Trends in Absolute and Relative Inequalities in Maternal Mortality Ratio in 179 countries

Transcription

1 Trends in Absolute and Relative Inequalities in Maternal Mortality Ratio in 179 countries Abstract The assessment of how different countries moving and converging in terms of average health and health inequalities is crucial for understanding the challenges of future health policy. As progress in average health in necessary but could not be the sufficient condition of progress in health inequality. The principal objective of this study is to assess the trend in absolute and relative inequality against the progress in reduction of average maternal mortality ratio in 179 countries. The result of study foster some important insights about progress in maternal mortality: First, the progress or decline in average maternal mortality ratio not necessarily will lead to decline in inequalities in maternal mortality ratio. Second, the decline in absolute dispersion in maternal mortality ratio will ratio not necessarily will lead to decline in relative inequalities in maternal mortality ratio. Therefore, policies aiming to reduce maternal mortality should aim at reducing both absolute and relative inequalities. Therefore, efficacy with equity should be a principle for convergence in progress in maternal health in world countries. Introduction The present scenario of the MDGs well acknowledged the obstacles in poor countries to achieved maternal mortality target MDG5 (Safe motherhood initiative 2006 &WHO 2005). Improving the odds of surviving for the world s mothers has become as increasingly urgent priority for policymakers and health advocates worldwide as barely three and half years left to accomplish the Millennium Development Goals (WHO et al., 2012). Millennium development Goal 5 (MDG5) set the ambitious target to reduce the maternal mortality ratio by three quarter between the 1990 to Hogan et al. (2010) has reported globally maternal deaths have dropped from an estimated 526,300 in 1980 to 342,900 in Since 1990, the annualized rate of decline in the maternal mortality ratio has been 1.3 percent, dropping to 251 deaths per 100,000 live births in The issue of maternal health have galvanized the health community and prompted the global health analysts and driven an increasing levels of development aid, policy attention, and research work (Goodburn and Campbell, 2001; Starrs, 2006; Hill et al. 2007; Murray et al., 2007; Countdown Coverage Writing Group on behalf of the Countdown to 2015 Core Group, 2008; Gregson et al., 2009; Hogan et al., 2010; Rajaratnam et al., 2010).

2 The group of the public health researchers had conferment the reduction of MMR and level will accelerate while prioritizing the skill attendant, antenatal care and if many other basic maternal health requirements will increase (Goodburn and Campbell, 2001; Starrs, 2006; Hill et al. 2007; Murray et al., 2007; Countdown Coverage Writing Group on behalf of the Countdown to 2015 Core Group, 2008; Gregson et al., 2009; Hogan et al., 2010; Rajaratnam et al., 2010)). However, Only 19 developing countries are on track to achieve MDGs5 while maternal death are more concentrated on the cluster of developing countries not on pace to reach MDG5 have been accelerating their rate of decline in ways that could still far and lagging behind from others (WHO, 2010; United Nations, 2010; WHO et al., 2012). Is it the right time to acknowledge Rosenfield and Maine through the international health thinker to turn their attention towards the question posed by them, Where M is went from the MCH (Rosenfield and Maine 1985)? Or how long maternal health could still be the heart of the MDGs (Rosenfield & Maine 2006)? Because, globally maternal death claim lesser than women every years but irony is nearly 80% of all maternal death occur in just 21 countries. These countries comprise up only 60% of the global live births and underline a disproportionate burden of maternal mortality in Asia and sub-saharan Africa. Only six countries account for half of the world s maternal deaths: India, Nigeria, Pakistan, Afghanistan, Ethiopia, and the Democratic Republic of the Congo. Altogether inverse trend had been found in the Canada and Afghanistan with maternal mortality of 7 and 1575 death per live birth 2008 (Mac Arthur Foundation, 2010). The asymmetric distribution of maternal health achievement have been not un-touch from some of the well developed countries, such as United Kingdom and Switzerland- the UK ranked 23 rd in the world based on its MMR despite its strong economy, education system and universal health coverage. Above arguments depicted that there is no symmetric progress across the globe. The regional level estimation by researcher depicted a huge variance in progress achieved across worldwide countries; of 68 priority countries, only quarters have tracked the MGD5. While trends are sluggish in sub-saharan Africa and Asia, and few developed countries, the contribution from three Asian countries is still counting for 29 percent of total maternal deaths in 2008.

3 Previous literature had covered maternal mortality ratio as an exciting, controversial and best to show the death are coming down. So far these literatures have been addressing the averages maternal mortality ratios which only show reduction in maternal mortality ratio across the nation or among the countries. This paper is an attempt to assess the existing inequality on equity perspective with respect to relative and absolute inequality across the 179 countries on deduction of MMR. The assessment of how different countries moving and converging in terms of health and health inequalities is crucial for understanding the challenges of future health policy. As conversion in average health in necessary but could not be the sufficient condition of conversing the health inequality. The principal objective of this study is to assess the trend in absolute and relative inequality against the progress in reduction of average maternal mortality ratio in 179 countries. Data Source This study used a compiled data base documented in a report titled Building Momentum: Global Progress toward Reducing Maternal and Child Mortality by Hogan and colleagues (2010) from the Institute for Health Metric Evaluation (IHME), Seattle, United States of America (USA). Primarily based on this data source, Hogan et al. (2010) published two pioneering articles published in The Lancet medical journal. Hogan et al. (2010) addressed the issues of maternal mortality. They have assessed the progress of 187 countries in terms of achievements in the goal 5 of MDGs. A recent report of The Lancet a medical journal indicates that article by Hogan et al. (2010) is the fourth most cited in The Lancet with 281 citations (The Lancet, 2012). In an attempt to invigorate the important study, the present study used the widely accepted new estimates popular among the public health community across the globe for the analysis [For details of the estimation procedures of maternal and child mortality indicators and their reliability, see Hogan et al. (2010)]. Methods Dispersion Measure of Mortality (DMM), Gini indices were respectively, used to assess the absolute and relative inequalities. The percentage reduction in DMM and Gini are used to show the change in absolute and relative inequalities in maternal mortality ratio across the 179 countries. Below, the mathematical procedures for estimation of DMM and Gini index are presented: Dispersion measure of mortality (DMM)

