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How Big Is Your Universe?

Ignorance is not bliss - certainly not for a government trying to explain the repeated failure to avert an estimated 100,000 preventable maternal deaths each year. Last month I traveled through rural India to try to understand why so many women there die from pregnancy-related causes, despite the Indian government's clear investment in programs for reducing maternal mortality. I think I found at least part of the reason: no one knows. I don't mean to say that no one knows what causes maternal death and disability. I mean that no one, certainly not in rural India, is gathering enough information about maternal deaths, near-deaths, and their causes to know why they continue despite the host of health-related programs.

Preventable deaths are tragic but they are doubly so when society learns nothing from them for the future. It's even worse when planners are left to guess how many women are even dying of such preventable causes. A former senior government official described a common situation: when a woman - let's call her Rani - dies of a heart attack after childbirth, the doctor certifies that the cause of death is cardiac arrest, failing to mention that she had just given birth and was hemorrhaging.

While poor death registration and cause of death classification is not the stuff of international maternal mortality conferences, let alone popular TV shows, its practical and long-term impact on public health is enormous. It means other women won't benefit from the lessons of a death like Rani's. In such a case, the lack of information is unlikely to bring about the improved nutrition, care during pregnancy and access to emergency obstetric care for women in and around the woman's village that might save others in her situation.

Seemingly mundane administration - the accurate reporting of maternal deaths and their medical causes through national civil registration systems - is crucial for sustained maternal mortality monitoring. Under current conditions, the UN Millennium Development Goal on maternal mortality, set by the international community to be achieved by 2015, will likely be achieved more than 60 years off the target date. According to health analysts, south Asian countries are set to achieve this goal of reducing maternal mortality by 75 percent only by 2076. The prediction for sub-Saharan Africa is far worse.

The UN said last year that it intends to monitor the progress toward the Millennium Development Goals. But health experts cannot glean the trends in maternal mortality from the available data.

Now, accurate information may not sound like a particularly powerful medical intervention. But it is essential. Beyond their use in monitoring, this data are of enormous importance to those who are trying to make the best use of limited resources for health planning.

At least in the developed world, women who do not have access to timely health care leave a trace of what happened to them. The civil registration system captures their death and cause of death. But in countries such as India, where one pregnant woman is said to die every five minutes, more often than not, the health information system is oblivious of such deaths. More disturbing, even where the death is captured, the cause of death is many a times wrongly or inadequately classified, leading to a false sense of progress. In Rani's case above, while on paper one maternal death has been reduced, in reality, the death was poorly classified.

A related Millennium Development Goal states that countries should ensure universal access to reproductive health care by 2015, but that can only happen if all births and deaths are accurately recorded. Not knowing the size of the "universe" makes the goal of universal access meaningless.

Having crossed the halfway mark to 2015, the international community cannot afford to lose more time. International agencies and western states should put their financial and technical resources together to energize the civil registration systems in developing countries. The Millennium Development Goals Africa group has predicted that improving the civil registration system costs a paltry 10 US cents per person.

To be sure, the best reporting systems cannot eliminate maternal mortality and disability. However, decades of research have shown that reporting is a critical first step in determining what policies and measures are needed to lower the risk of death in pregnancy and childbirth.

The United States, with its own strong registration system, should take the lead in developing a strong global monitoring system and intervene to strengthen the systems of other countries in the developing world. Unless this is done, and done immediately, 2076 will come and go, and the international community will continue to unravel the mystery of whether there has been any progress in ending the scourge of maternal mortality.

Hopefully it will mean fewer deaths for women like Rani in the future.

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Aruna Kashyap is the Asia researcher for the Women's Rights Division of Human Rights Watch.

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