Mortality data are hard to find The biggest stumbling block to tracking maternal health trends is the paucity of good data. Most developing countries do not have vital registration systems that capture 4 Connections 5 Innovations Continued on page 2 6 Ripple effect Dr. Christopher Murray introduces IHME’s first newsletter For more information, please visit IHME’s Web site: www.healthmetricsandevaluation.org or contact us at [email protected] or +1-206-897-2800 1
5 Innovations IHME’s recently published work examines global health aid, diabetes, and more
6 Ripple effectIHME helps Brazil calculate effects of death, disease
Even years later, Dr. Maureen Mayhew cannot shake the image of a woman being brought into the rural clinic where she was working in Afghanistan.
She had been carried in a wheelbarrow for 10 days, bleeding from her uterus after a difficult childbirth that left the child dead and the mother near death.
“I thought what a terrible and unfortunate situation it is that women have to die to have kids,” said Mayhew, a University of British Columbia maternal health specialist who has frequented Afghanistan for the past decade.
It’s because of the state of maternal health in places like Afghanistan that the Institute for Health Metrics and Evaluation (IHME) has launched a four-part effort to investigate the state of maternal health worldwide and the effectiveness of interventions aimed at preventing women and their children from dying prematurely. The effort includes:
•Turningovereverystoneinorderto uncover new data sources for estimating the number of women who die every year from complications related to pregnancy and childbirth.
•Studyinghowmanywomengivebirthinamedical facility, or with the help of a skilled birth attendant – such as a doctor, nurse, or midwife – or some combination of both.
•Narrowingthefocustooneofthecountrieswith the greatest disparities in maternal mortality: India. Researchers are attempting
IHME assesses threats to maternal health and interventions that work
BENEATH THE SURFACE
Continued on page 2
Photo by Dr. Maureen Mayhew
An Afghan mother and child in 2000.
to gauge the effectiveness of financial incentive programs to encourage women to give birth in medical facilities.
“One of the Millennium Development Goals aims to lower maternal mortality by 75% between 1990 and 2015, yet from what our research is showing so far, that simply will not happen,” said Dr. Stephen Lim, an IHME researcher and University of Washington Assistant Professor of Global Health. “We do think there are some bright spots, and we want to provide better estimates than were previously available to show where progress is being made in some countries and, eventually, why progress is not being made in other countries.”
Mortality data are hard to findThe biggest stumbling block to tracking maternal health trends is the paucity of good data. Most developing countries do not have vital registration systems that capture
For more information, please visit IHME’s Web site: www.healthmetricsandevaluation.org or contact us at [email protected] +1-206-897-2800
THE DIRECTOR’S VIEW BENEATH THE SURFACE (continued)
Two years ago, a small group of us started the Institute for Health Metrics and Evaluation at the University of Washington in an attempt to create something new: a research institute with a home in academia that would operate with the independence of a non-governmental organization.
Surrounded by a century of public health research, we plunged into the data that existed to find the gaps and areas that needed improvement. We now are working to uncover new data sources and create new methods and tools, making all of our discoveries freely accessible to all.
Within a world-class university and with the stability of long-term funding from the Bill & Melinda Gates Foundation and the state of Washington, we have attracted some of the leading minds in quantitative analysis to join us as faculty members, research scientists, and fellows. That critical mass of talent, funding, and real-world experience – operating free of political advocacy and personal conflicts of interest – helps make us unique and brings with it a great responsibility to deliver on our mission. We aim to improve the health of the world’s populations by providing accurate, relevant, and comparable information on population health, its
determinants, and the performance of health systems. We want to go beyond best guesses to investigate accepted practices and to prove whether a program is meeting its objectives.
A key part of our mission is helping people understand how we gather and analyze data, where we are focusing our research, and what effect our work is having. IHME Impact is a quarterly newsletter that attempts to answer those questions with four components:
1. Beneath the Surface will tell the stories behind our research, offering an early glimpse of work in the pipeline or providing new detail on published material. In this issue, we describe how our research teams are studying maternal health from four different vantage points.
