Maternal mortality and morbidity burden in the Eastern Mediterranean Region: findings from the Global Burden of Disease 2015 study

Maternal mortality and morbidity burden in the Eastern Mediterranean Region: findings from the... Int J Public Health (2018) 63 (Suppl 1):S47–S61 https://doi.org/10.1007/s00038-017-1004-3 O R I G IN AL ARTI CL E Maternal mortality and morbidity burden in the Eastern Mediterranean Region: findings from the Global Burden of Disease 2015 study GBD 2015 Eastern Mediterranean Region Maternal Mortality Collaborators Received: 1 May 2017 / Revised: 15 June 2017 / Accepted: 21 June 2017 / Published online: 3 August 2017 The Author(s) 2017. This article is an open access publication Abstract to make sure that adequate and timely services and inter- Objectives Assessing the burden of maternal mortality is ventions are available for women at each stage of repro- important for tracking progress and identifying public ductive life. health gaps. This paper provides an overview of the burden of maternal mortality in the Eastern Mediterranean Region Keywords Maternal mortality  Maternal health  Eastern (EMR) by underlying cause and age from 1990 to 2015. Mediterranean Region  Burden of disease Methods We used the results of the Global Burden of Disease 2015 study to explore maternal mortality in the EMR countries. Introduction Results The maternal mortality ratio in the EMR decreased 16.3% from 283 (241–328) maternal deaths per 100,000 live Maternal mortality ratio (MMR), which measures deaths births in 1990 to 237 (188–293) in 2015. Maternal mortality per 100,000 live births, is a standard measure for global, ratio was strongly correlated with socio-demographic status, regional, and national comparison (Abouzahir and Ward- where the lowest-income countries contributed the most to law 2001). It is also one of the main criteria of health the burden of maternal mortality in the region. outcomes and an indicator of the socioeconomic develop- Conclusion Progress in reducing maternal mortality in the ment level of countries that is recognized worldwide EMR has accelerated in the past 15 years, but the burden (Liang et al. 2010). Country estimates of maternal mor- remains high. Coordinated and rigorous efforts are needed tality over time are crucial to inform the planning of maternal, sexual, and reproductive health programs and to guide advocacy efforts and research at the national level. This article is part of the supplement ‘‘The state of health in the These estimates are also needed at the international level to Eastern Mediterranean Region, 1990–2015’’. inform decision-making concerning resource allocation by development partners and donors (WHO et al. 2007). The members of GBD (Global Burden of Disease) 2015 Eastern Mediterranean Region Maternal Mortality Collaborators are listed at In 2015, 275,288 women are estimated to have died as a the end of the article. Ali H. Mokdad, on behalf of GBD 2015 Eastern result of pregnancy or childbirth globally (Kassebaum et al. Mediterranean Region Maternal Mortality Collaborators, is the 2016b). Maternal death is defined by ICD-10 as the death corresponding author. of a woman while pregnant or within 42 days and up to 1 Electronic supplementary material The online version of this year (late maternal death); of termination of pregnancy, article (doi:10.1007/s00038-017-1004-3) contains supplementary irrespective of the duration and site of the pregnancy, from material, which is available to authorized users. any cause related to or aggravated by the pregnancy or its & GBD 2015 Eastern Mediterranean Region Maternal management, but not from accidental or incidental causes Mortality Collaborators (World Health Organization 1992). mokdaa@uw.edu The primary causes of maternal deaths are hemorrhage, hypertension, infections, pre-existing medical conditions, Institute for Health Metrics and Evaluation, University of and lack of literacy, family planning (unmet need and birth Washington, Seattle, WA, USA 123 S48 GBD 2015 Eastern Mediterranean Region Maternal Mortality Collaborators spacing), and access to pregnancy termination when nee- infrastructures but face resource constraints; and low-in- ded. Identifying and improving the main factors related to come countries that lack the resources and infrastructure for maternal mortality depend on a correct definition of the effective health interventions. Many countries in the region required priorities for appropriate prevention, diagnosis, are suffering from political instability, conflicts, and other and treatment (Ribeiro et al. 2008). complex development challenges. This range from low to Poverty, illiteracy, malnutrition, and the low social sta- high incomes can be seen as a microcosm of the variability in tus of women are usually among the major underlying maternal mortality present globally. This paper seeks to causes of maternal mortality. Analyzing the economic, examine in detail the burden of maternal mortality within the social, and health system factors affecting maternal mor- EMR using the results of the GBD 2015 study. tality can provide some credible information and evidence for public health interventions to improve maternal health. A few general studies on nonclinical determinants of Methods maternal mortality have analyzed different factors includ- ing access to safe drinking water, access to food, fertility A detailed methodology of maternal mortality estimation rate, education level, life expectancy at birth, access to for GBD 2015 has been published elsewhere (Kassebaum health services, delivery done by skilled birth attendants, et al. 2016b). In short, sources with population-level data out-of-pocket payment, GDP per capita, health expendi- were processed using standardized algorithms to adjust for tures, and government corruption (Hertz et al. 1994; Mid- age-specific, year-specific, and geography-specific patterns het et al. 1998; Buor and Bream 2004; Alvarez et al. 2009; of incompleteness. Additional steps were taken to account Muldoon et al. 2011). for underestimations of maternal mortality in vital regis- From 1990 to 2015, the global MMR decreased 30.6% tration systems. ICD-10 vital registration codes pertaining from 280.4 (95% uncertainty interval (UI): 262.6–299.0) to to HIV-related maternal deaths were excluded and quan- 194.7 (172.6–233.2) (Institute for Health Metrics and Eval- tified separately (Kassebaum et al. 2014). Overall maternal uation 2017). This decrease was driven in part by the mortality was modeled using cause-of-death ensemble recognition of maternal health as one of the priorities in the modeling (CODEm), where all combinations of covariates UN Millennium Development Goals (MDGs), which pro- were tested and ranked on the basis of out-of-sample pre- vided a strong incentive to reduce MMR by country (Rons- dictive validity performance. All data sources are available mans and Graham 2006). New goals outlined in the on our website, and we provide a visualization to show sustainable development goals (SDGs) for 2015 to 2030 each source used in our analyses (Institute for Health build on the momentum of the MDGs and seek to bring the Metrics and Evaluation 2016). global MMR below 70 deaths per 100,000 live births (United We calculated years of life lost (YLLs) by multiplying Nations 2015). The greatest challenge in meeting this goal deaths by the residual expected individual lifespan at the lies with countries in the bottom two quintiles of wealth, age of death as derived from the GBD 2015 standard model where improvement is most needed and has historically life table. Years lived with disability (YLDs) were calcu- occurred slowly if at all (Abouzahir and Wardlaw 2001). lated by multiplying the number of prevalent cases of a The variation in MMR between countries by income certain health outcome by the disability weight assigned to group is drastic, where the burden of maternal mortality this health outcome. A disability weight reflects the mag- falls almost exclusively upon developing countries (Rons- nitude of the health loss associated with an outcome and mans and Graham 2006). Globally, the average MMR for has a value that is anchored between 0, equivalent to full countries in the top quintile of wealth for 2015 was 14.5 health, and 1, equivalent to death. YLLs were calculated by (13.7–15.4) compared to 440.2 (357.4–543.5) in the bottom multiplying deaths by the remaining life expectancy at the quintile (Institute for Health Metrics and Evaluation 2017). age of death from a standard life table chosen as the norm Despite this variation, inequalities in maternal mortality for estimating premature mortality in GBD. Disability-ad- exist between and within countries, where mortality in all justed life years (DALYs) were calculated by adding YLLs locations is exacerbated by a lack of access to quality and YLDs. Detailed methods on YLLs, YLDs, and DALYs obstetric care, whether because of the remoteness of certain are published elsewhere (Kassebaum et al. 2016a; Vos regions or the inability of health facilities to provide proper et al. 2016; Wang et al. 2016). care (Peterson et al. 2012). We evaluated the associations between maternal mortality The Eastern Mediterranean Region (EMR) is a diverse and socio-demographic status using the socio-demographic region consisting of 22 countries, including high-income index (SDI). SDI is a composite measure developed for GBD countries, where socioeconomic development has pro- 2015 that accounts for fertility rate, lag-dependent income per gressed considerably over the last decades; middle-income capita, and education. To capture the average relationships for countries that have well-developed health service delivery each age group, we applied a simple least squares spline 123 Maternal mortality and morbidity burden in the Eastern Mediterranean Region: findings from… S49 regression of the maternal mortality rate on SDI. The SDI is highest YLL rate in 2015 was in Somalia with 7774 scaled from 0 to 1, where 0 represents the lowest possible (1497–23,408) YLLs per 100,000 women aged 15–49, observed SDI and 1 is the highest. We reported uncertainty for compared to Kuwait at 21 (16–27) (Table 3). Somalia all our estimates (Kassebaum et al. 2016a). also had the smallest percent change from 1990 to 2015, a decrease of 18% (Table 3). Results YLDs Mortality Average YLD rates in the region fell from 161 (114–215) per 100,000 women aged 15–49 to 82 (57–113), a 49% decrease The total number of deaths due to maternal disorders (Table 3). Globally, there was a 41% decrease (Institute for increased 4.5% from 38,595 (32,859–44,785) deaths in Health Metrics and Evaluation 2017). Inter-country vari- 1990 to 40,338 (31,965–49,954) in 2015 in the EMR, ability in the YLD rate was less than that of YLLs, with the compared to a 29.5% decrease globally (Institute for Health highest seen in Somalia with 254 (171–362) YLDs per Metrics and Evaluation 2017). In 1990, the maternal 100,000 women aged 15–49 and the lowest in the United mortality ratio was similar in the EMR and globally at 283 Arab Emirates with 16 (10–26) (Table 3). (241–328) maternal deaths per 100,000 live births in the EMR and 280 (263–299) globally (Institute for Health YLL/YLD Metrics and Evaluation 2017). By 1995, a gap between the regional and global trends had opened, and this persisted The YLL/YLD ratio was included as an indicator of health steadily through 2015. By then, the EMR had a maternal system effectiveness in dealing with fatal and non-fatal out- mortality ratio of 237 (188–293) compared to 194 comes of maternal disorders. Large values, such as that of (173–223) globally (Institute for Health Metrics and Afghanistan, a ratio of 89.6 in 2015, demonstrated cases, where Evaluation 2017). By country, only Afghanistan and Dji- fatal outcomes heavily outweigh non-fatal ones (Table 3). bouti had an annual increase in maternal mortality ratio Kuwait in 2015 had a ratio of 1.11, signifying a near equal between 1990 and 2015 (Table 1). Palestine also had an burden of fatal and non-fatal outcomes for maternal disorders increase in maternal mortality ratio between 2000 and (Table 3). Lower income countries with SDI less than 0.5 all 2015, but still had a lower ratio in 2015 compared to 1990 had ratios greater than 10, whereas higher income countries (Table 1). with SDI greater than 0.7 had ratios under 4 (Table 3). In the Both globally and regionally, maternal hemorrhage was countries with SDI less than 0.5, all but Sudan had an increase in the leading cause of maternal mortality in 1990 and 2015 YLL/YLD ratio from 1990 to 2015 (Table 3). Large decreases (Institute for Health Metrics and Evaluation 2017). By in the ratio from 1990 to 2015 highlighted effective improve- country within the EMR, hemorrhage was also the most ments in treatment, such as in Morocco, where the ratio common, followed by other maternal disorders, noticeably decreased from 35.2 to 8.5 (Table 3). within the Gulf states (Fig. 1). In all countries, all causes of maternal mortality decreased from 1990 to 2015 (Table 2). DALYs In 2015, maternal hemorrhage in Somalia was the largest contributor to maternal mortality by country and causes at From 1990 to 2015, DALY rates decreased in all countries 72.3 (13.2–229.0) deaths per 100,000 among women aged in the region. The overall DALY rate for the region 15–49 (Table 2). The GBD study expanded the analysis to decreased by 49% during this interval, compared to 51% the full reproductive age range of 10–54 years (Kassebaum globally (Institute for Health Metrics and Evaluation 2017). et al. 2016b). In general, the countries with the highest As discussed in the YLL/YLD section above, the propor- mortality rates by cause also showed the least improvement tional contribution of YLDs to the DALYs rate increased from 1990 to 2015 (Table 2). as SDI increased (Table 3). Like YLL rates, DALY rates showed large inter-country variation, as shown in Fig. 2. YLLs DALY rates peaked in the 20–25-year age group, decreasing until ages 35–40, then steeply falling off in YLL rates fell 49% in the EMR between 1990 and 5-year increments (Fig. 3). By sub-cause, complication of 2015, the same as the global mean, from 2,683 abortions contributed the most to the DALY rate in young (2284–3103) per 100,000 women aged 15–49 to 1377 (10–15) and old (45?) age groups (e-Fig. 1). Percent of (1091–1695) (Table 3). In that time frame, the YLL DALYs attributable to obstructed labor increased steadily rate decreasedinall countries (Table 3). There was with age, spiking drastically for the 50–55-year age group significant inter-country variation in YLL rates. The (e-Fig. 1). 