Musings: Maternal mortality

This is a supplementary page, for Maternal mortality (May 7, 2010).


The report is apparently freely available (details below), but I thought it would be helpful to provide some pieces here.

* There are issues about the quality of the data. In fact, the main data table in the report gives ranges for most of the data, and some are rather broad. The report also discusses the data quality. Remember, this is a world goal, a quantitative goal, so it is important -- for them -- to understand the data quality. Here, for the most part, we will take the data at face value -- but not make much of small differences.
* Most numbers are given as the MMR, a ratio. But occasionally they talk about absolute numbers. For example, they note that six countries account for half of the maternal deaths. One is India -- a huge country, with a medium MMR and a very good record at bringing it down. Another is Afghanistan, a small country, with by far the highest MMR in the world and no progress. (You may wonder... The rate has improved substantially since the US invasion of Afghanistan.)
* The MMR goal is stated in terms of 1990-2015. The report deals with 1980-2008, with data at each decade, except for the final 2008. Just be careful, if you care about years.

One place to start is with a map colored to show the current MMR. Map, showing MMR for 2008 (Fig 3 of the paper) [link opens in new window].

If you find the amount of information a little much, you might try grouping the colors. For example, you might consider any kind of blue is "good"; green and yellow are "medium", and red/salmon is "bad".

Another map, with similar coloring scheme, shows the progress: the average yearly rate of decline of the MMR. Map, showing rate of decline of MMR (Fig 4 of the paper) [link opens in new window].

Striking in Fig 4 is the group of red countries -- with the poorest improvements. Africa (especially southern Africa) and North America (US and Canada). HIV is a major contributor to the poor performance in Africa. And the North America data, in part, is a lesson that we must look at both the MMR and the rate of decline of MMR. Canada has one of the very best MMR in the world -- and it has been steady over the entire time; no progress. The US has a "very good" MMR, with some fluctuation -- but an increase overall. (They suggest that part of the fluctuation is due to a recent change in how deaths are reported here, leading to an increase in the more recent numbers.) Even with the increase, the US data is "very good" -- but not as good as other developed countries. This is a political issue here, and relevant to the recent debate about US health care; who says our system is "the best"?

There is plenty of good news in this pair of figures. For example, look at the band of countries across northern Africa. As an example, Egypt has already decreased its MMR by 78% since 1990, and is now in the "good" range -- with room for further improvement. (You can see the idea from the two figures; I looked up actual numbers, in the table that is shown below.) As an example in Asia, Laos has a 72% decline since 1990; at the start of that period, it had one of the worst MMR in the world, and in 18 years has improved to near average. Even within sub-Saharan Africa, the region with generally the worst results, there are individual countries where the MMR has declined by 50% over this period.

As noted, it is good news that some countries are doing very well. This is not restricted to "highly developed" countries. So what makes for such improvement? The Discussion section of the article offers some comments on this. Among the points...
* Higher incidence of having a trained attendant at the birth is very helpful.
* There is a trend that MMR improves as fertility decreases. Remember that MMR is the ratio of maternal deaths per birth, so this means that the number of maternal deaths goes down more than proportionally as the number of births goes down. The reasons for this are not clear, and multiple factors may be involved. One is that, as general conditions improve, fertility tends to go down; the same conditions likely make childbirth safer. Another may be that as women move away from frequent child-bearing they may maintain better health (and they may have improved social status). (Lowest MMR? Italy -- at 4. Not sure I would have guessed that, but it is a country with a very low birth rate.)

A major feature of the report is a big data table. Unfortunately, the table does not display well either in the online HTML file or in the pdf file. So here is that table, for your convenience: Data table [link opens in new window]. The countries are grouped geographically -- in a way that is not obvious. (If you do use the html or pdf tables, you can search through it.) The four data columns are basically by decade, except for the final 2008. Thus if you browse the four entries for a country and they vary in some regular way, it gives some confidence that the trend may be meaningful.

The article is freely available, with registration: Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. (M C Hogan et al, Lancet 375:1609, May 8, 2010.) (Those who have subscription access may prefer to access the article through their own system.)

There is also a short "Comment" article, perhaps something like an editorial. It discusses some of the controversies around the data. This, too, is freely available, with registration: Maternal mortality: surprise, hope, and urgent action. (R Horton, Lancet 375:1581, May 8, 2010.) (Again, those who have subscription access may prefer to access the article through their own system.)

The MMR issue raises some biology questions. What is the MMR of humans "in the wild"? Of other animals? What is the limit? That is, how far can we improve MMR? I don't know the answers to those, but we can make some brief points.

There are several MMR values in the table above 1000; the worst is 2116. An MMR of 2000 means that 2% of the mothers die from motherhood. Is it higher in the wild? One might think so, but I don't know. And what about our closest relatives, such as chimps? Is there some basic information? Perhaps we have insufficient observations to know. It is well known that the human body is poorly suited to childbirth, so one might expect humans to have more problems with childbirth than the chimps. But that may be too simple, only one factor among many.

How low can MMR go? We already noted that Italy has the best MMR, at 4. There are many countries below 10; values of 7 or so seem common in the table. Is the limit in this range, or could we go even lower?

Regardless... The paper notes that there were 340,000 maternal deaths worldwide in 2008, with an MMR of 251. Reducing that MMR 10-fold, to 25, would save about 300,000 lives -- of mothers -- per year. Is that do-able? The world's "developed" countries are probably all below 25, and diverse countries around the world are in the range of 25. Look at Figure 3: vast regions are one or another blue on this map, meaning that they are already below 75. These are countries of diverse economic status and cultures. Many of these countries have been making steady improvements. Is there any reason to doubt that they can reach 25? That the world as a whole can reach 25? Sounds like a good longer range goal?

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