2000-2021 年全球 204 个国家直接与间接孕产妇死亡联合轨迹及演变特征

Joint trajectories and evolution patterns of direct and indirect maternal mortality across 204 countries from 2000 to 2021

摘要

目的：以直接与间接孕产妇死亡率（maternal mortality ratio，MMR）为联合结局，识别2000—2021年全球国家层面联合轨迹类型，并比较不同轨迹类型在跨千年发展目标期间（millennium development goals，MDG，2000-2015年）与可持续发展目标（sustainable development goals，SDG，2015—2021年）阶段变化特征及其卫生系统与制度环境差异。方法：基于全球疾病负担（Global Burden Disease，GBD）研究数据库，纳入 2000-2021 年全球 204 个国家和地区 15∼49 岁育龄妇女的孕产妇死亡指标。选取2000、2005、2010、2015和2021年国家直接产科死因与间接产科死因死亡率作为联合结局变量，取对数后采用纵向 K-means 聚类（k=2∼6）识别联合轨迹类型，并依据 Calinski-Hara-basz（CH）指数确定最优类别数。在聚类分型基础上，构建分段线性混合效应模型（随机截距），以2015年为结点分别估计2000年基线截距及 MDG、SDG 两个阶段的变化斜率。进一步提取2021年至少4次产前检查覆盖率、满足现代化避孕的比例、剖宫产率、女性人类免疫缺陷病毒（human immunodeficiency virus，HIV）流行率、机构分娩率、专业助产人员覆盖率及流产合法性指数等指标，采用 Kruskal-Wallis H 检验比较不同轨迹类型国家在卫生服务覆盖、健康风险暴露与制度环境方面的差异。结果：纵向聚类结果显示，当 k=3 时 CH 指数达到峰值（CH=342.63），最终将204个国家和地区划分为高负担组（n=66）、中等负担组（n=88）与低负担组（n=50） 3 类联合轨迹。2021年 3 组直接孕产妇死亡率分别为 334.6/10 万活产（95%CI:282.5∼386.7）、 65.6/10 万活产（95%CI:50.4∼80.7）和 5.4/10 万活产（95%CI:3.7∼7.0）；间接 MMR 分别为 33.6/10 万活产（95%CI:27.9∼39.2）、 18.2/10 万活产（95%CI:13.5∼22.9）和 0.9/10 万活产（95%CI:0.6∼1.3）。分段混合效应模型显示，在 MDG 阶段（2000—2015年）， 3 组直接孕产妇死亡率均呈显著下降趋势（斜率分别为 -0.020、-0.016、-0.036, P 均 <0.001）；进人 SDG阶段（2015—2021年）后，直接孕产妇死亡率下降明显放缓并趋于停滞（斜率分别为 $-0.011 、 0.011 、-0.006, ~ P>$0.05）。间接孕产妇死亡率方面，MDG 阶段高负担组与中等负担组呈小幅上升（斜率分别为 0.029 与 $0.015, ~ P<$0.05），低负担组变化不显著（P>0.05）；SDG 阶段中等负担组间接孕产妇死亡率出现显著加速上升（斜率为$0.121,\text{ }95\mathrm{\%}\mathit{C}\mathit{I}:0.092\sim 0.151,\text{ }\mathit{P}<0.001$），而高负担组与低负担组总体平稳（P>0.05）。卫生系统与制度环境指标比较显示，3组差异均具有统计学意义 (P<0.001) ：高负担组至少4次产前检查覆盖率、机构分娩率与专业助产覆盖率相对较低，现代避孕方法需求满足率较低且女性 HIV 流行率较高；中等负担组机构分娩率与专业助产覆盖率接近全覆盖，但剖宫产率处于较高水平；低负担组多项指标处于较优水平且流产合法性指数更高。结论：2000—2021 年全球国家层面直接与间接孕产妇死亡存在显著分化的联合轨迹。MDG 阶段直接死因下降显著，但 SDG 阶段普遍放缓并出现停滞；与此同时，中等负担国家间接死因在 SDG 阶段显著上升，提示在总体孕产妇死亡率相对稳定的情况下可能存在结构性风险累积。将直接与间接死因的联合轨迹纳入常规监测框架，有助于分阶段、分类型识别不同国家孕产妇死亡转型特征并确定干预重点。

