Abstract
BACKGROUND: Maternal hemorrhage remains the leading cause of maternal mortality worldwide, hindering progress toward Sustainable Development Goal (SDG) 3.1, which aims to reduce the global maternal mortality ratio (MMR) to less than 70 deaths per 100,000 livebirths by 2030. Comprehensive estimates of its global burden and inequalities are limited. METHODS: Based on data from the Global Burden of Disease Study 2021, we assessed maternal hemorrhage burden across 204 countries from 1990 to 2021. Indicators included incidence, maternal mortality ratio (MMR), and disability-adjusted life years (DALYs). Temporal trends were analyzed using estimated/average annual percentage changes (EAPC/AAPC), and health inequality was quantified using the Slope Index of Inequality (SII) and Concentration Index (CI). The relationship between burden and Socio-demographic Index (SDI) was examined via LOESS and frontier analysis. Projections to 2030 were conducted using a Bayesian age-period-cohort model. RESULTS: From 1990 to 2021, the global age-standardized incidence rate decreased by 27.7% (from 495.93 to 358.57 per 100,000 population), and MMR declined by 58.2% (from 86.63 to 36.23 per 100,000 livebirths). South Asia and East Asia were the fastest decrease in ASIR (EAPC = -2.71 [-2.86 to -2.55]) and MMR (EAPC = -7.76 [-8.47 to -7.05]), respectively. In 2021, low-SDI regions bore the highest burden, with maternal mortality up to 93 times higher than in high-SDI regions. Inequality analysis showed narrowing absolute disparities (SII: -980.27 to -288.12) but widening relative inequalities (CI: -0.57 to -0.66). Adolescents (10-14 years) and women aged ≥ 35 years had elevated MMRs. Frontier analysis revealed inefficient outcomes in some high-SDI countries. By 2030, maternal hemorrhage is projected to cause approximately 13 million incident cases and 33,186 deaths. CONCLUSIONS: Despite global improvements, maternal hemorrhage persists as a major public health challenge with significant regional inequalities. Tailored strategies are urgently needed to reduce the burden in low-resource settings and accelerate progress toward SDG 3.1.