска материнской смерти в течение жизни для 15-летней девочки оценивался как 1 из 190; что почти вполовину меньше уровня риска в 2000 г., составлявшего 1 из 100. Общий показатель доли случаев смерти женщин репродуктивного возраста (15–49 лет) от причин, связанных с материнством (ДМС), в 2017 г. оценивался на уровне 9,2% (ИН 8,7–10,6%), что является снижением по сравнению с 26,3% в 2000 г. Это означает, что в общей структуре смертности женщин репродуктивного возраста происходит снижение доли случаев, объяснимых причинами, имеющими отношение к материнству. Кроме того, в 2017 г. по сравнению с предыдущими годами на материнскую смертность менее выражено воздействовала ВИЧ-инфекция; на долю случаев косвенной материнской смерти, отягченной ВИЧ, в настоящее время приходится примерно 1% всех случаев смерти матерей по сравнению с 2,5% на пике эпидемии в 2005 г. Оценки странового и регионального уровня за 2017 г. Высокое значение КМС характерно для наименее развитых стран (НРС)5, где оно оценивается на уровне 415 (ИН 396–477) случаев материнской смерти на 100 000 живорождений, что более чем в 40 выше КМС в Европе (10; ИН 9–11) и почти в 60 раз выше, чем в Австралии и Новой Зеландии (7; ИН 6–8). В 2017 г. в НРС мира, согласно оценкам, произошло 130 000 случаев материнской смерти, риск материнской смерти в течение жизни оценивался на уровне 1 из 56. Единственным регионом с крайне высоким КМС в 2017 г. была Африка к югу от Сахары, где он оценивался на уровне 542 (ИН 498–649), а риск материнской смерти в течение жизни составлял 1 из 37 по сравнению со всего лишь 1 из 7800 в Австралии и Новой Зеландии. Умеренные расчетные значения КМС (100–299) были получены для Северной Африки, Океании (исключая Австралию и Новую Зеландию), Южной Азии, Юго-Восточной Азии и малых островных развивающихся государств. КМС имеет низкие значения (< 100 случаев материнской смерти на 100 000 живорождений) в четырех подрегионах (Австралия и Новая Зеландия, Центральная Азия, Восточная Азия и Западная Азия) и двух регионах (Латинская Америка и Карибский бассейн, а также Европа и Северная Америка). В 2017 г. примерно 86% (254 000) случаев материнской смерти в мире произошло, согласно оценкам, в странах Африки к югу от Сахары и Южной Азии, при этом на долю Африки к югу от Сахары пришлось приблизительно 66% случаев (196 000), а на долю Южной Азии — почти 20% (58 000). Помимо этого, свыше 5% случаев материнской смерти в мире (16 000) произошло в Юго-Восточной Азии. В 2017 г. КМС оценивался как экстремальной высокий (определяется как свыше 1000 случаев материнской смерти на 100 000 живорождений) в трех странах: Южном Судане (1150; ИН 789–1710), Чаде (1140; ИН 847–1590) и Сьерра-Леоне (1120; ИН 808–1620). Еще в 16 странах, из которых все кроме одной (Афганистан) расположены в Африке к югу от Сахары, КМС в 2017 г. был очень высоким (т.е. составлял, согласно расчетам, от 500 до 999). Только три страны Африки к югу от Сахары имели низкий КМС: Маврикий (61; ИН 46–85), Кабо-Верде (58; ИН 45–75) и Сейшельские Острова (53; ИН 26 109). За пределами Африки к югу от Сахары высокий КМС был отмечен только в одной стране — Гаити (480; ИН 346 718). В 90 странах значение КМС в 2017 г. оценивалось на уровне 50 и менее. Количество случаев материнской смерти было наиболее высоким в Нигерии и Индии, на долю которых в 2017 г. РЕЗЮМЕ 3Оценки ВОЗ, ЮНИТЭЙД, ЮНФПА, Группы Всемирного банка и Отдела народонаселения Организации Объединенных Наций Таблица 1. Оценки коэффициента материнской смертности (КМС; число случаев материнской смерти на 100 000 живорождений), числа случаев материнской смерти, риска в течение жизни и доли случаев смерти женщин репродуктивного возраста от причин, связанных с материнством (PM), в разбивке по регионам, подрегионам и другим географическим единицам, отслеживаемым в процессе достижения Целей в области устойчивого развития Организации Объединенных Наций (ЦУР), 2017 г. ИН: интервал неопределенности. a Группы стран основаны на географических регионах, определенных в Стандартных кодах стран или регионов для статистического использования (известных как M49). https://unstats.un.org/sdgs/report/2019/regional-groups/. b Расчетные значения КМС округлены следующим образом: < 100 округлены до ближайшей единицы; 100–999 округлены до ближайшей единицы; и ≥ 1000 округлены до ближайшего десятка. c Значения числа случаев материнской смерти округлены следующим образом: < 100 округлены до ближайшей единицы; 100–999 округлены до ближайшего десятка; 1000–9999 округлены до ближайшей сотни; и ≥ 10 000 округлены до ближайшей тысячи. d Значения риска в течение жизни округлены следующим образом: < 100 округлены до ближайшей единицы; 100–999 округлены до ближайшего десятка; и ≥ 1000 округлены до ближайшей сотни. e Число случаев материнской смерти за определенный временной период, разделенное на общее количество случаев смерти среди женщин в возрасте 15–49 лет. Регион ЦУРa Точечная оценка КМСb и диапазон интервала неопределенности (ИН: 80%) Число случаев материнской смертиc Риск материнской смерти в течение жизнисd PMe (%) Нижнее значение ИН Точечная оценка КМС Верхнее значение ИН Весь мир 199 211 243 295 000 190 9,2 Африка к югу от Сахарыe 498 542 649 196 000 37 18,2 Северная Африка и Западная Азия 73 84 104 9 700 380 5,9 Северная Африкаf 91 112 145 6 700 260 8,4 Западная Азияg 45 55 69 3 000 650 3,6 Центральная и Южная Азия 131 151 181 58 000 260 6,6 Центральная Азияh 21 24 28 390 1 400 1,7 Южная Азияi 136 157 189 58 000 250 6,8 Восточная и Юго-Восточная Азия 61 69 85 21 000 790 3,3 Восточная Азияj 22 28 35 5 300 2 200 1,5 Юго-Восточная Азияk 115 137 173 16 000 320 5,5 Латинская Америка и Карибский бассейнl 69 73 80 7 700 640 3,8 Океания 34 60 120 400 690 4,1 Австралия и Новая Зеландия 6 7 8 26 7 800 0,6 Океания (искл. Австралию и Новую Зеландию)m 69 129 267 380 210 6,5 Европа и Северная Америка 12 12 14 1 500 4 800 0,6 Европаn 9 10 11 740 6 500 0,5 Северная Америкаo 16 18 20 760 3 100 0,9 Развивающиеся страны, не имеющие выхода к морюp 377 407 483 64 000 57 17,4 Наименее развитые страныq 396 415 477 130 000 56 17,5 Малые островные развивающиеся государстваr 178 210 277 2 600 190 8,5 4 Тенденции материнской смертности, 2000–2017 гг. пришлась примерно треть (35%) расчетного количества случаев материнской смерти в мире, составив примерно 67 000 и 35 000 случаев смерти в связи с материнством (23% и 12% глобального количества) соответственно. Еще в трех странах количество случаев материнской смерти превысило 10 000: в Демократической Республике Конго (16 000), Эфиопии (14 000) и Объединенной Республике Танзания (11 000). В 61 стране, согласно оценкам, в 2017 г. произошло 10 и менее случаев материнской смерти. В 2017 г. согласно индексу нестабильных государств6 к категориям «высокая нестабильность» и «очень высокая нестабильность» были отнесены 15 стран (в порядке убывания индекса: Южный Судан, Сомали, Центральноафриканская Республика, Йемен, Сирийская Арабская Республика, Судан, Демократическая Республика Конго, Чад, Афганистан, Ирак, Гаити, Гвинея, Нигерия, Зимбабве и Эфиопия), в которых значение КМС в 2017 г. варьировалось от 31 (Сирийская Арабская Республика) до 1150 (Южный Судан). Тенденции регионального и странового уровня, 2000–2017 гг. С 2000 по 2017 г. среднегодовые темпы сокращения КМС составили менее 5% во всех 10 странах, характеризовавшихся наиболее высоким значением КМС на 2017 г. (в порядке убывания КМС: Южный Судан, Чад, Сьерра-Леоне, Нигерия, Центральноафриканская Республика, Сомали, Мавритания, Гвинея-Бисау, Либерия, Афганистан). Кроме того, поскольку среднегодовые темпы сокращения в этих 10 странах в 2010–2017 гг. по сравнению с периодом 