123 S50 GBD 2015 Eastern Mediterranean Region Maternal Mortality Collaborators Table 1 Maternal deaths, maternal mortality ratio, and annualized change in maternal mortality ratio in the Eastern Mediterranean Region, 1990–2015 (Global Burden of Disease 2015 study, Eastern Mediterranean countries, 1990–2015) Country Number of maternal deaths Maternal mortality ratio (per 100,000 livebirths) Annualized rate of change in maternal mortality ratio (%) 1990 2000 2015 1990 2000 2015 1990–2000 2000–15 1990–2015 Afghanistan 4590 7328 8525 732.3 753.3 788.9 0.4 (-4.8–5.0) 0.3 (-3.6–3.8) 0.3 (-2.1–2.7) (2825–7111) (4529–11,007) (5010–13,221) (451.0–1130.9) (466.5–1130.7) (464.1–1219.2) Bahrain 8 (6–11) 5 (4–7) 5 (4–7) 53.6 (39.9–73.5) 35.6 (27.3–47.3) 24.6 (18.3–35.4) -4.0 (-7.9 to -2.5 (-5.1 to -3.1 (-4.9 to -0.6) 0.4) -1.3) Djibouti 86 (35–159) 118 (43–283) 107 (43–299) 378.3 523.8 486.2 2.8 (-9.8 to -0.5 (-9.4 to 0.6 (-4.1 to (154.4–698.7) (192.3–1247.0) (193.8–1353.5) 15.3) 9.9) 6.6) Egypt 2744 1186 (976–1414) 1052 (809–1340) 146.7 69.2 (57.0–82.5) 42.3 (32.5–53.9) -7.5 (-9.7 to -3.3 (-5.3 to -5.0 (-6.1 to (2308–3176) (123.4–169.7) -5.5) -1.2) -3.7) Iran 1039 (704–1432) 426 (337–539) 281 (192–421) 56.6 (38.5–78.0) 34.5 (27.3–43.7) 20.8 (14.2–31.1) -5.0 (-8.6 to -3.5 (-6.4 to -4.1 -0.6) -0.2) (-6.0 to -1.9) Iraq 969 (702–1300) 950 (655–1311) 729 (428–1199) 146.0 113.4 58.6 (34.4–96.1) -2.5 (-6.7 to -4.5 (-8.2 to -3.7 (-6.0 to (105.9–195.9) (78.3–156.4) 1.4) -1.0) -1.3) Jordan 116 (89–149) 121 (88–159) 48 (36–63) 97.9 81.2 24.2 (17.9–31.5) -1.9 (-5.1 to -8.0 (-10.7 to -5.6 (-7.2 to (74.6–125.4) (58.7–106.2) 1.1) -5.4) -4.1) Kuwait 4 (3–5) 5 (4–6) 4 (3–6) 9.7 (8.1–11.8) 11.9 (10.4–13.5) 5.9 (4.4–7.5) 2.1 (0.0–4.1) -4.8 (-6.8 to -2.0 (-3.4 to -2.8) -0.7) Lebanon 24 (15–38) 17 (11–24) 13 (8–21) 35.6 (22.8–55.1) 26.7 (18.0–39.0) 15.3 (9.0–24.0) -2.9 (-7.6 to -3.9 (-7.6 to -3.3 (-6.2 to 1.6) 0.3) -0.7) Libya 34 (24–45) 28 (20–37) 30 (20–43) 26.6 (19.1–36.0) 23.9 (17.2–31.5) 22.8 (15.6–32.9) -1.0 (-4.8 to -0.3 -0.6 2.3) (-3.5 to 2.8) (-2.6 to 1.3) Morocco 2441 1197 (894–1560) 479 (299–756) 332.7 192.0 68.5 -5.4 (-8.8 to -7.0 (-10.1 to -6.4 (-8.6 to (1891–3201) (258.7–436.1) (143.4–249.6) (42.8–108.1) -2.4) -3.4) -4.3) Pakistan 16,973 22,038 19,005 391.5 498.9 348.6 2.4 (-0.3 to -2.4 (-4.7 to -0.5 (-1.9 to (13,060–21,189) (17,789–26,598) (14,012–24,369) (301.3–488.4) (404.1–601.7) (257.2–447.0) 5.5) -0.3) 0.9) Palestine 29 (19–43) 17 (14–21) 25 (17–35) 29.3 (19.0–43.7) 14.2 (11.3–17.8) 16.2 (11.5–23.2) -7.1 (-11.2 to 0.8 (-1.9 to -2.4 (-4.7 to -3.1) 3.9) 0.2) Oman 24 (14–38) 12 (8–18) 13 (9–18) 34.1 (20.0–54.8) 21.4 (14.8–31.7) 15.5 (11.0–21.6) -4.5 (-8.7 to -2.2 (-5.5 to -3.1 (-5.6 to -0.3) 1.2) -0.7) Qatar 7 (4–10) 7 (5–10) 7 (4–9) 64.0 (42.0–91.5) 59.9 (41.4–84.2) 25.5 (16.4–35.7) -0.6 (-4.6 to -5.7 (-9.5 to -3.7 (-6.0 to 3.6) -2.4) -1.6) Saudi Arabia 124 (93–162) 101 (86–119) 97 (82–115) 21.3 (16.0–27.9) 17.9 (15.2–21.0) 15.7 (13.3–18.5) -1.6 (-4.0 to -0.9 (-2.4 to -1.2 (-2.5 to 0.6) 0.6) 0.1) Somalia 2509 (418–6 772) 2899 (489–7449) 3443 (661–10 830.5 811.0 731.1 -0.3 (-11.8 to -0.8 (-8.6 to -0.6 (-6.7 to 512) (138.5–2193.9) (137.5–2077.9) (140.5–2218.6) 10.4) 8.8) 6.5) Maternal mortality and morbidity burden in the Eastern Mediterranean Region: findings from… S51 Discussion Our study showed that maternal mortality has declined in the EMR except in Djibouti, Palestine, and Afghanistan in recent years. However, the burden is still higher than the global average. Our findings call for increased efforts to reduce maternal mortality in the region. Moreover, with unrest in the region, there is a risk of losing some of the observed gains. Efforts to reduce maternal mortality in the EMR have varied in scope, approach, and success by country. This has resulted in great variations and disparities in maternal mortality levels between countries. The high-income countries in the region (Kuwait, Oman, Qatar, Saudi Ara- bia, and United Arab Emirates) have achieved reductions between 25 and 50% compared to levels in 1990. Maternal mortality ratios in these countries ranged from 6 to 26 deaths per 100,000 live births, consistent with countries of similar income around the world. Certain middle-income countries such as Morocco and Jordan have successfully implemented interventions that have drastically reduced maternal mortality by greater than 75% from 1990 levels. Low-income countries have seen the least improvement, or in some cases none at all. Reduction in maternal mortality in Pakistan, Somalia, Sudan, and Yemen ranged from 11 to 39%, and maternal mortality in Afghanistan and Djibouti increased from 1990 to 2015. Maternal mortality ratios for these countries ranged from 299 deaths per 100,000 live births in Sudan to 789 in Afghanistan. This discussion will examine the obstacles to effective maternal care, the direct and underlying causes of maternal mortality, and the challenges faced by countries in the region to improve maternal health. The process of improving maternal health in the region faces many challenges which have slowed progress in recent years. For many years, the EMR has been devastated by manmade disasters and conflicts, which have destroyed infrastructure in several nations and have tremendously affected the health of the population, especially for vul- nerable groups such as mothers and children. The human- itarian community has made several efforts to address these challenges, and these have reduced the potential impact of the unrest. However, the disruption of health care systems has had a negative impact. The social and health impacts of political instability, domestic crises, and economic sanc- tions are well-documented in the region (Mokdad et al. 2016). Recent distress in the region will result in deterio- rating health conditions in these countries for many years to come. Despite this, however, the region has experienced improved health and life expectancy. The region is in need of efforts to improve preventive strategies for reducing maternal mortality. A literature Table 1 continued Country Number of maternal deaths Maternal mortality ratio (per 100,000 livebirths) Annualized rate of change in maternal mortality ratio (%) 1990 2000 2015 1990 2000 2015 1990–2000 2000–15 1990–2015 Sudan 4131 4653 3941 485.5 414.4 298.8 -1.5 -2.3 (-5.5 to -2.0 (-4.3 to (2736–5570) (2790–6731) (2098–5999) (321.7–654.4) (248.7–598.0) (159.2–454.7) (-5.7–1.9) 1.0) 0.1) Syria 560 (421–719) 365 (276–480) 237 (181–309) 125.7 73.6 (55.6–96.7) 54.1 (41.3–70.5) -5.3 (-8.1 to -2.0 (-4.7 to -3.4 (-5.0 to (94.6–161.6) -2.6) 0.5) -1.8) Tunisia 183 (143–231) 99 (74–126) 82 (54–115) 85.6 59.2 (44.3–75.2) 40.6 (26.6–56.9) -3.7 (-6.6 to -2.6 (-5.5 to -3.0 (-4.9 to (66.9–108.0) -0.8) 0.2) -1.4) United Arab 15 (9–23) 12 (9–17) 18 (11–28) 31.8 (19.9–48.8) 24.0 (17.0–32.4) 18.0 (10.7–28.3) -2.6 (-7.3 to -2.0 (-6.1 to -2.3 (-5.3 to Emirates 2.0) 2.0) 0.4) Yemen 2559 2810 2631 402.6 399.6 307.4 -0.3 (-4.1 to -1.9 (-5.5 to -1.3 (-3.7 to (1342–3890) (1509–4648) (1402–5009) (211.8–611.4) (215.7–659.8) (164.5–583.8) 4.5) 2.1) 1.8) S52 GBD 2015 Eastern Mediterranean Region Maternal Mortality Collaborators Fig. 1 Top cause of maternal deaths in Eastern Mediterranean Region countries, 2015 (Global Burden of Disease 2015 study, Eastern Mediterranean Countries 2015) review (Warren et al. 2015) that evaluated the evidence on expensive. In addition, data on maternal deaths that occur the effectiveness of sexual and reproductive health inter- on the way to a health facility are scarce. The third and ventions delivered in humanitarian crises found some evi- final delays are in receiving adequate care at health facility, dence to support increased access and demand creation for which can be attributed to insufficient staff, drugs, and family planning services through community health equipment. It is necessary for interventions to effectively workers, health care subsidies, and discussions within lit- address the underlying causes of these delays on a country- eracy groups. Involving communities in maternal and child by-country basis (Thaddeus and Maine 1994). health and birth preparedness programs, as well as refur- This conceptual model is backed by an extensive body bishing clinics and hospital facilities, was also associated of research on the direct and underlying causes of maternal with increased positive health outcomes (Warren et al. mortality. Improving women’s literacy and knowledge can 2015). significantly contribute to their health. Alvarez et al. Female genital mutilation (FMG) is still practiced in reported a significant negative relationship between MMR many countries in the EMR due to a mix of sociocultural and gross domestic product (GDP) per capita, health factors within families and communities (UNICEF 2016). expenditure (HE), women’s literacy rate, and the number Experience of FGM increases the short- and long-term of deliveries by skilled birth attendants in the study region health risks to women and young girls between infancy and in Africa (Alvarez et al. 2009). Another study in sub-Sa- age 15, and is unacceptable from a human rights and health haran African countries, concluded that birth in the pres- perspective. Procedures can cause severe bleeding and ence of health professionals and the life expectancy at birth problems urinating, and later, cysts, infections, as well as are highly correlated to maternal mortality. Furthermore, a complications in childbirth and increased risk of newborn convincing relationship was found between GDP per capita deaths (WHO 2017). and health expenditure per capita and maternal mortality Thaddeus and Maine provide a conceptual model for (Buor and Bream 2004). Similarly, a study in Pakistan understanding factors that obstruct favorable obstetric reported that a significant relationship was observed outcomes that consists of three types of delays a pregnant between having access to health services, professional woman faces when seeking care—delays in deciding to health staff, and health care during pregnancy and reduc- seek care, in reaching an adequate facility, and in receiving tions in MMR (Midhet et al. 1998). The positive impacts of adequate care in a facility. The first delay manifests itself in GDP, HE, and female education level on health outcomes the way women and their families perceive the accessibility were also reported in other studies in the EMR (Bayati of services, often shaped by prior experiences with health et al. 2013; Homaie Rad et al. 2013). facilities. Any number of factors may influence a decision Success stories do exist in the region: for example, to delay treatment, such as cost, distance, lack of proper Morocco was one of only ten countries globally that met medical supplies, and unhelpful or impolite staff. The the MDG 5 requirement of an annual rate of decline second delay accounts for the time taken to reach a medical exceeding 5.5% for maternal mortality ratio every year facility. This is a particularly large obstacle for rural areas from 1990 to 2015 (Kassebaum et al. 2016b). This in which the availability of transportation is uncertain or improvement can be