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Maternal and child mortality indicators across 187 countries of the world:
Converging or diverging
Article in Global Public Health · March 2014

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Maternal and child mortality indicators

across 187 countries of the world:
Converging or diverging
a b
Srinivas Goli & Perianayagam Arokiasamy
a
Department of Development Studies, Giri Institute of
Development Studies, Lucknow, India
b
Department of Development Studies, International Institute for
Population Sciences, Deonar, Mumbai, India
Published online: 04 Mar 2014.
To cite this article: Srinivas Goli & Perianayagam Arokiasamy (2014): Maternal and child mortality
indicators across 187 countries of the world: Converging or diverging, Global Public Health: An
International Journal for Research, Policy and Practice, DOI: 10.1080/17441692.2014.890237
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Global Public Health, 2014
http://dx.doi.org/10.1080/17441692.2014.890237
Maternal and child mortality indicators across 187 countries of the

world: Converging or diverging
Srinivas Golia* and Perianayagam Arokiasamyb
a
Department of Development Studies, Giri Institute of Development Studies, Lucknow, India;
b
Department of Development Studies, International Institute for Population Sciences, Deonar,
Mumbai, India
(Received 6 April 2013; accepted 8 January 2014)
This study reassessed the progress achieved since 1990 in maternal and child mortality
indicators to test whether the progress is converging or diverging across countries
worldwide. The convergence process is examined using standard parametric and non-
parametric econometric models of convergence. The results of absolute convergence
estimates reveal that progress in maternal and child mortality indicators is diverging
for the entire period of 1990–2010 [maternal mortality ratio (MMR) − β = .00033,
p < .574; neonatal mortality rate (NNMR) − β = .04367, p < .000; post-neonatal
mortality rate (PNMR) − β = .02677, p < .000; under-five mortality rate (U5MR)
− β = .00828, p < .000)]. In the recent period, such divergence is replaced with
convergence for MMR but diverged for all the child mortality indicators. The results
of Kernel density estimate reveal considerable reduction in divergence of MMR for
the recent period; however, the Kernel density distribution plots show more than one
‘peak’ which indicates the emergence of convergence clubs based on their mortality
levels. For child mortality indicators, the Kernel estimates suggest that divergence is in
progress across the countries worldwide but tended to converge for countries with low
mortality levels. A mere progress in global averages of maternal and child mortality
indicators among a global cross-section of countries does not warranty convergence
unless there is a considerable reduction in variance, skewness and range of change.
Keywords: maternal mortality; child mortality; convergence; divergence; world
countries
Introduction
Maternal and child health are arguably the heart of the Millennium Development Goals
(MDGs; Lawn, Tinker, Munjanja, & Cousens, 2006). The world has barely two and half
years left to accomplish the MDGs of reducing maternal and child mortality to the targeted
level. In the past two decades, ‘maternal, newborn and child health subjects were
engrossing, debatable, and fast moving as people pay greater attention to these subjects,
the data are evolving and, on a positive note, the deaths are falling’ (Ehiri, 2010). Maternal
and child mortality are two of the eight goals adopted by 189 countries in the Millennium
Declaration in 2000. MDG5 set the ambitious target to reduce the maternal mortality ratio
(MMR) by three-quarters during 1990–2015. Similarly, MDG4 aims to reduce under-five
mortality rate (U5MR) by two-thirds during the same period (United Nations, 2010). These
two issues have prompted the global health analysts to drive an increased levels of
*Corresponding author. Email: sirispeaks2u@gmail.com