2000–2010 гг. существенно не изменились или даже снизились, эти страны остаются в категории наибольшего риска. В кризисных ситуациях и условиях нестабильности следует учитывать влияние такого фактора, как перебои в медицинском обслуживании или недоступность качественных услуг по охране здоровья. Наиболее высоких среднегодовых темпов сокращения материнской смертности (в среднем на уровне 7% или Рисунок 1. Значения коэффициента материнской смертности по странам, 2017 г. 6 Индекс нестабильных государств — результат оценки 178 стран на основе 12 экономических, социальных и политических показателей и показателя социальной консолидации, по итогам которой выводится балльная оценка, отражающая их подверженность нестабильности. Более подробную информацию о показателях и методологии оценки см. по адресу https://fragilestatesindex.org/. В верхней части диапазона (наибольшая нестабильность) балльные оценки группируются следующим образом: > 110 = очень высокая нестабильность; 100–110 = высокая нестабильность. В эти две категории входят 15 упомянутых здесь наименее стабильных стран. Остальные 163 страны распределяются по другим 10 категориям в диапазоне от «крайней стабильности» до «нестабильности». 0 1,750 3,500875 KM 1−19 20−99 100−299 300−499 500−999 ≥ 1000 Нет данных Не применимо © Всемирная организация здравоохранения, 2019 Некоторые права защищены. Настоящая публикация распространяется на условиях лицензии CC BY-NC-SA 3.0 IGO. Используемые в настоящей публикации обозначения и приводимые в ней материалы не означают выражения мнения ВОЗ относительно правового статуса любой страны, территории, города или района или их органов власти или относительно делимитации границ. Штрихпунктирные линии на картах обозначают приблизительные границы, которые могут быть не полностью согласованы. РЕЗЮМЕ 5Оценки ВОЗ, ЮНИТЭЙД, ЮНФПА, Группы Всемирного банка и Отдела народонаселения Организации Объединенных Наций выше) с 2000 по 2017 г. добились следующие страны, перечисленные в порядке уменьшения показателя: Беларусь, Казахстан, Тимор-Лешти, Руанда, Туркменистан, Монголия, Ангола и Эстония. Если же рассматривать среднегодовые темпы сокращения с учетом интервалов неопределенности, то столь высокие показатели ускорения можно уверенно констатировать только в отношении Беларуси, Казахстана, Тимор-Лешти и Руанды. В 13 странах за тот же период произошел рост КМС. Полагаем, что с учетом факторов неопределенности в отношении темпов и направленности изменений реальный рост КМС имел место в Соединенных Штатах Америки и Доминиканской Республике. Эти результаты необходимо рассматривать в контексте, поскольку на положительные и отрицательные тенденции изменения материнской смертности влияет целый ряд факторов. Выводы В рамках ЦУР сформулирована однозначная задача по сокращению материнской смертности и одновременно подчеркивается необходимость не ограничиваться исключительно критерием выживания матерей. Несмотря на намерение к 2030 г. положить конец предотвратимой материнской смертности, при нынешних темпах прогресса мировое сообщество не сможет выполнить эту задачу и такое отставание обернется потерей более 1 миллиона жизней. Здоровье и выживание матерей должно оставаться в числе первоочередных задач глобальной повестки дня в области здравоохранения и развития; между состоянием здоровья матерей и усилиями по повышению доступности и качества помощи существует прямая взаимосвязь. В Астанинской декларации 2018 г. первичной медико- санитарной помощи была отведена роль наиболее эффективного (по затратам) и всеохватного механизма оказания услуг здравоохранения, позволяющего достичь ЦУР. Соответственно, первичная медико-санитарная помощь считается базовым условием достижения всеобщего охвата услугами здравоохранения (ВОУЗ), который обеспечивается только тогда, когда все люди получают необходимые им качественные услуги по охране здоровья, не испытывая при этом финансовых трудностей. Вместе с тем запланированному достижению ВОУЗ препятствует отсутствие/недоступность услуг здравоохранения. Усилия по расширению охвата женщин квалифицированной и эффективной помощью до, во время и после рождения ребенка должны осмысляться в контексте внешних факторов, к которым, в частности, относятся изменение климата, миграция и гуманитарные кризисы. Кроме того, правительствам настоятельно рекомендуется создать надлежащим образом функционирующие системы РГСДС, обеспечивающие правильный учет причин смерти. Основным фактором повышения качества учета должны быть общенациональные усилия по созданию при государственных органах систем сбора данных, отвечающих их конкретным информационным потребностям; и при этом соответствующих стандартам, обеспечивающим сравнимость данных на международном уровне. Для достижения большей международной сравнимости данных в мире должны быть приняты стандартизованные методы контроля ошибок (т.е. неполноты данных и ошибок классификации случаев) в отчетности РГСДС. С учетом сказанного выше следует отметить, что в настоящем докладе об уровнях и тенденциях материнской смертности представлен лишь один из важных информационных аспектов проблемы, в рамках которого на основе синтеза и изучения имеющихся данных оценивается прогресс в области сокращения материнской смертности в целях выполнения задачи 3.1 ЦУР. Полученные к настоящему моменты результаты свидетельствуют о том, что в период с 2000 по 2017 г. страны мира добились значительных успехов в деле сокращения материнской смертности, однако эти успехи распределяются неравномерно. Мировому сообществу следует ускорить свои усилия, поскольку сохранение тех же темпов продвижения вперед, что и в описываемом периоде, не позволить к 2030 г. достичь глобального целевого показателя на уровне менее 70 случаев материнской смертности на 100 000 живорождений. В конечном счете, наряду с обеспечением надлежащих мер по поддержке планирования семьи, здоровой беременности и безопасных родов, нам необходимо обращать внимание не только на проблему смертности, но и на более широкие аспекты ситуации и текущих тенденций в странах и регионах, в том числе на состояние систем здравоохранения, обеспечение ВОУЗ, качество помощи, показатели заболеваемости и социально-экономические детерминанты реализации прав, возможностей и образовательных достижений женщин. 6 Тенденции материнской смертности, 2000–2017 гг. Таблица 2. Тенденции изменения оценок коэффициента материнской смертности (КМС; число случаев материнской смерти на 100 000 живорождений) по странам и территориям, 2000–2017 ггa Страна и территория Точечная оценка КМСa,b Общее изменение КМС за 2000–2017 гг.c (%) Точечная оценка среднегодового сокращения и диапазон интервала неопределенности среднегодового сокращения с 2000 по 2017 г. (ИН 80%) (%) 2000 г. 2005 г. 2010 г. 2015 г. 2017 г. Нижняя граница ИН Усредненная точечная оценка среднегодового сокращенияdd Верхняя граница ИН Афганистан 1450 1140 954 701 638 56 1,4 4,8 7,3 Албания 23 22 21 15 15 35 -0,1 2,5 5,7 Алжир 161 127 115 114 112 30 -0,5 2,1 4,4 Ангола 827 519 326 251 241 71 5,4 7,2 9,3 Антигуа и Барбуда 44 40 44 43 42 5 -1,8 0,2 2,4 Аргентина 66 59 51 41 39 41 2,1 3,1 4,2 Армения 43 35 32 28 26 40 1,5 3,0 4,3 Австралия 7 5 5 6 6 14 -1,4 0,2 1,7 Австрия 6 6 5 5 5 17 -0,5 1,6 3,1 Азербайджан 47 42 31 27 26 45 2,2 3,5 4,9 Багамские Острова 75 77 78 74 70 7 -2,4 0,4 2,6 Бахрейн 27 19 18 15 14 48 1,6 3,6 5,4 Бангладеш 434 343 258 200 173 60 3,4 5,4 7,1 Барбадос 50 42 36 31 27 46 1,9 3,7 6,0 Беларусь 22 11 5 3 2 91 9,6 13,0 16,7 Бельгия 8 7 6 5 5 38 1,0 2,5 4,1 Белиз 89 70 54 43 36 60 3,7 5,3 7,5 Бенин 520 500 464 421 397 24 -0,4 1,6 3,2 Бутан 423 310 247 203 183 57 2,1 4,9 7,0 Боливия 520 500 464 421 