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The good news on maternal mortality: Uncertainty about everything except the advocates’ response

UPDATE 4/15, 4pm EDT: see end of post.

The NYT lead story today (as well as other media) reports a new study with some very good news:

For the first time in decades, researchers are reporting a significant drop worldwide in the number of women dying each year from pregnancy and childbirth, to about 342,900 in 2008 from 526,300 in 1980.

So happy about success! Alas, the universal rule with media reports of development statistics is that they are mishandled so badly that they raise more questions than answers, such as:

(1) why is this reported as an absolute number rather than a maternal mortality rate (usually per 100,000 live births), which is the usual thing of interest, and would show even better news because of the large population increase since 1980?

(2) why attempt to estimate it for the whole world rather than only for those countries that have the most solid data?

(3) it’s well known that maternal mortality numbers over the years have been mostly made up, a problem that has only recently been (partially) corrected (i.e. sometime since 2000). The 1980 and 1990 numbers are worthless, so the headline-grabbing sentence above is the wrong way to present the findings. Indeed the NYT story notes:

the new study was based on more and better data, and more sophisticated statistical methods than were used in a previous analysis by a different research team that estimated more deaths, 535,900 in 2005.

The story cannot simultaneously report “more and better data” and report a trend “drop,” since the new numbers will not be comparable to the old “less and inferior” data. We can’t know from this story what part of the change is due to change in methods, and which is real.

The most clear and interesting thing to emerge from this story is this:

But some advocates for women’s health tried to pressure The Lancet into delaying publication of the new findings, fearing that good news would detract from the urgency of their cause, Dr. Horton said in a telephone interview.

“I think this is one of those instances when science and advocacy can conflict,” he said.

Dr. Horton said the advocates, whom he declined to name, wanted the new information held and released only after certain meetings about maternal and child health had already taken place.

He said the meetings included one at the United Nations this week, and another to be held in Washington in June, where advocates hope to win support for more foreign aid for maternal health from Secretary of State Hillary Rodham Clinton. Other meetings of concern to the advocates are the Pacific Health Summit in June, and the United Nations General Assembly meeting in December.

People have long accused aid officials and advocates of being afraid of putting themselves out of business by success, but it’s rare that such an episode is documented so clearly.  Sad, very sad.

But there does seem to be some good news on maternal mortality in here somewhere, so let all non-self-interested people celebrate!

UPDATE: Columbia Journalism Review on 4/14 posted a story on the massive confusion caused by the press on both aspects of the story discussed here.

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11 Comments

  1. geckonomist wrote:

    The incentive for every aid worker is to keep poor people as poor and miserable as possible.

    They are very effective at that.

    Posted April 14, 2010 at 8:55 am | Permalink
  2. Rachael Burke wrote:

    That’s not entirely fair. I realise this is a post about media response to a story rather than the story. But fundamentally it’s not necessarily “new and better data” but new and better (=systematic, peer reviewed, with confidence limits, from a mathematical model that’s transparent). The authors use their method to piece together the existing data and fill in the gaps… so they can report a trend from 1980s.
    Chris Murray’s health metrics group (authors of this) have been publishing some very interesting findings recently. They have recently questioned the WHO/UNICEF figures on vaccination too… suggesting GAVI is disbursing too much money for vaccines due to incentives to overreport.

    The obvious answers to 1. and 2. are 1. absolute numbers were what was reported in abstract and (presumably) press release and most people know the ~500,000 figure rather than the MMR because that’s what advocacy people use. 2. Because the countries that have a high MMR, and the ones we care about are also the ones that don’t have the great data. “According to accurate reporting in US and Western Europe MMR stayed reasonably low and constant in past 30 years” isn’t much of a story.

    Basically, the underlying data is pretty patchy in most countries. The WHO/UN agencies try to fill in the gaps using consultation and ‘best guesses’, without rigorous confidence intervals and with implicit assumptions. Murray et al try to build statistical models with explicit assumptions, that are uniform, clear, review-able by others and give statistical confidence intervals.

    Posted April 14, 2010 at 9:35 am | Permalink
  3. Rachael Burke wrote:

    As ever, the accompanying editorial in the Lancet sets out nicely some of the advocacy issues and what others have said about the work. You need a free account to see the page: http://www.lancet.com/journals/lancet/article/PIIS0140-6736(10)60547-8/fulltext

    Posted April 14, 2010 at 9:36 am | Permalink
  4. Anon wrote:

    I think the advocates are just aware of people’s/donors impressionability and wanted to ensure donors didn’t feel “off the hook” around women. MM REMAINS a big problem, regardless of gains made. Someone (the Lancet? NYT?) seems to be sensationalizing a couple phone calls and creating some distorted narrative that likely doesn’t reflect the reality of the situation.

    Casting aid workers as villains with malicious intents to keep down the poor so they can stay in business is a gross caricature that I would categorize as ANTI-AID PORN.

    Posted April 14, 2010 at 12:17 pm | Permalink
  5. RJS wrote:

    Good post, Bill.

    Posted April 14, 2010 at 1:14 pm | Permalink
  6. Douglas Barnes wrote:

    “there does seem to be some good news on maternal mortality in here somewhere”

    I’m reminded of a joke involving a gift of a large quantity of manure, with the punchline, “there must be a pony in here somewhere.”