© 2014 Taylor & Francis
2 S. Goli and P. Arokiasamy
development aid, policy attention and research work (Black et al., 2010; Child Mortality
Coordination Group, 2006; Chowdhury et al., 2007; Countdown Coverage Writing Group
on Behalf of the Countdown to 2015 Core Group, 2008; Goesling & Firebaugh, 2004;
Goodburn & Campbell, 2001; Gregson et al., 2009; Hill et al., 2007; Hogan et al., 2010a;
Murray, Laakso, Shibuya, Hill, & Lopez, 2007; Rajaratnam et al., 2010a; Starrs, 2006).
The estimates of MMRs during 1990–2008 for many countries reveal, for the first
time, a substantial decline of 30–45% in the number of annual maternal deaths worldwide
(Hogan et al., 2010a; Lozano et al., 2011; Rajaratnam et al., 2010a; Yadamsuren et al.,
2010). Hogan et al. (2010a) have reported:
Global maternal deaths have dropped from an estimated 526,300 in 1980 to 342,900 in 2008.
Since 1990, the annualised rate of decline in the maternal mortality ratio has been 1.3
percent, dropping to 251 deaths per 100,000 live births in 2008.
Another study by Rajaratnam et al. (2010a) reported:
Worldwide mortality in children younger than 5 years has dropped from 11.9 million deaths
in 1990 to 7.7 million deaths in 2010, consisting of 3.1 million neonatal deaths, 2.3 million
postneonatal deaths, and 2.3 million childhood deaths (deaths in children aged 1–4 years).
The global decline from 1990 to 2010 is 2.1 percent per year for neonatal mortality,
2.3 percent in postneonatal mortality, and 2.2 percent of childhood mortality. Among the
13 regions of the world, including all regions in sub-Saharan Africa, there is evidence of
accelerating declines from 2000 to 2010 compared with 1990 to 2000. Similarly, the under-
five mortality rate declined 2.1 percent annually during 1990 to 2008, and the death rate for
postneonatal mortality between one month and one year of age declined by 2.3 percent.
Regardless of these notable progresses, a recent United Nations report (2010) on MDGs
evaluation suggests ‘though progress has been made, it is uneven. Moreover, without a
considerable push forward, many of MDG targets are likely to be missed out in most
regions. Old and new challenges threaten to further slow progress in some areas or even
undo the successes achieved so far’. WHO, UNICEF, UNFPA & The World Bank
estimates (2012) also reported ‘nearly 80 percent of all maternal deaths in 2008 crop up in
just 21 countries, and half of all maternal deaths are occurring in 6 developing countries:
India, Nigeria, Pakistan, Afghanistan, Ethiopia, and the Democratic Republic of the
Congo’. ‘A comparison of maternal mortality rates in Canada and Afghanistan in 2008
reveal the most striking disparity between one of the lowest and highest in the world:
7 vs. 1575 maternal deaths per 100,000 live births in Canada and Afghanistan represents
a difference of 251 times’ (John & Catherine T. MacArthur Foundation, 2010). This is a
clear demonstration of the scale of disparity and divergent trend as a result of uneven
progress. For example, the rates of change in the MMR vary widely across countries:
from an annualised rate of decline of more than 8 percent in the Maldives to an increase of
5.5 percent in Zimbabwe during 1990 to 2008. Moreover, only 31 developing countries in
the world are likely to meet the MDG4 goal in case of child mortality indicators. (Rajaratnam
et al., 2010a)
The reported anomalies in the progress of maternal and child mortality indicators provide
a basis to test the convergence hypothesis across 187 countries worldwide in maternal
and child mortality indicators. It may be noted that several previous studies assessed and
reported a remarkable progress in maternal and child indicators (Hogan et al., 2010a;
Lozano et al., 2011; Rajaratnam et al., 2010a; WHO et al., 2012; Yadamsuren et al., 2010).
Global Public Health 3
However, none of these studies attempted to test and quantify whether such progress is
reflected in convergence and at what speed the gap is closing in terms of absolute
convergence in maternal and child mortality indicators for the 187 world countries.
Numerous studies have argued that the global progress in demographic and public
health indicators does not necessarily warrant convergence across countries (Becker,
Philipson, & Soares, 2005; Dorius, 2008, 2010; McMichael, McKee, Shkolnikov, &
Valkonen, 2004; Moser, Shkolnikov, & Leon, 2005; Neumayer, 2004a). However,
theoretically, following homogeneous pre-transition phase of health transition, progressive
transition generates multidimensional geographic heterogeneity, until the reappearance of a
homogeneous post-transition phase (Oeppen, 1999). Based on this perspective while
assessing the progress of health indicators at global and local level, a few studies found
evidence of divergence hypothesis during the initial and progressive stages of health
transition, followed by convergence. Other studies found setbacks in convergence of life
expectancy at birth (LEB) across the countries worldwide (Becker et al., 2005; Bloom &
Canning, 2007; Clark, 2011; Dorius, 2008, 2010; Gächter & Engelbert, 2011; McMichael
et al., 2004; Moser et al., 2005; Neumayer, 2004a). Testing a convergence hypothesis reveals
whether the reported progress in global averages of maternal and child mortality indicators is
contributed only from few developed countries or across all world countries. Therefore, the
critical research question of this study is whether the progress in maternal and child mortality
indicators across the 187 world countries in the recent two decades is heading towards
convergence or divergence? To examine this, we test the convergence hypothesis for
progress in maternal and child mortality indicators across the 187 world countries.
Methods
Data source
This study used a compiled database documented in a report titled ‘Building momentum:
Global progress towards reducing maternal and child mortality’ by Hogan et al. (2010b)
from the Institute for Health Metric Evaluation (IHME), Seattle, USA. This study
assessed progress in four indicators: MMR, neonatal mortality rate (NNMR), post-
neonatal mortality rate (PNMR) and U5MR across the 187 world countries. MMR is
measured as ‘number of maternal deaths per 100000 live births’ and all child mortality
indicators are measured as ‘number of child deaths per 1000 live births’.
Maternal mortality estimates of Hogan et al. (2010b) are considered for being more
robust compared with other available estimates (The Lancet, 2012). Although, Hogan
et al. (2010b) constructed a data-set based mainly on the WHO mortality database (World
Health Organization, 2010), but they supplemented it by systematic review of various
sources of data on maternal mortality and classified them into four types: vital registration
systems; sibling history data from household surveys; data from censuses and surveys for
deaths in the household; and published work reporting population-based studies of
maternal mortality, both national and sub-national. Several issues relating to vital
registration data have been taken into consideration: first, periodic changes in the
International Classification of Diseases (ICD) rules and codes can lead to discontinuities
that are not an indication of true trends. Second, the estimates were adjusted for
misclassification of maternal deaths. Third, the estimates were based on sibling history
micro data from the Demographic and Health Surveys (DHS) and International
Reproductive Health Surveys. Fourth, they undertook a literature review to identify
published estimates of maternal mortality including all citations in the WHO publication
‘Maternal Mortality: A global fact book’ to cross check the results.
Childhood mortality rates were estimated from the pooled data of DHS. The pooling
approach mitigates some of the concerns of bias in the complete birth histories, such as
selection bias in surveys in countries with high prevalence of HIV. However, if microdata
were not available, they obtained tabulated data for children who died and children ever
born by mother’s age and applied the maternal age cohort-derived method. If tabulated
data were also not available, they added estimated values of childhood mortality rates
from DHS reports. They adjusted estimates on the basis of household deaths from single
surveys by use of the growth balance method. When completeness of death reporting was
estimated to be more than 100%, they adjusted the death rates downwards, with the logic
that respondents might be telescoping deaths –i.e., including deaths that occurred outside
the recall period in the period of recall. They used two criteria for identifying outliers:
rates of child mortality that were far beyond the plausible range in view of a country’s
level of development and rates of child mortality that were substantially inconsistent with
other sources of information for the same country that cannot be explained by a known
mortality shock (for more details, see Hogan et al. [2010b] and Rajaratnam et al. [2010b]).
Convergence metrics
According to the Solow (1956) growth model:
if the progress is greater among the developing countries compared with developed countries,
it leads to convergence across the world countries. On the contrary, if the progress is greater
among the developed countries, it widens the gaps leading to overall divergence among
countries. (Barro & Sala-I-Martin, 1991)
Constructing based on this theoretical perspective, this study used three types of
convergence metrics: first, the two-way scatter graphical plots are used to examine the
catching-up process. Second, the volume and speed of convergence are calculated by
using standard parametric econometric models of convergence such as absolute
β-convergence and σ-convergence. Third, non-parametric econometric models of
convergence such as Kernel density estimates and plots are also used to explain the
convergence clubs. The detailed specifications of the methods used in this study are given
below.
Catching-up process
Before estimating β- or σ-convergence, this study assessed the catching-up process, which
is a necessary pre-condition for β-convergence. The catching-up process is assessed
through two-way scatter plots that show the change in maternal and child mortality
indicators ‘y’ as against their initial levels ‘x’. The catching-up process indicates greater
change in laggard countries compared to advanced countries.
Although scatter plots showing the catching-up mechanism do provide some evidence
in the process of convergence, it is not enough to prove or quantify convergence.
Therefore, testing of the convergence hypothesis with an appropriate convergence.
Moreover, few of the previous studies also reported that during the period of progressive
transition, in spite of considerable change or progress, the indicators may not experience
convergence, instead they can indicate divergence (Dorius, 2008; Neumayer, 2004b).
Therefore, this study further used econometric models to test convergence hypothesis.
Absolute β-convergence
Among standard parametric analyses of convergence, we used absolute β-convergence
measure as a method of convergence analyses. An assessment of β-convergence
demonstrates whether the catching-up process of laggard countries with advanced
countries in selected indicators is resulting into convergence or not. Absolute β-
convergence is used where the gap between the rich and poor countries shrinks especially
due to greater progress in laggard countries, a concept that originated from the work of
Barro and Sala-I-Martin (1991). In this study, absolute convergence was tested using the
following linear regression model specified in Rey and Montouri (1999):

