Maternal Mortality Transition and Subnational Inequities in China, 1990–2023: Comparative Analysis of GBD 2023 and National Surveillance Data

Jian-Bo Wei,1,* Huayu Huang,2,* Jie Zhang,3,* Xiao-Fei Li,1 Yuan Xu,1 Mingwei Lv,3 Liang-Sheng Fan1,4 1Department of Obstetrics and Gynecology, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, People’s Republic of China; 2Department of Dermatology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China; 3Department of Obstetrics and Gynecology, Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning, People’s Republic of China; 4Department of Obstetrics and Gynecology, Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology, Guangzhou, People’s Republic of China*These authors contributed equally to this workCorrespondence: Mingwei Lv, Department of Obstetrics and Gynecology, Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning, People’s Republic of China, Email [email protected] Liang-Sheng Fan, Department of Obstetrics and Gynecology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, People’s Republic of China, Email [email protected]: The maternal mortality ratio (MMR) is a core indicator of health-system performance and equity. In China, interpretation of recent maternal mortality trends is increasingly influenced by differences between modeled global estimates and national surveillance data. We aimed to characterize the maternal mortality transition and subnational inequities in China from 1990 to 2023 by comparing Global Burden of Disease (GBD) 2023 estimates with data from the National Maternal Mortality Surveillance System (NMMSS).Methods: We integrated model-based estimates from the GBD 2023 with real-world data from China’s NMMSS. Assessment focused on key burden metrics, including disability-adjusted life years, MMR, mortality and incidence. Joinpoint regression was used to identify temporal trend changes. Scenario-based projections and Bayesian age-period-cohort (BAPC) models were applied to forecast progress toward the “Healthy China 2030 target”. Subnational inequalities in maternal healthcare service coverage were also examined.Results: GBD estimates showed China’s MMR declined from 121.9 (1990) to 10.7 (2023) per 100,000 live births, while NMMSS reported 15.1 per 100,000 live births in 2023. According to GBD, the leading cause shifted from maternal hemorrhage to indirect disorders, whereas NMMSS consistently identified obstetric hemorrhage as the primary cause. The urban–rural disparity narrowed substantially, but subnational inequities persisted, particularly in western provinces. The MMR rapid decline during 2004– 2015 was followed by a plateau. Scenario-based projections indicate that sustaining recent progress would enable China to achieve the Healthy China 2030 target (MMR < 12 per 100,000 live births).Conclusion: China has made remarkable progress in maternal health and significantly reduced urban–rural disparities. However, critical differences between GBD estimates and NMMSS data underscore the need for improved local data collection. Targeted strategies, such as integrating cardiovascular risk screening in eastern provinces and strengthening obstetric emergency capacity in western regions, are essential to further reduce maternal mortality and achieve the Healthy China 2030 goal. Infographic comparing GBD 2023 and NMMSS maternal mortality ratios, causes and inequities in western provinces.Keywords: maternal mortality ratio, maternal disorders, disease burden, China, global burden of disease, epidemiological transition, health policy