The improvements in maternal mortality seen in the

Transcription

1 WOMEN'S HEALTH Female Education and Maternal Mortality: A Worldwide Survey Chryssa McAlister, BSc, 1 Thomas F. Baskett, MB, FRCSC 2 1 Faculty of Medicine, Dalhousie University, Halifax NS 2 Department of Obstetrics and Gynaecology, Dalhousie University, Halifax NS Abstract Objective: In terms of social and political development, women s human rights have not evolved in many developing countries to the same extent as they have in the developed world. We examined the relationship between women s status and human development and maternal mortality. Methods: Using polynomial regression analysis with a sample of 148 countries, we investigated the impact of gender-related predictors, including education, political activity, economic status, and health, and human development predictors, such as infant mortality and Human Development Index, using data from the United Nations Human Development Report 23. Results: The Human Development Index and Gender Development Index are powerful predictors of both maternal and infant mortality rates. Female literacy rate and combined enrolment in educational programs are moderate predictors of maternal mortality rates. Conclusion: Strategic investment to improve quality of life through female education will have the greatest impact on maternal mortality reduction. Résumé Objectif : Dans le contexte du développement social et politique, les droits des femmes n ont pas évolué, dans bon nombre de pays en développement, dans la même mesure que dans les pays développés. Nous avons étudié la relation qui existe entre le statut des femmes, le développement humain et la mortalité maternelle. Méthodes : Nous avons étudié, à l aide d une analyse de régression polynomiale de 148 pays, l effet d indicateurs prévisionnels liés au sexe (éducation, activité politique, situation économique et santé) et d indicateurs prévisionnels liés au développement humain (mortalité infantile, indice du développement humain), compte tenu de données publiées dans le Rapport mondial sur le développement humain 23. Résultats : L indice du développement humain et l indicateur sexospécifique de développement humain constituent d importants indicateurs prévisionnels quant aux taux de mortalité maternelle et de mortalité infantile. Le taux d alphabétisation des femmes et l inscription à des programmes éducatifs constituent des Key Words: Maternal mortality, human development, women s education, maternal welfare Competing Interests: None declared. Received on March 21, 26 Accepted on May 26, 26 indicateurs prévisionnels modérés quant aux taux de mortalité maternelle. Conclusion : Un investissement stratégique dans l amélioration de la qualité de vie par l entremise de l éducation des femmes est la méthode qui aura le plus d effet sur la réduction de la mortalité maternelle. J Obstet Gynaecol Can 26;28(11): INTRODUCTION The improvements in maternal mortality seen in the developed world during the 2th century have not been reflected in the developing world, where 98% of maternal deaths occur. 1 Rates of maternal mortality in the developing world remain at 18th century levels despite increased international attention and aid. In more absolute numbers, approximately 6 women between the ages of 15 and 49 die each year as a result of complications of pregnancy and childbirth, and it is believed that this figure may be underestimated by 25%. 2 4 This translates into a one in 16 chance of maternal death for a woman in Africa, while the risk is one in 4 for a woman from Northern Europe. Furthermore, these numbers do not even take account of permanent disability and chronic illness that result from pregnancy-related complications, which are estimated to be 3 times higher. 1 A review of this disconcerting trend in reported rates of maternal deaths must take into consideration the source of the data. Reporting of maternal mortality in the developing world is not always accurate or consistent, and good vital statistics registration systems are rare. 5 As a result, data are often taken from health service records or collected via surveys, which raises concerns regarding accuracy of data. Rates of maternal mortality are often underestimated because many women in developing countries do not have access to regular health care, and deaths are often misclassified. 6 It is possible that increased international awareness might contribute to better and more frequent NOVEMBER JOGC NOVEMBRE