Yi;tþk
ln ¼ a þ b: ln Yi;t þ eit
Yi;t
h i
Y
where ln Yi;tþk
i;t
is the mean annualised growth rate of the variable Y in country i in the
period (t, t + k), Yi,t is the value in the initial time t and εit are corresponding residuals.
The speed of convergence is computed as s = 1/T [ln (1 + Tβ)], where, s = speed of
convergence and Tβ is the β-convergence in T period.
According to Dorius (2008), ‘the long term assessments of convergence sometimes
hide trends in convergence for sub-periods. From a policy perspective, progress in recent
periods is much important’. Accordingly, in this study also, we estimated piece wise
absolute β-convergence by disaggregating the entire period (1990–2008) into two parts
(1990–2000 and 2000–2008).
σ-convergence
Another standard parametric econometric model of convergence is σ-convergence
(Friedman, 1992; Quah, 1993), usually measured either by the standard deviation or
the coefficient of variation (CV) in two different periods of time. The measurement of σ-
convergence assumes importance because the presence of a β-convergence will not give a
warranty of σ-convergence. As explained by Quah (1993), the β-convergence is necessary
but not sufficient to achieve the σ-convergence, and therefore, β-convergence should be
complemented by the analysis of σ-convergence (Dorius, 2008, 2010; Sala-I-Martin,
1996; Young, Higgins, & Levy, 2008). Indeed, Quah (1993) and Friedman (1992) both
suggest that σ-convergence is of greater interest since it illustrates directly as to whether
the distribution of an indicator across the countries is becoming more equitable or not.
Therefore, in this study also, we used σ-convergence measure as a method of convergence
analyses. Based on σ-convergence analysis, it is possible to determine if maternal and
child mortality indicators are turning outincreasingly similar across the countries or not.
Friedman (1992) considers that the true test of σ-convergence is a decline in the variance
among individual observations. σ-convergence is estimated by using CV. CV is estimated
as:
rt
CV ¼
l
where σt is the standard deviation (or assimilated measure) of the indicator at the time t.
µ is the mean of the indicator. If the parameter CVt + T declined over time, it implies
convergence.
Although parametric convergence metrics are widely used to examine the conver-
gence process, non-parametric methods offer useful alternative approaches to the analysis
of the convergence process. Among non-parametric convergence metrics, histogram
density estimates and Kernel density estimates are widely used methods. The latter is
closely related to histograms, but can be endowed with properties such as smoothness or
continuity by using a suitable Kernel. ‘The smoothness of the Kernel density estimate is
better interpreted compared to the discreteness of the histogram as Kernel density
estimates converge faster to the true underlying density for continuous random variables’
(Scott, 1979). Therefore, in the second stage, we used Kernel density estimates as they
allow a closer look at changes in the distribution in relative terms. Kernel density
estimation allows data to be modelled without presuming that the data follow a normal
distribution and identify the short-term divergent paths, which may occur in long-term
convergence process (Quah, 1993). Further, the Kernel density estimator is the best
testing tool for identifying the number of clusters of MMR and childhood mortality. The
advantage of Kernel density estimators is that the clusters are not prejudiced by
geographical regions (which is prone to huge heterogeneity within the region). Rather,
they are emerging from the distribution of the prevalence of MMR and childhood
mortality. In this study, we used the Epanechnikov Kernel, which is an optimal in a
minimum variance sense (Epanechnikov, 1969). We used this adaptive bandwidth Kernel
density estimation. If the bandwidth is not held fixed, but varied depending upon the
location of either the estimate (balloon estimator) or the samples (point wise estimator),
this produces a particularly powerful method termed bandwidth Kernel density
estimation. We used this adaptive bandwidth Kernel density estimation. This will provide
more robust estimates and is not likely to affect the results.
A general form of Kernel densities is estimated by using the following equation:
Xn x Xi
^f ð xÞ ¼ 1 k
hn i¼1 h
where, ^f ð xÞ is the density estimation of the variable x, n is the number of observations, h