2. In Connections, we will showcase some of our programs and partnerships. In this issue, we feature our new cohorts of Post-Bachelor and Post-Graduate Fellows and our new Master of Public Health track.
3. Our research is constantly being examined internally by our teams, our collaborators, and often our scientific oversight advisors before being submitted to journals for rigorous peer review. Innovations will compile our most recently published work.
4. In Ripple Effect, we will capture some of the markers of our success, including our ongoing collaboration with researchers in Brazil.
Our goal is to produce a newsletter that is informative, engaging, and useful. We welcome your thoughts.
Sincerely,
Christopher J.L. MurrayInstitute Director and Professor of Global Health
all births and deaths, and because maternal deaths are relatively rare, they are difficult to estimate using surveys. Even when deaths are recorded, they sometimes are not identified as maternal.
“Doctors may be reluctant to write it down as a maternal death because it might hurt their reputation,” said Mollie Hogan, an IHME researcher working on her PhD at the UW. “This can make accurate identification of maternal deaths a challenge even in places with very good vital registration systems.”
Hogan is building on work done by the World Health Organization (WHO) in tracking maternal mortality. WHO produces a report every five years that mostly relies on national health surveys to estimate the number of maternal deaths. Hogan is finding new data sources to fill in gaps and examine trends, and she is analyzing the numbers using a variety of methods that will more accurately determine the likely range of estimates for a given year – what is known as the confidence interval.
Hogan hopes to publish her work in 2010.
Progress slow in skilled birth attendance coverageIn the meantime, on a parallel track, Lim and his team are taking a critical look at progress made in encouraging women to either give birth in a hospital or clinic or to have a skilled birth attendant on hand during the delivery.
His team has systematically compiled health surveys going back 20 years for more than 140 countries. In some cases, the researchers have surveys that have been conducted at regular intervals, allowing them to build a consistent time trend. In other cases, they have no surveys at all, and the team has had to develop statistical modeling methods to estimate trends in those countries. They are using a technique pioneered by Lim and IHME Post-Bachelor Fellow David Stein called bidirectional distance-
dependent regression to create a trend line using past, present, and future survey data and data from a given country’s health or census agencies.
The research so far has shown that, despite pronouncements from developed countries about focusing on maternal health, the rate of progress has remained almost constant.
“The numbers have gone up slowly, but there has not been an acceleration of coverage in the use of skilled birth attendants,” Lim said. “It looks like we are where we would have been even without the Millennium Development Goals. Unlike AIDS or malaria or TB, there just hasn’t been the same level of funding or concentrated effort made to improve maternal health.”
Presence of skilled attendants at birth improves neonatal survival rateThe team also has been addressing another critical and, to date, unanswered question: If women give birth with skilled attendants or in a health care facility, by how much does this actually improve health outcomes for
their babies? To answer that question, the team analyzed health surveys that had treatment and outcome information for more than 10,000 births and used a statistical matching technique in a way that breaks new ground by linking skilled birth attendance, in-facility births, and neonatal deaths.
“In this sample, skilled birth attendance and in-facility births reduce the probability of neonatal death significantly,” said Rebecca Myerson, an IHME Post-Bachelor Fellow earning her Master of Public Health degree from the UW while working with Lim.
Myerson first became interested in health care disparities in the developing world while studying psychology in China as a Fulbright scholar.
“I was fascinated by the different kinds of medical care available to people in different parts of the country,” Myerson said, adding that quality of care appeared to depend on geography, transportation, and cultural differences within the country.
India tries a new approachDr. Lalit Dandona, an IHME researcher and UW Professor of Global Health, is trying to track changes in the use of skilled birth attendants and in-facility births in India. India saw major improvements in birth care between 1998 and 2004, especially in the Northwest. Since then, the country has launched a major new initiative that pays mothers a financial incentive to deliver children at a health facility. It also pays providers to use a medical facility for the birth.
“No one has done any research to properly evaluate whether these incentive programs work,” said Lim, who is working with
Dandona on the project. “Hopefully we will have a good sense of that fairly soon.”