397 24 -0.4 1.6 3.2 (Многонациональное государство) 331 271 212 168 155 53 2,7 4,5 6,2 Босния и Герцеговина 17 13 11 10 10 41 1,3 3,3 6,3 Ботсвана 262 239 179 156 144 45 2,1 3,5 4,7 Бразилия 69 71 65 63 60 13 0,7 0,9 1,1 Бруней–Даруссалам 28 29 28 30 31 -11 -2,5 -0,7 1,6 Болгария 19 15 12 10 10 47 1,9 4,0 6,5 Буркина-Фасо 516 437 385 343 320 38 0,9 2,8 4,9 Бурунди 1010 814 665 568 548 46 1,7 3,6 5,5 Кабо-Верде 118 86 70 61 58 51 2,5 4,2 5,7 Камбоджа 488 351 248 178 160 67 4,6 6,6 8,4 Камерун 886 692 597 554 529 40 0,8 3,0 4,8 Канада 9 11 11 11 10 -11 -2,5 -0,6 1,2 РЕЗЮМЕ 7Оценки ВОЗ, ЮНИТЭЙД, ЮНФПА, Группы Всемирного банка и Отдела народонаселения Организации Объединенных Наций Таблица 2 (продолжение). Тенденции изменения оценок коэффициента материнской смертности (КМС; число случаев материнской смерти на 100 000 живорождений) по странам и территориям, 2000–2017 ггa Страна и территория Точечная оценка КМСa,b Общее изменение КМС за 2000–2017 гг.c (%) Точечная оценка среднегодового сокращения и диапазон интервала неопределенности среднегодового сокращения с 2000 по 2017 г. (ИН 80%) (%) 2000 г. 2005 г. 2010 г. 2015 г. 2017 г. Нижняя граница ИН Усредненная точечная оценка среднегодового сокращенияdd Верхняя граница ИН Центрально африканская Республика 1280 1200 1000 912 829 35 0,3 2,6 4,9 Чад 1420 1330 1240 1160 1140 20 -0,7 1,3 2,9 Чили 31 25 20 14 13 58 4,3 5,4 6,7 Китай 59 44 36 30 29 51 2,9 4,2 6,0 Колумбия 94 83 85 85 83 12 -0,4 0,8 1,7 Коморские Острова 444 404 341 285 273 39 0,8 2,9 4,9 Конго 739 677 506 416 378 49 2,0 3,9 5,7 Коста-Рика 40 33 32 28 27 33 1,2 2,2 3,4 Кот-д’Ивуар 704 704 701 658 617 12 -1,2 0,8 2,7 Хорватия 11 10 9 8 8 27 0,0 2,0 3,7 Куба 46 41 41 38 36 22 0,6 1,4 2,2 Кипр 14 12 8 7 6 57 2,9 4,9 7,0 Чехия 7 5 4 4 3 57 2,0 4,0 6,3 Корейская Народно- Демократическая Республика 139 120 106 91 89 36 0,2 2,6 4,9 Демократическая Республика Конго 760 627 542 490 473 38 0,1 2,8 4,7 Дания 8 6 5 4 4 50 2,8 4,3 6,2 Джибути 507 393 283 247 248 51 2,0 4,2 6,5 Доминиканская Республика 80 83 96 94 95 -19 -1,6 -1,0 -0,5 Эквадор 122 94 78 63 59 52 3,4 4,3 5,2 Египет 64 52 45 39 37 42 1,7 3,2 5,4 Сальвадор 73 62 54 48 46 37 1,3 2,7 4,3 Экваториальная Гвинея 454 344 308 296 301 34 0,3 2,4 4,5 Эритрея 1280 804 567 518 480 63 3,6 5,8 7,9 Эстония 29 18 11 10 9 69 5,0 7,1 9,6 Эсватини 521 532 450 435 437 16 -1,6 1,0 3,0 Эфиопия 1030 865 597 446 401 61 3,0 5,5 7,4 Фиджи 51 46 39 35 34 33 0,8 2,4 4,0 Финляндия 6 5 4 3 3 50 1,7 3,6 5,2 8 Тенденции материнской смертности, 2000–2017 гг. Таблица 2 (продолжение). Тенденции изменения оценок коэффициента материнской смертности (КМС; число случаев материнской смерти на 100 000 живорождений) по странам и территориям, 2000–2017 ггa Страна и территория Точечная оценка КМСa,b Общее изменение КМС за 2000–2017 гг.c (%) Точечная оценка среднегодового сокращения и диапазон интервала неопределенности среднегодового сокращения с 2000 по 2017 г. (ИН 80%) (%) 2000 г. 2005 г. 2010 г. 2015 г. 2017 г. Нижняя граница ИН Усредненная точечная оценка среднегодового сокращенияdd Верхняя граница ИН Франция 10 9 9 8 8 20 0,2 1,4 2,6 Габон 380 348 314 261 252 34 0,1 2,4 4,3 Гамбия 932 756 661 625 597 36 0,6 2,6 4,5 Грузия 31 39 32 27 25 19 0,1 1,3 2,5 Германия 7 6 6 5 7 0 -1,3 0,2 1,8 Гана 484 371 339 320 308 36 0,9 2,7 4,5 Греция 3 3 3 3 3 0 -1,3 0,6 2,7 Гренада 38 33 29 25 25 34 0,4 2,4 4,5 Гватемала 161 142 129 103 95 41 2,5 3,1 3,7 Гвинея 1020 920 747 699 576 44 1,6 3,4 4,9 Гвинея-Бисау 1210 979 779 694 667 45 1,0 3,5 5,4 Гайана 231 223 179 172 169 27 0,4 1,8 3,3 Гаити 437 459 506 488 480 -10 -2,7 -0,6 1,3 Гондурас 85 77 74 67 65 24 0,4 1,6 2,7 Венгрия 16 15 13 12 12 25 -0,6 2,0 4,2 Исландия 6 5 5 4 4 33 0,7 2,7 4,9 Индия 370 286 210 158 145 61 4,2 5,5 7,0 Индонезия 272 252 228 192 177 35 0,5 2,5 4,3 Иран (Исламская Республика) 48 34 22 17 16 67 5,0 6,3 8,0 Ирак 79 127 70 83 79 0 -1,9 0,0 2,5 Ирландия 7 7 6 6 5 29 0,0 2,5 4,3 Израиль 7 5 4 3 3 57 3,4 4,9 6,5 Италия 4 3 2 2 2 50 3,3 5,1 6,9 Ямайка 77 80 79 78 80 -4 -1,5 -0,2 0,9 Япония 9 7 6 5 5 44 2,1 3,8 5,7 Иордания 70 62 53 48 46 34 0,6 2,4 4,7 Казахстан 61 43 22 12 10 84 9,2 10,9 12,6 Кения 708 618 432 353 342 52 2,4 4,3 5,9 Кирибати 136 119 112 97 92 32 0,1 2,3 4,7 Кувейт 10 10 10 11 12 -20 -2,8 -0,7 1,2 Кыргызстан 79 82 79 66 60 24 0,0 1,6 2,8 Лаосская Народно- Демократическая Республика 544 410 292 209 185 66 4,4 6,3 8,0 РЕЗЮМЕ 9Оценки ВОЗ, ЮНИТЭЙД, ЮНФПА, Группы Всемирного банка и Отдела народонаселения Организации Объединенных Наций Таблица 2 (продолжение). Тенденции изменения оценок коэффициента материнской смертности (КМС; число случаев материнской смерти на 100 000 живорождений) по странам и территориям, 2000–2017 ггa Страна и территория Точечная оценка КМСa,b Общее изменение КМС за 2000–2017 гг.c (%) Точечная оценка среднегодового сокращения и диапазон интервала неопределенности среднегодового сокращения с 2000 по 2017 г. (ИН 80%) (%) 2000 г. 2005 г. 2010 г. 2015 г. 2017 г. Нижняя граница ИН Усредненная точечная оценка среднегодового сокращенияdd Верхняя граница ИН Латвия 34 30 26 23 19 44 1,6 3,5 5,0 Ливан 28 24 23 29 29 -4 -2,9 -0,4 1,6 Лесото 614 679 594 574 544 11 -1,6 0,7 2,5 Либерия 894 816 708 691 661 26 -0,4 1,8 3,5 Литва 17 14 10 9 8 53 2,1 4,2 6,5 Люксембург 10 9 8 5 5 50 2,4 4,5 6,3 Мадагаскар 559 526 453 363 335 40 1,0 3,0 5,0 Малави 749 610 444 370 349 53 2,3 4,5 6,5 Малайзия 38 31 30 30 29 24 0,2 1,5 2,7 Мальдивские Острова 125 75 67 54 53 58 2,1 5,1 7,3 Мали 836 691 660 620 562 33 0,3 2,3 3,9 Мальта 9 8 8 7 6 33 0,1 2,3 4,4 Мавритания 834 826 824 785 766 8 -2,0 0,5 2,6 Маврикий 59 53 66 73 61 -3 -2,8 -0,2 1,9 Мексика 55 54 46 36 33 40 2,6 3,0 3,3 Микронезия (Федеративные Штаты) 154 133 110 95 88 43 1,0 3,3 5,6 Монголия 155 98 66 47 45 71 5,8 7,3 8,8 Черногория 12 9 7 6 6 50 2,1 4,3 6,9 Марокко 188 131 92 74 70 63 4,2 5,8 7,5 Мозамбик 798 577 412 318 289 64 3,9 6,0 7,7 Мьянма 340 299 265 246 250 26 -0,7 1,8 4,1 Намибия 348 346 266 217 195 44 1,4 3,4 4,9 Непал 553 415 305 236 186 66 4,0 6,4 8,4 Нидерланды 13 11 7 6 5 62 3,8 5,6 7,5 Новая Зеландия 12 11 11 10 9 25 0,5 1,8 3,3 Никарагуа 162 131 112 101 98 40 1,2 3,0 4,5 Нигер 813 755 663 555 509 37 0,8 2,7 4,5 Нигерия 1200 1080 978 931 917 24 -0,8 1,6 3,5 Норвегия 6 5 4 3 2 67 3,4 5,3 7,8 Оман 20 19 18 19 19 5 -1,0 0,3 1,6 Пакистан 286 237 191 154 140 51 2,0 4,2 6,4 10 Тенденции материнской смертности, 2000–2017 гг. Таблица 2 (продолжение). Тенденции изменения оценок коэффициента материнской смертности (КМС; число случаев материнской смерти на 100 000 живорождений) по странам и территориям, 2000–2017 ггa Страна и территория Точечная оценка КМСa,b Общее изменение КМС за 2000–2017 гг.c (%) Точечная оценка среднегодового сокращения и диапазон интервала неопределенности среднегодового сокращения с 2000 по 2017 г. (ИН 80%) (%) 2000 г. 2005 г. 2010 г. 2015 г. 2017 г. Нижняя граница ИН Усредненная точечная оценка среднегодового сокращенияdd Верхняя граница ИН Панама 91 88 79 58 52 43 2,1 3,3 4,7 Папуа-Новая Гвинея 249 200 168 151 145 42 0,9 3,2 5,5 Парагвай 165 137 108 88 84 49 2,6 4,0 5,6 Перу 144 118 104 94 88 39 1,5 2,9 4,6 Филиппины 160 156 144 127 121 24 -0,3 1,7 3,3 Польша 7 4 3 2 2 71 4,5 6,6 8,9 Португалия 10 9 9 9 8 20 -0,6 1,6 3,3 Пуэрто-Рико 26 23 21 20 21 19 -0,6 1,3 2,7 Катар 14 12 10 9 9 36 0,5 2,6 4,5 Республика Корея 17 15 15 12 11 35 1,4 2,4 3,6 Республика Молдова 44 34 29 22 19 57 3,3 4,9 6,6 Республика Северная Македония 13 10 8 8 7 46 1,7 3,5 5,8 Румыния 54 35 27 21 19 65 4,3 6,3 8,3 Российская Федерация 56 42 25 18 17 70 5,0 6,9 8,9 Руанда 1160 643 373 275 248 79 7,0 9,1 10,7 Сент-Люсия 86 83 109 115 117 -36 -4,7 -1,8 0,8 