is the bandwidth (smoothing parameter) and K (.) is the smooth and symmetric Kernel
function integrated to unity.
Results
Descriptive statistics
Table 1 presents summary statistics of maternal and child mortality indicators for the period
1990–2008. Results show that the total number of cases (units) for three of the child
mortality indicators is same for three periods. Among the 189 countries that have taken the
pledge for MDGs, the data on child mortality indicators are available for 187 countries.
However, in case of MMR with seven missing cases, the total number of cases is 180 for all
periods. The results show that the global mean MMR has declined from 280 to 214 maternal
deaths per 100,000 live births during 1990–2008; this represented an overall reduction of
24%. However, the standard deviation of MMR across the 180 world countries rose from
344 to 383 per 100,000 live births during the initial period of 1990–2000, but dropped
modestly from 383 to 302 per 100,000 live births for the recent period of 2000–2008.
A similar pattern is observed for a range estimate of MMR across 180 world countries,
which increased during 1990–2000 but declined during the later period of 2000–2008.
For child mortality indicators, the estimates of mean, standard deviation and range
showed a declining trend during 1990–2008. The global mean of NNMR is 24 per 1000
live births in 1990 declined to 16 per 1000 live births in 2008. Commensurately, the
standard deviation of NNMR also declined from 17 to 13 per 1000 live births during
Table 1. Summary statistics of maternal and child mortality indicators across world countries,
1990–2008.
Indicator Time points Obs Mean SD Min Max Range
MMR 1990 180 280.24 343.72 6 1757 1751

2000 180 279.62 382.89 5 1988 1983
2008 180 214.88 302.49 4 1575 1571
NNMR 1990 187 24.5 16.6 3 70 67
2000 187 19.74 14.47 2 63 61
2008 187 16.18 12.71 1 58 57
PNMR 1990 187 23.66 21.64 2 96 94
2000 187 18.11 17.89 1 78 77

2008 187 14.02 14.83 1 64 63
U5MR 1990 187 70.08 65.42 7 297 290
2000 187 54.37 54.25 4 224 220
2008 187 43.87 44.95 3 180 177
Obs, observations; SD, standard deviations; Min, minimum; Max, maximum.
1990–2008. A similar pattern is observed in case of PNMR and U5MR. In case of

PNMR, the global mean declined from 23 to 14 per 1000 live births during 1990–2008
representing more than 56% decline. While during the same period, the standard
deviation also declined from 22 to 15 per 1000 live births. Global mean and standard
deviation of U5MR decline 30 per 1000 live births and 20 per 1000 live births,
respectively, in the period of 18 years.
Catching-up process
Figure 1 shows the scatter plot of the change in MMR by initial levels of MMR in 180
countries during 1990–2008. The results shown in Figures 1–3 show a mixed pattern of
1000
MMR Change (1990–2008)
500
0
–500
0 500 1000 1500 2000

MMR in 1990
MMR Change (1990–2008) Fitted values
Figure 1. Change in MMR (per 100,000) by MMR in initial period for 180 world countries,
1990–2008.
8
30
S. Goli and P. Arokiasamy

Change in NNMR (1990–2008)
20
10
0
–10
0 20 40 60 80
NNMR in 1990
Change in NNMR (1990–2008) Fitted values
Figure 2. Change in NNMR (per 1000) by NNMR in initial period for 187 world countries, 1990–2008.
60
Change in PNMR (1990–2008)
40
20
0
–20
0 20 40 60 80 100
PNMR in 1990
Change in PNMR (1990–2008) Fitted values
Figure 3. Change in PNMR by PNMR in initial period for 187 world countries, 1990–2008.
change and catching-up process in terms of maternal and child mortality indicators. While
a few of the laggard countries (with higher levels of maternal and child mortality rates in
the initial period) reveal considerable improvement in MMR, but a number of countries
showed either no change or negative change. In a comparative assessment, however, the
results showed a clear catching-up process for child mortality indicators with greater
changes in laggard countries compared to advanced countries (Figures 2–4). Comple-
mentarily, fewer countries experienced zero or negative change and the numbers are very
small compared with countries which showed greater progress in MMR. Overall, three
150
Change in U5MR (1990–2008)
100
50
0
–50
0 100 200 300