traced to a number of programs 123 Maternal mortality and morbidity burden in the Eastern Mediterranean Region: findings from… S53 Table 2 Mortality rates for causes of maternal mortality in the Eastern Mediterranean Region countries, ages 15–49, 2015 and percent change 1990–2015 (Global Burden of Disease 2015 study, Eastern Mediterranean countries, 1990–2015) Country Maternal hemorrhage Maternal hypertension Other maternal Complication of abortion Mortality rate per % change, Mortality rate per % change, Mortality rate per % change, Mortality rate per % change, 100,000, 2015 1990–2015 100,000, 2015 1990–2015 100,000, 2015 1990–2015 100,000, 2015 1990–2015 Eastern 7.61 (5.51–10.37) -52.27 4.49 (3.29–6.11) -40.39 3.27 (2.37–4.34) -48.51 2.59 (1.84–3.53) -50.05 Mediterranean Region Afghanistan 47.70 (27.17–77.35) -36.96 20.12 (11.20–32.87) -29.85 13.99 (7.81 to 23.27) -33.95 12.82 (7.07–21.40) -35.04 Bahrain 0.28 (0.19–0.42) -80.69 0.31 (0.21–0.47) -73.93 0.43 (0.30–0.65) -77.48 0.22 (0.15–0.33) -74.69 Djibouti 17.36 (6.43–49.10) -30.30 7.26 (2.58–20.67) -29.47 4.04 (1.39–11.26) -30.29 3.61 (1.12–9.89) -30.47 Egypt 1.90 (1.43–2.48) -81.48 0.76 (0.54–0.99) -71.80 0.32 (0.24–0.44) -55.19 0.59 (0.44–0.78) -73.29 Iran 0.29 (0.19–0.45) -88.16 0.17 (0.11–0.27) -81.40 0.13 (0.09–0.21) -88.48 0.14 (0.09–0.22) -88.12 Iraq 3.04 (1.71–5.24) -70.49 1.04 (0.56–1.85) -61.10 0.91 (0.47–1.63) -66.49 1.74 (0.96–2.85) -66.30 Jordan 0.38 (0.25–0.54) -89.46 0.34 (0.23–0.49) -83.99 0.99 (0.69–1.34) -82.45 0.18 (0.12–0.26) -86.30 Kuwait 0.07 (0.04–0.09) -52.16 0.04 (0.03–0.06) -31.67 0.10 (0.07–0.14) -48.26 0.09 (0.07–0.13) -44.51 Lebanon 0.1‘6 (0.09–0.27) -80.68 0.18 (0.10–0.29) -73.17 0.16 (0.09–0.26) -76.51 0.10 (0.06–0.17) -78.00 Libya 0.42 (0.26–0.64) -54.16 0.26 (0.16–0.41) -45.63 0.34 (0.21–0.53) -51.63 0.26 (0.15–0.43) -46.24 Morocco 1.17 (0.71–1.95) -89.64 1.19 (0.72–1.91) -85.15 1.06 (0.64–1.70) -86.86 0.57 (0.34–0.92) -88.82 Oman 0.18 (0.11–0.28) -83.85 0.34 (0.22–0.50) -77.27 0.35 (0.22–0.52) -80.07 0.25 (0.16–0.36) -82.47 Pakistan 9.63 (6.44–13.52) -52.83 8.81 (5.88–12.43) -35.15 5.54 (3.46–7.77) -44.39 4.08 (2.57–6.09) -47.04 Palestine 0.47 (0.30–0.72) -70.21 0.38 (0.24–0.58) -59.52 0.34 (0.22–0.53) -67.21 0.49 (0.32–0.73) -65.73 Qatar 0.23 (0.13–0.35) -83.54 0.35 (0.21–0.52) -76.08 0.38 (0.23–0.57) -79.73 0.16 (0.09–0.24) -80.55 Saudi Arabia 0.15 (0.11–0.20) -74.35 0.09 (0.06–0.12) -66.88 0.50 (0.40–0.63) -59.58 0.25 (0.18–0.33) -68.39 Somalia 72.34 (13.24–229.05) -17.78 15.14 (2.95–47.52) -17.10 10.88 (2.01–33.59) -18.94 11.63 (2.13–35.48) -17.53 Sudan 8.52 (4.32–13.68) -64.24 5.09 (2.55–8.46) -51.00 5.49 (2.83–9.17) -55.11 3.02 (1.51–4.90) -53.80 Syria 1.70 (1.18–2.34) -77.15 0.66 (0.43–0.97) -69.42 1.17 (0.82–1.62) -74.60 0.33 (0.22–0.48) -72.31 Tunisia 1.00 (0.60–1.46) -72.70 0.36 (0.22–0.55) -67.89 0.48 (0.30–0.72) -68.33 0.20 (0.11–0.32) -67.14 United Arab 0.18 (0.10–0.31) -79.78 0.24 (0.13–0.39) -73.34 0.27 (0.15–0.46) -78.40 0.18 (0.10–0.30) -76.09 Emirates Yemen 12.07 (6.03–24.02) -64.23 5.40 (2.66–10.39) -55.94 7.08 (3.51–14.63) -60.55 5.48 (2.70–10.85) -63.71 Country Maternal indirect Obstructed labor Maternal sepsis Maternal late Mortality rate per % change, Mortality rate per % change, Mortality rate per % change, Mortality rate per % change, 100,000, 2015 1990–2015 100,000, 2015 1990–2015 100,000, 2015 1990–2015 100,000, 2015 1990–2015 Eastern 2.05 (1.40–2.91) -48.67 1.93 (1.33–2.65) -38.25 1.86 (1.32–2.57) -54.00 0.63 (0.37–1.00) -46.51 Mediterranean Region Afghanistan 6.94 (3.71–11.87) -33.85 6.56 (3.57–10.95) -28.66 4.49 (2.42–7.52) -34.04 1.82 (0.90–3.29) -30.65 S54 GBD 2015 Eastern Mediterranean Region Maternal Mortality Collaborators Table 2 continued Country Maternal indirect Obstructed labor Maternal sepsis Maternal late Mortality rate per % change, Mortality rate per % change, Mortality rate per % change, Mortality rate per % change, 100,000, 2015 1990–2015 100,000, 2015 1990–2015 100,000, 2015 1990–2015 100,000, 2015 1990–2015 Bahrain 0.18 (0.12–0.27) -77.82 0.02 (0.01–0.03) -74.29 0.09 (0.06–0.13) -76.25 0.03 (0.01–0.04) -77.72 Djibouti 5.95 (2.00–16.88) -30.94 1.36 (0.38–4.09) -31.64 2.51 (0.80–7.26) -30.79 1.88 (0.55–5.39) -26.60 Egypt 0.13 (0.07–0.21) -83.00 0.16 (0.11–0.23) -61.01 0.55 (0.39–0.74) -83.76 0.06 (0.04–0.09) -77.93 Iran 0.24 (0.16–0.37) -81.40 0.05 (0.03–0.08) -85.86 0.11 (0.07–0.17) -85.22 0.02 (0.01–0.04) -85.56 Iraq 0.42 (0.21–0.76) -68.17 0.18 (0.09–0.33) -56.85 0.67 (0.36–1.20) -65.77 0.15 (0.07–0.28) -65.80 Jordan 0.19 (0.12–0.28) -87.75 0.11 (0.07–0.17) -84.20 0.20 (0.13–0.29) -86.93 0.04 (0.03–0.07) -86.91 Kuwait 0.04 (0.03–0.06) -43.63 0.01 (0.01–0.02) -36.29 0.04 (0.02–0.05) -39.62 0.01 (0.00–0.01) -43.71 Lebanon 0.08 (0.04–0.14) -76.84 0.03 (0.01–0.06) -74.99 0.07 (0.04–0.12) -76.85 0.02 (0.01–0.03) -76.89 Libya 0.15 (0.09–0.25) -55.50 0.06 (0.03–0.10) -42.48 0.16 (0.09–0.25) -51.42 0.04 (0.02–0.06) -49.31 Morocco 0.24 (0.13–0.41) -86.68 0.34 (0.19–0.59) -82.51 0.45 (0.27–0.74) -86.78 0.06 (0.03–0.10) -87.29 Oman 0.17 (0.11–0.26) -80.48 0.02 (0.01–0.03) -78.77 0.07 (0.04–0.10) -81.47 0.02 (0.01–0.04) -79.45 Pakistan 2.75 (1.69–4.11) -44.69 4.84 (3.21–6.91) -37.12 2.88 (1.77–4.28) -44.67 1.16 (0.62–1.90) -45.07 Palestine 0.18 (0.11–0.29) -67.34 0.04 (0.02–0.07) -62.46 0.12 (0.07–0.19) -67.65 0.07 (0.04–0.12) -64.98 Qatar 0.23 (0.14–0.36) -81.22 0.02 (0.01–0.03) -78.54 0.22 (0.14–0.35) -78.62 0.07 (0.04–0.11) -74.65 Saudi Arabia 0.07 (0.05–0.10) -73.74 0.02 (0.01–0.03) -70.76 0.14 (0.10–0.18) -70.85 0.02 (0.01–0.03) -69.15 Somalia 15.86 (2.85–50.91) -19.42 3.35 (0.53–11.26) -21.48 6.66 (1.16–21.53) -20.07 5.38 (0.95–17.98) -17.88 Sudan 7.44 (3.88–11.88) -57.43 1.09 (0.54–1.97) -47.24 6.91 (3.65–11.12) -52.96 1.09 (0.52–1.95) -58.23 Syria 0.33 (0.22–0.49) -75.16 0.28 (0.18–0.43) -72.32 0.53 (0.36–0.75) -72.64 0.13 (0.07–0.20) -73.98 Tunisia 0.17 (0.10–0.27) -77.38 0.12 (0.06–0.22) -60.52 0.21 (0.13–0.32) -72.55 0.07 (0.04–0.13) -75.21 United Arab Emirates 0.08 (0.04–0.14) -78.97 0.05 (0.02–0.09) -73.71 0.04 (0.02–0.07) -77.92 0.03 (0.01–0.05) -75.71 Yemen 3.77 (1.79–7.49) -60.35 1.15 (0.48–2.43) -55.61 3.28 (1.64–6.14) -61.43 0.90 (0.42–1.90) -58.58 Maternal mortality and morbidity burden in the Eastern Mediterranean Region: findings from… S55 Table 3 Socio-demographic Index (SDI); years of life lost (YLL), years lived with disability (YLD), and disability-adjusted life years (DALY) rates and percent change; and YLL/YLD ratio for maternal causes in the Eastern Mediterranean Region, women ages 15–49, 1990–2015 (Global Burden of Disease 2015 study, Eastern Mediterranean countries, 1990–2015) Country SDI YLL rate (per 100,000) YLD rate (per 100,000) YLL/YLD DALY rate (per 100,000) ratio 1990 2015 % 1990 2015 % 1990 2015 1990 2015 % change change change Eastern Mediterranean 0.55 600 (512–694) 354 (281–435) -41 39 (27–52) 22 -43 15.38 16.09 639 (549–735) 376 (303–457) -41 Region (15–30) Afghanistan 0.29 2036 1431 -30 26 (17–37) 16 -39 78.31 89.44 2062 1446 -30 (1253–3135) (842–2218) (10–23) (1274–3160) (856–2233) Bahrain 0.78 85 (63–116) 19 (14–27) -78 14 (9–21) 6 (4–10) -56 6.07 3.17 99 (77–132) 25 (19–33) -75 Djibouti 0.46 869 (357–1586) 681 (274–1901) -22 68 (45–98) 48 -30 12.78 14.19 937 (424–1659) 729 (319–1941) -22 (31–68) Egypt 0.62 274 (229–319) 65 (50–82) -76 15 (9–21) 11 (7–17) -26 18.27 5.91 289 (245–333) 76 (61–94) -74 Iran 0.72 104 (71–146) 19 (13–29) -81 15 (9–22) 7 (4–10) -56 6.93 2.71 119 (84–162) 26 (19–37) -78 Iraq 0.58 312 (226–417) 109 (63–178) -65 17 (10–24) 13 (8–20) -21 18.35 8.38 329 (241–436) 122 (75–190) -63 Jordan 0.7 196 (149–252) 35 (26–46) -82 20 (13–30) 14 (8–22) -31 9.80 2.50 216 (168–271) 49 (37–61) -77 Kuwait 0.86 10 (9–13) 6 (4–8) -43 6 (4–9) 5 (3–8) -9 1.67 1.20 16 (14–20) 11 (9–15) -30 Lebanon 0.75 51 (33–79) 13 (8–21) -74 10 (6–15) 5 (3–8) -47 5.10 2.60 61 (42–90) 18 (13–27) -70 Libya 0.64 41 (29–56) 24 (16–34) -42 12 (8–18) 8 (5–13) -34 3.42 3.00 54 (41–69) 32 (23–43) -40 Morocco 0.5 541 (418–714) 74 (47–117) -86 15 (9–22) 9 (5–14) -41 36.07 8.22 556 (432–730) 83 (54–127) -85 Oman 0.73 71 (42–113) 15 (11–21) -78 18 (11–26) 7 (4–12) -59 3.94 2.14 88 (58–131) 23 (17–30) -74 Pakistan 0.47 910 (696–1142) 581 (426–744) -36 74 (50–102) 41 -45 12.30 14.17 984 (777–1213) 622 (469–784) -37 (28–57) Palestine 0.57 76 (50–113) 29 (21–43) -62 19 (12–28) 12 (7–18) -38 4.00 2.42 95 (66–132) 41 (32–55) -57 Qatar 0.8 77 (51–110) 16 (11–23) -79 10 (6–15) 4 (3–7) -55 7.70 4.00 87 (60–120) 21 (14–27) -76 Saudi Arabia 0.76 42 (32–55) 16 (14–19) -61 16 (10–24) 8 (5–12) -49 2.63 2.00 58 (46–72) 25 (20–30) -58 Somalia 0.15 2144 (361–5693) 1741 -19 102 61 -40 21.02 28.54 2246 (464–5797) 1802 -20 (341–5215) (68–149) (42–87) (409–5273) Sudan 0.43 1159 (758–1561) 526 (284–785) -55 43 (28–64) 26 -41 26.95 20.23 1202 (803–1602) 552 (306–810) -54 (17–36) Syria 0.58 264 (199–341) 74 (56–97) -72 17 (11–26) 10 (6–16) -42 15.53 7.40 281 (216–357) 84 (65–106) -70 Tunisia 0.65 128 (100–163) 39 (26–55) -69 11 (7–17) 7 (4–11) -36 11.64 5.57 140 (110–175) 47 (33–63) -67 United Arab Emirates 0.88 44 (28–68) 10 (6–16) -77 11 (7–16) 3 (2–5) -72 4.00 3.33 55 (37–79) 13 (9–19) -76 Yemen 0.41 1235 (656–1865) 562 (304–1058) -55 104 42 -60 11.88 13.38 1339 (754–1982) 604 (347–1103) -55 (73–141) (29–59) S56 GBD 2015 Eastern Mediterranean Region Maternal Mortality Collaborators Fig. 2 Disability-adjusted life- year (DALY) rates per 100,000 women ages 15–49 for maternal causes by country, 2015 (Global Burden of Disease 2015 Study, Eastern Mediterranean Countries 2015) Fig. 3 Disability-adjusted life- year (DALY) rates per 100,000 women ages 10–54 for maternal causes in the Eastern Mediterranean Region by age, 2015 (Global Burden of Disease 2015 study, Eastern Mediterranean Region 2015) implemented to improve determinants of health and health care—that are all known to decrease the risk of negative coverage. Increases in the number of health facilities and pregnancy outcomes (Lim et al. 2010; Randive et al. 2014). training programs led to the percentage of deliveries Quality of care must also be considered during buildup of assisted by skilled personnel increasing from 31% in 1992 the maternal health care system. Programs for reproductive to 73.5% in 2011. Other successes in the region occurred in health care must ensure that women are receiving the care Jordan and Iran, where maternal mortality was reduced by they need during pregnancy and the post-partum period more than 50% from levels in 1990 (Kassebaum et al. (Rowe et al. 2005). Care should be integrated and not be 2016b). focused on single vertical interventions (Campbell et al. Uneven improvements in MMR in the region may be 2006). related to differing levels of ramp-up in coverage for It has been challenging for many countries to produce specific types of reproductive health care—antenatal care, timely and accurate data on levels of maternal mortality in-facility delivery, skilled birth attendance, family plan- that would indicate the extent of their progress in reducing ning services, emergency obstetric care, and post-natal maternal deaths (Mokdad et al. 2016). Reliable information 123 Maternal mortality and morbidity burden in the Eastern Mediterranean Region: findings from… S57 Australia. Foad Abd-Allah, MD, Department of Neurology, Cairo is a necessary component of any strategy aimed at reducing University, Cairo, Egypt. Haftom Niguse Abraha, MS, Mekelle maternal mortality. Continued progress in data collection University, Mekelle, Ethiopia. Laith J. Abu-Raddad, PhD, Infectious in the EMR is key to evaluating progress in reducing Disease Epidemiology Group, Weill Cornell Medical College in maternal mortality. Qatar, Doha, Qatar. Aliasghar Ahmad Kiadaliri, PhD, Department of Clinical Sciences Lund, Orthopedics, Clinical Epidemiology Unit, Our study has several limitations. First, many countries Lund University, Lund, Sweden. Alireza Ahmadi, PhD, Kermanshah in the region have poor health data and vital statistics. We University of Medical Sciences, Kermanshah, Iran. Kedir Yimam used GBD methodology to account for quality and lack of Ahmed, MPH, Debre Markos University, Debre Markos, Ethiopia. data. We also applied our standard GBD garbage code Muktar Beshir Ahmed, MPH, College of Health Sciences, Depart- ment of Epidemiology, ICT and e-Learning Coordinator, Jimma correction to address this limitation. Second, little infor- University, Jimma, Ethiopia. Faris Hasan Al Lami, PhD, Baghdad mation is available on unsafe abortion in the region due to College of Medicine, Baghdad, Iraq. Khurshid Alam, PhD, Murdoch religion and culture. However, our study is the most Childrens Research Institute, The University of Melbourne, Parkville, comprehensive on burden of diseases and applies the Victoria, Australia; The University of Melbourne, Melbourne, VIC, Australia; The University of Sydney, Sydney, NSW, Australia. Deena standard methodology that allows global comparison. Alasfoor, MSc, Ministry of Health, Al Khuwair, Oman. Reza Aliza- deh-Navaei, PhD, Gastrointestinal Cancer Research Center, Mazan- daran University of Medical Sciences, Sari, Iran. Juma M Alkaabi, MD, College of Medicine and Health Sciences United Arab Emirates Conclusion University, Al-Ain City, United Arab Emirates. Fatma Al-Maskari, PhD, College of Medicine & Health Sciences, United Arab Emirates; Progress in reducing maternal mortality in the EMR has University, Al-Ain City, United Arab Emirates. Rajaa Al-Raddadi, accelerated in the past 15 years, but there is still much to PhD, Joint Program of Family and Community Medicine, Jeddah, Saudi Arabia. Khalid A. Altirkawi, MD, King Saud University, do to reduce preventable deaths. Extending basic maternal Riyadh, Saudi Arabia. Nahla Anber, PhD, Mansoura University, health services, improving quality of care, and eliminating Mansoura, Egypt. Hossein Ansari, PhD, Health Promotion Research unmet need for contraception are all crucial, proven steps Center, Department of Epidemiology and Biostatistics, Zahedan University of Medical Sciences, Zahedan, Iran. Hamid Asayesh, PhD, effective at reducing MMR. Our study showed the impor- Department of Medical Emergency, School of Paramedic, Qom tance of empowering women: increased women’s rights are University of Medical Sciences, Qom, Iran. Rana Jawad Asghar, MD, needed to improve their health. Finally, coordinated and South Asian Public Health Forum, Islamabad, Pakistan. Tesfay rigorous efforts are needed to make sure that every woman Mehari Atey, MS, Mekelle University, Mekelle, Ethiopia. Tadesse in need receives these interventions in a timely fashion at Awoke Ayele, MS, University of Gondar, Gondar, Ethiopia. Till Ba ¨rnighausen, MD, Department of Global Health and Population, each stage of her reproductive life. Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA, United States; Africa Health Research Institute, Mtu- GBD 2015 Eastern Mediterranean Region Maternal Mortality batuba, KwaZulu-Natal, South Africa; Institute of Public Health, Collaborators: Ali H. Mokdad, PhD (corresponding author), Insti- Heidelberg University, Heidelberg, Germany. Umar Bacha, PhD, tute for Health Metrics and Evaluation, University of Washington, School of Health Sciences, University of Management and Technol- Seattle, Washington, United States. Ibrahim Khalil, MD, Institute for ogy, Lahore, Pakistan. Aleksandra Barac, PhD, Faculty of Medicine, Health Metrics and Evaluation, University of Washington. Michael University of Belgrade, Belgrade, Serbia. Suzanne L. Barker-Collo, Collison, BS, Institute for Health Metrics and Evaluation, University PhD, School of Psychology, University of Auckland, Auckland, New of Washington, Seattle, Washington, United States. Charbel El Zealand. Bernhard T. Baune, PhD, School of Medicine, University of Bcheraoui, PhD, Institute for Health Metrics and Evaluation, Adelaide, Adelaide, South Australia, Australia. Shahrzad Bazargan- University of Washington. Raghid Charara, MD, American Univer- Hejazi, PhD, College of Medicine, Charles R. Drew University of sity of Beirut, Beirut, Lebanon. Maziar Moradi-Lakeh, MD, Depart- Medicine and Science, Los Angeles, CA, United States; David Geffen ment of Community Medicine, Preventative Medicine and Public School of Medicine, University of California at Los Angeles, Los Health Research Center, Gastrointestinal and Liver Disease Research Angeles, CA, United States. Neeraj Bedi, MD, College of Public Center (GILDRC), University of Medical Sciences, Tehran, Iran. Health and Tropical Medicine, Jazan, Saudi Arabia. Isabela M Ben- Ashkan Afshin MD, Institute for Health Metrics and Evaluation, senor, PhD, University of Sa ˜o Paulo, Sa ˜o Paulo, Brazil. Adugnaw University of Washington, Seattle, Washington, United States. Berhane, PhD, College of Health Sciences, Debre Berhan University, Adrienne Chew, ND, Institute for Health Metrics and Evaluation, Debre Berhan, Ethiopia. Addisu Shunu Beyene, MPH, College of University of Washington. Farah Daoud, BA/BS, Institute for Health Health and Medical Science, Haramaya University, Harar, Ethiopia. Metrics and Evaluation, University of Washington. Kristopher J. Zulfiqar A. Bhutta, PhD, Centre of Excellence in Women and Child Krohn, BA, Institute for Health Metrics and Evaluation, University of Health, Aga Khan University, Karachi, Pakistan; Centre for Global Washington, Seattle, Washington, United States. Danny Colombara, Child Health, The Hospital for Sick Children, Toronto, ON, Canada. PhD, Institute for Health Metrics and Evaluation, University of Dube Jara Boneya, MPH, Department of Public Health, Debre Mar- Washington, Seattle, Washington, United States. Rebecca Ehrenk- kos University, Debre Markos, Ethiopia. Rohan Borschmann, PhD, ranz, MPH, Institute for Health Metrics and Evaluation, University of The University of Melbourne, Melbourne, VIC, Australia; Murdoch Washington, Seattle, Washington, United States. Michael Kutz, BS, Childrens Research Institute, Melbourne, VIC, Australia. Nicholas J. Institute for Health Metrics and Evaluation, University of Washing- K. Breitborde, PhD, The Ohio State University, Columbus, OH, ton, Seattle, Washington, United States. Haidong Wang, PhD, Insti- United States. Zahid A. Butt, PhD, Al Shifa Trust Eye Hospital, tute for Health Metrics and Evaluation, University of Washington, Rawalpindi, Punjab, Pakistan. Ferra ´n Catala ´-Lo ´ pez, PhD, Department Seattle, Washington, United States. Amanuel Alemu Abajobir, MPH, of Medicine, University of Valencia/INCLIVA Health Research School of Public Health, University of Queensland, Brisbane, QLD, Institute and CIBERSAM, Valencia, Spain; Clinical Epidemiology 123 S58 GBD 2015 Eastern Mediterranean Region Maternal Mortality Collaborators Program, Ottawa Hospital Research Institute, Ottawa, Canada. Liliana Ardeshir Khosravi, PhD, Iranian Ministry of Health and Medical G. Ciobanu, MS, School of Medicine, University of Adelaide, Ade- Education, Tehran, Iran, Non-communicable Diseases Research laide, South Australia, Australia. Hadi Danawi, PhD, Walden Center, Tehran University of Medical Sciences, Tehran, Iran. Jagdish University, Minneapolis, Minnesota, United States. Amare Deribew, Khubchandani, PhD, Department of Nutrition and Health Science, PhD, Nuffield Department of Medicine, University of Oxford, Ball State University, Muncie, Indiana, United States. Daniel Kim, Oxford, United Kingdom; KEMRI-Wellcome Trust Research Pro- DrPH, Department of Health Sciences, Northeastern University, gramme, Kilifi, Kenya. Samath D. Dharmaratne, MD, Department of Boston, Massachusetts, United States. Yun Jin Kim, PhD, Faculty of Community Medicine, Faculty of Medicine, University of Per- Chinese Medicine, Southern University College, Skudai, Malaysia. adeniya, Peradeniya, Sri Lanka. Kerrie E. Doyle, PhD, RMIT Yoshihiro Kokubo, PhD, Department of Preventive Cardiology, University, Bundoora, VIC, Australia; Australian National Univer- National Cerebral and Cardiovascular Center, Suita, Japan. Ai Koy- sity, Canberra, ACT, Australia. Aman Yesuf Endries, MPH, Arba anagi, MD, Research and Development Unit, Parc Sanitari Sant Joan Minch University, Arba Minch, Ethiopia. Emerito Jose Aquino Far- de Deu (CIBERSAM), Barcelona, Spain. Barthelemy Kuate Defo, aon, MD, College of Public Health, University of the Philippines PhD, Department of Social and Preventive Medicine, School of Manila, Manila, Philippines; Department of Health, Manila, Philip- Public Health, University of Montreal, Montreal, Quebec, Canada; pines. Andre ´ Faro, PhD, Federal University of Sergipe, Aracaju, Department of Demography and Public Health Research Institute, Brazil. Maryam S. Farvid, PhD, Department of Nutrition, Harvard University of Montreal, Montreal, Canada. Heidi J. Larson, PhD, T. H. Chan School of Public Health, Harvard University, Boston, Department of Infectious Disease Epidemiology, London School of MA, United States; Harvard/MGH Center on Genomics, Vulnerable Hygiene & Tropical Medicine, London, United Kingdom; Institute for Populations, and Health Disparities, Mongan Institute for Health Health Metrics and Evaluation, University of Washington, Seattle, Policy, Massachusetts General Hospital, Boston, MA, United States. Washington, United States. Asma Abdul Latif, PhD, Department of Wubalem Fekadu, MS, Bahir Dar University, Bahir Dar, Ethiopia. Zoology, Lahore College for Women University, Lahore, Punjab, Seyed-Mohammad Fereshtehnejad, PhD, Department of Neurobiol- Pakistan. Paul H Lee, PhD, Hong Kong Polytechnic University, Hong ogy, Care Sciences and Society (NVS), Karolinska Institutet, Stock- Kong, China. Cheru Tesema Leshargie, MPH, Debre Markos holm, Sweden. Florian Fischer, PhD, School of Public Health, University, Debre Markos, Ethiopia. Ricky Leung, PhD, State Bielefeld University, Bielefeld, Germany. Tsegaye Tewelde Gebre- University of New York, Albany, Rensselaer, NY, United States. hiwot, MPH, Jimma University, Jimma, Ethiopia. Ababi Zergaw Loon-Tzian Lo, MD, UnionHealth Associates, LLC, St. Louis, MO, Giref, PhD, Addis Ababa University, Addis Ababa, Ethiopia. Melk- United States; Alton Mental Health Center, Alton, IL, United States. amu Dedefo Gishu, MS, Haramaya University, Dire Dawa, Ethiopia; Raimundas Lunevicius, PhD, Aintree University Hospital National Kersa Health and Demographic Surveillance System, Harar, Ethiopia. Health Service Foundation Trust, Liverpool, United Kingdom; School Alessandra Carvalho Goulart, PhD, Center for Clinical and Epi- of Medicine, University of Liverpool, Liverpool, United Kingdom. demiological Research Center- Hospital Universitario-University of Hassan Magdy Abd El Razek, MBBCH, Mansoura Faculty of Med- Sa ˜o Paulo, Sa ˜o Paulo, Brazil; Center of Check of Hospital Sirio icine, Mansoura, Egypt. Mohammed Magdy Abd El Razek, MBBCH, Libanes, Sa ˜o Paulo, Brazil. Tesfa Dejenie Habtewold, MS, University Aswan University Hospital, Aswan Faculty of Medicine, Aswan, of Groningen, Groningen, Netherlands; Debre Berhan University, Egypt. Reza Majdzadeh, PhD, Knowledge Utilization Research Debre Berhan, Ethiopia. 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Maternal mortality and morbidity burden in the Eastern Mediterranean Region: findings from the Global Burden of Disease 2015 study

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Abstract

Int J Public Health (2018) 63 (Suppl 1):S47–S61 https://doi.org/10.1007/s00038-017-1004-3 O R I G IN AL ARTI CL E Maternal mortality and morbidity burden in the Eastern Mediterranean Region: findings from the Global Burden of Disease 2015 study GBD 2015 Eastern Mediterranean Region Maternal Mortality Collaborators Received: 1 May 2017 / Revised: 15 June 2017 / Accepted: 21 June 2017 / Published online: 3 August 2017 The Author(s) 2017. This article is an open access publication Abstract to make sure that adequate and timely services and inter- Objectives Assessing the burden of maternal mortality is ventions are available for women at each stage of repro- important for tracking progress and identifying public ductive life. health gaps. This paper provides an overview of the burden of maternal mortality in the Eastern Mediterranean Region Keywords Maternal mortality  Maternal health  Eastern (EMR) by underlying cause and age from 1990 to 2015. Mediterranean Region  Burden of disease Methods We used the results of the Global Burden of Disease 2015 study to explore maternal mortality in the EMR countries. Introduction Results The maternal mortality ratio in the EMR decreased 16.3% from 283 (241–328) maternal deaths per 100,000 live Maternal mortality ratio (MMR), which measures deaths births in 1990 to 237 (188–293) in 2015. Maternal mortality per 100,000 live births, is a standard measure for global, ratio was strongly correlated with socio-demographic status, regional, and national comparison (Abouzahir and Ward- where the lowest-income countries contributed the most to law 2001). It is also one of the main criteria of health the burden of maternal mortality in the region. outcomes and an indicator of the socioeconomic develop- Conclusion Progress in reducing maternal mortality in the ment level of countries that is recognized worldwide EMR has accelerated in the past 15 years, but the burden (Liang et al. 2010). Country estimates of maternal mor- remains high. Coordinated and rigorous efforts are needed tality over time are crucial to inform the planning of maternal, sexual, and reproductive health programs and to guide advocacy efforts and research at the national level. This article is part of the supplement ‘‘The state of health in the These estimates are also needed at the international level to Eastern Mediterranean Region, 1990–2015’’. inform decision-making concerning resource allocation by development partners and donors (WHO et al. 2007). The members of GBD (Global Burden of Disease) 2015 