Сент-Винсент и Гренадины 80 59 63 64 68 15 -0,9 0,9 3,1 Самоа 88 72 58 45 43 51 1,7 4,2 6,6 Сан-Томе и Принсипи 179 163 140 130 130 27 -0,1 1,9 4,3 Саудовская Аравия 24 22 19 17 17 29 -0,2 2,1 4,5 Сенегал 553 519 447 346 315 43 1,4 3,3 4,8 Сербия 13 12 12 13 12 8 -2,0 0,6 2,9 Сейшельские Острова 53 55 55 54 53 0 -2,4 0,0 2,4 Сьерра-Леоне 2480 1760 1360 1180 1120 55 2,2 4,7 6,6 Сингапур 13 13 10 9 8 38 0,4 2,9 5,3 Словакия 8 7 6 6 5 38 0,6 2,3 4,0 Словения 12 10 8 7 7 42 1,6 3,3 5,0 Соломоновы Острова 245 188 141 112 104 58 3,0 5,0 7,0 РЕЗЮМЕ 11Оценки ВОЗ, ЮНИТЭЙД, ЮНФПА, Группы Всемирного банка и Отдела народонаселения Организации Объединенных Наций Таблица 2 (продолжение). Тенденции изменения оценок коэффициента материнской смертности (КМС; число случаев материнской смерти на 100 000 живорождений) по странам и территориям, 2000–2017 ггa Страна и территория Точечная оценка КМСa,b Общее изменение КМС за 2000–2017 гг.c (%) Точечная оценка среднегодового сокращения и диапазон интервала неопределенности среднегодового сокращения с 2000 по 2017 г. (ИН 80%) (%) 2000 г. 2005 г. 2010 г. 2015 г. 2017 г. Нижняя граница ИН Усредненная точечная оценка среднегодового сокращенияdd Верхняя граница ИН Сомали 1210 1040 985 855 829 31 0,3 2,2 4,6 Южная Африка 160 201 171 125 119 26 0,1 1,7 3,0 Южный Судан 1730 1480 1100 1110 1150 34 0,1 2,4 4,5 Испания 5 5 4 4 4 20 0,0 1,7 3,0 Шри-Ланка 56 45 38 36 36 36 1,7 2,7 3,5 Государство Ливия 70 57 53 70 72 -3 -2,6 -0,2 2,3 Судан 667 529 408 320 295 56 2,7 4,8 7,1 Суринам 221 164 148 122 120 46 2,3 3,6 5,4 Швеция 5 5 4 4 4 20 -0,2 1,5 2,9 Швейцария 7 7 6 5 5 29 0,4 2,6 4,2 Сирийская Арабская Республика 26 25 27 30 31 -19 -4,0 -1,1 1,3 Таджикистан 53 32 23 18 17 68 4,3 6,8 9,5 Таиланд 43 43 42 38 37 14 -0,5 0,8 2,1 Тимор-Лешти 745 415 219 160 142 81 7,7 9,8 11,9 Того 489 492 440 398 396 19 -0,5 1,3 3,1 Тонга 77 66 57 54 52 32 0,0 2,3 4,6 Тринидад и Тобаго 81 76 71 68 67 17 -0,6 1,1 2,7 Тунис 66 51 46 46 43 35 0,7 2,4 4,8 Турция 42 33 24 19 17 60 3,6 5,3 7,5 Туркменистан 29 18 10 8 7 76 5,9 8,2 10,5 Уганда 578 491 430 387 375 35 0,5 2,5 4,2 Украина 35 33 25 21 19 46 1,6 3,6 5,5 Объединенные Арабские Эмираты 6 5 4 3 3 50 1,9 4,0 6,9 Соединенное Королевство Великобритании и Северной Ирландии 10 11 10 8 7 30 1,9 2,7 3,6 Объединенная Республика Танзания 854 721 644 556 524 39 0,9 2,9 4,4 Соединенные Штаты Америки 12 13 15 18 19 -58 -3,3 -2,6 -1,9 Уругвай 26 22 17 18 17 35 1,2 2,4 3,6 12 Тенденции материнской смертности, 2000–2017 гг. Таблица 2 (продолжение). Тенденции изменения оценок коэффициента материнской смертности (КМС; число случаев материнской смерти на 100 000 живорождений) по странам и территориям, 2000–2017 ггa a Оценки рассчитывались таким образом, чтобы обеспечить сопоставимость между странами и поэтому могут отличаться от официальных статистических данных по странам, при расчете которых могли быть использованы альтернативные методы точного анализа. b Расчетные значения КМС округлены следующим образом: < 100 округлены до ближайшей единицы; 100–999 округлены до ближайшей единицы; и ≥ 1000 округлены до ближайшего десятка; во всех расчетах использованы округленные значения. c Общее изменение за весь период с первого года тысячелетия (с 1 января 2000 г.). d Среднегодовое сокращение за весь период с первого года тысячелетия (1 января 2000 г.). e ЮНИСЕФ, ЮНФПА, Группа Всемирного банка и Отдел народонаселения ООН обозначают эту территорию как «Государство Палестина». Страна и территория Точечная оценка КМСa,b Общее изменение КМС за 2000–2017 гг.c (%) Точечная оценка среднегодового сокращения и диапазон интервала неопределенности среднегодового сокращения с 2000 по 2017 г. (ИН 80%) (%) 2000 г. 2005 г. 2010 г. 2015 г. 2017 г. Нижняя граница ИН Усредненная точечная оценка среднегодового сокращенияdd Верхняя граница ИН Узбекистан 41 38 31 30 29 29 0,1 2,0 3,6 Вануату 140 113 92 76 72 49 1,6 4,0 6,1 Венесуэла (Боливарианская Республика) 119 113 117 115 125 -5 -2,2 -0,3 1,3 Вьетнам 68 54 47 45 43 37 0,5 2,6 4,6 Западный берег и сектор Газаe 70 59 45 32 27 61 3,4 5,6 8,1 Йемен 301 242 192 169 164 46 1,7 3,6 6,1 Замбия 528 421 305 232 213 60 3,7 5,3 6,8 Зимбабве 579 685 598 480 458 21 0,1 1,4 2,9 2000–2017 гг. ТЕНДЕНЦИИ МАТЕРИНСКОЙ СМЕРТНОСТИ Оценки ВОЗ, ЮНИТЭЙД, ЮНФПА, Группы Всемирного банка и Отдела народонаселения Организации Объединенных НацийЗа дополнительной информацией обращайтесь: Департамент репродуктивного здоровья и научных исследований Всемирной организации здравоохранения Avenue Appia 20 CH-1211 Geneva 27 Switzerland Электронная почта: reproductivehealth@who.int www.who.int/reproductivehealth Резюме WHO/RHR/19.23 © Всемирная организация здравоохранения, 2019 Некоторые права защищены. Данная работа распространяется на условиях лицензии Creative Commons. «С указанием авторства — На некоммерческих условиях — Распространение на тех же условиях» 3.0 IGO (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/ licenses/by-nc-sa/3.0/igo/). Russian-Cover-MMR_ES_FINAL_April2020_AML.indd 1 17.06.20 18:16
For more information, please contact: Department of Reproductive Health and Research World Health Organization Avenue Appia 20 CH-1211 Geneva 27 Switzerland Email: reproductivehealth@who.int www.who.int/reproductivehealth WHO/RHR/19.23 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Résumé d’orientation ةصاخلا تاهاجتلاا ةموملأا تايفوب 2017 ماع لىإ 2000 ماع نم ةيلماعلا ةحصلا ةمظنم ةطساوب تاريدقت )فيسينويلا( ةلوفطلل ةدحتلما مملأا ةمظنمو ةعومجمو ،ناكسلل ةدحتلما مملأا قودنصو ناكسلل ةدحتلما مملأا ةبعشو ليودلا كنبلا يذيفنتلا زجولما Cover ES MMR Arabic.indd 1 01.08.20 19:19 الاتجاهات الخاصة بوفيات الأمومة من عام 0002 إلى عام 7102 1 الموجز التنفيذي معلومات أساسية أعلن عن أهداف التنمية المستدامة في 52 أيلول/سبتمبر 5102 وبدأ تنفيذها في 1 كانون الثاني/يناير 6102 لفترة 51 سنة تمتد حتى 13 كانون الأول/ديسمبر 0302. وضمن أهداف التنمية المستدامة الـــــ 71 ترد الغايات المتصلة اتصالاً مباشرا ًبالصحة في إطار هدف التنمية المستدامة رقم 3: ضمان تمتع الجميع بأنماط عيش صحية وبالرفاهية في جميع الأعمار. وباعتماد أهداف التنمية المستدامة، قامت الدول الأعضاء في الأمم المتحدة بتوسيع نطاق التزاماتها العالمية التي تعهدت والتي ،)sGDM( بها في عام 0002 لكي تشمل الأهداف الإنمائية للألفية تغطي الفترة حتى عام 5102. واستباقا ًلإعلان أهداف التنمية المستدامة، أصدرت منظمة الصحة العالمية وشركائها بيانا ًبتوافق الآراء وورقة استراتيجية كاملة بشأن إنهاء وفيات الأمومة الممكن تلافيها. واعتُمد الهدف الخاص بإنهاء وفيات الأمومة الممكن تلافيها من أجل تخفيض المعدل العالمي للوفيات بحلول عام 0302 بوصفه الغاية 1-3 من أهداف )RMM( النفاسية التنمية المستدامة: خفض النسبة العالمية للوفيات النفاسية إلى أقل من 07 وفاة لكل 000 001 مولود حي بحلول عام 0302. إن تحديد أهداف لخفض الوفيات أمر هام، ولكن يظل القياس الدقيق لمعدل وفيات الأمومة أمرا ًيتسم بالصعوبة حيث يظل عدد كبير من الوفيات غير محتسب. ولا تزال الكثير من البلدان تفتقر إلى نظم السجلات المدنية والإحصاءات الحيوية التي تعمل بشكل جيد، وفي حالة وجود هذه النظم، لا تزال أخطاء الإبلاغ – سواء عدم اكتمال البيانات )الوفيات غير المسّجلة والمعروفة أيضا ًبوصف «المفقودة»( أو سوء تصنيف أسباب الوفاة، تشكل تحديا ًكبيرا ًأمام دقة البيانات. الطرائق والتفسير قام فريق الأمم المتحدة المشترك بين الوكالات المعني بتقدير وفيات والذي يتكون من منظمة الصحة العالمية — )GIEMM NU( الأمومة وصندوق الأمم المتحدة )FECINU( ومنظمة الأمم المتحدة للطفولة للسكان ومجموعة البنك الدولي وشعبة الأمم المتحدة للسكان التابعة لإدارة الشؤون الاقتصادية والاجتماعية — بالتعاون مع الخبراء الفنيين احتُسبت التقديرات من أجل ضمان المقارنة في جميع البلدان، ومن ثم فهي ليست بالضرورة مماثلة للإحصاءات الرسمية بالبلدان، والتي قد تستخدم طرائق صارمة بديلة. الخارجيين بشأن مجموعة جديدة من التقديرات لفترة السنوات 7102-0002. وللتوصل إلى تقديرات