EDITORIALS
postponement of childbearing by many couples. The continued fourfold higher maternal mortality among blacks demolishes the argument that we have now reached an "irreducible minimum" of maternal deaths. Finally, Schaffner notes the paradox of an increase in preventable maternal deaths over the years, apparently based on increased committee expectations for standards of care, which also serves to emphasize that the battle is not yet over. The subject of maternal deaths has been popular to study because they are fairly easy to identify and the end point of death is definite. As opposed to perinatal deaths, for example, there are no decisions about whether the patient was really alive, weight categories, anomalies incompatible with life, and so on. We all like to deal with the simple and clear cut. Witness any committee faced with long range planning or setting measurable objectives-the sole item that will be discussed to a decision is the time and place of the next meeting. Numbers of maternal deaths are small. They merit continued'study, but not at the intensity of former years, nor to the exclusion of perinatal mortality studies. As opposed to probably 400 direct maternal deaths in the United States in 1977, stillbirths and neonatal deaths will approximate 75,000. Committees already organized should concentrate their experience and consequent educational efforts on the fetus, and a committee geographic base tied into a regional maternal and perinatal health planning area seems most desirable. Lest we become complacent about maternal deaths, however, the world is larger than just the United States. If
one accepts the conservative* estimate of Ravenholt that there were 110 million births on this earth in the year 1975,4 there were at least 50,000 direct maternal deaths. Surely here is a public health problem of great magnitude. It should receive as much attention as smallpox, and one may hope it will have a similar outcome someday.
WARREN H. PEARSE, MD, FACOG *The word conservative is used since the Aird estimates given in the same publication are substantially higher, based primarily on different estimates of births in China. The estimate of at least 50,000 direct maternal deaths is my own, based on a conservative rate estimate of 46/100,000 births.
Address reprint requests to Dr. Warren H. Pearse, Executive Director, American College of Obstetricians and Gynecologists, One East Wacker Drive, Chicago, IL 60601.
REFERENCES
1. History of Maternal Mortality Study Committees in the United States; Marmol, J. G., Scriggins, A. L., and Vollman, R. F. Obstetrics and Gynecology 34:123-138, 1969. 2. Grimes, D. A., and Cates, W. Jr. The impact of state maternal mortality study committees on maternal deaths in the United States. Am. J. Public Health 67:830-833, 1977. 3. Schaffner,W., Federspiel, C. F., Fulton, M. L., Gilbert, D. G., and Stevenson, L. B. Maternal mortality in Michigan: An epidemiologic analysis, 1950-1971. Am. J. Public Health 67:821829, 1977. 4. Population Reports, George Washington University Medical Center, Series J 12, p J212, November, 1976.
A Tool for Health Planners For those who are involved with local health planning, a question that is immediately resolved into a non-issue is whether mortality statistics should be used as one of the measures of the health status of local area populations. No evidence on problems of quality of the data or on inadequacy of the information to identify significant health deficits and their correlates can override the unique characteristics of mortality statistics. Simply put, they represent the only continuous source of information on an unequivocal manifestation of health status that dates back many years and is assured of continuity into the foreseeable future, and the data can be examined on a geographically disaggregated level often down to subareas within a city, for example, or aggregated across civil subdivisions for medical market analysis. The question faced by the user of mortality statistics for planning purposes is how to maximize the utility of this resource. Here there are both conceptual and technical issues, a number of which have been receiving renewed attention. Important contributions on the subject are found in Statistical Notes for Health Planners, a cooperative effort of the National Center for Health Statistics and the Bureau of Health Planning and Resources Development. These reports 816
are systematically probing into the nature of mortality statistics, including their limitations, and presenting statistical approaches to the data that increase their power to measure variability among local areas and to assess trends. The paper, Age-Adjusted Mortality Indexes for Small Areas by Joel Kleinman, in the current issue of the Journal,1 is a significant addition to the primer on the calculation of such indexes and the measurement of sampling variability that appears in issue Number 3, February, 1977 of the Statistical Notes.2 The implications of options that are technically available for adjusting tabulated data on local area mortality to take into account age differentials among areas and changes over time are well known to the health statistician. However, a change from the past for many is the focus on the relative value of the indexes for health planners when faced with the need for indicators of relative health status among communities and changes taking place. Thus high marks are given to the Years of Life Lost (YLL) index which is based on the number of years between age at death and some advanced age; in Kleinman's illustration age 70 is used, others may argue for a more advanced age. Variations in mortality at the younger ages are accordingly emphasized by the YLL AJPH September, 1977, Vol. 67, No. 9