Eastern Mediterranean Region Maternal Mortality Collaborators are listed at In 2015, 275,288 women are estimated to have died as a the end of the article. Ali H. Mokdad, on behalf of GBD 2015 Eastern result of pregnancy or childbirth globally (Kassebaum et al. Mediterranean Region Maternal Mortality Collaborators, is the 2016b). Maternal death is defined by ICD-10 as the death corresponding author. of a woman while pregnant or within 42 days and up to 1 Electronic supplementary material The online version of this year (late maternal death); of termination of pregnancy, article (doi:10.1007/s00038-017-1004-3) contains supplementary irrespective of the duration and site of the pregnancy, from material, which is available to authorized users. any cause related to or aggravated by the pregnancy or its & GBD 2015 Eastern Mediterranean Region Maternal management, but not from accidental or incidental causes Mortality Collaborators (World Health Organization 1992). mokdaa@uw.edu The primary causes of maternal deaths are hemorrhage, hypertension, infections, pre-existing medical conditions, Institute for Health Metrics and Evaluation, University of and lack of literacy, family planning (unmet need and birth Washington, Seattle, WA, USA 123 S48 GBD 2015 Eastern Mediterranean Region Maternal Mortality Collaborators spacing), and access to pregnancy termination when nee- infrastructures but face resource constraints; and low-in- ded. Identifying and improving the main factors related to come countries that lack the resources and infrastructure for maternal mortality depend on a correct definition of the effective health interventions. Many countries in the region required priorities for appropriate prevention, diagnosis, are suffering from political instability, conflicts, and other and treatment (Ribeiro et al. 2008). complex development challenges. This range from low to Poverty, illiteracy, malnutrition, and the low social sta- high incomes can be seen as a microcosm of the variability in tus of women are usually among the major underlying maternal mortality present globally. This paper seeks to causes of maternal mortality. Analyzing the economic, examine in detail the burden of maternal mortality within the social, and health system factors affecting maternal mor- EMR using the results of the GBD 2015 study. tality can provide some credible information and evidence for public health interventions to improve maternal health. A few general studies on nonclinical determinants of Methods maternal mortality have analyzed different factors includ- ing access to safe drinking water, access to food, fertility A detailed methodology of maternal mortality estimation rate, education level, life expectancy at birth, access to for GBD 2015 has been published elsewhere (Kassebaum health services, delivery done by skilled birth attendants, et al. 2016b). In short, sources with population-level data out-of-pocket payment, GDP per capita, health expendi- were processed using standardized algorithms to adjust for tures, and government corruption (Hertz et al. 1994; Mid- age-specific, year-specific, and geography-specific patterns het et al. 1998; Buor and Bream 2004; Alvarez et al. 2009; of incompleteness. Additional steps were taken to account Muldoon et al. 2011). for underestimations of maternal mortality in vital regis- From 1990 to 2015, the global MMR decreased 30.6% tration systems. ICD-10 vital registration codes pertaining from 280.4 (95% uncertainty interval (UI): 262.6–299.0) to to HIV-related maternal deaths were excluded and quan- 194.7 (172.6–233.2) (Institute for Health Metrics and Eval- tified separately (Kassebaum et al. 2014). Overall maternal uation 2017). This decrease was driven in part by the mortality was modeled using cause-of-death ensemble recognition of maternal health as one of the priorities in the modeling (CODEm), where all combinations of covariates UN Millennium Development Goals (MDGs), which pro- were tested and ranked on the basis of out-of-sample pre- vided a strong incentive to reduce MMR by country (Rons- dictive validity performance. All data sources are available mans and Graham 2006). New goals outlined in the on our website, and we provide a visualization to show sustainable development goals (SDGs) for 2015 to 2030 each source used in our analyses (Institute for Health build on the momentum of the MDGs and seek to bring the Metrics and Evaluation 2016). global MMR below 70 deaths per 100,000 live births (United We calculated years of life lost (YLLs) by multiplying Nations 2015). The greatest challenge in meeting this goal deaths by the residual expected individual lifespan at the lies with countries in the bottom two quintiles of wealth, age of death as derived from the GBD 2015 standard model where improvement is most needed and has historically life table. Years lived with disability (YLDs) were calcu- occurred slowly if at all (Abouzahir and Wardlaw 2001). lated by multiplying the number of prevalent cases of a The variation in MMR between countries by income certain health outcome by the disability weight assigned to group is drastic, where the burden of maternal mortality this health outcome. A disability weight reflects the mag- falls almost exclusively upon developing countries (Rons- nitude of the health loss associated with an outcome and mans and Graham 2006). Globally, the average MMR for has a value that is anchored between 0, equivalent to full countries in the top quintile of wealth for 2015 was 14.5 health, and 1, equivalent to death. YLLs were calculated by (13.7–15.4) compared to 440.2 (357.4–543.5) in the bottom multiplying deaths by the remaining life expectancy at the quintile (Institute for Health Metrics and Evaluation 2017). age of death from a standard life table chosen as the norm Despite this variation, inequalities in maternal mortality for estimating premature mortality in GBD. Disability-ad- exist between and within countries, where mortality in all justed life years (DALYs) were calculated by adding YLLs locations is exacerbated by a lack of access to quality and YLDs. Detailed methods on YLLs, YLDs, and DALYs obstetric care, whether because of the remoteness of certain are published elsewhere (Kassebaum et al. 2016a; Vos regions or the inability of health facilities to provide proper et al. 2016; Wang et al. 2016). care (Peterson et al. 2012). We evaluated the associations between maternal mortality The Eastern Mediterranean Region (EMR) is a diverse and socio-demographic status using the socio-demographic region consisting of 22 countries, including high-income index (SDI). SDI is a composite measure developed for GBD countries, where socioeconomic development has pro- 2015 that accounts for fertility rate, lag-dependent income per gressed considerably over the last decades; middle-income capita, and education. To capture the average relationships for countries that have well-developed health service delivery each age group, we applied a simple least squares spline 123 Maternal mortality and morbidity burden in the Eastern Mediterranean Region: findings from… S49 regression of the maternal mortality rate on SDI. The SDI is highest YLL rate in 2015 was in Somalia with 7774 scaled from 0 to 1, where 0 represents the lowest possible (1497–23,408) YLLs per 100,000 women aged 15–49, observed SDI and 1 is the highest. We reported uncertainty for compared to Kuwait at 21 (16–27) (Table 3). Somalia all our estimates (Kassebaum et al. 2016a). also had the smallest percent change from 1990 to 2015, a decrease of 18% (Table 3). Results YLDs Mortality Average YLD rates in the region fell from 161 (114–215) per 100,000 women aged 15–49 to 82 (57–113), a 49% decrease The total number of deaths due to maternal disorders (Table 3). Globally, there was a 41% decrease (Institute for increased 4.5% from 38,595 (32,859–44,785) deaths in Health Metrics and Evaluation 2017). Inter-country vari- 1990 to 40,338 (31,965–49,954) in 2015 in the EMR, ability in the YLD rate was less than that of YLLs, with the compared to a 29.5% decrease globally (Institute for Health highest seen in Somalia with 254 (171–362) YLDs per Metrics and Evaluation 2017). In 1990, the maternal 100,000 women aged 15–49 and the lowest in the United mortality ratio was similar in the EMR and globally at 283 Arab Emirates with 16 (10–26) (Table 3). (241–328) maternal deaths per 100,000 live births in the EMR and 280 (263–299) globally (Institute for Health YLL/YLD Metrics and Evaluation 2017). By 1995, a gap between the regional and global trends had opened, and this persisted The YLL/YLD ratio was included as an indicator of health steadily through 2015. By then, the EMR had a maternal system effectiveness in dealing with fatal and non-fatal out- mortality ratio of 237 (188–293) compared to 194 comes of maternal disorders. Large values, such as that of (173–223) globally (Institute for Health Metrics and Afghanistan, a ratio of 89.6 in 2015, demonstrated cases, where Evaluation 2017). By country, only Afghanistan and Dji- fatal outcomes heavily outweigh non-fatal ones (Table 3). bouti had an annual increase in maternal mortality ratio Kuwait in 2015 had a ratio of 1.11, signifying a near equal between 1990 and 2015 (Table 1). Palestine also had an burden of fatal and non-fatal outcomes for maternal disorders increase in maternal mortality ratio between 2000 and (Table 3). Lower income countries with SDI less than 0.5 all 2015, but still had a lower ratio in 2015 compared to 1990 had ratios greater than 10, whereas higher income countries (Table 1). with SDI greater than 0.7 had ratios under 4 (Table 3). In the Both globally and regionally, maternal hemorrhage was countries with SDI less than 0.5, all but Sudan had an increase in the leading cause of maternal mortality in 1990 and 2015 YLL/YLD ratio from 1990 to 2015 (Table 3). Large decreases (Institute for Health Metrics and Evaluation 2017). By in the ratio from 1990 to 2015 highlighted effective improve- country within the EMR, hemorrhage was also the most ments in treatment, such as in Morocco, where the ratio common, followed by other maternal disorders, noticeably decreased from 35.2 to 8.5 (Table 3). within the Gulf states (Fig. 1). In all countries, all causes of maternal mortality decreased from 1990 to 2015 (Table 2). DALYs In 2015, maternal hemorrhage in Somalia was the largest contributor to maternal mortality by country and causes at From 1990 to 2015, DALY rates decreased in all countries 72.3 (13.2–229.0) deaths per 100,000 among women aged in the region. The overall DALY rate for the region 15–49 (Table 2). The GBD study expanded the analysis to decreased by 49% during this interval, compared to 51% the full reproductive age range of 10–54 years (Kassebaum globally (Institute for Health Metrics and Evaluation 2017). et al. 2016b). In general, the countries with the highest As discussed in the YLL/YLD section above, the propor- mortality rates by cause also showed the least improvement tional contribution of YLDs to the DALYs rate increased from 1990 to 2015 (Table 2). as SDI increased (Table 3). Like YLL rates, DALY rates showed large inter-country variation, as shown in Fig. 2. YLLs DALY rates peaked in the 20–25-year age group, decreasing until ages 35–40, then steeply falling off in YLL rates fell 49% in the EMR between 1990 and 5-year increments (Fig. 3). By sub-cause, complication of 2015, the same as the global mean, from 2,683 abortions contributed the most to the DALY rate in young (2284–3103) per 100,000 women aged 15–49 to 1377 (10–15) and old (45?) age groups (e-Fig. 1). Percent of (1091–1695) (Table 3). In that time frame, the YLL DALYs attributable to obstructed labor increased steadily rate decreasedinall countries (Table 3). There was with age, spiking drastically for the 50–55-year age group significant inter-country variation in YLL rates. The (e-Fig. 1). 