متزايدة الدقة بشأن معدلات وفيات الأمومة، فقد جرى صقل طرائق التقييم السابقة لتحقيق استخدام أمثل للبيانات على المستوى القطري. وأجريت بهذا الشأن مشاورات مع البلدان أثناء شهري أيار/مايو وحزيران/يونيو 9102، حيث أسفر ذلك عن بيانات إضافية لإدراجها في نموذج تقدير وفيات الأمومة، مما يبّين توسيع نطاق الجهود المبذولة داخل البلدان من أجل رصد وفيات الأمومة. ويعرض هذا التقرير التقديرات الدولية القابلة للمقارنة على المستوى العالمي والإقليمي والقطري والاتجاهات الخاصة بوفيات الأمومة بين عامي 0002 و7102 1. وجميع البلدان والأقاليم التي شملتها التحليلات هي من الدول الأعضاء في منظمة الصحة العالمية والتي يتجاوز عدد سكانها 000 001 نسمة، بالإضافة إلى إقليمين )بورتوريكو والضفة الغربية وقطاع غزة(2. وتشمل النتائج الواردة في هذا التقرير التقديرات الأولى المتوفرة بشأن وفيات الأمومة في فترة الإبلاغ الخاصة بأهداف التنمية المستدامة; ولكن حيث أن فترة سنتين )6102 و7102( لا تكفي لبيان الاتجاهات، فقد ُوضعت التقديرات وُعرضت لتشمل الفترة من عام 0002 إلى عام 7102. وتحّل التقديرات الجديدة المعروضة في هذا التقرير محل جميع التقديرات المنشورة في السابق بالنسبة للسنوات التي تقع ضمن نفس الفترة الزمنية. ويتعين مراعاة استخدام هذه التقديرات فقط من أجل تفسير الاتجاهات الخاصة بوفيات الأمومة من عام 0002 إلى عام 7102; ونظرا ًللتعديلات المدخلة على المنهجية والبيانات المتوفرة، لا ينبغي تفسير الاختلافات بين هذه التقديرات والتقديرات السابقة على أنها تمثل الاتجاهات الزمنية. وبالإضافة إلى ذلك، فعند تفسير التغييرات الخاصة بمعدلات وفيات الأمومة على مر الزمن، يتعين مراعاة أنه من السهل تخفيض معدلات وفيات الأمومة عندما يكون المستوى مرتفعا ًأكثر مما هو عليه عندما يكون مستوى معدل وفيات الأمومة منخفضا ًبالفعل. ويمكن الاطلاع عن طريق الانترنت على قاعدة البيانات الكاملة وعلى بيانات البلدان وجميع رموز مواصفات النماذج.3 بورتوريكو هي عضو منتسب والضفة الغربية وقطاع غزة عضو في اللجنة الإقليمية الخاصة بإقليم شرق المتوسط التابع لمنظمة الصحة العالمية. متوفر على الموقع التالي :/ne/7102-ytilatrom-lanretam/snoitacilbup/htlaehevitcudorper/tni.ohw.www 1 2 3 تقديرات بواسطة منظمة الصحة العالمية ومنظمة الأمم المتحدة للطفولة (اليونيسيف) وصندوق الأمم المتحدة للسكان، ومجموعة البنك الدولي وشعبة الأمم المتحدة للسكان 2 السنوات 7102-0002التقديرات العالمية لعام 7102 والاتجاهات لفترة تشير التقديرات العالمية لعام 7102 إلى حدوث 000 592 وفاة من وفيات الأمومة )هامش عدم اليقين من 000 972 إلى 000 043(4، أي أقل بنسبة %53 مما كان عليه في عام 0002 عندما أشارت التقديرات إلى حدوث 000 154 وفاة من وفيات الأمومة )هامش عدم اليقين من 000 134 إلى 000 584(. ويُقّدر المعدل العالمي لوفيات الأمومة في عام 7102 بـــــ 112 وفاة من وفيات الأمومة )هامش عدم اليقين من 99 إلى 342( لكل 000 001 مولود حي، مما يمثّل انخفاضا ًبنسبة %83 منذ عام 0002، عندما كانت التقديرات تشير إلى 243 وفاة من وفيات في المعدل العالمي )RPA( الأمومة. وكان متوسط معدل الخفض السنوي لوفيات الأمومة أثناء الفترة من عام 0002 إلى عام 7102 بنسبة %9.2، مما يعني أن المعدل العالمي لوفيات الأمومة، قد انخفض، في المتوسط، بنسبة %9.2 كل سنة بين عامي 0002 وعام 7102. وقُدرت مخاطر وفيات الأمومة العالمية طوال العمر بالنسبة لفتاة عمرها 51 سنة في عام 7102 بوفاة واحدة في كل 091 فتاة من نفس العمر، أي نحو نصف معدل المخاطر في عام 0002 أي بنسبة 1 إلى 001. وقُّدرت نسبة الوفيات الإجمالية للنساء في سن الإنجاب )من 51 إلى 94 سنة( والناجمة عن أسباب تتعلق بالأمومة بنسبة %2.9 )هامش عدم اليقين من %7.8 إلى %6.01( في عام 7102 — أي أقل بنسبة %3.62 من عام 0002. مما يعني أنه بالمقارنة مع أسباب الوفيات الأخرى للنساء في سن الإنجاب، فإن الجزء الذي يُعزى إلى أسباب تتعلق بالأمومة آخذ في الانخفاض. وبالإضافة إلى ذلك، يبدو أن تأثير فيروس العوز المناعي البشري على وفيات الأمومة في عام 7102 أقل بروزا ًمما كان عليه في السنوات السابقة، فوفيات الأمومة المتصلة اتصالاً غير مباشر بالفيروس تُقّدر الآن بنحو %1 من مجموع وفيات الأمومة بالمقارنة مع %5.2 في عام 5002، أثناء ذروة انتشار هذا الوباء. التقديرات الإقليمية والُقطرية في عام 7102 تتّسم معدلات وفيات الأمومة في البلدان الأقل نموا ًبالعالم بارتفاعها،5 إذ تقّدر بـــ 514 وفاة )هامش عدم اليقين من 693 إلى 774 وفاة( لكل 000 001 ولادة حيّة، أي أنها أكثر بـــــ 04 مرة من معدلات وفيات الأمومة في أوروبا )01، هامش عدم اليقين من 9 إلى 11(، وأعلى بنحو 06 مرة مما هي عليه في أستراليا ونيوزيلندا )7، هامش عدم اليقين من 6 إلى 8(. وفي أقل البلدان نموا ًفي العالم، التي ُسّجل فيها ما يُقّدر بــــ 000 031 وفاة من وفيات الأمومة عام 7102، تمثل مخاطر وفيات الأمومة أثناء العمر نسبة 1 إلى 65. وتُعتبر بلدان أفريقيا جنوبي الصحراء المنطقة الوحيدة التي سجلت معدلات مرتفعة جدا ًلوفيات الأمومة في عام 7102، إذ قُّدرت بــــ 245 وفاة )هامش عدم اليقين من 894 إلى 946(، بينما تُقّدر مخاطر وفيات الأمومة طوال العمر بنسبة 1 إلى 73، بمقارنة بنسبة 1 إلى 0087 في أستراليا ونيوزيلندا. وقُّدرت معدلات معتدلة لوفيات الأمومة )992-001( في شمال أفريقيا وأوقيانوسيا )باستثناء أستراليا ونيوزيلندا( وآسيا الجنوبية وجنوب شرق آسيا وفي البلدان النامية الجزرية الصغيرة، فيما قُّدرت معدلات منخفضة لوفيات الأمومة )أقل من 001 وفاة من وفيات الأمومة لكل 000 001 مولود حي( في أربعة أقاليم فرعية )أستراليا ونيوزيلندا ووسط آسيا وشرق آسيا وغرب آسيا( وإقليمين )أمريكا اللاتينية ومنطقة الكاريبي وأوروبا وأمريكا الشمالية(. وسجلت أفريقيا جنوب الصحراء الكبرى وجنوب آسيا نحو %68 )000 452 وفاة( من مجموع وفيات الأمومة العالمية التقديرية في عام 7102، حيث استأثرت أفريقيا جنوب الصحراء الكبرى وحدها بنسبة %66 )000 691 وفاة(، بينما بلغ معدلها في جنوب آسيا حوالي %02 )000 85 وفاة(. وسجلت منطقة جنوب شرق آسيا كذلك نسبة تتجاوز %5 من وفيات الأمومة على الصعيد العالمي )000 61 وفاة(. وهناك ثلاثة بلدان تشير التقديرات إلى معدلات مرتفعة جدا ًلوفيات الأمومة فيها عام 7102 )تُعرّف بأكثر من 000 1 وفاة من وفيات الأمومة لكل 000 001 مولود حّي(، وهي: جنوب السودان )0511 وفاة، هامش عدم اليقين من 987 إلى 0171(، وتشاد )0411 وفاة، هامش عدم اليقين من 748 إلى 0951( وسيراليون )0211 وفاة، هامش عدم اليقين من 808 إلى 0261(. وسجل ستة عشر بلدا آخر، جميعها أيضا ًمن بلدان أفريقيا جنوبي الصحراء الكبرى باستثناء بلد واحد )أفغانستان( معدلات مرتفعة جدا ًلوفيات الأمومة في عام 7102 )تتراوح التقديرات بين 005 إلى 999 وفاة(. ولم تحظ إلا ثلاثة بلدان من بلدان أفريقيا جنوبي الصحراء بمعدل منخفض لوفيات الأمومة، هي: موريشيوس )16، هامش عدم اليقين من 64 على 58(، والرأس الأخضر )85، هامش عدم اليقين من 54 إلى 57( وسيشيل )35، هامش عدم اليقين من 62 على 901(. ولم يسّجل سوى بلد واحد خارج إقليم أفريقيا جنوبي الصحراء معدلاً مرتفعاً لوفيات الأمومة، هو هايتي )084، هامش عدم اليقين من 643 إلى 817(. وقُّدرت معدلات وفياة الأمومة بالنسبة لتسعين بلدا ًبمعدل 05 وفاة أو أقل في عام 7102. وسجلت كل من نيجيريا والهند أعلى أرقام تقديرية لوفيات الأمومة، إذ سجلتا معا ًما يقرب من ثلث )%53( وفيات الأمومة العالمية التقديرية في عام 7102، بنحو000 76 وفاة من وفيات الأمومة في نيجيريا و 000 53 من وفيات الأمومة في الهند )%32 من وفيات الأمومة على الصعيد العالمي في نيجيريا و%21 في الهند(. وسجلت ثلاثة بلدان أخرى أيضاً 000 01 وفاة من وفيات الأمومة أو أكثر، وهي: جمهورية الكونغو الديمقراطية )000 61 وفاة(، وإثيوبيا )000 41 وفاة( وجمهورية تنزانيا المتحدة )000 11 وفاة(. وقُّدر معدل وفياة الأمومة في 16 بلدا ًبعشرة وفيات أو أقل في عام 7102. 5 قيني دامعش انماه اهنع غّلبيقين الملدام اعش انماوه عيمج لّكشت %ة08بسنب مالاًتاح كانه نأ ينعت اهت على أنانايبلسير افت نة 08% . ويمكبيقين، ونسلدام اعش انماه نمقيقية ضحلة امقيلا عقت نة01% أمقيلا نوكت نأ نى ودد الأحلا نم لققيقية أحلد الأعلى.01%احلا قوقيقية فحلة امقيلا عقت نة أبسنب دلعم برتعُي ،فينصتلا ضلأغراموأ ناك اذإ ًاضفخنم ةمقل من و001 ،ةاوف متوينب ناك اذإ ًاطس ر992 و001مو ةاوف تفعايًنب ناك اذر994 و003 إمو ةاوف تفعايًنب ناك اذر999 و005 جدا ًإفمو ةاوف طا ًفي الارتفاواسي ناك اذإ عي ت الأ0001اوفي نم ثركأو أ ةاوف مولكل ةم 000 001 مولو.