U5MR in 1990
Change in U5MR (1990–2008) Fitted values
Figure 4. Change in U5MR by U5MR in initial period for 187 world countries, 1990–2008.
broad patterns of progress are discernible from the laggard countries (Figures 1–4). The
first is a set of countries that moved ahead catching-up mechanism with greater progress
in maternal and child mortality indicators. The second is a set of countries that showed
slow progress; these countries are yet to pick up speed on the progress to result in
substantial catching-up mechanism. And the third set is those countries which have either
stagnated or showed negative progress. Such variations in the patterns of progress across
187 countries may or may not be necessarily result into convergence.
Absolute β-convergence model estimates

Table 2 presents the results of absolute β-convergence model for MMR for 180 countries
of the world. The results reveal that during the last two decades, the progress in MMR is
overall divergent (β =. 00033, p < .574) across the countries of the world. While this
estimate is statistically insignificant, piecewise absolute β-convergence estimates showed
statistically significant divergence (β = .00220, p < .007) in the progress of MMR across
countries of the world for the base period of 1990–2000; this is contrasted by significant
progress in convergence during the later period of 2000–2008 (β = −.00113, p < .027).
The speed of convergence estimates reveals that progress in MMR across the countries is
converging at the rate of 0.11% per year during 2000–2008.
In spite of considerable catching-up process shown by the scatter plot analyses, the
absolute β-convergence estimates for NNMR presented in Table 3 show evidence of
significant divergence (β = .04367, p < .000) in the progress of the NNMR across
countries for the entire period of observation, 1990–2008. However, the convergence
estimates for the sub-periods indicate greater divergence (β = .05584, p < .000) during
2000–08 compared to 1990–2000 (β = .04678, p < .000). The speed of convergence
estimate also shows that the divergence is greater and statistically significant during
2000–2008 (4.6%) than 1990–2000 (3.84%).
Convergence estimates presented in Tables 4 and 5 also showed evidence of
divergence in the progress of PNMR (β = .02677, p < .000) and U5MR (β = .00828,
p < .000) for all the 187 countries during 1990–2008. Results show that the model
estimates are statistically significant. Parallel to the trend observed in the NNMR, the
results for PNMR and U5MR also reveal that divergence is greater during 2000–2008
(β = .04225, p < .000 and β = .011066, p < .000, respectively) than 1990–2000 (β =
.02820, p < .000; β = .00968, p < .000, respectively). The speed of convergence estimates
for PNMR, postneonatal and U5MR also showed that the rate of divergence (−4.62%,
−3.64%, −1.06%, respectively) was greater during 2000–2008 compared to 1990–2000
(−3.22%, −2.18%, −0.77%).
Table 2. β-Convergence estimates for MMR across the 187 countries of the world, 1990–2008.
Speed of convergence
Period β-Coefficient p-Value Adjusted R2 (in % per annum)
1990–2008 .00033 (.00058) .574 .004 −0.03

1990–2000 .00220 (.00080) .007 .035 −0.22
2000–2008 −.00113 (.00050) .027 .021 0.11
Note: n = 180, df = 179, heteroscedasticity-consistant standard errors are reported in parentheses.
Table 3. β-Convergence estimated for NNMR across the 187 countries of the world, 1990–2008.
Speed of convergence
Period β-Coefficient p-Value Adjusted R2 (in % per annum)
1990–2008 .04367 (.00685) .000 .17 −3.22

1990–2000 .04678 (.00789) .000 .15 −3.84
2000–2008 .05584 (.00949) .000 .15 −4.62
Table 4. β-Convergence estimated for PNMR across the 187 countries of the world, 1990–2008.
Period β-Coefficient p-Value Adjusted R2 Speed of convergence
1990–2008 .02677 (.00700) .000 .068 −2.18

1990–2000 .02820 (.00853) .000 .050 −2.48
2000–2008 .04225 (.01152) .000 .062 −3.64
Table 5. β-Convergence estimated for U5MR across the 187 countries of the world, 1990–2008.
Period β-Coefficient p-Value Adjusted R2 Speed of convergence
1990–2008 .00828 (.00186) .000 .0912 −0.77

1990–2000 .00968 (.00223) .000 .087 −0.92
2000–2008 .011066 (.00270) .000 .072 −1.06
σ-convergence model estimates

Figure 5 shows the trends in CV in maternal and child mortality indicators for all 187
countries of the world, during 1990–2008. The trends of CV in MMR, for all countries,
show that the world became more dissimilar in terms of progress in the reduction of
MMR in 2008 than 1990. However, observation of disaggregated trends indicates that the
increase of CV for MMR of countries of the world is sharper during 1990–2000 (0.14
points) compared to the later period of 2000–2008 (0.04 points). Previous literature
reported that the increase in CV for MMR signifies a divergent progress (Dorius, 2008).
However, the rate of divergence in MMR progress slowed (0.14 in 1990–2000 compared
to only 0.04 in 2000–2008) for the recent period of 2000–2008.
The trends of CV for NNMR showed a considerable increase (0.79 in 2008 compared
to 0.68 in 1990) during 1990–2008. The rate of divergence in two disaggregated periods,
1990–2000 and 2000–2008, showed that for both the periods the increase in CV for
NNMR, across the countries was more or less similar suggesting a divergence in the
progress for NNMR. Similar results are observed for PNMR that the trends in CV for
PNMR of 187 countries showed a steep increase during 1990–2008. For a total period of
18 years, the CV increased by 0.14 points (0.91 in 1990 to 1.06 in 2008). The estimates
of CV for U5MR of the countries of the world indicated a steep increase (0.07 points)
during 1990–2000, but in the post-2000 phase the CV increased with declining slope
(0.02 points). Overall, for child mortality indicators, σ-convergence estimates suggest
evidence for the divergence hypothesis during 1990–2008.
MMR PNMR
CV
CV
Period Period
NNMR U5MR
CV
CV
Period Period
Figure 5. Trends in CV in maternal and child mortality indicators in 187 world countries,
1990–2008.
Kernel density estimates