123 S50 GBD 2015 Eastern Mediterranean Region Maternal Mortality Collaborators Table 1 Maternal deaths, maternal mortality ratio, and annualized change in maternal mortality ratio in the Eastern Mediterranean Region, 1990–2015 (Global Burden of Disease 2015 study, Eastern Mediterranean countries, 1990–2015) Country Number of maternal deaths Maternal mortality ratio (per 100,000 livebirths) Annualized rate of change in maternal mortality ratio (%) 1990 2000 2015 1990 2000 2015 1990–2000 2000–15 1990–2015 Afghanistan 4590 7328 8525 732.3 753.3 788.9 0.4 (-4.8–5.0) 0.3 (-3.6–3.8) 0.3 (-2.1–2.7) (2825–7111) (4529–11,007) (5010–13,221) (451.0–1130.9) (466.5–1130.7) (464.1–1219.2) Bahrain 8 (6–11) 5 (4–7) 5 (4–7) 53.6 (39.9–73.5) 35.6 (27.3–47.3) 24.6 (18.3–35.4) -4.0 (-7.9 to -2.5 (-5.1 to -3.1 (-4.9 to -0.6) 0.4) -1.3) Djibouti 86 (35–159) 118 (43–283) 107 (43–299) 378.3 523.8 486.2 2.8 (-9.8 to -0.5 (-9.4 to 0.6 (-4.1 to (154.4–698.7) (192.3–1247.0) (193.8–1353.5) 15.3) 9.9) 6.6) Egypt 2744 1186 (976–1414) 1052 (809–1340) 146.7 69.2 (57.0–82.5) 42.3 (32.5–53.9) -7.5 (-9.7 to -3.3 (-5.3 to -5.0 (-6.1 to (2308–3176) (123.4–169.7) -5.5) -1.2) -3.7) Iran 1039 (704–1432) 426 (337–539) 281 (192–421) 56.6 (38.5–78.0) 34.5 (27.3–43.7) 20.8 (14.2–31.1) -5.0 (-8.6 to -3.5 (-6.4 to -4.1 -0.6) -0.2) (-6.0 to -1.9) Iraq 969 (702–1300) 950 (655–1311) 729 (428–1199) 146.0 113.4 58.6 (34.4–96.1) -2.5 (-6.7 to -4.5 (-8.2 to -3.7 (-6.0 to (105.9–195.9) (78.3–156.4) 1.4) -1.0) -1.3) Jordan 116 (89–149) 121 (88–159) 48 (36–63) 97.9 81.2 24.2 (17.9–31.5) -1.9 (-5.1 to -8.0 (-10.7 to -5.6 (-7.2 to (74.6–125.4) (58.7–106.2) 1.1) -5.4) -4.1) Kuwait 4 (3–5) 5 (4–6) 4 (3–6) 9.7 (8.1–11.8) 11.9 (10.4–13.5) 5.9 (4.4–7.5) 2.1 (0.0–4.1) -4.8 (-6.8 to -2.0 (-3.4 to -2.8) -0.7) Lebanon 24 (15–38) 17 (11–24) 13 (8–21) 35.6 (22.8–55.1) 26.7 (18.0–39.0) 15.3 (9.0–24.0) -2.9 (-7.6 to -3.9 (-7.6 to -3.3 (-6.2 to 1.6) 0.3) -0.7) Libya 34 (24–45) 28 (20–37) 30 (20–43) 26.6 (19.1–36.0) 23.9 (17.2–31.5) 22.8 (15.6–32.9) -1.0 (-4.8 to -0.3 -0.6 2.3) (-3.5 to 2.8) (-2.6 to 1.3) Morocco 2441 1197 (894–1560) 479 (299–756) 332.7 192.0 68.5 -5.4 (-8.8 to -7.0 (-10.1 to -6.4 (-8.6 to (1891–3201) (258.7–436.1) (143.4–249.6) (42.8–108.1) -2.4) -3.4) -4.3) Pakistan 16,973 22,038 19,005 391.5 498.9 348.6 2.4 (-0.3 to -2.4 (-4.7 to -0.5 (-1.9 to (13,060–21,189) (17,789–26,598) (14,012–24,369) (301.3–488.4) (404.1–601.7) (257.2–447.0) 5.5) -0.3) 0.9) Palestine 29 (19–43) 17 (14–21) 25 (17–35) 29.3 (19.0–43.7) 14.2 (11.3–17.8) 16.2 (11.5–23.2) -7.1 (-11.2 to 0.8 (-1.9 to -2.4 (-4.7 to -3.1) 3.9) 0.2) Oman 24 (14–38) 12 (8–18) 13 (9–18) 34.1 (20.0–54.8) 21.4 (14.8–31.7) 15.5 (11.0–21.6) -4.5 (-8.7 to -2.2 (-5.5 to -3.1 (-5.6 to -0.3) 1.2) -0.7) Qatar 7 (4–10) 7 (5–10) 7 (4–9) 64.0 (42.0–91.5) 59.9 (41.4–84.2) 25.5 (16.4–35.7) -0.6 (-4.6 to -5.7 (-9.5 to -3.7 (-6.0 to 3.6) -2.4) -1.6) Saudi Arabia 124 (93–162) 101 (86–119) 97 (82–115) 21.3 (16.0–27.9) 17.9 (15.2–21.0) 15.7 (13.3–18.5) -1.6 (-4.0 to -0.9 (-2.4 to -1.2 (-2.5 to 0.6) 0.6) 0.1) Somalia 2509 (418–6 772) 2899 (489–7449) 3443 (661–10 830.5 811.0 731.1 -0.3 (-11.8 to -0.8 (-8.6 to -0.6 (-6.7 to 512) (138.5–2193.9) (137.5–2077.9) (140.5–2218.6) 10.4) 8.8) 6.5) Maternal mortality and morbidity burden in the Eastern Mediterranean Region: findings from… S51 Discussion Our study showed that maternal mortality has declined in the EMR except in Djibouti, Palestine, and Afghanistan in recent years. However, the burden is still higher than the global average. Our findings call for increased efforts to reduce maternal mortality in the region. Moreover, with unrest in the region, there is a risk of losing some of the observed gains. Efforts to reduce maternal mortality in the EMR have varied in scope, approach, and success by country. This has resulted in great variations and disparities in maternal mortality levels between countries. The high-income countries in the region (Kuwait, Oman, Qatar, Saudi Ara- bia, and United Arab Emirates) have achieved reductions between 25 and 50% compared to levels in 1990. Maternal mortality ratios in these countries ranged from 6 to 26 deaths per 100,000 live births, consistent with countries of similar income around the world. Certain middle-income countries such as Morocco and Jordan have successfully implemented interventions that have drastically reduced maternal mortality by greater than 75% from 1990 levels. Low-income countries have seen the least improvement, or in some cases none at all. Reduction in maternal mortality in Pakistan, Somalia, Sudan, and Yemen ranged from 11 to 39%, and maternal mortality in Afghanistan and Djibouti increased from 1990 to 2015. Maternal mortality ratios for these countries ranged from 299 deaths per 100,000 live births in Sudan to 789 in Afghanistan. This discussion will examine the obstacles to effective maternal care, the direct and underlying causes of maternal mortality, and the challenges faced by countries in the region to improve maternal health. The process of improving maternal health in the region faces many challenges which have slowed progress in recent years. For many years, the EMR has been devastated by manmade disasters and conflicts, which have destroyed infrastructure in several nations and have tremendously affected the health of the population, especially for vul- nerable groups such as mothers and children. The human- itarian community has made several efforts to address these challenges, and these have reduced the potential impact of the unrest. However, the disruption of health care systems has had a negative impact. The social and health impacts of political instability, domestic crises, and economic sanc- tions are well-documented in the region (Mokdad et al. 2016). Recent distress in the region will result in deterio- rating health conditions in these countries for many years to come. Despite this, however, the region has experienced improved health and life expectancy. The region is in need of efforts to improve preventive strategies for reducing maternal mortality. A literature Table 1 continued Country Number of maternal deaths Maternal mortality ratio (per 100,000 livebirths) Annualized rate of change in maternal mortality ratio (%) 1990 2000 2015 1990 2000 2015 1990–2000 2000–15 1990–2015 Sudan 4131 4653 3941 485.5 414.4 298.8 -1.5 -2.3 (-5.5 to -2.0 (-4.3 to (2736–5570) (2790–6731) (2098–5999) (321.7–654.4) (248.7–598.0) (159.2–454.7) (-5.7–1.9) 1.0) 0.1) Syria 560 (421–719) 365 (276–480) 237 (181–309) 125.7 73.6 (55.6–96.7) 54.1 (41.3–70.5) -5.3 (-8.1 to -2.0 (-4.7 to -3.4 (-5.0 to (94.6–161.6) -2.6) 0.5) -1.8) Tunisia 183 (143–231) 99 (74–126) 82 (54–115) 85.6 59.2 (44.3–75.2) 40.6 (26.6–56.9) -3.7 (-6.6 to -2.6 (-5.5 to -3.0 (-4.9 to (66.9–108.0) -0.8) 0.2) -1.4) United Arab 15 (9–23) 12 (9–17) 18 (11–28) 31.8 (19.9–48.8) 24.0 (17.0–32.4) 18.0 (10.7–28.3) -2.6 (-7.3 to -2.0 (-6.1 to -2.3 (-5.3 to Emirates 2.0) 2.0) 0.4) Yemen 2559 2810 2631 402.6 399.6 307.4 -0.3 (-4.1 to -1.9 (-5.5 to -1.3 (-3.7 to (1342–3890) (1509–4648) (1402–5009) (211.8–611.4) (215.7–659.8) (164.5–583.8) 4.5) 2.1) 1.8) S52 GBD 2015 Eastern Mediterranean Region Maternal Mortality Collaborators Fig. 1 Top cause of maternal deaths in Eastern Mediterranean Region countries, 2015 (Global Burden of Disease 2015 study, Eastern Mediterranean Countries 2015) review (Warren et al. 2015) that evaluated the evidence on expensive. In addition, data on maternal deaths that occur the effectiveness of sexual and reproductive health inter- on the way to a health facility are scarce. The third and ventions delivered in humanitarian crises found some evi- final delays are in receiving adequate care at health facility, dence to support increased access and demand creation for which can be attributed to insufficient staff, drugs, and family planning services through community health equipment. It is necessary for interventions to effectively workers, health care subsidies, and discussions within lit- address the underlying causes of these delays on a country- eracy groups. Involving communities in maternal and child by-country basis (Thaddeus and Maine 1994). health and birth preparedness programs, as well as refur- This conceptual model is backed by an extensive body bishing clinics and hospital facilities, was also associated of research on the direct and underlying causes of maternal with increased positive health outcomes (Warren et al. mortality. Improving women’s literacy and knowledge can 2015). significantly contribute to their health. Alvarez et al. Female genital mutilation (FMG) is still practiced in reported a significant negative relationship between MMR many countries in the EMR due to a mix of sociocultural and gross domestic product (GDP) per capita, health factors within families and communities (UNICEF 2016). expenditure (HE), women’s literacy rate, and the number Experience of FGM increases the short- and long-term of deliveries by skilled birth attendants in the study region health risks to women and young girls between infancy and in Africa (Alvarez et al. 2009). Another study in sub-Sa- age 15, and is unacceptable from a human rights and health haran African countries, concluded that birth in the pres- perspective. Procedures can cause severe bleeding and ence of health professionals and the life expectancy at birth problems urinating, and later, cysts, infections, as well as are highly correlated to maternal mortality. Furthermore, a complications in childbirth and increased risk of newborn convincing relationship was found between GDP per capita deaths (WHO 2017). and health expenditure per capita and maternal mortality Thaddeus and Maine provide a conceptual model for (Buor and Bream 2004). Similarly, a study in Pakistan understanding factors that obstruct favorable obstetric reported that a significant relationship was observed outcomes that consists of three types of delays a pregnant between having access to health services, professional woman faces when seeking care—delays in deciding to health staff, and health care during pregnancy and reduc- seek care, in reaching an adequate facility, and in receiving tions in MMR (Midhet et al. 1998). The positive impacts of adequate care in a facility. The first delay manifests itself in GDP, HE, and female education level on health outcomes the way women and their families perceive the accessibility were also reported in other studies in the EMR (Bayati of services, often shaped by prior experiences with health et al. 2013; Homaie Rad et al. 2013). facilities. Any number of factors may influence a decision Success stories do exist in the region: for example, to delay treatment, such as cost, distance, lack of proper Morocco was one of only ten countries globally that met medical supplies, and unhelpful or impolite staff. The the MDG 5 requirement of an annual rate of decline second delay accounts for the time taken to reach a medical exceeding 5.5% for maternal mortality ratio every year facility. This is a particularly large obstacle for rural areas from 1990 to 2015 (Kassebaum et al. 2016b). This in which the availability of transportation is uncertain or improvement can be traced to a number of programs 123 Maternal mortality and morbidity burden in the Eastern Mediterranean Region: findings from… S53 Table 2 Mortality rates for causes of maternal mortality in the Eastern Mediterranean Region countries, ages 15–49, 2015 and percent change 1990–2015 (Global Burden of Disease 2015 study, Eastern Mediterranean countries, 1990–2015) Country Maternal hemorrhage Maternal hypertension Other maternal Complication of abortion Mortality rate per % change, Mortality rate per % change, Mortality rate per % change, Mortality rate per % change, 100,000, 2015 1990–2015 100,000, 2015 1990–2015 100,000, 2015 1990–2015 100,000, 2015 1990–2015 Eastern 7.61 (5.51–10.37) -52.27 4.49 (3.29–6.11) -40.39 3.27 (2.37–4.34) -48.51 2.59 (1.84–3.53) -50.05 Mediterranean Region Afghanistan 47.70 (27.17–77.35) -36.96 20.12 (11.20–32.87) -29.85 13.99 (7.81 to 23.27) -33.95 12.82 (7.07–21.40) -35.04 Bahrain 0.28 (0.19–0.42) -80.69 0.31 (0.21–0.47) -73.93 0.43 (0.30–0.65) -77.48 0.22 (0.15–0.33) -74.69 Djibouti 17.36 (6.43–49.10) -30.30 7.26 (2.58–20.67) -29.47 4.04 (1.39–11.26) -30.29 3.61 (1.12–9.89) -30.47 Egypt 1.90 (1.43–2.48) -81.48 0.76 (0.54–0.99) -71.80 0.32 (0.24–0.44) -55.19 0.59 (0.44–0.78) -73.29 Iran 0.29 (0.19–0.45) -88.16 0.17 (0.11–0.27) -81.40 0.13 (0.09–0.21) -88.48 0.14 (0.09–0.22) -88.12 Iraq 3.04 (1.71–5.24) -70.49 1.04 (0.56–1.85) -61.10 0.91 (0.47–1.63) -66.49 1.74 (0.96–2.85) -66.30 Jordan 0.38 (0.25–0.54) -89.46 0.34 (0.23–0.49) -83.99 0.99 (0.69–1.34) -82.45 0.18 (0.12–0.26) -86.30 Kuwait 0.07 (0.04–0.09) -52.16 0.04 (0.03–0.06) -31.67 0.10 (0.07–0.14) -48.26 0.09 (0.07–0.13) -44.51 Lebanon 0.1‘6 (0.09–0.27) -80.68 0.18 (0.10–0.29) -73.17 0.16 (0.09–0.26) -76.51 0.10 (0.06–0.17) -78.00 Libya 0.42 (0.26–0.64) -54.16 0.26 (0.16–0.41) -45.63 0.34 (0.21–0.53) -51.63 0.26 (0.15–0.43) -46.24 Morocco 1.17 (0.71–1.95) -89.64 1.19 (0.72–1.91) -85.15 1.06 (0.64–1.70) -86.86 0.57 (0.34–0.92) -88.82 Oman 0.18 (0.11–0.28) -83.85 0.34 (0.22–0.50) -77.27 0.35 (0.22–0.52) -80.07 0.25 (0.16–0.36) -82.47 Pakistan 9.63 (6.44–13.52) -52.83 8.81 (5.88–12.43) -35.15 5.54 (3.46–7.77) -44.39 4.08 (2.57–6.09) -47.04 Palestine 0.47 (0.30–0.72) -70.21 0.38 (0.24–0.58) -59.52 0.34 (0.22–0.53) -67.21 0.49 (0.32–0.73) -65.73 Qatar 0.23 (0.13–0.35) -83.54 0.35 (0.21–0.52) -76.08 0.38 (0.23–0.57) -79.73 0.16 (0.09–0.24) -80.55 Saudi Arabia 0.15 (0.11–0.20) -74.35 0.09 (0.06–0.12) -66.88 0.50 (0.40–0.63) -59.58 0.25 (0.18–0.33) -68.39 Somalia 72.34 (13.24–229.05) -17.78 15.14 (2.95–47.52) -17.10 10.88 (2.01–33.59) -18.94 11.63 (2.13–35.48) -17.53 Sudan 8.52 (4.32–13.68) -64.24 5.09 (2.55–8.46) -51.00 5.49 (2.83–9.17) -55.11 3.02 (1.51–4.90) -53.80 Syria 1.70 (1.18–2.34) -77.15 0.66 (0.43–0.97) -69.42 1.17 (0.82–1.62) -74.60 0.33 (0.22–0.48) -72.31 Tunisia 1.00 (0.60–1.46) -72.70 0.36 (0.22–0.55) -67.89 0.48 (0.30–0.72) -68.33 0.20 (0.11–0.32) -67.14 United Arab 0.18 (0.10–0.31) -79.78 0.24 (0.13–0.39) -73.34 0.27 (0.15–0.46) -78.40 0.18 (0.10–0.30) -76.09 Emirates Yemen 12.07 (6.03–24.02) -64.23 5.40 (2.66–10.39) -55.94 7.08 (3.51–14.63) -60.55 5.48 (2.70–10.85) -63.71 Country Maternal indirect Obstructed labor Maternal sepsis Maternal late Mortality rate per % change, Mortality rate per % change, Mortality rate per % change, Mortality rate per % change, 100,000, 2015 1990–2015 100,000, 2015 1990–2015 100,000, 2015 1990–2015 100,000, 2015 1990–2015 Eastern 2.05 (1.40–2.91) -48.67 1.93 (1.33–2.65) -38.25 1.86 (1.32–2.57) -54.00 0.63 (0.37–1.00) -46.51 Mediterranean Region Afghanistan 6.94 (3.71–11.87) -33.85 6.56 (3.57–10.95) -28.66 4.49 (2.42–7.52) -34.04 1.82 (0.90–3.29) -30.65 S54 GBD 2015 Eastern Mediterranean Region Maternal Mortality Collaborators Table 2 continued Country Maternal indirect Obstructed labor Maternal sepsis Maternal late Mortality rate per % change, Mortality rate per % change, Mortality rate per % change, Mortality rate per % change, 100,000, 2015 1990–2015 100,000, 2015 1990–2015 100,000, 2015 1990–2015 100,000, 2015 1990–2015 Bahrain 0.18 (0.12–0.27) -77.82 0.02 (0.01–0.03) -74.29 0.09 (0.06–0.13) -76.25 0.03 (0.01–0.04) -77.72 Djibouti 5.95 (2.00–16.88) -30.94 1.36 (0.38–4.09) -31.64 2.51 (0.80–7.26) -30.79 1.88 (0.55–5.39) -26.60 Egypt 0.13 (0.07–0.21) -83.00 0.16 (0.11–0.23) -61.01 0.55 (0.39–0.74) -83.76 0.06 (0.04–0.09) -77.93 Iran 0.24 (0.16–0.37) -81.40 0.05 (0.03–0.08) -85.86 0.11 (0.07–0.17) -85.22 0.02 (0.01–0.04) -85.56 Iraq 0.42 (0.21–0.76) -68.17 0.18 (0.09–0.33) -56.85 0.67 (0.36–1.20) -65.77 0.15 (0.07–0.28) -65.80 Jordan 0.19 (0.12–0.28) -87.75 0.11 (0.07–0.17) -84.20 0.20 (0.13–0.29) -86.93 0.04 (0.03–0.07) -86.91 Kuwait 0.04 (0.03–0.06) -43.63 0.01 (0.01–0.02) -36.29 0.04 (0.02–0.05) -39.62 0.01 (0.00–0.01) -43.71 Lebanon 0.08 (0.04–0.14) -76.84 0.03 (0.01–0.06) -74.99 0.07 (0.04–0.12) -76.85 0.02 (0.01–0.03) -76.89 Libya 0.15 (0.09–0.25) -55.50 0.06 (0.03–0.10) -42.48 0.16 (0.09–0.25) -51.42 0.04 (0.02–0.06) -49.31 Morocco 0.24 (0.13–0.41) -86.68 0.34 (0.19–0.59) -82.51 0.45 (0.27–0.74) -86.78 0.06 (0.03–0.10) -87.29 Oman 0.17 (0.11–0.26) -80.48 0.02 (0.01–0.03) -78.77 0.07 (0.04–0.10) -81.47 0.02 (0.01–0.04) -79.45 Pakistan 2.75 (1.69–4.11) -44.69 4.84 (3.21–6.91) -37.12 2.88 (1.77–4.28) -44.67 1.16 (0.62–1.90) -45.07 Palestine 0.18 (0.11–0.29) -67.34 0.04 (0.02–0.07) -62.46 0.12 (0.07–0.19) -67.65 0.07 (0.04–0.12) -64.98 Qatar 0.23 (0.14–0.36) -81.22 0.02 (0.01–0.03) -78.54 0.22 (0.14–0.35) -78.62 0.07 (0.04–0.11) -74.65 Saudi Arabia 0.07 (0.05–0.10) -73.74 0.02 (0.01–0.03) -70.76 0.14 (0.10–0.18) -70.85 0.02 (0.01–0.03) -69.15 Somalia 15.86 (2.85–50.91) -19.42 3.35 (0.53–11.26) -21.48 6.66 (1.16–21.53) -20.07 5.38 (0.95–17.98) -17.88 Sudan 7.44 (3.88–11.88) -57.43 1.09 (0.54–1.97) -47.24 6.91 (3.65–11.12) -52.96 1.09 (0.52–1.95) -58.23 Syria 0.33 (0.22–0.49) -75.16 0.28 (0.18–0.43) -72.32 0.53 (0.36–0.75) -72.64 0.13 (0.07–0.20) -73.98 Tunisia 0.17 (0.10–0.27) -77.38 0.12 (0.06–0.22) -60.52 0.21 (0.13–0.32) -72.55 0.07 (0.04–0.13) -75.21 United Arab Emirates 0.08 (0.04–0.14) -78.97 0.05 (0.02–0.09) -73.71 0.04 (0.02–0.07) -77.92 0.03 (0.01–0.05) -75.71 Yemen 3.77 (1.79–7.49) -60.35 1.15 (0.48–2.43) -55.61 3.28 (1.64–6.14) -61.43 0.90 (0.42–1.90) -58.58 Maternal mortality and morbidity burden in the Eastern Mediterranean Region: findings from… S55 Table 3 Socio-demographic Index (SDI); years of life lost (YLL), years lived with disability (YLD), and disability-adjusted life years (DALY) rates and percent change; and YLL/YLD ratio for maternal causes in the Eastern Mediterranean Region, women ages 15–49, 1990–2015 (Global Burden of Disease 2015 study, Eastern Mediterranean countries, 1990–2015) Country SDI YLL rate (per 100,000) YLD rate (per 100,000) YLL/YLD DALY rate (per 100,000) ratio 1990 2015 % 1990 2015 % 1990 2015 1990 2015 % change change change Eastern Mediterranean 0.55 600 (512–694) 354 (281–435) -41 39 (27–52) 22 -43 15.38 16.09 639 (549–735) 376 (303–457) -41 Region (15–30) Afghanistan 0.29 2036 1431 -30 26 (17–37) 16 -39 78.31 89.44 2062 1446 -30 (1253–3135) (842–2218) (10–23) (1274–3160) (856–2233) Bahrain 0.78 85 (63–116) 19 (14–27) -78 14 (9–21) 6 (4–10) -56 6.07 3.17 99 (77–132) 25 (19–33) -75 Djibouti 0.46 869 (357–1586) 681 (274–1901) -22 68 (45–98) 48 -30 12.78 14.19 937 (424–1659) 729 (319–1941) -22 (31–68) Egypt 0.62 274 (229–319) 65 (50–82) -76 15 (9–21) 11 (7–17) -26 18.27 5.91 289 (245–333) 76 (61–94) -74 Iran 0.72 104 (71–146) 19 (13–29) -81 15 (9–22) 7 (4–10) -56 6.93 2.71 119 (84–162) 26 (19–37) -78 Iraq 0.58 312 (226–417) 109 (63–178) -65 17 (10–24) 13 (8–20) -21 18.35 8.38 329 (241–436) 122 (75–190) -63 Jordan 0.7 196 (149–252) 35 (26–46) -82 20 (13–30) 14 (8–22) -31 9.80 2.50 216 (168–271) 49 (37–61) -77 Kuwait 0.86 10 (9–13) 6 (4–8) -43 6 (4–9) 5 (3–8) -9 1.67 1.20 16 (14–20) 11 (9–15) -30 Lebanon 0.75 51 (33–79) 13 (8–21) -74 10 (6–15) 5 (3–8) -47 5.10 2.60 61 (42–90) 18 (13–27) -70 Libya 0.64 41 (29–56) 24 (16–34) -42 12 (8–18) 8 (5–13) -34 3.42 3.00 54 (41–69) 32 (23–43) -40 Morocco 0.5 541 (418–714) 74 (47–117) -86 15 (9–22) 9 (5–14) -41 36.07 8.22 556 (432–730) 83 (54–127) -85 Oman 0.73 71 (42–113) 15 (11–21) -78 18 (11–26) 7 (4–12) -59 3.94 2.14 88 (58–131) 23 (17–30) -74 Pakistan 0.47 910 (696–1142) 581 (426–744) -36 74 (50–102) 41 -45 12.30 14.17 984 (777–1213) 622 (469–784) -37 (28–57) Palestine 0.57 76 (50–113) 29 (21–43) -62 19 (12–28) 12 (7–18) -38 4.00 2.42 95 (66–132) 41 (32–55) -57 Qatar 0.8 77 (51–110) 16 (11–23) -79 10 (6–15) 4 (3–7) -55 7.70 4.00 87 (60–120) 21 (14–27) -76 Saudi Arabia 0.76 42 (32–55) 16 (14–19) -61 16 (10–24) 8 (5–12) -49 2.63 2.00 58 (46–72) 25 (20–30) -58 Somalia 0.15 2144 (361–5693) 1741 -19 102 61 -40 21.02 28.54 2246 (464–5797) 1802 -20 (341–5215) (68–149) (42–87) (409–5273) Sudan 0.43 1159 (758–1561) 526 (284–785) -55 43 (28–64) 26 -41 26.95 20.23 1202 (803–1602) 552 (306–810) -54 (17–36) Syria 0.58 264 (199–341) 74 (56–97) -72 17 (11–26) 10 (6–16) -42 15.53 7.40 281 (216–357) 84 (65–106) -70 Tunisia 0.65 128 (100–163) 39 (26–55) -69 11 (7–17) 7 (4–11) -36 11.64 5.57 140 (110–175) 47 (33–63) -67 United Arab Emirates 0.88 44 (28–68) 10 (6–16) -77 11 (7–16) 3 (2–5) -72 4.00 3.33 55 (37–79) 13 (9–19) -76 Yemen 0.41 1235 (656–1865) 562 (304–1058) -55 104 42 -60 11.88 13.38 1339 (754–1982) 604 (347–1103) -55 (73–141) (29–59) S56 GBD 2015 Eastern Mediterranean Region Maternal Mortality Collaborators Fig. 2 Disability-adjusted life- year (DALY) rates per 100,000 women ages 15–49 for maternal causes by country, 2015 (Global Burden of Disease 2015 Study, Eastern Mediterranean Countries 2015) Fig. 3 Disability-adjusted life- year (DALY) rates per 100,000 women ages 10–54 for maternal causes in the Eastern Mediterranean Region by age, 2015 (Global Burden of Disease 2015 study, Eastern Mediterranean Region 2015) implemented to improve determinants of health and health care—that are all known to decrease the risk of negative coverage. Increases in the number of health facilities and pregnancy outcomes (Lim et al. 2010; Randive et al. 2014). training programs led to the percentage of deliveries Quality of care must also be considered during buildup of assisted by skilled personnel increasing from 31% in 1992 the maternal health care system. Programs for reproductive to 73.5% in 2011. Other successes in the region occurred in health care must ensure that women are receiving the care Jordan and Iran, where maternal mortality was reduced by they need during pregnancy and the post-partum period more than 50% from levels in 1990 (Kassebaum et al. (Rowe et al. 2005). Care should be integrated and not be 2016b). focused on single vertical interventions (Campbell et al. Uneven improvements in MMR in the region may be 2006). related to differing levels of ramp-up in coverage for It has been challenging for many countries to produce specific types of reproductive health care—antenatal care, timely and accurate data on levels of maternal mortality in-facility delivery, skilled birth attendance, family plan- that would indicate the extent of their progress in reducing ning services, emergency obstetric care, and post-natal maternal deaths (Mokdad et al. 2016). Reliable information 123 Maternal mortality and morbidity burden in the Eastern Mediterranean Region: findings from… S57 Australia. Foad Abd-Allah, MD, Department of Neurology, Cairo is a necessary component of any strategy aimed at reducing University, Cairo, Egypt. Haftom Niguse Abraha, MS, Mekelle maternal mortality. Continued progress in data collection University, Mekelle, Ethiopia. Laith J. Abu-Raddad, PhD, Infectious in the EMR is key to evaluating progress in reducing Disease Epidemiology Group, Weill Cornell Medical College in maternal mortality. Qatar, Doha, Qatar. Aliasghar Ahmad Kiadaliri, PhD, Department of Clinical Sciences Lund, Orthopedics, Clinical Epidemiology Unit, Our study has several limitations. First, many countries Lund University, Lund, Sweden. Alireza Ahmadi, PhD, Kermanshah in the region have poor health data and vital statistics. We University of Medical Sciences, Kermanshah, Iran. Kedir Yimam used GBD methodology to account for quality and lack of Ahmed, MPH, Debre Markos University, Debre Markos, Ethiopia. data. We also applied our standard GBD garbage code Muktar Beshir Ahmed, MPH, College of Health Sciences, Depart- ment of Epidemiology, ICT and e-Learning Coordinator, Jimma correction to address this limitation. Second, little infor- University, Jimma, Ethiopia. Faris Hasan Al Lami, PhD, Baghdad mation is available on unsafe abortion in the region due to College of Medicine, Baghdad, Iraq. Khurshid Alam, PhD, Murdoch religion and culture. However, our study is the most Childrens Research Institute, The University of Melbourne, Parkville, comprehensive on burden of diseases and applies the Victoria, Australia; The University of Melbourne, Melbourne, VIC, Australia; The University of Sydney, Sydney, NSW, Australia. Deena standard methodology that allows global comparison. Alasfoor, MSc, Ministry of Health, Al Khuwair, Oman. Reza Aliza- deh-Navaei, PhD, Gastrointestinal Cancer Research Center, Mazan- daran University of Medical Sciences, Sari, Iran. Juma M Alkaabi, MD, College of Medicine and Health Sciences United Arab Emirates Conclusion University, Al-Ain City, United Arab Emirates. Fatma Al-Maskari, PhD, College of Medicine & Health Sciences, United Arab Emirates; Progress in reducing maternal mortality in the EMR has University, Al-Ain City, United Arab Emirates. Rajaa Al-Raddadi, accelerated in the past 15 years, but there is still much to PhD, Joint Program of Family and Community Medicine, Jeddah, Saudi Arabia. Khalid A. Altirkawi, MD, King Saud University, do to reduce preventable deaths. Extending basic maternal Riyadh, Saudi Arabia. Nahla Anber, PhD, Mansoura University, health services, improving quality of care, and eliminating Mansoura, Egypt. Hossein Ansari, PhD, Health Promotion Research unmet need for contraception are all crucial, proven steps Center, Department of Epidemiology and Biostatistics, Zahedan University of Medical Sciences, Zahedan, Iran. Hamid Asayesh, PhD, effective at reducing MMR. Our study showed the impor- Department of Medical Emergency, School of Paramedic, Qom tance of empowering women: increased women’s rights are University of Medical Sciences, Qom, Iran. Rana Jawad Asghar, MD, needed to improve their health. Finally, coordinated and South Asian Public Health Forum, Islamabad, Pakistan. Tesfay rigorous efforts are needed to make sure that every woman Mehari Atey, MS, Mekelle University, Mekelle, Ethiopia. Tadesse in need receives these interventions in a timely fashion at Awoke Ayele, MS, University of Gondar, Gondar, Ethiopia. Till Ba ¨rnighausen, MD, Department of Global Health and Population, each stage of her reproductive life. Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA, United States; Africa Health Research Institute, Mtu- GBD 2015 Eastern Mediterranean Region Maternal Mortality batuba, KwaZulu-Natal, South Africa; Institute of Public Health, Collaborators: Ali H. Mokdad, PhD (corresponding author), Insti- Heidelberg University, Heidelberg, Germany. Umar Bacha, PhD, tute for Health Metrics and Evaluation, University of Washington, School of Health Sciences, University of Management and Technol- Seattle, Washington, United States. Ibrahim Khalil, MD, Institute for ogy, Lahore, Pakistan. Aleksandra Barac, PhD, Faculty of Medicine, Health Metrics and Evaluation, University of Washington. Michael University of Belgrade, Belgrade, Serbia. Suzanne L. Barker-Collo, Collison, BS, Institute for Health Metrics and Evaluation, University PhD, School of Psychology, University of Auckland, Auckland, New of Washington, Seattle, Washington, United States. Charbel El Zealand. Bernhard T. Baune, PhD, School of Medicine, University of Bcheraoui, PhD, Institute for Health Metrics and Evaluation, Adelaide, Adelaide, South Australia, Australia. Shahrzad Bazargan- University of Washington. Raghid Charara, MD, American Univer- Hejazi, PhD, College of Medicine, Charles R. Drew University of sity of Beirut, Beirut, Lebanon. Maziar Moradi-Lakeh, MD, Depart- Medicine and Science, Los Angeles, CA, United States; David Geffen ment of Community Medicine, Preventative Medicine and Public School of Medicine, University of California at Los Angeles, Los Health Research Center, Gastrointestinal and Liver Disease Research Angeles, CA, United States. Neeraj Bedi, MD, College of Public Center (GILDRC), University of Medical Sciences, Tehran, Iran. Health and Tropical Medicine, Jazan, Saudi Arabia. Isabela M Ben- Ashkan Afshin MD, Institute for Health Metrics and Evaluation, senor, PhD, University of Sa ˜o Paulo, Sa ˜o Paulo, Brazil. Adugnaw University of Washington, Seattle, Washington, United States. Berhane, PhD, College of Health Sciences, Debre Berhan University, Adrienne Chew, ND, Institute for Health Metrics and Evaluation, Debre Berhan, Ethiopia. Addisu Shunu Beyene, MPH, College of University of Washington. Farah Daoud, BA/BS, Institute for Health Health and Medical Science, Haramaya University, Harar, Ethiopia. Metrics and Evaluation, University of Washington. Kristopher J. Zulfiqar A. Bhutta, PhD, Centre of Excellence in Women and Child Krohn, BA, Institute for Health Metrics and Evaluation, University of Health, Aga Khan University, Karachi, Pakistan; Centre for Global Washington, Seattle, Washington, United States. Danny Colombara, Child Health, The Hospital for Sick Children, Toronto, ON, Canada. PhD, Institute for Health Metrics and Evaluation, University of Dube Jara Boneya, MPH, Department of Public Health, Debre Mar- Washington, Seattle, Washington, United States. Rebecca Ehrenk- kos University, Debre Markos, Ethiopia. Rohan Borschmann, PhD, ranz, MPH, Institute for Health Metrics and Evaluation, University of The University of Melbourne, Melbourne, VIC, Australia; Murdoch Washington, Seattle, Washington, United States. Michael Kutz, BS, Childrens Research Institute, Melbourne, VIC, Australia. Nicholas J. Institute for Health Metrics and Evaluation, University of Washing- K. Breitborde, PhD, The Ohio State University, Columbus, OH, ton, Seattle, Washington, United States. Haidong Wang, PhD, Insti- United States. Zahid A. Butt, PhD, Al Shifa Trust Eye Hospital, tute for Health Metrics and Evaluation, University of Washington, Rawalpindi, Punjab, Pakistan. Ferra ´n Catala ´-Lo ´ pez, PhD, Department Seattle, Washington, United States. Amanuel Alemu Abajobir, MPH, of Medicine, University of Valencia/INCLIVA Health Research School of Public Health, University of Queensland, Brisbane, QLD, Institute and CIBERSAM, Valencia, Spain; Clinical Epidemiology 123 S58 GBD 2015 Eastern Mediterranean Region Maternal Mortality Collaborators Program, Ottawa Hospital Research Institute, Ottawa, Canada. Liliana Ardeshir Khosravi, PhD, Iranian Ministry of Health and Medical G. Ciobanu, MS, School of Medicine, University of Adelaide, Ade- Education, Tehran, Iran, Non-communicable Diseases Research laide, South Australia, Australia. Hadi Danawi, PhD, Walden Center, Tehran University of Medical Sciences, Tehran, Iran. Jagdish University, Minneapolis, Minnesota, United States. Amare Deribew, Khubchandani, PhD, Department of Nutrition and Health Science, PhD, Nuffield Department of Medicine, University of Oxford, Ball State University, Muncie, Indiana, United States. Daniel Kim, Oxford, United Kingdom; KEMRI-Wellcome Trust Research Pro- DrPH, Department of Health Sciences, Northeastern University, gramme, Kilifi, Kenya. Samath D. Dharmaratne, MD, Department of Boston, Massachusetts, United States. Yun Jin Kim, PhD, Faculty of Community Medicine, Faculty of Medicine, University of Per- Chinese Medicine, Southern University College, Skudai, Malaysia. adeniya, Peradeniya, Sri Lanka. Kerrie E. Doyle, PhD, RMIT Yoshihiro Kokubo, PhD, Department of Preventive Cardiology, University, Bundoora, VIC, Australia; Australian National Univer- National Cerebral and Cardiovascular Center, Suita, Japan. Ai Koy- sity, Canberra, ACT, Australia. Aman Yesuf Endries, MPH, Arba anagi, MD, Research and Development Unit, Parc Sanitari Sant Joan Minch University, Arba Minch, Ethiopia. Emerito Jose Aquino Far- de Deu (CIBERSAM), Barcelona, Spain. Barthelemy Kuate Defo, aon, MD, College of Public Health, University of the Philippines PhD, Department of Social and Preventive Medicine, School of Manila, Manila, Philippines; Department of Health, Manila, Philip- Public Health, University of Montreal, Montreal, Quebec, Canada; pines. Andre ´ Faro, PhD, Federal University of Sergipe, Aracaju, Department of Demography and Public Health Research Institute, Brazil. Maryam S. Farvid, PhD, Department of Nutrition, Harvard University of Montreal, Montreal, Canada. Heidi J. Larson, PhD, T. H. Chan School of Public Health, Harvard University, Boston, Department of Infectious Disease Epidemiology, London School of MA, United States; Harvard/MGH Center on Genomics, Vulnerable Hygiene & Tropical Medicine, London, United Kingdom; Institute for Populations, and Health Disparities, Mongan Institute for Health Health Metrics and Evaluation, University of Washington, Seattle, Policy, Massachusetts General Hospital, Boston, MA, United States. Washington, United States. Asma Abdul Latif, PhD, Department of Wubalem Fekadu, MS, Bahir Dar University, Bahir Dar, Ethiopia. Zoology, Lahore College for Women University, Lahore, Punjab, Seyed-Mohammad Fereshtehnejad, PhD, Department of Neurobiol- Pakistan. Paul H Lee, PhD, Hong Kong Polytechnic University, Hong ogy, Care Sciences and Society (NVS), Karolinska Institutet, Stock- Kong, China. Cheru Tesema Leshargie, MPH, Debre Markos holm, Sweden. Florian Fischer, PhD, School of Public Health, University, Debre Markos, Ethiopia. Ricky Leung, PhD, State Bielefeld University, Bielefeld, Germany. Tsegaye Tewelde Gebre- University of New York, Albany, Rensselaer, NY, United States. hiwot, MPH, Jimma University, Jimma, Ethiopia. Ababi Zergaw Loon-Tzian Lo, MD, UnionHealth Associates, LLC, St. Louis, MO, Giref, PhD, Addis Ababa University, Addis Ababa, Ethiopia. Melk- United States; Alton Mental Health Center, Alton, IL, United States. amu Dedefo Gishu, MS, Haramaya University, Dire Dawa, Ethiopia; Raimundas Lunevicius, PhD, Aintree University Hospital National Kersa Health and Demographic Surveillance System, Harar, Ethiopia. Health Service Foundation Trust, Liverpool, United Kingdom; School Alessandra Carvalho Goulart, PhD, Center for Clinical and Epi- of Medicine, University of Liverpool, Liverpool, United Kingdom. demiological Research Center- Hospital Universitario-University of Hassan Magdy Abd El Razek, MBBCH, Mansoura Faculty of Med- Sa ˜o Paulo, Sa ˜o Paulo, Brazil; Center of Check of Hospital Sirio icine, Mansoura, Egypt. Mohammed Magdy Abd El Razek, MBBCH, Libanes, Sa ˜o Paulo, Brazil. Tesfa Dejenie Habtewold, MS, University Aswan University Hospital, Aswan Faculty of Medicine, Aswan, of Groningen, Groningen, Netherlands; Debre Berhan University, Egypt. Reza Majdzadeh, PhD, Knowledge Utilization Research Debre Berhan, Ethiopia. Randah Ribhi Hamadeh, DPhil, Arabian Center and Community Based Participatory Research Center, Tehran Gulf University, Manama, Bahrain. Mitiku Teshome Hambisa, MPH, University of Medical Sciences, Tehran, Iran. Azeem Majeed, MD, College of Health and Medical Sciences, Haramaya University, Department of Primary Care & Public Health, Imperial College Harar, Ethiopia. Samer Hamidi, DrPH, Hamdan Bin Mohammed London, London, United Kingdom. Reza Malekzadeh, MD, Digestive Smart University, Dubai, United Arab Emirates. Josep Maria Haro, Diseases Research Institute, Tehran University of Medical Sciences, MD, Parc Sanitari Sant Joan de De ´u - CIBERSAM, Sant Boi de Tehran, Iran; Digestive Diseases Research Institute, Tehran Univer- Llobregat (Barcelona), Spain. Mohammad Sadegh Hassanvand, PhD, sity of Medical Sciences, Tehran, Iran. Jose Martinez-Raga, PhD, Center for Air Pollution Research, Institute for Environmental Hospital Universitario Doctor Peset, Valencia, Spain; CEU Cardinal Research, Tehran University of Medical Sciences, Tehran, Iran. Herrera University, Moncada, Spain. Habibolah Masoudi Farid, MD, Nobuyuki Horita, MD, Department of Pulmonology, Yokohama City State Welfare Organisation, Tehran, Iran. Mohsen Mazidi, PhD, Key University Graduate School of Medicine, Yokohama, Kanagawa, State Laboratory of Molecular Developmental Biology, Institute of Japan. Mohamed Hsairi, MD, Department of Epidemiology, Salah Genetics and Developmental Biology, Chinese Academy of Sciences, Azaiz Institute, Tunis, Tunisia. Hsiang Huang, MD, Cambridge Beijing, China. John J. McGrath, PhD, Queensland Centre for Mental Health Alliance, Cambridge, MA, United States. Abdullatif Husseini, Health Research, The Park Centre for Mental Health, Wacol, PhD, Institute of Community and Public Health, Birzeit University, Queensland, Australia; Queensland Brain Institute, University of Birzeit, Palestine. Mihajlo B. Jakovljevic, PhD, Faculty of Medical Queensland, St. Lucia, QLD, Australia, National Centre for Register- Sciences, University of Kragujevac, Kragujevac, Central Serbia - Based Research, Aarhus School of Business and Social Sciences, Sumadija, Serbia; The Center for Health Trends and Forecasts, Aarhus University, Aarhus, Denmark. Ziad A. Memish, MD, Saudi Institute for Health Metrics and Evaluation, University of Washing- Ministry of Health, Riyadh, Saudi Arabia; College of Medicine, ton, Seattle, Washington, United States. Spencer Lewis James, MD, Alfaisal University, Riyadh, Saudi Arabia. Walter Mendoza, MD, Denver Health/University of Colorado, Denver, CO, United States. United Nations Population Fund, Lima, Peru. Melkamu Merid Jost B. Jonas, MD, Department of Ophthalmology, Medical Faculty Mengesha, MPH, College of Health and Medical Sciences, Haramaya Mannheim, Ruprecht-Karls-University Heidelberg, Mannheim, Ger- University, Harar, Ethiopia. Mubarek Abera Mengistie, MS, Jimma many. Amir Kasaeian, PhD, Hematology-Oncology and Stem Cell University, Jimma, Ethiopia. George A. Mensah, MD, Center for Transplantation Research Center, Tehran University of Medical Sci- Translation Research and Implementation Science, National Heart, ences, Tehran, Iran; Endocrinology and Metabolism Population Sci- Lung, and Blood Institute, National Institutes of Health, Bethesda, ences Institute, Tehran University of Medical Sciences, Tehran, Iran. MD, United States. Haftay Berhane Mezgebe, MS, Mekelle Univer- Yousef Saleh Khader, ScD, Department of Community Medicine, sity, Mekelle, Ethiopia. Ted R. Miller, PhD, Pacific Institute for Public Health and Family Medicine, Jordan University of Science and Research & Evaluation, Calverton, MD, United States, Centre for Technology, Irbid, Jordan. Ejaz Ahmad Khan, MD, Health Services Population Health, Curtin University, Perth, WA, Australia. Philip B. Academy, Islamabad, Pakistan. Abdullah Tawfih Abdullah Khoja, Mitchell, MD, University of New South Wales, Kensington, New MD, Mohammed Ibn Saudi University, Riyadh, Saudi Arabia. South Wales, Australia. Alireza Mohammadi, PhD, Neuroscience 123 Maternal mortality and morbidity burden in the Eastern Mediterranean Region: findings from… S59 Research Center, Baqiyatallah University of Medical Science, Teh- Shamsizadeh, MPH, Department of Medical Surgical Nursing, School ran, Iran. Shafiu Mohammed, PhD, Health Systems and Policy of Nursing and Midwifery, Hamadan University of Medical Sciences, Research Unit, Ahmadu Bello University, Zaria, Nigeria; Institute of Hamadan, Iran. Diego Augusto Santos Silva, PhD, Federal University Public Health, Heidelberg University, Heidelberg, Germany. Carla of Santa Catarina, Florianopolis, Brazil. Jasvinder A. Singh, MD, Makhlouf Obermeyer, DSc, Center for Research on Population and University of Alabama at Birmingham and Birmingham Veterans Health, Faculty of Health Sciences, American University of Beirut, Affairs Medical Center, Birmingham, Alabama, United States. Badr Beirut, Lebanon. Felix Akpojene Ogbo, MPH, Centre for Health H. A. Sobaih, MD, King Saud University, Riyadh, Saudi Arabia. Research, Western Sydney University, Sydney, New South Wales, Chandrashekhar T. Sreeramareddy, MD, Department of Community Australia. Elizabeth Palomares Castillo, PhD, Ministry of Health, Medicine, International Medical University, Kuala Lumpur, Malay- Mexico City, Mexico City, Mexico; Universidad Nacional Auto ´ noma sia. Dan J. 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International Journal of Public HealthSpringer Journals

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