1. HOW MANY WOMEN DIE IN
INDIA
The Lancet, Volume 383, Issue 9931, Page 1792, 24
May 2014
doi:10.1016/S0140-6736(14)60839-4 Cite or Link
Using DOI
Copyright © 2014 Elsevier Ltd All rights reserved.

2. How many women die
during pregnancy and
childbirth in India? If you
believe the estimate from
the United Nations, the
number is 50 000.

3. • But if you believe the Institute for
Health Metrics and Evaluation
(IHME), the figure balloons to 71
792. Both numbers are vast, of
course. India has the unfortunate
distinction of being the country with
the highest number of maternal
deaths, whichever way you
calculate the figure.

4. • But if you were India's new Prime-Minister-
elect, Narendra Modi, you might just alter
the urgency with which you acted to reduce
maternal mortality if you believed the UN
figure, which records a remarkable 21 792
fewer maternal deaths than the
independently calculated estimate from a
competing large international collaboration.
It would not be unreasonable if other
Presidents and Prime Ministers, let alone
Ministers of Health, were confused by these
often strikingly divergent results.

5. • 75 countries are officially monitored by
the independent Expert Review Group
on Information and Accountability for
Women's and Children's Health (iERG).
This small group (Joy Phumaphi and I are
co-chairs) was created in 2011 to
monitor, among other measures,
progress towards Millennium
Development Goals 4 (on child
mortality) and 5 (on maternal and
reproductive health).

6. • Our 75 countries of concern
represent 97—98% of all global
maternal deaths. 15 of these
countries must now weigh up
the meaning of differences of
over 1000 maternal deaths
between the two best sources of
data they can turn to. The table
below lists these 15 countries

7. • Each figure uses the UN number as a baseline and
indicates the IHME difference, plus or minus,
compared with that UN estimate. So, 10 875 for
the Democratic Republic of Congo means that
IHME calculates maternal deaths to be 10 875
fewer than the official UN figure. These differences
are not at all obvious when one examines the
headline numbers from each source. IHME's global
estimate for maternal deaths is 292 982. The
equivalent UN figure is 289 000. But at the regional
level, big differences begin to appear. Of the iERG's
75 countries, 42 are in sub-Saharan Africa.

8. • IHME puts total maternal deaths in these 42
countries at 141 252, the UN at 169 976. This
difference of 28 724 maternal deaths is not a small
rounding error. For southeast Asia, IHME estimates
94 275 maternal deaths, the UN 67 310—this time,
26 965 fewer. For the Eastern Mediterranean
region of WHO, the UN estimates 11 084 fewer
deaths than IHME (25 205 vs 36 289). For regional
health leaders, such as WHO's Regional Directors,
these large differences must be perplexing. Just
what are they supposed to advise their member
states when faced with such discrepancies?

9. • Ever since IHME began publishing child and
maternal mortality estimates, differences between
the two groups were smoothed over by arguing
that trends mattered more than individual
numbers. For small differences, perhaps this
explanation is fair. But when differences are large,
the credibility of both estimates risks being
challenged. There is one opportunity to
understand, if not fully resolve, these differences.
Peter Piot, Director of the London School of
Hygiene & Tropical Medicine, chairs a Gates
Foundation funded Independent Advisory
Committee for the Global Burden of Disease. That
committee meets next month in Seattle.

10. • One of its remits is to “engage in
dialogue with other efforts on global
health estimates”. A further goal is to
review strengths and weaknesses of the
GBD's methods. But this second
objective will solve only half of the
problem. Someone also needs to assess
the strengths and weaknesses of the
UN's methods. Peter Piot's committee
could consider conducting a careful
comparison of methods used by both
the UN and IHME.

11. • When Modi asks how many Indian
women die during pregnancy and
childbirth, he deserves a better
answer than a number that varies by
over 20 000 deaths. One also hopes
that Modi's likely confusion will
motivate his new Government to
invest in India's neglected systems of
civil registration and vital statistics.