2 reporting of maternal mortality by developing countries, so the rates might not be increasing but reporting might be more frequent and accurate. Nonetheless, rates of maternal mortality in the developing world are unacceptably high, and the majority are considered to be due to preventable causes. 7 Studies show that in countries where maternal health is a national public health priority, rates of maternal deaths are decreasing. 8,9 In Jamaica, for example, maternal mortality rates declined from 6 per 1 births in 193 to 1 per 1 births in 198. Increased survival was partially due to social policies introduced in the 197s that improved women s access to health care and education. 1 This is also reflected in the history of maternal mortality in the Western world, where countries that acknowledged the need for improved maternal care (Sweden, Great Britain) had lower maternal mortality rates than those countries that recognized the problem at a later date (United States). Although a relationship exists between high maternal mortality rates and the absence of a professional association of obstetricians, many of the programs established in developing countries to improve maternal care have not been shown to reduce maternal mortality. The introduction of traditional birth attendants (TBAs) has failed to decrease maternal mortality, and there is distrust between TBAs and health care workers in many countries. 9 Since the 19th century, the developed world has seen social and political enhancement of the stature of women within society. The advent of the women s rights movement and the eventual reduction in gender inequality via the introduction of equal rights in education, work, voting, and political participation, paralleled to an extent the reduction in rates of maternal mortality. Although scientific developments have, to some degree, been available to the developing world, social change has not kept pace, especially with respect to the role of females within society. Despite the visibility of the women s rights movement, many governments in developing countries maintain laws and regulations that discriminate against women. In some countries, women have secondary status in society. They may be denied full citizenship, denied access to education and health care, denied justice when crimes are committed against them, and denied property and inheritance rights. 11 This inequity was addressed in the UN Human Development Report with the addition of a Gender Development Index (GDI) and Gender Empowerment Measure (GEM). 12 These composite indices compile data pertaining to gender-related inequalities for both developed and developing nations around the world. The UN Human Development Report, first published in 199, is an independent report commissioned by the United Nations Development Programme (UNDP) that attempts to assess the wealth of a country in terms of the overall well-being of its people and includes indices for health, economic, and social status. It is available worldwide, published in more than a dozen languages, and considered to be an accurate source of data for measures of human development. One such measure, the Human Development Index (HDI), is a composite index of the overall wealth of a nation in terms of socioeconomic factors, including life expectancy, literacy, and per capita gross domestic product (GDP). The HDI has been shown to be a powerful predictor of maternal mortality, accounting for 82% to 85% of the variation in maternal mortality rates between countries. 13 Maternal mortality rates have also been shown to be predicted by economic status, education, and health care. 14 Although the need to empower women in the developed world is mentioned in several sources that discuss maternal mortality, little research has looked at the relationship between gender-related development and cross-national differences in maternal mortality We used objective data compiled by the UNDP as the UN Human Development Report 23 to assess the association between gender-specific factors and maternal mortality. We hypothesized that indices of gender-related inequality would be powerful predictors of maternal mortality rates. Indices included in our analysis show inequalities between males and females in education, political activity, economic status, and health. METHODS Information was obtained from UN Human Development Report (HDR23) tables 12 on the following: maternal mortality rates; total fertility rates; female literacy rates; female combined primary, secondary, and tertiary gross education enrolment ratios; years women received the right to vote; number of seats in parliament held by women; gender empowerment measures; percent female professional and technical workers; ratio of estimated female to male earned incomes; female economic activity rates; genderrelated development indices; and human development indices. Three composite indices published in the UNHDR are included in our analysis: HDI, GDI, and GEM Human Development Index The HDI is a summary measure of three dimensions: (1) a long and healthy life, as measured by life expectancy at birth; (2) knowledge, as measured by the adult literacy rate (with 2/3 weight) and the combined primary, secondary, and tertiary gross education enrolment ratio (with 1/3 weight); and (3) decent standard of living, as measured by GDP per capita (PPP USD). For each dimension, an index was created with minimum and maximum values for each. Performance in each dimension is then expressed as a value 984 NOVEMBER JOGC NOVEMBRE 26

