India makes progress on reducing maternal mortality rate.
In 2005, Pratham shocked the nation's conscience by documenting that about 52% of the country’s children could not read, and about 65% cannot do simple divisions.
It would be good if there were some simple tests that we could use to evaluate statistical literacy of the Indian civil society.
In the last few days, many newspaper headlines have focused on the fact that India tops the list of countries with large number of maternal deaths, beating countries like Afghanistan, Congo and Ethiopia.
These news headlines would give the impression that the crores of rupees spent on Janani Suraksha Yojana (JSY) have had no impact.
These headlines refer the findings of a recent WHO-Unicef-UNFPA-World Bank report, Trends in maternal mortality, which says that 63,000 of the estimated 3,58,000 deaths due to complications during pregnancy and childbirth worldwide occur in India. That is, one in six women who die due to pregnancy-related causes worldwide live in India.
We know that one in six persons lives in India. The country’s large population puts it at or near the top of many statistical results including number of births, number of poor and number of new engineers.
So, it is necessary to probe further to see what the statistics on maternal mortality mean before we give in to our ritual cynicism and condemn the national record on improvement in maternal mortality. The report on maternal mortality mentioned above offers a good starting point.
It contains the results of a painstaking exercise collating maternal mortality statistics from around the world. These are some of the most difficult statistics to obtain since it is easy to conflate deaths from maternity-related causes with those from other causes, and the report carefully documents the band of uncertainty around their estimates.
The report tells us that, first, Indian maternal mortality ratio (MMR) fell from 570 per 1,00,000 births in 1990 to 230 in 2008. This is a 59% decline. Second, given the uncertainty of estimation, it is possible that MMR could be as low as 150 or as high as 350 in 2008.
Third, the estimate of 230 implies an annual decline in MMR of 4.9% between 1990 and 2008, only slightly below the 5.5% annual decline needed to achieve the ambitious Millennium Development Goal (MDG) of 75% reduction in MMR by 2015.
Fourth, the report documents MMR decline from 390 to 230 between 2000 and 2008, nearly 6% annual decline with JSY only getting rolled out towards the middle of this period.
Acknowledging this success should not encourage complacency. Regardless of the magnitude of the decline, MMR of 230 is hardly a cause for celebration.
While India has lower MMR than Pakistan, Bangladesh and Nepal and considerably lower than over 600 in most sub-Saharan African countries, comparison with MMR of 38 in China and 39 in Sri Lanka gives enough sense of the task ahead. However, the question is whether a strategy of focusing on a glass half empty is useful here.
This is particularly relevant when schemes such as JSY are criticised and the government is accused of playing dangerous games with women’s lives by showcasing rising institutional deliveries while large number of maternal deaths are ignored.
This Indian drama is played out against the leitmotif of a similar drama in the international arena. In the May 2010 issue of The Lancet, Christopher Murray and colleagues published results of an exercise similar to the WHO report. They noted substantial progress in reducing maternal mortality worldwide while identifying future areas of action.
An unprecedented editorial in that issue also noted the intense pressure on the journal to not publish or to delay publication of the article for the fear that documentation of progress will shift governments’ focus and ignore maternal health. The journal resisted the pressure and published the article, while providing critics space to dissent.
While few newspapers are equipped to critically evaluate statistical techniques that are expected of scientific journals, it is a pity that news reports based on the WHO report and immediate civil society responses did not include careful analyses of the material included in the report.
The report classifies countries in four categories: ‘on track’, ‘making progress’, ‘insufficient progress’ and ‘no progress’. India is classified as ‘making progress’ because its annual rate of decline of 4.9% falls below the 5.5% cut-off used for inclusion in the top category, ‘on track’.
Given the band of uncertainty around maternal mortality estimation, it does not make sense to harp on these arbitrary categories to evaluate national progress.
It is sad that Unicef, one of the organisations involved in preparing this report, had to come to the defence of the Indian government to say that the country is making substantial progress in reducing maternal mortality.
This instance also raises questions about the broader strategy for achieving socially-desirable goals. Do we really believe that documenting progress is synonymous with complacency and reduction in governmental commitment?
As parents and teachers, we know that withholding legitimate praise and harping on deficiencies dampens children’s motivation for further achievements. Are governments so different? Could unwarranted criticism lead to devaluation of good programmes and diversion of funds towards other priorities?
A thoughtful approach that focuses on the strengths and weaknesses of a large conditional cash transfer programme like JSY may be more productive in the long-run than summary judgements based on superficial reading of global reports.
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