Figure 6 presents the univariate Kernel density estimators and density plots showing the
distribution of maternal and child mortality indicators across world countries. The first
row of Figure 6 shows that the distribution of MMR for all countries of the world for the
year 1990, 2000 and 2008. The plots indicate that a bimodal distribution of MMR across
countries of the world for the base year 1990. However, a mode on the left side with high
peak is located at the lower levels of the MMR = <500 per 100,000 live births and as mall
peak is located in the values of the MMR range from 500 to 600 per 100,000 live births.
A bimodal distribution with ‘two peaks’ is referred in literature as ‘convergence clubs’
(Quah, 1996). However, in 2000, the second peak appeared in plateau shape at MMR
values range from 500 to 1000 per 100,000 live births. This clearly indicates a divergence
trend in MMR across the countries. In 2008, with narrowing distribution particularly
among those countries with low MMR values and the disappearance of any significant
secondary peaks indicated an emerging convergence process in MMR across countries of
the world.
The second row in Figure 6 shows the univariate Kernel density estimators and
density plots for NNMR for three points of time, 1990, 2000 and 2008. A comparative
assessment of results for three periods shows a narrow dispersion in 1990 with the
emergence of ‘two peaks’ in 2000 and the rise in the height of the second peak for the
latest year 2008 thus, indicated evidence of divergence in NNMR across the world
countries. However, it also indicates the convergence across two different clubs of
countries: one is at a low level (NNMR < 20 per 1000 live births) and the second is
between NNMR 25 and 35 per 1000 live births. The results for post-natal mortality also
MMR-1990 MMR-2000 MMR-2008
Density .002 .002 .003
.0015 .0015
Density
Density
.002
.001 .001
.0005 .0005 .001
0 0 0
0 500 1000 1500 2000 0 500 1000 1500 2000 0 500 1000 1500 2000
MMR per 100000 MMR per 100000 MMR per 100000
kernel = epanechnikov, kernel = epanechnikov, kernel = epanechnikov,
bandwidth = 105.5562 bandwidth = 109.6887 bandwidth = 71.1973
NNMR-1990 NNMR-2000 NNMR-2008

.03 .04 .04
Density
Density
Density
.02 .03 .03
.02 .02
.01 .01 .01
0 0 0
0 20 40 60 80 0 20 40 60 80 0 20 40 60
NNMR per 1000 NNMR per 1000 NNMR per 1000

PNMR-1990 PNMR-2000 PNMR-2008
.025 .04 .04
Density
.02
Density
.03
Density
.015 .03
.01 .02 .02
.005 .01 .01
0 0 0
0 20 40 60 80 100 0 20 40 60 80 0 20 40 60 80
PNMR per 1000 PNMR per 1000
PNMR per 1000
U5MR-1990 U5MR-2000 U5MR-2008

.015
.008 .01
Density
Density
Density
.006 .01
.004 .005 .005
.002
0 0 0
0 100 200 300 0 50 100 150 200 250 0 50 100 150 200
U5MR per 1000 U5MR per 1000 U5MR per 1000
Figure 6. Kernel Density estimation and curves of maternal and child mortality indicators for 187
world countries, 1990–2008.
showed similar evidence: the distribution across the countries somewhat narrowed in
2008 compared to 1990. However, there was no clear evidence of convergence; rather it
suggests the emergence of bimodality in the year 2008, indicating the existence of
convergence clubs.
The last row of Figure 6 displays the univariate Kernel density estimates for U5MRs
for the year 1990, 2000 and 2008. The plots reveal that though the distribution of under-
five mortality narrowed in 2000 compared to 1990, the reduction of dispersion in the
distribution of under-five mortality is stagnant during 2000–2008. The results suggest no
clear evidence of bimodality or multimodality, but the distribution in under-five mortality
is not very smooth either, implying much less evidence of absolute convergence.
Reasons for convergence in MMR and divergence in child mortality rates

Table 6 presents the variance, skewness and range of change for maternal and child
mortality indicators during 1990–2008. The results clearly indicated that convergence in
MMR for the recent decade of 2000–2008 is driven by more than 50% decline in
variation (28,764–11,764) and range of change (1583–696), and a considerable increase
in skewness (−1.49 to 2.28) of change across the countries between the two periods of
1990–2000 and 2000–2008. However, during the same period, the decline in variance of
Table 6. Trends of variance, skewness and range of change in maternal and child mortality
indicators during 1990–2000 and 2000–2008 across the 187 countries of the world.
Change
MMR NNMR PNMR U5MR
Characteristics 1990– 2000– 1990– 2000– 1990– 2000– 1990– 2000–

of change 2000 2008 2000 2008 2000 2008 2000 2008
Standard 169.60 108.46 3.92 2.92 5.87 4.66 16.34 12.74

deviation
Variance 28764.94 11764.21 15.40 8.53 34.48 21.72 267.18 162.42
Skewness −1.49 2.28 1.39 1.48 1.02 2.01 1.26 1.78