3 Female Education and Maternal Mortality: A Worldwide Survey between and 1. A formula is applied to average the three dimension indices to determine the performance of a country. 2. Gender-Related Development Index The GDI looks at the three dimensions used in the HDI, but it adjusts the average achievement of a country to reflect gender inequalities. A formula is applied to calculate the harmonic mean of male and female indices. The adjusted three dimension indices are placed into the HDI formula to determine the performance of a country. 3. Gender Empowerment Measure The GEM reflects opportunity rather than capability. It addresses gender inequality using three dimensions: (1) political participation and decision-making power, as measured by women s and men s percentage shares of parliamentary seats; (2) economic participation and decision-making power as measured by two indicators: women s and men s percentage shares of positions as legislators, senior officials, and managers and women s and men s percentage shares of professional and technical positions; and (3) power over economic resources, as measured by women s and men s estimated earned income (PPP USD). The equally distributed equivalent percentage (EDEP) is calculated according to population for each dimension. For the political and economic participation dimension, the EDEP is divided by 5, under the assumption that in a fully equal society the GEM variables would equal 5%. GEM is calculated by averaging the three indexed EDEPs. The 23 UNHDR data were used, and only those countries with listed maternal mortality rates were selected. Statistical analyses of data were performed using MINITAB, via polynomial regression analysis, coefficients of simple determination (R-squared values) and observed significance (P values), to examine the relationship of the aforementioned indicators of gender inequality and human development to maternal mortality rates. In this study, R-squared values of more than 7% were considered to be powerful predictors; R-squared values between 4% and 7%, moderate predictors; R-squared values between 5% and 4%, weak predictors, and R-squared values below 5%, negligible. P values of <.5 were regarded as statistically significant. RESULTS Estimated rates of maternal mortality were missing for 27 of the 175 countries listed in the UN Human Development Report 23, and these countries were excluded from our analysis. A list of countries and their associated rates of maternal mortality is available on the UNDP website. 12 Maternal mortality rates in the 148 countries included in this report arise from data for each country dating from 1985 to 21. These reported rates range between zero and 18 deaths per 1 live births. Of the countries with low human development, the rates of maternal mortality range between 35 and 18 deaths per 1 live births. Countries with high human development reported rates of maternal mortality ranging between zero and 13 deaths per 1, with most rates below 5 per 1. In this study, the HDI was the most powerful predictor of variation in maternal mortality rates between countries (R-squared: 82.9%, P <.1) (Figure 1). The GDI was an equally strong predictor of variation in maternal mortality rates, taking into account issues of gender-inequality within each country (R-squared: 81.2%, P <.1) (Figure 2). These indices were both negatively correlated with maternal mortality. One might expect these composite indices to have similar predictive values, as they represent similar dimensions of human development. The third composite index analyzed in this study, the GEM, revealed a much weaker and statistically insignificant association (R-squared: 25%, P =.187) (Figure 3). Measures of female education include female literacy rate (R-squared: 48.6%, P =.39) (Figure 4) and combined primary, secondary, and tertiary enrolment ratio (R-squared: 48.%, P =.4) (Figure 5). Both these measures were shown to be significant and moderately powerful predictors of maternal mortality rates, explaining around 5% of variance. A negative correlation was observed between these measures of female education and maternal mortality. Infant mortality rates were shown to be highly significant and powerful predictors of variation in rates of maternal mortality (R-squared: 77.2%, P =.2) (Figure 6). There was a strong positive correlation between infant mortality and maternal mortality. Total fertility rates (R-squared: 65.4%, P =.424) were shown to be moderately powerful albeit statistically insignificant (P =.424), predictors of variation in rates of maternal mortality. The three measures of female economic activity analyzed in this study female professional and technical workers (R-squared: 16.5%, P =.111), ratio of estimated female to male earned incomes (R-squared: 7.6%, P =.75), and female economic activity (R-squared: 4.6%, P =.634) were all shown to be weak predictors of maternal mortality, explaining less than 2% of variance in the rates of maternal mortality. These indices have low observational significance. Measures of female political involvement include the year women obtained the right to vote (R-squared: 18.1%, P =.574) and seats in parliament held by women (R-squared: 2.%, P =.75). The year women obtained suffrage was a NOVEMBER JOGC NOVEMBRE

4 Figure 1. Relationship between maternal mortality rates and human development indices (value) 12 Maternal Mortality and Human Development Index Maternal Mortality (rate per 1, live births) = **2 S = R-Sq = 81.2% R-Sq(adj) = 81.% Human Development Index (HDI) Value () Best fit curve for data correlating maternal mortality and Human Development Index. Figure 2. Relationship between maternal mortality rates and gender-related development indices (value) 12 Maternal Mortality and Gender-Related Development Index Maternal Mortality (rate per 1, live births) = **2 S = R-Sq = 82.9% R-Sq(adj) = 82.7% Gender-Related Development Index (GDI) Value () Best fit curve for data correlating maternal mortality and Gender-Related Development Index. weak predictor of maternal mortality, explaining less than 2% of variance. The number of seats in parliament held by women was not a predictor of maternal mortality, as it explains a negligible percentage of variance (< 5%). Both these calculations were statistically insignificant (P =.574; P =.75). DISCUSSION Maternal mortality is one of the strongest predictors of the health of a nation and reflects the disparity between wealthy and poor nations more than any other measure of health. 17 As an indicator of inequality, maternal mortality is considered by many to be a measure of women s place in society, 986 NOVEMBER JOGC NOVEMBRE 26