    Posted April 14, 2010 at 2:51 pm | Permalink
  7. Simon Scott wrote:

    Bill,

    Agree with most of your post, but point 1 could be qualified a bit. The usual denominator for the maternal mortality rate is the number of live births (i.e. maternal deaths are expressed per 100 000 live births). Since the number of live births has hardly changed since 1980, the story is more or less the same whether the rate or number of maternal deaths is taken.

    Posted April 15, 2010 at 7:03 am | Permalink
  8. William Easterly wrote:

    Simon, thanks for your comment and the useful clarification about live births. I knew birth rates had fallen, but didn’t realize it was so drastically as to almost completely offset the large population increase. I still think the NYT should have followed good statistical practice of reporting rates as well as absolute amounts (except of course for the fact that the 1980 data on maternal mortality is worthless anyway).

    Posted April 15, 2010 at 12:00 pm | Permalink
  9. Karen Grepin wrote:

    Bill,

    I have to disagree with you here on all 3 arguments above. Here is why:

    (1) Technically the metric of interest here is neither the level of maternal deaths nor the maternal mortality rate (deaths per women in reproductive years) but rather the maternal mortality ratio (deaths per100,000 live births). Both the rate and the level depend on fertilty, while the ratio does not. Had the NYTimes reported the ratio rather than the level – you are right – it would have actually shown an even larger decline but not nearly by as much as you would think (40% vs. 35%). While there are more women in their reproductive years on the planet today than there were in 1980, fertility rate declines have been so substantial that the size of the birth cohort has remained relatively stable over this time period. The difference is small. Therefore, I really don’t fault the NYTimes for using a metric that is much easier for the general public to understand. And as one of your earlier commenters suggest the 500,000 is the number that has been used in the advocacy community for decades and thus does suggest a real departure from previous estimates.

    (2) Your second comment – why not estimate maternal mortality only for the countries for which we had solid data – completely misses the point – that is the entire point of the exercise! If we had solid data on maternal deaths (e.g. vital registration systems) than we would not need to come up with complex models to estimate it. Most of the developing world lacks complete national vital registration systems and this is where nearly all maternal deaths occur.

    (3) The 1980 estimate to which they compare the declines does come from the same exercise and therefore they are internally consistent and thus does represent a valid reference for comparison. Of course, less data was available during this time period and thus is less well estimated, but the authors can make this comparison. What is dangerous is a comparison of any new that comes out of this exercise with any other estimate from other exercise.

    Where I think the big problem with the interpretation and understanding of these new estimates has come from those trying to attribute causation to these declines. There is no evidence from this article that anything that the international health community has done has led to these declines, in fact it does suggest that declines in fertility rate and increases in GDP per capita explain most of the declines, and that these gains were offset by increases in HIV prevalence in Africa. After controlling for fertility and per capita GDP, the proportion of births supervised had no predictive power. But whether it was policy that led to lower fertility rates and GDP growth is a whole other debate…

    The other major interpretation of these results, which has been downplayed, is that there still has been little progress in Africa where many countries have actually even seen significant increases. As well, the overall declines – described as “sharp” – are no where in the range required to meet MDG5 (1.8% p.a. vs. the 5.5% required, although their numbers would be even lower since 1990). I still find these numbers to be a real good news story.

    Karen Grepin
    Assistant Professor of Global Health Policy, NYU-Wagner
    http://karengrepin.blogspot.com/

    Posted April 15, 2010 at 4:39 pm | Permalink
  10. Benson wrote:

    Hey guys,

    This reminds me of the time when I was working in India, when women advocacy groups tried to prevent the publishing of an article showing that increase in educational levels of women correlates with an increase in the domestic abuse in India.

    What takes precedence, the honest truth or the harm that it might potentially create?

    Posted April 15, 2010 at 8:31 pm | Permalink
  11. First, thanks to Bill Easterly for highlighting our research published in The Lancet, Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5 and for raising important questions about the study. We appreciate the opportunity to help clarify the research.
    As the lead author of the maternal mortality study, I wanted to address the question of whether it is possible to actually estimate the real drop in the number of maternal deaths. And the answer is, yes we can. In the IHME study, we have re-estimated maternal mortality numbers and ratios using a database of 2651 observations of maternal mortality from vital registration data, censuses, surveys, and verbal autopsy studies. And we have developed improved methods, enabling us to recalculate maternal deaths for all years between 1980 and 2008. The reported drop in the number of maternal deaths (as well as the maternal mortality ratio) is therefore based on new estimates for both 1980 and 2008. Therefore, we are not producing new estimates for 2008 and comparing them to old estimates for 1980.
    Again, we appreciate – and encourage – open dialogue on our methods and our findings in order to stimulate the opening of new avenues for consultation and collaboration, which will in turn serve to improve and strengthen the evidence base in the long run.
    Please feel free to contact us at IHME@healthmetricsandevaluation.org should you have any further questions.

    Margaret Hogan

    Posted April 16, 2010 at 1:55 pm | Permalink
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    The Aid Watch blog is a project of New York University's Development Research Institute (DRI). This blog is principally written by William Easterly, author of "The Elusive Quest for Growth: Economists' Adventures and Misadventures in the Tropics" and "The White Man's Burden: Why the West's Efforts to Aid the Rest Have Done So Much Ill and So Little Good," and Professor of Economics at NYU. It is co-written by Laura Freschi and by occasional guest bloggers. Our work is based on the idea that more aid will reach the poor the more people are watching aid.

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