Range 1583.00 696.00 25.00 20.00 38.00 38.00 98.00 88.00
Minimum −919.00 −127.00 −4.00 −3.00 −12.00 −9.00 −25.00 −19.00
Maximum 664.00 569.00 21.00 17.00 26.00 29.00 73.00 69.00
change in child mortality indicators across the countries was smaller in comparison to the
change observed in MMR. Moreover, for two out of three child mortality indicator results
reveal that the range of change is virtually stagnant. Moreover, for all the child mortality
indicators, the increase in the skewness of change is lower in comparison to the change
witnessed in the case of MMR. These results indicate that there is unequal progress across
countries in spite of the remarkable decline in global averages of child mortality
indicators during 1990–2008.
Discussion
A growing number of studies have assessed the global progress in maternal and child
health indicators. However, a critical constraint in these studies is they did not attempt to
quantify whether the progress has been converging or diverging across the world
countries (Gregson et al., 2009; Hill et al., 2007; Hogan et al., 2010a; Lozano et al., 2011;
Rajaratnam et al., 2010a; Starrs, 2006; Yadamsuren et al., 2010). In this paper, we
attempted to fill this crucial research gap and tested the convergence hypothesis in 187
countries of the world for key maternal and child mortality indicators. We used both
parametric and non-parametric measures of convergence to assess the progress in health
indicators and the results provided a number of fresh insights.
Testing convergence hypothesis for trends in maternal and child mortality indicators
during 1990–2008 using three different types of convergence metrics points out
conundrums in the progress achieved in terms of MDG4 and MDG5. While the graphical
assessment indicated clear evidence of the catching-up process for all the maternal and
child mortality indicators, the convergence model estimates showed a lack of conver-
gence and uneven progress. The results of absolute β-convergence estimates revealed an
over all diverging trend in the progress of MMR for a global cross-section of countries for
the entire period of 1990–2008 contested by a convergence trend for the recent period of
2000–2008. The progress in all child mortality indicators is also divergent which is
accentuated for the recent period of 2000–2008. The results of σ-convergence estimates
revealed a divergence in the progress of MMR and child mortality indicators across the
world countries during the entire period of 1990–2008 and for the sub-periods of 1990–
2000 and 2000–2008. However, on the positive note, the speed of divergence has slowed
down for MMR and U5MRs during 2000–2008. The Kernel density estimates and plots
also supported the results of σ-convergence estimates, which showed the divergence
process, for MMR and child mortality indicators for the entire period but showed
reduction in the speed of divergence for the MMR during 2000–2008.
Nevertheless, the emergence of more than one ‘peak’ in Kernel density distribution is
the indication of presence of convergence clubs. This implies that, though, there is no
evidence of clear convergence process on a global scale, but countries are converging in
different clusters based on their mortality levels. Convergence clubs are located among
countries with two different levels of mortality: the first club represents countries with
low mortality levels (about <300 for MMR, <20 for NNMR and PNMR, <50 for U5MR)
and second club are those countries with high mortality levels (between 500 and 1000 for
MMR, 20 and 40 for NNMR and PNMR, 100 and 200 for U5MR). However, the highest
‘peaks’ of the Kernel density distribution for all the selected variables are located at lower
levels, which implies that a larger number of countries clustered at mortality levels <300
for MMR, <20 for NNMR and PNMR, <50 for U5MR (Figure 6).
Overall, the results suggest that there are no doubts in the fact that there is a
considerable progress in the global averages of both maternal and child mortality
indicators as observed in the previous studies (Gregson et al., 2009; Hill et al., 2007;
Hogan et al., 2010a; Lozano et al., 2011; Rajaratnam et al., 2010a; Starrs, 2006;
Yadamsuren et al., 2010). However, a mere progress in maternal and child mortality
indicators does not warrant a convergence process unless dissimilar progress across
different clubs of the countries is monitored by effective health interventions. From a
policy perspective, it is beneficial to find the reasons of convergence or divergence.
Therefore, this study also assessed the reasons for convergence for the recent period of
2000–2008 in global MMR contrasted by divergence, in child mortality indicators. The
reasons assessed in this study also foster an idea that some countries have been
progressing much faster compared to other countries. The uneven progress among the
laggard countries in MMR during 1990–2000 led to a divergence. During this period, 46
out of 180 countries experienced negative change due to increase in MMR in 2000 in
comparison with MMR levels in 1990. Many of these are sub-Saharan African and
Central Asian countries. However, the situation has changed during 2000–2008, where
only 11 countries have experienced an increase in MMR. Moreover, the level of increase
in MMR is insignificant compared with the level of increase observed during 1990–2000.
Thus, the emerging convergence or reduction in divergence in MMR for the recent period
of 2000–2008 is attributable to the dramatic decline in variance and skewness of progress
in MMR across the world countries. Contrastingly, greater divergence for the most recent
period for child mortality indicators showed that some countries have accelerated
progress while few other countries are virtually stagnant. For instance, the progress
achieved in many of the countries of sub-Saharan Africa and Central Asia is smaller in
comparison with other developed and developing countries. Moreover, the skewness of
change in child mortality indicators across the world countries showed much less
improvement, which could be a strong reason for the recent divergence, in these
indicators (Table 6). Moreover, the literature on maternal and child health indicators
fosters that the change starts with maternal health and reflects on child health (Murray
et al., 2007; Starrs, 2006). Therefore, followed by MMR, in the near future we expect
further reductions in divergence in the progress of child mortality indicators too.
In conclusion, this study illustrates that the global trends in average maternal and
child mortality indicators show the momentum towards progress and development.
However, inter-country disparities and discrepancies in the relative levels of progress
point to divergent development. Based on their assessment of progress in the total fertility
rate (TFR) and LEB, Neumayer (2004b), Dorius (2008), Arokiasamy and Goli (2012) and
Goli and Arokiasamy (2013) concluded that during the progressive transition, divergent
progress is inevitable because the steady state of different countries in terms of their socio-
economic conditions, prevailing policy and resource constraints led to a difference in the
rate of progress. This indicates that though many of the countries across the world made an
effort to eradicate excess and avoidable maternal and child mortality but the progress is
unequal. While the progress in some countries is tremendous but in many countries it is yet
to pick up, stagnant or reversing (Table 6 and Appendix 1 in the supplementary material).
However, a strong programme of action and intervention to bring equity with efficiency
can override this consequence. Thus, the findings of the study provide a strong policy
message that global health policy needs to focus on efficiency, but with equity, because
though both developed and developing countries are progressing in terms of maternal and
child health, there is a large gap between these two groups, which must be reduced.
Therefore, the strategies focusing to eradicate avoidable maternal and child mortality are
needed to focus not only on the progress or change, but also to the convergence of such
progress across the worldwide countries.
Such efforts need identification of challenges in view of achieving MDG4 and MDG5
in the laggard countries and greater efforts in terms of maternal and child health services.
A country-specific intervention strategy has to be adopted to improve maternal and child
health in laggard countries. These countries should receive adequate investment,
especially from local governments. Still, the public health spending on primary health
care in the majority of the developing countries is far below that of many developed
countries (Hopkins, 2010). A strong commitment from local governments is needed to
accelerate progress in order to catch-up not only the MDGs, but also the levels and
standards set by other developed countries in terms of maternal and child health. Global
agencies and leaders need to identify the backbenchers in terms of progress and act as a
creator to push forward and accelerate progress in maternal and child health. Unless the
laggard countries scale-up maternal and child health coverage interventions to create
acceleration in the catching-up process, it is difficult to achieve convergence in the
progress of child mortality indicators worldwide. Another message of this analysis is that
convergence measures can be effectively used as a tool for measuring and monitoring of
equitable and sustainable progress of health outcomes. Convergence rates are also a key
input in the component methods of projection of population and public health indicators.
In an effort to continuously track global and regional progress in public health indicators,
it is important to test the convergence hypothesis for health indicators for every 5 years
by WHO at the global level and the health ministries of the respective countries at the
local level.
Supplemental data
Supplemental data for this article can be accessed here.
Acknowledgements
The authors would like to thank Shawn F. Dorius and Christopher Wilson for their valuable
suggestions on convergence theory and metrics. We also thank Lalit Dandona for his useful
comments on earlier drafts of this paper. This paper earlier presented at 27th IUSSP meeting where
it received valuable comments from John Cleland and Alan Lopez. However, the views expressed
in the paper purely belong to the authors.
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Article in Global Public Health · March 2014