يح د ت الأاوفي 4 الموجز التنفيذي الاتجاهات الخاصة بوفيات الأمومة من عام 0002 إلى عام 71023 أسباب متعلقة بالأمومة5 )النسبة المئوية( خطر حدوث وفيات الأمومة طوال العمر4 عدد وفيات الأموم3 تقديرات معدل وفيات الأمومة 2 ونطاق هامش عدم اليقين )هامش بنسبة %08( لأدنى الحدإقليم هدف التنمية المستدامة 1 لهامش عدم اليقين تقديرات معدل وفيات الأمومة الحد الأدنى لهامش عدم اليقين العالم 991 112 342 000 592 091 2.9 أفريقيا جنوب الصحراء الكبرى 894 245 946 000 691 73 2.81 شمال أفريقيا وغرب آسيا 37 48 401 007 9 083 9.5 شمال أفريقيا 19 211 541 007 6 062 4.8 غرب آسيا 54 55 96 000 3 056 6.3 وسط وجنوب آسيا 131 151 181 000 85 062 6.6 وسط آسيا 12 42 82 093 004 1 7.1 جنوب آسيا 631 751 981 000 85 052 8.6 شرق وجنوب شرق آسيا 16 96 58 000 12 097 3.3 شرق آسيا 22 82 53 003 5 002 2 5.1 جنوب شرق آسيا 511 731 371 000 61 023 5.5 أمريكا اللاتينية ومنطقة الكاريبي 96 37 08 007 7 046 8.3 أوقيانوسيا 43 06 021 004 096 1.4 أستراليا ونيوزيلندا 6 7 8 62 008 7 6.0 )أوقيانوسيا )باستثناء أستراليا ونيوزيلندا 96 921 762 083 012 5.6 أوروبا وأمريكا الشمالية 21 21 41 005 1 008 4 6.0 أوروبا 9 01 11 047 005 6 5.0 أمريكا الشمالية 61 81 02 067 001 3 9.0 الدول النامية غير الساحلية 773 704 384 000 46 75 4.71 أقل البلدان نموا ً 693 514 774 000 031 65 5.71 الدول الجزرية الصغيرة النامية 871 012 772 006 2 091 5.8 الجدول رقم 1. تقديرات معدل وفيات الأمومة )معدل وفيات الأمومة، وفيات الأمومة لكل 000 001 مولود حّي( وعدد وفيات الأمومة حسب الإقليم والإقليم )MP( وخطر حدوثها طوال العمر ونسبة الوفيات بين النساء في سن الإنجاب الناجمة عن أسباب تتعلق بالأمومة الفرعي أو غيرها من التقسيمات المناطقية لأهداف التنمية المستدامة للأمم المتحدة، عام 7102 تستند مجموعات البلدان إلى المناطق الجغرافية المحددة تحت رموز البلد أو المنطقة القياسية للاستخدام الإحصائي )المعروف باسم م 94( /spuorg-lanoiger/9102/troper/sgds/gro.nu.statsnu//:sptth تقديرات وفيات الأمومة احتُسبت وفقا ًللمخطط التالي: أقل من 001 وفاة إلى أقرب وفاة واحدة، و 001-999 وفاة تُحسب إلى أقرب وفاة واحدة، وأعلى من 0001 تُحسب إلى أقرب 01 وفيات. تُحتسب أعداد وفيات الأمومة وفقا ًللمخطط التالي: أقل من 001 وفاة إلى أقرب وفاة واحدة، 001-999 وفاة تُحسب إلى أقرب 01 وفيات، و0001-9999 وفاة تُحسب إلى أقرب 001 وفاة، وأعلى من 000 01 وفاة تُحسب إلى أقرب 0001 وفاة. تُحسب أعداد المخاطر أثناء العمر وفقا ًللمخطط التالي: أقل من 001 إلى أقرب وفاة واحدة، و 001-999 وفاة تُحسب إلى أقرب 01 وفيات، وأكثر من 0001 وفاة تُحسب إلى أقرب 001 وفاة. عدد وفيات الأمومة في فترة زمنية معينة مقّسما ًعلى مجموع الوفيات ضمن النساء بين الأعمار من 51 سنة إلى 94 سنة. 1 2 3 4 5 تقديرات بواسطة منظمة الصحة العالمية ومنظمة الأمم المتحدة للطفولة (اليونيسيف) وصندوق الأمم المتحدة للسكان، ومجموعة البنك الدولي وشعبة الأمم المتحدة للسكان 4 وفي عام 7102، ووفقا ًلمؤشر الدول الهّشة6، اعتُبر 51 بلدا ًضمن فئة «تحذير مرتفع جدا»ً أو «تحذير مرتفع» )من الأعلى إلى الأدنى: جنوب السودان والصومال وجمهورية أفريقيا الوسطى واليمن والجمهورية العربية السورية والسودان وجمهورية الكونغو الديمقراطية وتشاد وأفغانستان والعراق وهايتي وغينيا ونيجيريا وزمبابوي وأثيوبيا(، حيث تراوحت معدلات وفيات الأمومة لدى هذه البلدان الخمسة عشر في عام 7102 من 13 وفاة )الجمهورية العربية السورية( إلى 0511 وفاة )جنوب السودان(. 7102الاتجاهات الإقليمية والقطرية: من عام 0002 إلى عام بين عام 0002 وعام 7102، سجل الإقليم الفرعي لجنوب آسيا أعلى نسبة مئوية إجمالاً في خفض معدلات وفيات الأمومة بنسبة %95 )من 483 وفاة إلى 751 وفاة(، وهو ما يعادل متوسط خفض سنوي بنسبة %3.5. وقلصت أربعة أقاليم فرعية أخرى معدلات وفيات الأمومة لديها إلى النصف تقريبا ًأثناء هذه الفترة، وهي: آسيا الوسطى )%25( وشرق آسيا )%05( وأوروبا )%35( وشمال أفريقيا )%45(. كما انخفضت معدلات وفيات الأمومة في أقل البلدان نموا ًبنسبة %64. ورغم معدل وفيات الأمومة المرتفعة جدا ًفي بلدان أفريقيا جنوبي الصحراء في عام 7102، فقد حقق الإقليم خفضا ًكبيرا ًفي هذا المعدل بنحو %83 منذ عام 0002. ومن الملحوظ أن إقليما ًفرعيا ًواحدا كان لديه معدل منخفض جدا ًلوفيات الأمومة ) 21 وفاة( في عام 0002 — هو إقليم أمريكا الشمالية —شهد ارتفاعا ًفي معدل وفيات الأمومة لديه بحوالي %25 أثناء هذه الفترة، إذ سّجل 81 وفاة في عام 7102. ومن المرجح أن يُعزى ذلك إلى انخفاض مستويات معدل وفيات الأمومة أصلاً، فضلاً عن التحسينات المدخلة في جمع البيانات وتغييرات متوسط العمر المتوقع و/أو التغيرات في الفوارق بين الأقليات. وُسّجلت أكبر انخفاضات في نسب الوفيات الناجمة عن الأمومة بين النساء في سن الإنجاب في إقليمين، هما: وسط وجنوب آسيا )%4.65( وشمال أفريقيا وغرب آسيا )%6.24(. فيما لم يُسّجل تغيير يُذكر في معدل الوفيات لأسباب تتعلق بالأمومة في أي من أوروبا أو أمريكا الشمالية. والبلدان العشرة التي سجلت أعلى معدلات لوفيات الأمومة في عام 7102 )بالترتيب من الأعلى إلى الأدنى، هي: جنوب السودان وتشاد وسيراليون ونيجيريا وجمهورية أفريقيا الوسطى والصومال وموريتانيا وغينيا-بيساو وليبيريا وأفغانستان( وجميعها سجلت معدلات خفض سنوي تقل عن %5 بين عامي 0002 و7102. وعند مقارنة معدلات الخفض السنوي بين الفترتين من عام 0002 إلى عام 0102 ومن عام الشكل 1 – معدلات وفيات الأمومة، حسب البلد، لعام 7102 sertemoliK 578005,3 057,1 0 91−1 99−02 992−001 994−003 999−005 0001 ≥ 9102 noitazinagrO htlaeH dlroW © .OGI 0.3 AS-CN YB CC .devreser sthgir emoS مؤشر الدول الهّشة هو تقييم لــــ 871 بلدا ًعلى أساس 21 مؤشرا ًتتناول التماسك والجوانب الاقتصادية والاجتماعية والسياسية، يفضي إلى علامة تشير إلى مدى قابليتها لانعدام الاستقرار. ويمكن الاطلاع على مزيد من المعلومات بشأن المؤشرات والمنهجية على الموقع التالي: https://fragilestatesindex.org/. وعلى رأس الترتيب )الدول الأكثر هشاشة(، ُصّنفت النتائج على النحو التالي: أكثر من 011 = خطر للغاية، ومن 011-001 = خطر مرتفع. وتشمل هاتان الفئتان 51 بلدا ًمن البلدان الأكثر هشاشة المذكورة هنا. وتوجد 01 فئات أخرى تتراوح من «مستدام جدا»ً إلى «خطر»، والتي تشمل البلدان 361 المتبقية. 6 بيانات غير متوفرة غير منطبقة لا تعني التعيينات المستخدمة وعرض المواد في هذه الخريطة التعبير عن أي رأي على الإطلاق من جانب منظمة الصحة العالمية بشأن الوضع القانوني لأي بلد أو إقليم أو مدينة أو منطقة أو سلطاتها ، أو فيما يتعلق بتعيين حدودها. الحدود أو الحدود. تمثل الخطوط المنقطة والمتقطعة على الخرائط خطوط حدود تقريبية قد لا يكون هناك اتفاق كامل بشأنها. /gro.xednisetatseligarf//:sptth كيلومترات الموجز التنفيذي الاتجاهات الخاصة بوفيات الأمومة من عام 0002 إلى عام 71025 0102 إلى عام 7102، فقد سجلت هذه البلدان العشرة أيضا ًركودا ًأو وتيرة أبطأ لمعدلات الخفض السنوي، وبالتالي ظلت تواجه أشد المخاطر في هذا المضمار. ويجب مراعاة تأثير حالات انقطاع الخدمات الصحية الجيدة أو فقدانها في أوقات الأزمات أو غيرها من حالات انعدام الاستقرار. أما البلدان التي سجلت أعلى معدلات خفض سنوي بين عامي 0002 و7102 )متوسط معدل الخفض السنوي بنسبة %7 أو أعلى( ابتداء من أعلى المستويات هي بيلاروس وكازاخستان وتيمور-ليشتي ورواندا وتركمانستان ومنغوليا وأنغولا وإستونيا. وعند مراعاة هامش انعدام اليقين في متوسط معدلات الخفض السنوية لهذه البلدان، يمكن التيقن من مستوى التسارع المرتفع فقط في بيلاروس وكازاخستان وتيمور- ليشتي ورواندا. وبالمقابل ارتفع معدل وفيات الأمومة خلال نفس الفترة في 31 بلدا.ً وعند مراعاة هامش انعدام اليقين بشأن معدلات التغيير واتجاهاته، نعتقد أن ثمة زيادة حقيقية في معدل وفيات الأمومة في الولايات المتحدة الأمريكية وفي الجمهورية الدومينيكية. ويجب النظر إلى هذه الاستنتاجات ضمن سياقها — حيث أن هناك الكثير من العوامل التي قد تؤدي إلى اتجاهات إيجابية وسلبية في مجال وفيات الأمومة. الاستنتاجات تتضمن أهداف التنمية المستدامة تأكيدا ًمباشرا ًعلى خفض وفيات الأمومة في الوقت الذي تسلط الضوء على أهمية الذهاب إلى أبعد من مجرد البقاء على قيد الحياة. ورغم التطلع إلى إنهاء وفيات الأمومة التي يمكن تلافيها بحلول عام 0302، فإن العالم سيعجز عن تحقيق هذه الغاية بفقدان أكثر من مليون حياة إذا استمر التقدم على وتيرته الحالية. وثمة حاجة عاجلة ومستمرة إلى إبقاء صحة الأمهات ونجاتهن على رأس البرامج العالمية الخاصة بالصحة والتنمية، علما ًأن حالة صحة الأمهات تتفاعل مع الجهود الرامية إلى تحسين إمكانية الحصول على خدمات الرعاية الصحية ونوعيتها. وقد أعاد إعلان أستانا لعام 8102 وضع الرعاية الصحية الأولية في إطار أفضل السبل فعالية )من حيث التكلفة( وشمولاً لتوفير الخدمات الصحية على نحو يسهم في تحقيق أهداف التنمية المستدامة. ومن ثم تُعتبر الرعاية الصحية الأولية حجر الأساس لتحقيق التغطية الصحية الشاملة، التي لا تتحقق إلا في حالة حصول الجميع على الخدمات الصحية الجيدة التي يحتاجونها دون التعرض لصعوبات مالية. أما الخدمات الصحية غير المتوفرة أو التي يصعب الحصول عليها أو الرديئة فلن تدعم تحقيق التغطية الصحية الشاملة على النحو المنشود. ويجب كذلك النظر إلى الجهود