5 Female Education and Maternal Mortality: A Worldwide Survey Figure 3. Relationship between maternal mortality rates and gender empowerment 12 Maternal Mortality and Gender Empowerment Measure Maternal Mortality (rate per 1, live births) Gender Empow erment Measure (value) 3 = **2 S = R-Sq = 25.% R-Sq(adj) =22.5% Best fit curve for data correlating maternal mortality and Gender-Empowerment Measure. Figure 4. Relationship between maternal mortality rates and the rate of female literacy 12 Maternal Mortality and Female Literacy Maternal Mortality (rate per 1, live births) = **2 S = R-Sq = 48.6% R-Sq(adj) = 47.6% Female Literacy (as % of male rate, 15 years and above) 21 Best fit curve for data correlating maternal mortality and female literacy. representing the accessibility of social supports, economic opportunities, and health care. The direct and indirect obstetrical causes of maternal death are well known, and several international programs have attempted to decrease death rates with limited success. Background factors, such as those listed in indices of human and gender-related development, may influence the obstetrical causes of maternal mortality in the developing world. Our results show that HDI values are strong predictors of maternal mortality. This result is consistent with findings from other studies. 13 The lower a country ranks in terms of human development, the higher the expected rate of maternal mortality. This trend is also predictable because the HDI is a composite measure of the overall health of a nation that includes long and healthy life, knowledge, and decent standards of living. This powerful predictive value is NOVEMBER JOGC NOVEMBRE

6 Figure 5. Relationship between maternal mortality rates and the percent of combined primary, secondary and tertiary gross enrolment (females) 12 Maternal Mortality and Combined Enrolment Ratio Maternal Mortality (rate per 1, live births) = **2 S = R-Sq = 48.% R-Sq(adj) = 47.3% Combined Primary, Secondary and Tertiary Gross Enrolment Ratio (%) 1999 Best fit curve for data correlating maternal mortality and combined primary, secondary, and tertiary gross enrolment rate. Figure 6. Relationship between maternal mortality rates and infant mortality rates 12 Maternal Mortality and Infant Mortality Maternal Mortality (rate per 1, live births) = **2 S = R-Sq = 77.2% R-Sq(adj) = 76.9% 1 2 Infant Mortality (rate per 1, live births) 21 Best fit curve for data correlating maternal mortality and infant mortality. also seen when the average achievement of the country is adjusted to reflect gender-related inequalities in the GDI. In addition, the two measures of gender inequality relating to education, female literacy rate, and combined education enrolment ratio are predictors of maternal mortality. The female literacy rate is measured as a percentage of the male rate and is a moderately powerful predictor of maternal mortality with a negative correlation. Therefore rates of maternal mortality tend to be higher in countries where the female literacy rate is lower than the male literacy rate. This relationship also holds true for the combined education enrolment ratio variable that looks at the percentage of females enrolled in primary, secondary, and tertiary levels of education. It is not surprising that maternal mortality is 988 NOVEMBER JOGC NOVEMBRE 26