Srinivas Goli Perianayagam Arokiasamy

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Maternal and child mortality indicators across 187 countries of the

*Corresponding author. Email: sirispeaks2u@gmail.com

Another study by Rajaratnam et al. (2010a) reported:

where, ^f ð xÞ is the density estimation of the variable x, n is the number of observations, h

Indicator Time points Obs Mean SD Min Max Range

MMR 1990 180 280.24 343.72 6 1757 1751

2000 187 18.11 17.89 1 78 77

1990–2008. A similar pattern is observed in case of PNMR and U5MR. In case of

0 500 1000 1500 2000

MMR Change (1990–2008) Fitted values

S. Goli and P. Arokiasamy

Change in NNMR (1990–2008)

Change in NNMR (1990–2008) Fitted values

Change in PNMR (1990–2008) Fitted values

0 100 200 300

Change in U5MR (1990–2008) Fitted values

Absolute β-convergence model estimates

1990–2008 .00033 (.00058) .574 .004 −0.03

1990–2008 .04367 (.00685) .000 .17 −3.22

Period β-Coefficient p-Value Adjusted R2 Speed of convergence

1990–2008 .02677 (.00700) .000 .068 −2.18

Period β-Coefficient p-Value Adjusted R2 Speed of convergence

1990–2008 .00828 (.00186) .000 .0912 −0.77

σ-convergence model estimates

Kernel density estimates

NNMR-1990 NNMR-2000 NNMR-2008

kernel = epanechnikov, kernel = epanechnikov, kernel = epanechnikov,

U5MR-1990 U5MR-2000 U5MR-2008

Reasons for convergence in MMR and divergence in child mortality rates

MMR NNMR PNMR U5MR

Characteristics 1990– 2000– 1990– 2000– 1990– 2000– 1990– 2000–

Standard 169.60 108.46 3.92 2.92 5.87 4.66 16.34 12.74

Skewness −1.49 2.28 1.39 1.48 1.02 2.01 1.26 1.78

Proceedings of the National Academy of Sciences, 104, 16044–16049. doi:10.1073/pnas.

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