Dandona has gathered the results of national district-level health surveys from 1998 and 2004. Data from a similar survey done in 2008 on more than 700,000 households across the country are likely to be available soon. His team plans to track down additional data sources to augment findings from these surveys.
“Data from several other sources will also be needed to understand systematically whether financial incentives for giving birth at health facilities are working,” Dandona said. “Such evaluations of population health interventions are
necessary to inform effective utilization of societal resources in India.”
Mayhew, Clinical Assistant Professor at the University of British Columbia, and other researchers are eager to see the results of IHME’s work related to maternal health. She’s skeptical that women will break with tradition and have their births in a medical setting or with someone other than their mothers-in-law or sisters present, but she hopes that a better understanding of the problem will lead to innovative solutions.
“You see so many things in places like Afghanistan that you try not to judge but that you know are not good for the mothers or their children,” Mayhew said. “Pushing on the abdomen to get the baby out. Cutting the cord with some important person’s shoe. Using cow dung to stop bleeding. These are all detrimental practices, and we need to find ways to change them.
“There’s just no reason, with all the medical technology and knowledge we have, that women should still be dying at some of the rates we see in poor countries.”
William Heisel,Senior Communications Officer, IHME
Photo by Dr. Maureen Mayhew
An Afghan woman cradles her child after giving birth at home.
BENEATH THE SURFACE (continued)
“Unlike AIDS or malaria or TB, there just hasn’t been the same level of funding or concentrated effort made to improve maternal health.” Dr. Stephen Lim
IHME fellowships create future leaders in global health
CONNECTIONS
IHME welcomed two new cohorts to its Post-Bachelor Fellowship and Post-Graduate Fellowship programs in fall 2009.
TheInstitute’sfellowshipprogramsstrengthenthefieldofhealthmetricsandevaluationbycultivatingandtraining tomorrow’s leaders in global health, developing the fellows’ research andanalyticalskillsaswellastheirunderstanding of the global health landscape.
Fall 2009 Post-Graduate Fellows(pictured below, left to right):
M. Nathan Nair grewupinBuffalo,NY,andreceived both his MD and MPH degrees from Columbia University. At IHME, he is partoftheFunctionalHealthStatusworkgroup.
Sean Green is from Charleston, SC, and earned his PhD in Engineering and Public Policy from Carnegie Mellon University. He is in the Causes of Death and Models work groups.
Fall 2009 Post-Bachelor Fellows(pictured above, left to right):
Stephanie Ahn, originally from Pasadena, CA, received her Bachelor of Arts degree inPoliticalEconomyfromtheUniversityofCalifornia, Berkeley. She is in the Causes of Death work group.
Lisa Rosenfeld, originally from Stamford, CT, earned her Bachelor of Arts degree in Government from Harvard University. At IHME,sheisintheEffectiveCoverageworkgroup.
Joseph A. Hoisington, of Chicago, IL, received his Bachelor of Science degree in MathematicsfromtheUniversityofIllinoisat Urbana-Champaign. At IHME, he is in the EffectiveCoverageworkgroup.
Leslie Mallinger comes from Warren, OH, and earned her Bachelor of Science degree inMathematicalBiologyfromHarveyMudd College. She is in the Common Indicators work group.
Kathryn Andrews is from Lyman, ME, and received a Bachelor of Arts degree in EnglishmodifiedwithPublicHealthStudiesfrom Dartmouth College. She is in the CommonIndicatorsandEffectiveCoveragework groups.
Megan Costa comes from Stockton, CA, earning her Bachelor of Arts degree in Biological Anthropology from the University of Washington. She is in the Mortality work group.
Master of Public Health program
IHME has created a new Health Metrics andEvaluation(HME)trackoftheMaster of Public Health program within the UW’s Department of Global Health.
Thisfirst-of-its-kinddegreeprogram,launched in fall 2009, is designed for students intending to pursue careers inquantitativeresearch;methodsandmodelingdevelopment;surveydesignandanalysis;healthsystemandprogramevaluation;orpolicyanalysis.
