Factors Contributing to Maternal and Child Mortality Reductions in 146 Low- and Middle-Income Countries between 1990 and 2010

Abstract

Introduction: From 1990-2010, worldwide child mortality declined by 43%, and maternal mortality declined by 40%. This paper compares two sources of progress: improvements in societal coverage of health determinants versus improvements in the impact of health determinants as a result of technical change.

Methods: This paper decomposes the progress made by 146 low- and middle-income countries (LMICs) in lowering childhood and maternal mortality into one component due to better health determinants like literacy, income, and health coverage and a second component due to changes in the impact of these health determinants. Health determinants were selected from eight distinct health-impacting sectors. Health determinants were selected from eight distinct health-impacting sectors. Regression models are used to estimate impact size in 1990 and again in 2010. Changes in the levels of health determinants were measured using secondary data.

Findings: The model shows that respectively 100% and 89% of the reductions in maternal and child mortality since 1990 were due to improvements in nationwide coverage of health determinants. The relative share of overall improvement attributable to any single determinant varies by country and by model specification. However, in aggregate, approximately 50% of the mortality reductions were due to improvements in the health sector, and the other 50% of the mortality reductions were due to gains outside the health sector.

Conclusions: Overall, countries improved maternal and child health (MCH) from 1990 to 2010 mainly through improvements in the societal coverage of a broad array of health system, social, economic and environmental determinants of child health. These findings vindicate efforts by the global community to obtain such improvements, and align with the post-2015 development agenda that builds on the lessons from the MDGs and highlights the importance of promoting health and sustainable development in a more integrated manner across sectors.

Fig 1. Relationship between both Log (U5MR) and Log (MMR) and Log (GDP per capita).

The well-known Preston relationship is clearly visible, with correlation coefficients of between -.8 and -.9. A line of best fit curve is added showing a similar slope for both years, as well as a shift rightward and downward in 2010 compared to 1990. There are 170, 179, 162, 173 countries shown respectively (A-D).

Fig 2. Histograms.

Value examined is the relationship of changes in societal coverage level compared to total accounted changes, or (βΔX/(βΔX + XΔβ). The interaction term ΔXΔβ was small, usually negative, and thus ignored (Table A in S1 Appendix).

Fig 3. Contribution of changes in the levels of determinates of health (health interventions, social and environmental determinants) to reductions in U5MR, 1990–2010 (A).

Out of 768 models run, the contribution of factor level changes averaged 89%. Of these, half included a variable for fertility (Log of TFR lagged 5 years), and half did not out of concern for endogeneity. The decomposition to the right shows how these improvements averaged a breakdown by indicator. Details of this latter composition are shown in Table A in S1 Appendix. For uncertainty ranges around each estimate see Figure B in S1 Appendix.

Fig 4. Contribution of changes in the levels of determinates of health (health interventions, social and environmental determinants) to reductions in MMR, 1990–2010.

Out of 432 models run, the contribution of factor level changes averaged 133%, which is rescaled to 100% here. The decomposition to the right shows how these improvements averaged a breakdown by indicator. For uncertainty ranges around each estimate in the see Figure B in S1 Appendix.