Playing the Numbers Game

In 1987, Dr Mahler asked why maternal mortality had only recently become a cause for concern. His own answer was that the dimensions of the problem had previously remained unknown. “Sound estimates based on new data are ... the foundation of our current understanding and concern” (Mahler 1987). With the perspective of another decade of experience in collecting data on levels and trends in maternal mortality, his confidence seems remarkable. After all, the “sound estimates” were generated on the basis of a mere handful of community studies in developing countries. For many years WHO tabulations of available information were heavily dependent on hospital-based data, known to be problematic because of bias. (WHO 1986, 1991, 1996). Because of this, WHO did not venture into making estimates of the level of maternal mortality for individual countries but confined its estimation activities to regional and global totals.

The global totals served to draw attention to the overall dimensions of the problem but there are limits to such general advocacy. Countries with high levels of maternal mortality could hide with impunity behind relatively lower regional averages. Conversely, countries with maternal mortality levels lower than the regional average - Cuba and Sri Lanka being notable examples - resented being lumped together with countries whose performance in this area was so much inferior to their own. Furthermore, and this is particular important in the area of advocacy where today’s news is tomorrow’s history, the constant repetition of the same global totals became self-defeating. It became increasingly difficult to keep maternal health in the public eye when there was nothing new to report.

This changed in 1996 with the publication by WHO and UNICEF of the revised estimates for 1990 which included, for the first time, not only regional and global totals but also the individual country estimates from which they were derived (WHO/UNICEF 1996). These estimates were developed using a variety of adjustment factors designed to account for well-documented problems of underreporting and misclassification. They were in almost all cases, considerably higher than those previously published.

The new numbers were issued with great fanfare, including a joint press release. The powerful UNICEF publicity machine was brought into play with the publication of the estimates in the 1996 Progress of Nations, complete with individual country rankings and a leading article by Peter Adamson (UNICEF 1996). Other flagship publications started using the same data set including UNFPA’s State of the World Population and UNDP’s Human Development Report.

Nothing before had had such an explosive impact on the awareness of the problem. Reactions of national authorities were frequently critical and questions were asked in the governing bodies of UN agencies. Agency regional and country offices became involved in efforts to explain the origin of the numbers and limit the political fallout (WHO/Regional Office for South East Asia 1997).

As the saying goes, no publicity is bad publicity. The debate provoked by the new estimates was instrumental in ensuring that the issue of maternal mortality was given greater visibility and attention both at the national level and in international fora. Maternal mortality became a key indicator for assessing country eligibility for donor support.

The shock wave produced by the publication of country estimates of maternal mortality had a number of positive outcomes in terms of drawing attention to the issue². But the numbers game can be a double-edged sword. In order to ensure that the issue remains at the forefront of people’s consciousness, it is necessary to keep producing updated numbers or new variations on the numerical analysis. The Safe Motherhood Initiative proved adept at using the numbers for advocacy - “the equivalent of one jumbo jet full of pregnant women crashing every four hours” (WHO 1986); “every minute of every day a woman dies” (InterAgency Group for Safe Motherhood 1990). But other conditions, HIV/AIDS, malaria or tuberculosis, for example, cause more deaths and provide more compelling press copy than maternal mortality. Epidemic diseases subject to global surveillance have a new story to tell on a regular basis. Maternal mortality is neither an emerging epidemic nor one of the world’s major killers. Maternal deaths remain singular, individual and silent tragedies.

There are also technical reasons why it is hard to make a case for maternal health using the numbers of deaths alone. Maternal mortality is a difficult to measure outcome. Currently available measurement techniques have wide margins of uncertainty and it is impossible to be certain that observed trends are real rather than artefacts of the data collection methodology (UNICEF/WHO/UNFPA 1997). The most commonly used indicator, the maternal mortality ratio, is technically complex and intuitively hard to grasp. These factors combine to render it difficult to make a convincing and unambiguous case for safe motherhood programmes. Policy-makers and donors are likely to be wary of putting resources into programmes where the baseline point of departure is unknown and where there is no certainty about the direction of change.