EDITORIALS
index. By way of contrast, the more widely applied Standard Mortality Ratio (SMR) is heavily influenced by differences in mortality at the older ages and this is seen as a disadvantage since "death rates among the elderly are probably least amenable to health planning intervention." Actually, no index that is designed to reflect general mortality can show an impressive effect of such interventions within a reasonable period of time except under exceptional conditions. A major decrease in the death rate in a specific age group, e.g., infant mortality, or in the cause of death categories reflecting mortality related to hypertension would reduce both the YLL and SMR only slightly. The point is that even when planning is directed at improving the general availability and accessibility of health services in disadvantaged areas, effectiveness measures linked to mortality rates need to be particularized to age and cause of death subgroups. These considerations apply with equal force to the application of a mortality index to rank order areas for special attention. The index has the properties of all summary measures, i.e., convenience and an apparent capability of communicating a message that is uncomplicated by a large array of statistics. Also, sampling variability is lower than in agespecific comparisons. But, the summary index cannot usually stand isolated from more detailed mortality measures as
aids in identifying areas or population subgroups where more intensive studies of health issues and programs should be concentrated. Whether the YLL index by itself can serve as such a "preliminary screening measure" is susceptible to testing by examining specific goals of HSAs and the extent to which the YLL identifies the same local areas to be given high priority as disaggregated mortality measures. The result would be a more precise understanding of the utility of the YLL for planning agencies. The presentation in this issue of the Journal and the related treatment in the Statistical Notes for Health Planners should stimulate such explorations. SAM SHAPIRO Address reprint requests to Sam Shapiro, Professor of Health Services Administration, Department of Health Care Organization, and Director, Health Services Research and Development Center, Johns Hopkins School of Hygiene and Public Health, 624 N. Wolfe St., Baltimore, MD 21205. Mr. Shapiro is a member of the Journal Editorial Board.
REFERENCES 1. Kleinman, J.C. Age-adjusted mortality indexes for small areas: Applications to health planning. Am. J. Public Health 67:834-840, 1977. 2. Kleinman, J.C. Mortality. Statistical Notes for Health Planners, National Center for Health Statistics, Health Resources Administration, Dept. HEW, No. 3, February, 1977.
Abortions and Public Policy, 11 Pages 860-862 of the current issue of the Journal contain an estimate of the number of deaths of women of childbearing age to be expected as the result of cutting off Medicaid funds for abortion.1 We regret that this Public Health Brief could not have been published in July and covered by our editorial that month.2 Unfortunately we cannot function as a newspaper does; we have a minimum 2½// month lag time between delivery to the printer and publication of a manuscript, as do most professional journals. It is only on rare and fortuitous occasions that our pages reflect what is "front page news" in the rapidly changing world of the mass media. In this case, all we can say is that the abortion issue was hot in the summer solstice when the U.S. House of Representatives appropriated Medicaid funds with the stipulation that they could not be used to pay for abortions, and the U.S. Supreme Court handed down its decision allowing states to decide whether or not to use public funds to pay for abortions. The Congressional stipulation, in contrast to the Supreme Court's decision, forbids the use of federal funds to pay for abortions even if the mother's life is endangered. Petitti and Cates' estimates do not take into account the effect of canceling out abortions that are deemed medically necessary in order to protect a mother's life. Their calculations are AJPH September, 1977, Vol. 67, No. 9
based on the differentials in risk between abortions and term pregnancies, the substitution of illegal for legal abortions, and the added risk to the mother of delay in obtaining an abortion. As they point out, the exact combination of these effects that will ensue are impossible to predict but, regardless of the combination, the lives lost will be appreciable. Should abortions be denied even to protect a mother's life, the exact effect is also unpredictable, but surely additive. There are, of course, many other costs associated with the withdrawal of Medicaid funds for abortion. Some of them are cited by Petitti and Cates in an older study based on New York City data.3 Although not projected nationally, these social costs were of substantial magnitude. Still further costs could be projected by calculating the calamities avoided by abortions undertaken as a result of an amniocentesis diagnosis, or the predictable effects of a teratogenic agent. These costs can be expressed in terms of women's lives lost and the misery of unwanted and unwelcome children or in the dollars and cents figures of medical and social care and loss of productivity. In any case, one can predict with confidence that confusion and distortion of the health care system will follow in the wake of the variations in state laws that the Court and House actions portend. These are additional, though bitter, reasons for continuing to retain maternal mor817