الرامية إلى زيادة توفير الرعاية لمزيد من النساء على نحو يتسم بالكفاءة والمهارة ، قبل الولادة وأثناءها وبعدها، في سياق العوامل الخارجية بما في ذلك تغّير المناخ والهجرة والأزمات الإنسانية، على سبيل المثال لا الحصر. إضافة إلى ذلك، تُدعى الحكومات إلى استحداث نظم تسجيل مدني وإحصاءات حيوية تعمل بشكل جيد وتحدد على وجه الدقة أسباب الوفاة. ويجب أن تستند تحسينات القياس إلى العمل على المستوى القطري، على أن تنشئ الحكومات نُظما لتحصيل البيانات تلبي احتياجاتها الخاصة من المعلومات، على أن تفي هذه الُنظم بالمعايير المطلوبة لتكون قابلة للمقارنة على الصعيد الدولي. وعلى المستوى العالمي، ينبغي وضع طرائق معيارية لمنع حدوث أخطاء في الإبلاغ بشأن السجل المدني والإحصاءات الحيوية )مثل عدم الاكتمال وسوء التصنيف(، وذلك من أجل تعزيز إمكانية المقارنة على الصعيد الدولي. وبناء على ما تقدم ذكره، يجب الإشارة إلى أن هذا التقرير الخاص بمستويات واتجاهات وفيات الأمومة لا يوفّر إلا جانبا ًحاسما ًواحدا ًمن المعلومات يقوم على تجميع وتحليل البيانات المتوفرة، من أجل تقييم التقدم المحرز في خفض وفيات الأمومة لتحقيق الغاية 1 للهدف 3 من أهداف التنمية المستدامة. وتُظهر النتائج حتى الآن تقدما ًجيدا ًولكنه متفاوت في خفض وفيات الأمومة حول العالم بين عامي 0002 و7102. ويتعين على المجتمع الدولي تسريع وتيرة هذه الجهود، لأننا إذا واصلنا العمل فقط على نفس وتيرة التقدم المحرز أثناء هذه الفترة، فلن يتسنى تحقيق الغاية العالمية لهدف التنمية المستدامة بشأن خفض النسبة العالمية لوفيات الأمومة إلى أقل من 07 حالة وفاة لكل 000 001 مولود حي بحلول عام 0302. وفي نهاية المطاف، علينا أن نوسع آفاقنا لنتجاوز مجرد التركيز على الوفاة إلى النظر في الجوانب الأوسع نطاقا ً— أي الأوضاع والاتجاهات القطرية والإقليمية، بما في ذلك النظم الصحية والتغطية الصحية الشاملة وجودة الرعاية ومستويات الاعتلال والمُحددات الاجتماعية والاقتصادية لتمكين المرأة وتعليمها — وضمان اتخاذ الإجراءات المناسبة من أجل دعم تخطيط الأسرة والحمل الصحي والولادة المأمونة. تقديرات بواسطة منظمة الصحة العالمية ومنظمة الأمم المتحدة للطفولة (اليونيسيف) وصندوق الأمم المتحدة للسكان، ومجموعة البنك الدولي وشعبة الأمم المتحدة للسكان 6 الجدول 2 : اتجاهات تقديرات معدل وفيات الأمومة )معدل وفيات الأمومة، وفيات الأمومة لكل 000 001 مولود حّي(، حسب البلد والإقليم، الفترة 0002-7102أ القيم التقديرية لمتوسط معدل التخفيض السنوي ونطاق هامش انعدام اليقين بشأن معدل الخفض السنوي بين عامي 0002 و7102 )هامش بنسبة 08%( إجمالي التغّير في معدل وفيات الأمومة بين عامي 0002 ج7102و القيم التقديرية لمعدل وفيات الأمومةأ،ب البلد والإقليم الحد الأعلى لهامش انعدام اليقين متوسط معدل الخفض السنوي د الحد الأدنى لهامش انعدام اليقين 0002 5002 0102 5102 7102 أفغانستان 0541 0411 459 107 836 65 4.1 8.4 5.5 ألبانيا 32 22 12 51 51 53 1.0- 5.2 6.5 الجزائر 161 721 511 411 211 03 5.0- 1.2 6.4 أنغولا 728 915 623 152 142 17 4.5 2.7 3.3 أنتيغوا وبربودا 44 04 44 34 24 5 8.1- 2.0 9.8 الأرجنتين 66 95 15 14 93 14 1.2 1.3 3.3 أرمينيا 34 53 23 82 62 04 5.1 0.3 7.2 أستراليا 7 5 5 6 6 41 4.1- 2.0 5.4 النمسا 6 6 5 5 5 71 5.0- 6.1 6.3 أذربيجان 74 24 13 72 62 54 2.2 5.3 6.6 جزر البهاما 57 77 87 47 07 7 4.2- 4.0 8.5 البحرين 72 91 81 51 41 84 6.1 6.3 3.8 بنغلاديش 434 343 852 002 371 06 4.3 4.5 9.8 بربادوس 05 24 63 13 72 64 9.1 7.3 7.01 بيلاروس 22 11 5 3 2 19 6.9 0.31 8.0 بلجيكا 8 7 6 5 5 83 0.1 5.2 1.3 بليز 98 07 45 34 63 06 7.3 3.5 6.6 بنن 025 005 464 124 793 42 4.0- 6.1 3.4 بوتان 324 013 742 302 381 75 1.2 9.4 5.4 القوميات دولة بوليفيا متعددة 133 172 212 861 551 35 7.2 5.4 8.4 البوسنة والهرسك 71 31 11 01 01 14 3.1 3.3 9.2 بوتسوانا 262 932 971 651 441 54 1.2 5.3 4.2 البرازيل 96 17 56 36 06 31 7.0 9.0 6.6 بروني دار السلام 82 92 82 03 13 11- 5.2- 7.0- 3.5 بلغاريا 91 51 21 01 01 74 9.1 0.4 0.4 بوركينا فاسو 615 734 583 343 023 83 9.0 8.2 0.5 بوروندي 0101 418 566 865 845 64 7.1 6.3 0.7 الرأس الأخضر 811 68 07 16 85 15 5.2 2.4 6.4 الموجز التنفيذي الاتجاهات الخاصة بوفيات الأمومة من عام 0002 إلى عام 71027 القيم التقديرية لمتوسط معدل التخفيض السنوي ونطاق هامش انعدام اليقين بشأن معدل الخفض السنوي بين عامي 0002 و7102 )هامش بنسبة 08%( إجمالي التغّير في معدل وفيات الأمومة بين عامي 0002 ج7102و القيم التقديرية لمعدل وفيات الأمومةأ،ب البلد والإقليم الحد الأعلى لهامش انعدام اليقين متوسط معدل الخفض السنوي د الحد الأدنى لهامش انعدام اليقين 0002 5002 0102 5102 7102 كمبوديا 884 153 842 871 061 76 6.4 6.6 0.3 الكاميرون 688 296 795 455 925 04 8.0 0.3 5.4 كندا 9 11 11 11 01 11- 5.2- 6.0- 2.1 جمهورية أفريقيا الوسطى 0821 0021 0001 219 928 53 3.0 6.2 9.4 تشاد 0241 0331 0421 0611 0411 02 7.0- 3.1 9.2 شيلي 13 52 02 41 31 85 3.4 4.5 7.6 الصين 95 44 63 03 92 15 9.2 2.4 0.6 كولومبيا 49 38 58 58 38 21 4.0- 8.0 7.1 جزر القمر 444 404 143 582 372 93 8.0 9.2 9.4 الكونغو 937 776 605 614 873 94 0.2 9.3 7.5 كوستاريكا 04 33 23 82 72 33 2.1 2.2 4.3 كوت ديفوار 407 407 107 856 716 21 2.1- 8.0 7.2 كرواتيا 11 01 9 8 8 72 0.0 0.2 7.3 كوبا 64 14 14 93 63 22 6.0 4.1 2.2 قبرص 41 21 8 7 6 75 9.2 9.4 0.7 تشيكيا 7 5 4 4 3 75 0.2 0.4 3.6 الديمقراطية جمهورية كوريا الشعبية 931 021 601 19 98 63 2.0 6.2 9.4 الديمقراطية جمهورية الكونغو 067 726 245 094 374 83 1.0 8.2 7.4 الدنمارك 8 6 5 4 4 05 8.2 3.4 2.6 جيبوتي 705 393 382 742 842 15 0.2 2.4 5.6 الجمهورية الدومنيكية 08 38 69 49 59 91- 6.1- 0.1- 5.0- إكوادور 221 49 87 36 95 25 4.3 3.4 2.5 مصر 46 25 54 93 73 24 7.1 2.3 4.5 السلفادور 37 26 45 84 64 73 3.1 7.2 3.4 غينيا الإستوائية 454 443 803 692 103 43 3.0 4.2 5.4 إريتريا 0821 408 765 815 084 36 6.3 8.5 9.7 إستونيا 92 81 11 01 9 96 0.5 1.7 6.9 الجدول 2 (تابع) : اتجاهات تقديرات معدل وفيات الأمومة )معدل وفيات الأمومة، وفيات الأمومة لكل 000 001 مولود حّي(، حسب البلد والإقليم، الفترة 0002-7102أ تقديرات بواسطة منظمة الصحة العالمية ومنظمة الأمم المتحدة للطفولة (اليونيسيف) وصندوق الأمم المتحدة للسكان، ومجموعة البنك الدولي وشعبة الأمم المتحدة للسكان 8 القيم التقديرية لمتوسط معدل التخفيض السنوي ونطاق هامش انعدام اليقين بشأن معدل الخفض السنوي بين عامي 0002 و7102 )هامش بنسبة 08%( إجمالي التغّير في معدل وفيات الأمومة بين عامي 0002 ج7102و القيم التقديرية لمعدل وفيات الأمومةأ،ب البلد والإقليم الحد الأعلى لهامش انعدام اليقين متوسط معدل الخفض السنوي د الحد الأدنى لهامش انعدام اليقين 0002 5002 0102 5102 7102 إسواتيني 125 235 054 534 734 61 6.1- 0.1 0.3 إثيوبيا 0301 568 795 644 104 16 0.3 5.5 4.7 فيجي 15 64 93 53 43 33 8.0 4.2 0.4 فنلندا 6 5 4 3 3 05 7.1 6.3 2.5 فرنسا 01 9 9 8 8 02 2.0 4.1 6.2 الغابون 083 843 413 162 252 43 1.0 4.2 3.4 غامبيا 239 657 166 526 795 63 6.0 6.2 5.4 جورجيا 13 93 23 72 52 91 1.0 3.1 5.2 ألمانيا 7 6 6 5 7 0 3.1- 2.0 8.1 غانا 484 173 933 023 803 63 9.0 7.2 5.4 اليونان 3 3 3 3 3 0 3.1- 6.0 7.2 غرينادا 83 33 92 52 52 43 4.0 4.2 5.4 غواتيمالا 161 241 921 301 59 14 5.2 1.3 7.3 غينيا 0201 029 747 996 675 44 6.1 4.3 9.4 غينيا-بيساو 0121 979 977 496 766 54 0.1 5.3 4.5 غيانا 132 322 971 271 961 72 4.0 8.1 3.3 هايتي 734 954 605 884 084 01- 7.2- 6.0- 3.1 هندوراس 58 77 47 76 56 42 4.0 6.1 7.2 هنغاريا 61 51 31 21 21 52 6.0- 0.2 2.4 آيسلندا 6 5 5 4 4 33 7.0 7.2 9.4 الهند 073 682 012 851 541 16 2.4 5.5 0.7 أندونيسيا 272 252 822 291 771 53 5.0 5.2 3.4 جمهورية إيران الإسلامية 84 43 22 71 61 76 0.5 3.6 0.8 العراق 97 721 07 38 97 0 9.1- 0.0 5.2 إيرلندا 7 7 6 6 5 92 0.0 5.2 3.4 إسرائيل 7 5 4 3 3 75 4.3 9.4 5.6 إيطاليا 4 3 2 2 2 05 3.3 1.5 9.6 جامايكا 77 08 97 87 08 4- 5.1- 2.0- 9.0 الجدول 2 (تابع) : اتجاهات تقديرات معدل وفيات الأمومة )معدل وفيات الأمومة، وفيات الأمومة لكل 000 001 مولود حّي(، حسب البلد والإقليم، الفترة 0002-7102أ الموجز التنفيذي الاتجاهات الخاصة بوفيات الأمومة من عام 0002 إلى عام 71029 القيم التقديرية لمتوسط معدل التخفيض السنوي ونطاق هامش انعدام اليقين بشأن معدل الخفض السنوي بين عامي 0002 و7102 )هامش بنسبة 08%( إجمالي التغّير في معدل وفيات الأمومة بين عامي 0002 ج7102و القيم التقديرية لمعدل وفيات الأمومةأ،ب البلد والإقليم الحد الأعلى لهامش انعدام اليقين متوسط معدل الخفض السنوي د الحد الأدنى لهامش انعدام اليقين 0002 5002 0102 5102 7102 اليابان 9 7 6 5 5 44 1.2 8.3 7.5 الأردن 07 26 35 84 64 43 6.0 4.2 7.4 كازاخستان 16 34 22 21 