Abstract

Objective：To identify joint trajectory patterns of direct and indirect maternal mortality ratios（MMR）at the country level from 2000 to 2021，and to compare phase-specific changes during the millennium development goals（MDG， 2000 to 2015）and the sustainable development goals（SDG， 2015 to 2021）periods，as well as differences in health system and policy environments across trajectory groups. Methods：Data on maternal mortality among women aged 15-49 years in 204 countries and ter- ritories from 2000 to 2021 were obtained from the Global Burden of Disease（GBD）Study.Direct cause MMR and indirect cause MMR at five time points（2000,2005,2010,2015 ，and 2021）were jointly analyzed using longitudinal K-means clustering (k=2-6).The optimal number of clusters was deter- mined by the Calinski-Harabasz（CH）index.Based on the clustering results，a piecewise linear mixed effects model with random intercepts was fitted with a knot in 2015 to estimate the baseline intercept in 2000 and period-specific slopes for the MDG and SDG phases.For 2021，health system and policy- related indicators，including antenatal care coverage（⩾4 visits，ANC4），proportion of women with a demand for contraception that are using a modern method，cesarean section rate，female human immuno- deficiency virus（HIV）prevalence，in facility delivery rate，skilled birth attendance，and an abortion le- gality index were compared across clusters using the Kruskal-Wallis H test.All tests were two-sided，and P<0.05 was considered statistically significant. Results：The CH index peaked at k=3(CH= 342.63），classifying the 204 countries and territories into three joint trajectory clusters：high burden（n= 66），medium burden (n=88) ，and low burden (n=50).In 2021，direct MMR was 334.6(95%CI ： $282.5-386.7),65.6(95\mathrm{\%}\mathit{C}\mathit{I}:50.4-80.7)$ ，and 5.4(95%CI:3.7-7.0) per 100000 live births in the high，medium，and low burden clusters，respectively；indirect MMR was 33.6 （95%CI ： 27.9-39.2）， 18.2 （95%CI:13.5-22.9），and 0.9(95%CI:0.6-1.3) per 100000 live births， respectively.The piecewise mixed effects model showed significant declines in direct MMR during the MDG period in all clusters（slopes：-0.020，-0.016，and -0.036;P<0.001），whereas declines slowed and became non-significant during the SDG period (-0.011,0.011 ，and -0.006;P>0.05). For indirect MMR，modest increases were observed during the MDG period in the high and medium bur- den clusters（0.029 and 0.015;P<0.05），with no significant change in the low burden cluster（P> 0.05）.During the SDG period，indirect MMR increased markedly in the medium burden cluster（slope ： $0.121;95\mathrm{\%}\mathit{C}\mathit{I}:0.092-0.151;\mathit{P}<0.001$），while remaining broadly stable in the high and low bur- den clusters (P>0.05).Health system and policy indicators differed significantly across the clusters (P<0.001) ：the high burden cluster showed lower ANC4 coverage，lower in facility delivery and skilled birth attendance，lower demand for contraception satisfied by modern methods，and higher female HIV prevalence；the medium burden cluster achieved near universal in facility delivery and skilled birth at- tendance but had a higher cesarean section rate；the low-burden cluster generally showed more favorable indicator profiles and a higher abortion legality index. Conclusion：Distinct joint trajectories of direct and indirect maternal mortality were observed globally from 2000 to 2021.While reductions in direct maternal mortality were substantial during the MDG era，progress broadly slowed and plateaued during the SDG era.Meanwhile，the pronounced rise in indirect maternal mortality in medium-burden countries during the SDG period suggests potential structural risk accumulation even when overall MMR appears stable. Incorporating joint direct-indirect trajectories into routine monitoring may facilitate stage and cluster spe- cific prioritization of maternal health interventions.

关键词

孕产妇死亡率 / 直接产科死因 / 间接产科死因 / 联合轨迹 / 纵向聚类

Key words

Maternal mortality ratio / Direct maternal deaths / Indirect maternal deaths / Joint trajecto- ry / Longitudinal clustering

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