7 Female Education and Maternal Mortality: A Worldwide Survey Strength and significance of trends calculated during polynomial regression analysis for all variables in the study Variables Number of observations with all variable data R-squared value P Infant mortality rate (Figure 6) Total fertility rate Female literacy rate (Figure 4) Combined enrolment ratio (Figure 5) Year of suffrage Seats in parliament held by women Female professional and technical workers Ratio of estimated female to male earned income Female economic activity Human development index (Figure 1) Gender-related development index (Figure 2) Gender empowerment measure (Figure 3) correlated with a discrepancy in education levels between males and females. Education gives women the knowledge to demand and seek proper health care. In countries where infant mortality rates are high, maternal mortality rates are also high. If access to adequate maternal care is limited in a country, it is not surprising that both maternal and infant deaths will result. The seven other variables analyzed in this study were not shown to have adequate observed significance, likely because over 5% of countries analyzed provided no data (Table). Until these data become available, no conclusions can be drawn on the effects of these variables on maternal mortality. The accuracy of this analysis is dependent on the reliability of data provided in the United Nation s Human Development Report. 12 Listed maternal mortality rates are reported by national authorities. The UNHDR admits that problems of underreporting and misclassification of maternal deaths are ongoing and well documented. UNICEF and the WHO attempt to evaluate these data and make adjustments accordingly to provide the most accurate measure of maternal mortality. As a result, listed rates are only estimates of maternal mortality. It is also not clear how maternal mortality is defined by each country. The UNHDR defines maternal mortality as deaths per 1 live births, yet the International Classification of Diseases (ICD-9) defines maternal mortality as any death in a woman during pregnancy and up to 42 days post partum, 18 thus including deaths associated with abortion and stillbirth. Therefore, variations in how maternal mortality is defined could significantly alter reported rates. A limitation of our study is that countries not providing complete data on measures of human development and gender-related development are excluded. These countries are often the poorest, where good vital statistics registration systems are less common and where one might also expect to find high rates of maternal mortality. 5 When the WHO and UNICEF developed initial global estimates of maternal mortality in 199, the problems of co-linearity were acknowledged because the report uses models based on independent variables. Issues of co-linearity arise in all such statistical associations and may distort the regression statistics. Even so, the UNHDR data provide the most complete source of information available on gender inequality and maternal mortality and should be used to promote the creation of tools to guide improvements in gender equality and maternal mortality. Although some aspects of the relationship between gender status and maternal mortality have been published, the literature is limited and not comprehensive. 17 This preliminary study is only a crude analysis of the relationship of gender status and human development to maternal mortality. Data do, however, suggest a strong relationship between the level of female literacy and education, and maternal and infant mortality. Programs aimed at providing medical care to reduce maternal and infant mortality may have limited success unless carried out in parallel with improved availability of education for women. ACKNOWLEDGMENTS We thank Ms Mekalai Kumanan for help with statistical analyses. NOVEMBER JOGC NOVEMBRE

8 REFERENCES 1. Donnay F. Maternal survival in developing countries: what has been done, what can be achieved in the next decade. Int J Gynaecol Obstet ;7: World Health Organization, Reproductive Health and Research. Available at: reduction_of_maternal_mortality/reduction_maternal_mortality_preface.ht m Accessed: February 23, Current initiatives. Safe Motherhood Organization. Available at: Accessed: February 23, UN Wire. Maternal Mortality Is Not Decreasing In Developing Countries conference, Saving Lives: Skilled Attendance at Childbirth. November 18, 21. Available at: m2872/1_27/ /p1/article.jhtml. Accessed: February 23, Sivard, RL, Women: a world survey. World priorities, nd ed. Washington DC: World Priorities; The World Bank developmental goals. Available at: Accessed: February 23, United Nations. World s women, : trends and statistics. New York: United Nations Publications; De Brouwere V, Tonglet R, Van Lerberghe W. Strategies for reducing maternal mortality in developing countries: what can we learn from the history of the industrialized west? Trop Med Int Health 1998; 3: Chamberlain J, McDonagh R, Lalonde A, Arulkumaran S. The role of professional associations in reducing maternal mortality worldwide. Int J Gynaecol Obstet 23;83: McCaw-Binns A. Safe motherhood in Jamaica: from slavery to self-determination. Paediatr Perinat Epidemiol 25;19: Women s Human Rights. Human Rights Watch World Report Available at: Accessed: February Human Development Report 23, United Nations. Available at: Accessed: February 23, Lee KS, Park SC, Khoshnood B, Hsieh HL, Mittendorf R. Human development index as a predictor of infant and maternal mortality. J Pediatr 1997;131: Hertz E, Hebert JR, Landon J. Social and environmental factors and life expectancy, infant mortality and maternal mortality rates: results of a cross-national comparison. Soc Sci Med 1994;39: Priorities for Safe Motherhood. Available at: Accessed: February 23, Calculating the Human Development indices. Human Development Report 23. Available at: hdr3_backmatter_2.pdf. Accessed: February 23, Shen C, Williamson JB. Maternal mortality, women s status, and economic dependency in less developed countries: a cross-sectional analysis. Soc Sci Med 1999;49: Hoyert DL, Danel I, Tully P. Maternal Mortality, United States and Canada, Birth ;27: NOVEMBER JOGC NOVEMBRE 26