01 48 2.9 9.01 6.21 كينيا 807 816 234 353 243 25 4.2 3.4 9.5 كيريباتي 631 911 211 79 29 23 1.0 3.2 7.4 الكويت 01 01 01 11 21 02- 8.2- 7.0- 2.1 قيرغيزستان 97 28 97 66 06 42 0.0 6.1 8.2 الشعبية جمهورية لاو الديمقراطية 445 014 292 902 581 66 4.4 3.6 0.8 لاتفيا 43 03 62 32 91 44 6.1 5.3 0.5 لبنان 82 42 32 92 92 4- 9.2- 4.0- 6.1 ليسوتو 416 976 495 475 445 11 6.1- 7.0 5.2 ليبيريا 498 618 807 196 166 62 4.0- 8.1 5.3 ليتوانيا 71 41 01 9 8 35 1.2 2.4 5.6 لكسمبرغ 01 9 8 5 5 05 4.2 5.1 3.6 مدغشقر 955 625 354 363 533 04 0.1 0.3 0.5 ملاوي 947 016 444 073 943 35 3.2 5.4 5.6 ماليزيا 83 13 03 03 92 42 2.0 5.1 7.2 ملديف 521 57 76 45 35 85 1.2 1.5 3.7 مالي 638 196 066 026 265 33 3.0 3.2 9.3 مالطة 9 8 8 7 6 33 1.0 3.2 4.4 موريتانيا 438 628 428 587 667 8 0.2- 5.0 6.2 موريشيوس 95 35 66 37 16 3- 8.2- 2.0- 9.1 المكسيك 55 45 64 63 33 04 6.2 0.3 3.3 ولايات ميكرونيزيا الموحدة 451 331 011 59 88 34 0.1 3.3 6.5 منغوليا 551 89 66 74 54 17 8.5 3.7 8.8 الجبل الأسود 21 9 7 6 6 05 1.2 3.4 9.6 المغرب 881 131 29 47 07 36 2.4 8.5 5.7 الجدول 2 (تابع) : اتجاهات تقديرات معدل وفيات الأمومة )معدل وفيات الأمومة، وفيات الأمومة لكل 000 001 مولود حّي(، حسب البلد والإقليم، الفترة 0002-7102أ تقديرات بواسطة منظمة الصحة العالمية ومنظمة الأمم المتحدة للطفولة (اليونيسيف) وصندوق الأمم المتحدة للسكان، ومجموعة البنك الدولي وشعبة الأمم المتحدة للسكان 01 القيم التقديرية لمتوسط معدل التخفيض السنوي ونطاق هامش انعدام اليقين بشأن معدل الخفض السنوي بين عامي 0002 و7102 )هامش بنسبة 08%( إجمالي التغّير في معدل وفيات الأمومة بين عامي 0002 ج7102و القيم التقديرية لمعدل وفيات الأمومةأ،ب البلد والإقليم الحد الأعلى لهامش انعدام اليقين متوسط معدل الخفض السنوي د الحد الأدنى لهامش انعدام اليقين 0002 5002 0102 5102 7102 موزامبيق 897 775 214 813 982 46 9.3 0.6 7.7 ميانمار 043 992 562 642 052 62 7.0- 8.1 1.4 ناميبيا 843 643 662 712 591 44 4.1 4.3 9.4 نيبال 355 514 503 632 681 66 0.4 4.6 4.8 هولندا 31 11 7 6 5 26 8.3 6.5 5.7 نيوزيلندا 21 11 11 01 9 52 5.0 8.1 3.3 نيكاراغوا 261 131 211 101 89 04 2.1 0.3 5.4 النيجر 318 557 366 555 905 73 8.0 7.2 5.4 نيجيريا 0021 0801 879 139 719 42 8.0- 6.1 5.3 النرويج 6 5 4 3 2 76 4.3 3.5 8.7 ُعمان 02 91 81 91 91 5 0.1- 3.0 6.1 باكستان 682 732 191 451 041 15 0.2 2.4 4.6 بنما 19 88 97 85 25 34 1.2 3.3 7.4 بابوا غينيا الجديدة 942 002 861 151 541 24 9.0 2.3 5.5 باراغواي 561 731 801 88 48 94 6.2 0.4 6.5 بيرو 441 811 401 49 88 93 5.1 9.2 6.4 الفلبين 061 651 441 721 121 42 3.0- 7.1 3.3 بولندا 7 4 3 2 2 17 5.4 6.6 9.8 البرتغال 01 9 9 9 8 02 6.0- 6.1 3.3 بورتوريكو 62 32 12 02 12 91 6.0- 3.1 7.2 قطر 41 21 01 9 9 63 5.0 6.2 5.4 جمهورية كوريا 71 51 51 21 11 53 4.1 4.2 6.3 جمهورية مولدوفا 44 43 92 22 91 75 3.3 9.4 6.6 جمهورية مقدونيا الشمالية 31 01 8 8 7 64 7.1 5.3 8.5 رومانيا 45 53 72 12 91 56 3.4 3.6 3.8 الإتحاد الروسي 65 24 52 81 71 07 0.5 9.6 9.8 رواندا 0611 346 373 572 842 97 0.7 1.9 7.01 الجدول 2 (تابع) : اتجاهات تقديرات معدل وفيات الأمومة )معدل وفيات الأمومة، وفيات الأمومة لكل 000 001 مولود حّي(، حسب البلد والإقليم، الفترة 0002-7102أ الموجز التنفيذي الاتجاهات الخاصة بوفيات الأمومة من عام 0002 إلى عام 710211 القيم التقديرية لمتوسط معدل التخفيض السنوي ونطاق هامش انعدام اليقين بشأن معدل الخفض السنوي بين عامي 0002 و7102 )هامش بنسبة 08%( إجمالي التغّير في معدل وفيات الأمومة بين عامي 0002 ج7102و القيم التقديرية لمعدل وفيات الأمومةأ،ب البلد والإقليم الحد الأعلى لهامش انعدام اليقين متوسط معدل الخفض السنوي د الحد الأدنى لهامش انعدام اليقين 0002 5002 0102 5102 7102 سانت لوسيا 68 38 901 511 711 63- 7.4- 8.1- 8.0 غرينادين سانت فنسنت وجزر 08 95 36 46 86 51 9.0- 9.0 1.3 ساموا 88 27 85 54 34 15 7.1 2.4 6.6 ساو تومي وبرينسيبي 971 361 041 031 031 72 1.0- 9.1 3.4 المملكة العربية السعودية 42 22 91 71 71 92 2.0- 1.2 5.4 السنغال 355 915 744 643 513 34 4.1 3.3 8.4 صربيا 31 21 21 31 21 8 0.2- 6.0 9.2 سيشيل 35 55 55 45 35 0 4.2- 0.0 4.2 سيراليون 0842 0671 0631 0811 0211 55 2.2 7.4 6.6 سنغافورة 31 31 01 9 8 83 4.0 9.2 3.5 سلوفاكيا 8 7 6 6 5 83 6.0 3.2 0.4 سلوفينيا 21 01 8 7 7 24 6.1 3.3 0.5 جزر سليمان 542 881 141 211 401 85 0.3 0.5 0.7 الصومال 0121 0401 589 558 928 13 3.0 2.2 6.4 جنوب أفريقيا 061 102 171 521 911 62 1.0 7.1 0.3 جنوب السودان 0371 0841 011 0111 0511 43 1.0 4.2 5.4 أسبانيا 5 5 4 4 4 02 0.0 7.1 0.3 سري لانكا 65 54 83 63 63 63 7.1 7.2 5.3 دولة ليبيا 07 75 35 07 27 3- 6.2- 2.0- 3.2 السودان 766 925 804 023 592 65 7.2 8.4 1.7 سورينام 122 461 841 221 021 64 3.2 6.3 4.5 السويد 5 5 4 4 4 02 2.0- 5.1 9.2 سويسرا 7 7 6 5 5 92 4.0 6.2 2.4 الجمهورية العربية السورية 62 52 72 03 13 91- 0.4- 1.1- 3.1 طاجيكستان 35 23 32 81 71 86 3.4 8.6 5.9 تايلندا 34 34 24 83 73 41 5.0- 8.0 1.2 تيمور-ليشتي 547 514 912 061 241 18 7.7 8.9 9.11 الجدول 2 (تابع) : اتجاهات تقديرات معدل وفيات الأمومة )معدل وفيات الأمومة، وفيات الأمومة لكل 000 001 مولود حّي(، حسب البلد والإقليم، الفترة 0002-7102أ تقديرات بواسطة منظمة الصحة العالمية ومنظمة الأمم المتحدة للطفولة (اليونيسيف) وصندوق الأمم المتحدة للسكان، ومجموعة البنك الدولي وشعبة الأمم المتحدة للسكان 21 أ احتُسبت التقديرات لضمان إمكانية المقارنة بين جميع البلدان، ومن ثم فهي ليست بالضرورة نفس الاتجاهات الواردة في الإحصاءات الرسمية للبلدان، والتي قد تستخدم طرائق بديلة صارمة. ب تم تقريب أرقام وفيات الأمومة التقديرية وفقا ًللمخطط التالي: أقل من 001 وفاة إلى أقرب وفاة واحدة، و 001-999 وفاة إلى أقرب وفاة واحدة، وأكثر من 0001 إلى أقرب 01 وفيات، وتقوم جميع الحسابات على تقريب الأرقام. ج إجمالي التغّير بالنسبة للفترة كاملة من السنة الأولى من الألفية )اعتبارا ًمن 1 كانون الثاني/يناير 0002(. د متوسط معدل الخفض السنوي للفترة كاملة اعتبارا ًمن السنة الأولى للألفية )1 كانون الثاني/يناير 0002(. ه تشير منظمة الأمم المتحدة للطفولة وصندوق الأمم المتحدة للسكان ومجموعة البنك الدولي وبرنامج الأمم المتحدة الإنمائي إلى هذه الأراضي بصفتها دولة فلسطين. القيم التقديرية لمتوسط معدل التخفيض السنوي ونطاق هامش انعدام اليقين بشأن معدل الخفض السنوي بين عامي 0002 و7102 )هامش بنسبة 08%( إجمالي التغّير في معدل وفيات الأمومة بين عامي 0002 ج7102و القيم التقديرية لمعدل وفيات الأمومةأ،ب البلد والإقليم الحد الأعلى لهامش انعدام اليقين متوسط معدل الخفض السنوي د الحد الأدنى لهامش انعدام اليقين 0002 5002 0102 5102 7102 توغو 984 294 044 893 693 91 5.0- 3.1 1.3 تونغا 77 66 75 45 25 23 0.0 3.2 6.4 ترينيداد وتوباغو 18 67 17 86 76 71 6.0- 1.1 7.2 تونس 66 15 64 64 34 53 7.0 4.2 8.4 تركيا 24 33 42 91 71 06 6.3 3.5 5.7 تركمانستان 92 81 01 8 7 67 9.5 2.8 5.01 أوغندا 875 194 034 783 573 53 5.0 5.2 2.4 أوكرانيا 53 33 52 12 91 64 6.1 6.3 5.5 الإمارات العربية المتحدة 6 5 4 3 3 05 9.1 0.4 9.6 العظمى وشمال إيرلندا المملكة المتحدة لبريطانيا 01 11 01 8 7 03 9.1 7.2 6.3 جمهورية تنزانيا المتحدة 458 127 446 655 425 93 9.0 9.2 4.4 الولايات المتحدة الأمريكية 21 31 51 81 91 85- 3.3- 6.2- 9.1- أوروغواي 62 22 71 81 71 53 2.1 4.2 6.3 أوزبكستان 14 83 13 03 92 92 1.0 0.2 6.3 فانواتو 041 311 29 67 27 94 6.1 0.4 1.6 جمهورية فنزويلا البوليفارية 911 311 711 511 521 5- 2.2- 3.0- 3.1 فيتنام 86 45 74 54 34 73 5.0 6.2 6.4 الضفة الغربية وقطاع غزةه 07 95 54 23 72 16 4.3 6.5 1.8 اليمن 103 242 291 961 461 64 7.1 6.3 1.6 زامبيا 825 124 503 232 312 06 7.3 3.5 8.6 زمبابوي 975 586 895 084 854 12 1.0 4.1 9.2 الجدول 2 (تابع) : اتجاهات تقديرات معدل وفيات الأمومة )معدل وفيات الأمومة، وفيات الأمومة لكل 000 001 مولود حّي(، حسب البلد والإقليم، الفترة 0002-7102أ For more information, please contact: Department of Reproductive Health and Research World Health Organization Avenue Appia 20 CH-1211 Geneva 27 Switzerland Email: reproductivehealth@who.int www.who.int/reproductivehealth WHO/RHR/19.23 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Résumé d’orientation ةصاخلا تاهاجتلاا ةموملأا تايفوب 2017 ماع لىإ 2000 ماع نم ةيلماعلا ةحصلا ةمظنم ةطساوب تاريدقت )فيسينويلا( ةلوفطلل ةدحتلما مملأا ةمظنمو ةعومجمو ،ناكسلل ةدحتلما مملأا قودنصو ناكسلل ةدحتلما مملأا ةبعشو ليودلا كنبلا يذيفنتلا زجولما Cover ES MMR Arabic.indd 1 01.08.20 19:19