4 The DMM measures the degree of dispersion that exists at any point of time in the mortality experiences of the countries in the world or states in a country. It is calculated as the average absolute inter-country maternal mortality difference in world, weighted by population size, between every pair of countries. Change in the DMM over the time indicates whether mortality is becoming more or less similar across the countries of the world; decrease indicates convergence, while increase indicates divergence (Moser et al. 2004). The DMM for life expectancy at birth is measured in years of life, and the DMM for infant mortality is measured in terms of infant deaths per thousand live births (Shkolnikov et al., 2003). The DMM is obtained by means of the formula. Where, i, j are countries, and 1 i, j 179 M is the mortality rate ratio W is the weighting, and ; Wz weight is the India When applied to maternal mortality ratio, M = maternal mortality ratio of country i, represents the relative population size of the country i. Gini Coefficient Another, measure that we used to assess the relative inter-country inequality in maternal mortality ratio is Gini coefficient (G). G is a measure of relative inequality that is equal to DMM divided by the average maternal mortality ratio (Shkolnikov et al., 2003): When applied to maternal mortality ratio, DMM = Dispersion Measure of Mortality, is the average maternal mortality ratio and adjusted by population proportion of the countries i i n. Results Table 1 presents the descriptive statistics of MMR of 179 countries. The results show that, the mean MMR of 179 countries has decreased by just 30 women per live births in a period of two decades. However, the entire progress achieved in last decade, , while there is complete stall in decline in MMR in previous decade, The inter-

5 country in range in MMR is increased from 1990 to 2000 but decline considerably for recent period, However, over the period, , the skewness in maternal mortality ratio across the countries is increased. Figure 1 presents the estimates of trends in dispersion measure of mortality and Gini index. The results indicate that, over the period, the dispersion in maternal mortality ratio across the countries declined, that indicates reduction in absolute inequality across 179 countries in terms of maternal mortality ratio during Contrastingly, the results of Gini index show a steep rise in relative inequality in maternal mortality ratio across the countries during The results presented in figure 2 and 3 respectively, show percentage change in absolute and relative inequalities. The results are evident that over the period absolute inequalities are reduced by 9 percent in during and 15 percent in However, the results for relative inequalities show negative decline that, the relative inequalities are increased over the period and increase is more among the recent period (-2.68% in compared to % ). This indicates that the decline absolute inequalities are does not give guarantee that relative inequalities also simulatantiously decline. Conclusion The results of this study foster following important conclusions: First, the progress or decline in average maternal mortality ratio not necessarily will lead to decline in inequalities in maternal mortality ratio. Second, the decline in absolute dispersion in maternal mortality ratio will ratio not necessarily will lead to decline in relative inequalities in maternal mortality ratio. Therefore, policies aiming to reduce maternal mortality should aim at reducing both absolute and relative inequalities. Therefore, efficacy with equity should be a principle for convergence in progress in maternal health in world countries. References Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM et al. Maternal Mortality for 181 Countries, : A Systematic Analyses Of Progress Towards Millennium Development Gols5. Lancet. 375:

6 Hogan MC, Lopez AD, Lozano R, Murrey CJL, Naghavi Mohsen, Rajaratnam, JK et al Building Momentum: Global Progress toward Reducing Maternal and Child Mortality. Seattle, USA: Institute for Health Metric and Evaluation (IHME), University of Washington. Rosenfield A, Maine D. Maternal mortality a neglected tragedy. Where is the M in MCH? Lancet 1985; 2: Rosenfield A, Maine D, Freedman L. Meeting MDG-5: an impossible dream? Lancet 2006; published online Sept 28. DOI: /S (06) The Lancet The Lancet Most cited Paper. blank&utm_medium= &utm_campaign=if-12-lancet-active United Nations The Millennium Development Goals Report, New York, USA: United Nations. WHO, UNICEF, UNFPA and The World Bank estimates The World Trends in maternal mortality: 1990 to Geneva: World Health Organization. WHO. WHO Mortality Database. Geneva: World Health Organization, en/index.html (accessed March 23, 2010). Yadamsuren B, Merialdi M, Davaadorj I, et al Tracking maternal mortality declines in Mongolia between 1992 and 2007: the importance of collaboration. Bull World Health Organ. 88:

7 DMM Table 1 Descriptive Statistic of MMR of 179 Countries across the World in 1990 to 2008 Period Mean Minimum Maximum Std. Deviation Range Skewness N Figure 1 Trend of Dispersion Measure of Mortality (DMM) and Gini Index of Maternal Mortality Ratio across 179 Countries during Gini Index DMM per Gini

8 Change in relative inquality ( in percentage) Change in absolute inequality (in percentage) Figure 2 Change (decrease) in Absolute Inequality 1 in MMR across 179 countries during and to to 2008 Period Note: 1. Absolute inequality is based on Dispersion Measure of Mortality (DMM) Figure 3 Change (decrease) in Relative Inequality 1 in MMR across 179 countries during to to to 2008 Period Note: 1. Relative Inequality based on Gini Index