postponement of childbearing by many couples. The continued fourfold higher maternal mortality among blacks demolishes the argument that we have now reached an "irreducible minimum" of maternal deaths. Finally, Schaffner notes the paradox of an increase in preventable maternal deaths over the years, apparently based on increased committee expectations for standards of care, which also serves to emphasize that the battle is not yet over. The subject of maternal deaths has been popular to study because they are fairly easy to identify and the end point of death is definite. As opposed to perinatal deaths, for example, there are no decisions about whether the patient was really alive, weight categories, anomalies incompatible with life, and so on. We all like to deal with the simple and clear cut. Witness any committee faced with long range planning or setting measurable objectives-the sole item that will be discussed to a decision is the time and place of the next meeting. Numbers of maternal deaths are small. They merit continued'study, but not at the intensity of former years, nor to the exclusion of perinatal mortality studies. As opposed to probably 400 direct maternal deaths in the United States in 1977, stillbirths and neonatal deaths will approximate 75,000. Committees already organized should concentrate their experience and consequent educational efforts on the fetus, and a committee geographic base tied into a regional maternal and perinatal health planning area seems most desirable. Lest we become complacent about maternal deaths, however, the world is larger than just the United States. If
one accepts the conservative* estimate of Ravenholt that there were 110 million births on this earth in the year 1975,4 there were at least 50,000 direct maternal deaths. Surely here is a public health problem of great magnitude. It should receive as much attention as smallpox, and one may hope it will have a similar outcome someday.
WARREN H. PEARSE, MD, FACOG *The word conservative is used since the Aird estimates given in the same publication are substantially higher, based primarily on different estimates of births in China. The estimate of at least 50,000 direct maternal deaths is my own, based on a conservative rate estimate of 46/100,000 births.
Address reprint requests to Dr. Warren H. Pearse, Executive Director, American College of Obstetricians and Gynecologists, One East Wacker Drive, Chicago, IL 60601.
REFERENCES
1. History of Maternal Mortality Study Committees in the United States; Marmol, J. G., Scriggins, A. L., and Vollman, R. F. Obstetrics and Gynecology 34:123-138, 1969. 2. Grimes, D. A., and Cates, W. Jr. The impact of state maternal mortality study committees on maternal deaths in the United States. Am. J. Public Health 67:830-833, 1977. 3. Schaffner,W., Federspiel, C. F., Fulton, M. L., Gilbert, D. G., and Stevenson, L. B. Maternal mortality in Michigan: An epidemiologic analysis, 1950-1971. Am. J. Public Health 67:821829, 1977. 4. Population Reports, George Washington University Medical Center, Series J 12, p J212, November, 1976.
A Tool for Health Planners For those who are involved with local health planning, a question that is immediately resolved into a non-issue is whether mortality statistics should be used as one of the measures of the health status of local area populations. No evidence on problems of quality of the data or on inadequacy of the information to identify significant health deficits and their correlates can override the unique characteristics of mortality statistics. Simply put, they represent the only continuous source of information on an unequivocal manifestation of health status that dates back many years and is assured of continuity into the foreseeable future, and the data can be examined on a geographically disaggregated level often down to subareas within a city, for example, or aggregated across civil subdivisions for medical market analysis. The question faced by the user of mortality statistics for planning purposes is how to maximize the utility of this resource. Here there are both conceptual and technical issues, a number of which have been receiving renewed attention. Important contributions on the subject are found in Statistical Notes for Health Planners, a cooperative effort of the National Center for Health Statistics and the Bureau of Health Planning and Resources Development. These reports 816
are systematically probing into the nature of mortality statistics, including their limitations, and presenting statistical approaches to the data that increase their power to measure variability among local areas and to assess trends. The paper, Age-Adjusted Mortality Indexes for Small Areas by Joel Kleinman, in the current issue of the Journal,1 is a significant addition to the primer on the calculation of such indexes and the measurement of sampling variability that appears in issue Number 3, February, 1977 of the Statistical Notes.2 The implications of options that are technically available for adjusting tabulated data on local area mortality to take into account age differentials among areas and changes over time are well known to the health statistician. However, a change from the past for many is the focus on the relative value of the indexes for health planners when faced with the need for indicators of relative health status among communities and changes taking place. Thus high marks are given to the Years of Life Lost (YLL) index which is based on the number of years between age at death and some advanced age; in Kleinman's illustration age 70 is used, others may argue for a more advanced age. Variations in mortality at the younger ages are accordingly emphasized by the YLL AJPH September, 1977, Vol. 67, No. 9
