Surgical mortality data are collected routinely in high-income countries, yet virtually no low-or middle-income countries have outcome surveillance in place. The aim was prospectively to collect worldwide mortality data following emergency abdominal surgery, comparing findings across countries with a low, middle or high Human Development Index (HDI). Methods: This was a prospective, multicentre, cohort study. Self-selected hospitals performing emergency surgery submitted prespecified data for consecutive patients from at least one 2-week interval during July to December 2014. Postoperative mortality was analysed by hierarchical multivariable logistic regression. Results: Data were obtained for 10 745 patients from 357 centres in 58 countries; 6538 were from high-, 2889 from middle-and 1318 from low-HDI settings. The overall mortality rate was 1.6 per cent at 24 h (high 1.1 per cent, middle 1.9 per cent, low 3.4 per cent; P < 0.001), increasing to 5.4 per cent by 30 days (high 4.5 per cent, middle 6.0 per cent, low 8.6 per cent; P < 0.001). Of the 578 patients who died, 404 (69.9 per cent) did so between 24 h and 30 days following surgery (high 74.2 per cent, middle 68.8 per cent, low 60.5 per cent). After adjustment, 30-day mortality remained higher in middle-income (odds ratio (OR) 2.78, 95 per cent c.i. 1.84 to 4.20) and low-income (OR 2.97, 1.84 to 4.81) countries. Surgical safety checklist use was less frequent in low-and middle-income countries, but when used was associated with reduced mortality at 30 days. Conclusion: Mortality is three times higher in low-compared with high-HDI countries even when adjusted for prognostic factors. Patient safety factors may have an important role. Registration number: NCT02179112 (http://www.clinicaltrials.gov).1038971988