Spencer James, of Port Angeles, WA, received his Bachelor of Science degree in Biochemistry from the University of Washington. At IHME, he is in the Common Indicators work group.
Mengru Wang, originally from Sydney, Australia, earned a Bachelor of Arts degree in Biology, Culture, Health, and Science from Mount Holyoke College. She is in the Causes of Death work group.
Raymond Zhang, of Dublin, CA, received his Bachelor of Arts degree in Economics andMolecular/CellBiology-Immunologyfrom the University of California, Berkeley. HeisintheCostingworkgroup.
Laura Dwyer, of Naperville, IL, earned her Bachelor of Arts degree in Biology and Chemistry from Greenville College. At IHME, she is in the Mortality work group.
Iran traffic accidents more deadly than anywhere else
More than 30,000 people die annually in Iran from road traffic injuries, a rate of 44 people per 100,000, compared to 29 per 100,000 in sub-Saharan Africa and 19 per 100,000 globally.
Innovation: In addition to fatalities, researchers calculated the impact of nonfatal traffic-related injuries – reduced function, disability, or premature death, known as disability-adjusted life years (DALYs). Iranians lost 1.3 million years of healthy life due to traffic injuries, making road traffic injuries the leading cause of DALYs in Iran in 2005.
Naghavi M, Shahraz S, Bhalla K, Jafari N, Pourmalek
F, Bartels D, Puthenpurakal JA, Motlagh ME.
Adverse Health Outcomes of Road Traffic Injuries in
Iran after Rapid Motorization. Archives of Iranian
Medicine, May 2009
Global health aid soars, boosted by private donors
Health aid for developing countries has quadrupled over the past two decades – from $6 billion in 1990 to nearly $22 billion in 2007. Private citizens, private foundations, and NGOs now make up a larger piece of the health assistance pie, shifting the paradigm for health aid away from governments and agencies such as the World Bank. Health aid primarily goes to the poorest and unhealthiest countries, with notable exceptions.
Innovation: Researchers captured the most comprehensive picture to date of the total amount of private and public funding going to global health projects spanning
two decades. Prior to this report, nearly all private philanthropic giving for health was unaccounted for.
Ravishankar N, Gubbins P, Cooley RJ, Leach-Kemon
K, Michaud CM, Jamison DT, Murray CJL. Financing
of global health: tracking development assistance
for health from 1990 to 2007. The Lancet, June
2009
Surveys may muddle health status monitoring
Researchers hoping to find out whether US citizens are becoming healthier or getting sicker over time should be wary when using survey results based on self-reported health. IHME evaluated four national surveys from 1971 to 2007, covering more than 900,000 adults. While one set of surveys showed that Americans were increasingly likely to report “fair” or “poor” health over the past decade, another set of surveys showed the opposite trend. While researchers found responses to this question are good predictors of health care utilization and even mortality at the individual level, they are too inconsistent to be used to measure trends in overall population health.
Innovation: The team analyzed the structure of survey questions and found particular problems with the reliability of surveys that ask people to rate their health based on multiple choice responses with only a few options.
Salomon JA, Nordhagen S, Oza S, Murray CJL. Are
Americans Feeling Less Healthy? The Puzzle of
Trends in Self-rated Health. American Journal of
Epidemiology, August 2009
Diabetes dodges diagnosis in some states
The rate of diabetes in the US varies widely, as does the rate of diagnosis, depending in part on which state a person lives in, race, and whether the person has insurance. The prevalence of diabetes in the US was 13.7% among men and 11.7% among women aged 30 or older.
Diabetes prevalence in US males aged 30-59
Innovation: IHME and Harvard researchers evaluated data from two national health surveys spanning 2003 to 2007, estimating state-level prevalence of both diagnosed and undiagnosed diabetes cases. For the first time, they were able to describe the impact of diabetes state by state – both the total prevalence of the disease and the estimated proportion of undiagnosed diabetes.