EDITORIALS
index. By way of contrast, the more widely applied Standard Mortality Ratio (SMR) is heavily influenced by differences in mortality at the older ages and this is seen as a disadvantage since "death rates among the elderly are probably least amenable to health planning intervention." Actually, no index that is designed to reflect general mortality can show an impressive effect of such interventions within a reasonable period of time except under exceptional conditions. A major decrease in the death rate in a specific age group, e.g., infant mortality, or in the cause of death categories reflecting mortality related to hypertension would reduce both the YLL and SMR only slightly. The point is that even when planning is directed at improving the general availability and accessibility of health services in disadvantaged areas, effectiveness measures linked to mortality rates need to be particularized to age and cause of death subgroups. These considerations apply with equal force to the application of a mortality index to rank order areas for special attention. The index has the properties of all summary measures, i.e., convenience and an apparent capability of communicating a message that is uncomplicated by a large array of statistics. Also, sampling variability is lower than in agespecific comparisons. But, the summary index cannot usually stand isolated from more detailed mortality measures as
aids in identifying areas or population subgroups where more intensive studies of health issues and programs should be concentrated. Whether the YLL index by itself can serve as such a "preliminary screening measure" is susceptible to testing by examining specific goals of HSAs and the extent to which the YLL identifies the same local areas to be given high priority as disaggregated mortality measures. The result would be a more precise understanding of the utility of the YLL for planning agencies. The presentation in this issue of the Journal and the related treatment in the Statistical Notes for Health Planners should stimulate such explorations. SAM SHAPIRO Address reprint requests to Sam Shapiro, Professor of Health Services Administration, Department of Health Care Organization, and Director, Health Services Research and Development Center, Johns Hopkins School of Hygiene and Public Health, 624 N. Wolfe St., Baltimore, MD 21205. Mr. Shapiro is a member of the Journal Editorial Board.
REFERENCES 1. Kleinman, J.C. Age-adjusted mortality indexes for small areas: Applications to health planning. Am. J. Public Health 67:834-840, 1977. 2. Kleinman, J.C. Mortality. Statistical Notes for Health Planners, National Center for Health Statistics, Health Resources Administration, Dept. HEW, No. 3, February, 1977.
Abortions and Public Policy, 11 Pages 860-862 of the current issue of the Journal contain an estimate of the number of deaths of women of childbearing age to be expected as the result of cutting off Medicaid funds for abortion.1 We regret that this Public Health Brief could not have been published in July and covered by our editorial that month.2 Unfortunately we cannot function as a newspaper does; we have a minimum 2½// month lag time between delivery to the printer and publication of a manuscript, as do most professional journals. It is only on rare and fortuitous occasions that our pages reflect what is "front page news" in the rapidly changing world of the mass media. In this case, all we can say is that the abortion issue was hot in the summer solstice when the U.S. House of Representatives appropriated Medicaid funds with the stipulation that they could not be used to pay for abortions, and the U.S. Supreme Court handed down its decision allowing states to decide whether or not to use public funds to pay for abortions. The Congressional stipulation, in contrast to the Supreme Court's decision, forbids the use of federal funds to pay for abortions even if the mother's life is endangered. Petitti and Cates' estimates do not take into account the effect of canceling out abortions that are deemed medically necessary in order to protect a mother's life. Their calculations are AJPH September, 1977, Vol. 67, No. 9
based on the differentials in risk between abortions and term pregnancies, the substitution of illegal for legal abortions, and the added risk to the mother of delay in obtaining an abortion. As they point out, the exact combination of these effects that will ensue are impossible to predict but, regardless of the combination, the lives lost will be appreciable. Should abortions be denied even to protect a mother's life, the exact effect is also unpredictable, but surely additive. There are, of course, many other costs associated with the withdrawal of Medicaid funds for abortion. Some of them are cited by Petitti and Cates in an older study based on New York City data.3 Although not projected nationally, these social costs were of substantial magnitude. Still further costs could be projected by calculating the calamities avoided by abortions undertaken as a result of an amniocentesis diagnosis, or the predictable effects of a teratogenic agent. These costs can be expressed in terms of women's lives lost and the misery of unwanted and unwelcome children or in the dollars and cents figures of medical and social care and loss of productivity. In any case, one can predict with confidence that confusion and distortion of the health care system will follow in the wake of the variations in state laws that the Court and House actions portend. These are additional, though bitter, reasons for continuing to retain maternal mor817