Danaei G, Friedman AB, Oza S, Murray CJL, Ezzati
M. Diabetes prevalence and diagnosis in US states:
analysis of health surveys. Population Health
Metrics, October 2009
The generation of skeptical optimists
After being invited by The Lancet editor Richard Horton, IHME Post-Bachelor Fellows wrote a commentary for the scientific journal, making a compelling case for improving the availability and quality of health data. They underlined that while facts about the weather and popular culture are at this generation’s fingertips, accurate health data remain elusive.
The fellows proposed democratizing the process of gathering data, helping policymakers and field workers in low-income countries focus on raising the level of data quality.
IHME helps Brazil calculate the effects of death and disease
RIPPLE EFFECT
OswaldoCruzFoundation,anarmoftheBrazilian Ministry of Health and one of LatinAmerica’sleadinghealthinstitutions.To help guide their work, the researchers invited Lozano to speak at a conference in November in Rio de Janeiro and to help develop a new partnership with IHME.
“This is a crucial moment for Brazil in terms of understanding the extent of the health challenges we have in the decades to come,” said Dr. Joyce Schramm, one of thefoundation’sleadburdenofdiseasescientists.“BringingDr.Lozanoherewaslike bringing in our forefather to help us raiseourchild.Andstrengtheningourtieswith IHME will help us make sure that we are using the best methods possible and that we are always looking for ways to innovate.”
Lozano told the crowd that the world hadseenprofoundchangesincehefirstbecame interested in the global burden of diseasein1993,atimewhenresearcherscould not rank with certainty the 10 leading causes of death worldwide.
Lozano, while working at the Mexican HealthFoundation,helpedleadtheworld’sfirstnationalburdenofdiseasestudy.Usingthe concept of disease burden – including years lived with disability and healthy years
of life lost – is the best way for countries totranslatepublichealthrealitiesintoevidence-basedandcost-effectivepoliciesandinterventions,Lozanosaid.
“How can we know if the investment inourhealthsystemismakingpositiveresults?” Lozano asked. “If we say for each dollar, you are going to gain a number of years instead of losing years of life, you can convince people more easily that this is a worthwhile place to put money.”
Lozano and other faculty members at IHME are leading a new global burden of disease study that will update the workdonein1998.Incollaborationwithinstitutionsaroundtheworld,IHMEresearchersplantofinishthestudybytheendof2010,updatingallofthedatafrom1990tothepresentandprojectingthedata forward to 2020.
Theyalsoplantomakesignificantimprovementsoverpreviousiterationsofthestudy.Forone,IHMEisconductingsurveys throughout the world to help assigndifferentweightstodifferentstatesofhealth.TheInstitutealsoisworkingclosely with outside experts to create a more transparent process that will allow researchers in Brazil and throughout the world to replicate IHME’s results.
Schramm and Lozano hope the Oswaldo CruzFoundationandIHMEcanworkcloselyincomingyearstorefineBrazil’swork in studying disease burden.
“The burden of disease results have had a very strong impact on changing the way people think about public health in Brazil,” Schramm said.
“We are talking about making choices about where we should spend a limited amount of health funding and what are the best choices for improving public health overall.”
William Heisel,Senior Communications Officer, IHME
IHME researchers returned to Brazil recently to check in on a study they helped give birth to more than a decade ago.
In 1998, three leading researchers who are now part of IHME traveled to Brazil totrainscientistsinmethodsusedtoinitiatethecountry’sfirstburdenofdisease study: Dr. Christopher Murray, then Director of the Harvard Burden of DiseaseUnit;EmmanuelaGakidouofHarvardUniversity;andDr.RafaelLozanofromtheMexicanHealthFoundation.
ThiswasthefirsttimeBrazil,theworld’sfifthlargestcountry,hadattemptedtosystematicallyidentifythemajorcausesofdeathandsufferingamongitsnearly200 million people.
Thestudysparkednewconversationsabout public health and health resources. Brazilian researchers and health ministers have built on that foundationalworkduringthepast10years. For example, they developed more extensive surveys to understand the variety and extent of mental illnesses in the country.
Now they are embarking on a new burden of disease study through the
Dr. Rafael Lozano discusses IHME’s research at a recent symposium. Photo by Kelsey Pierce
