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Comment by tyoma | Hacker News Reader

Kind of relevant: https://www.noahpinion.blog/p/how-many-of-our-facts-about-so...

> In 2021, Joseph et al. published a paper in Obstetrics & Gynecology demonstrating that the entire recorded increase in maternal mortality since 2003 was due to a change in the way data was gathered. In 2003, U.S. states began to include pregnancy checkboxes on death certificates. This led to a whole lot more women who died while pregnant being identified as such. The apparent steady increase in maternal mortality was due to the fact that states adopted this new checkbox at different times:

> In fact, when the authors looked at the common causes of death from pregnancy, they found that these had all declined since 2000, implying that U.S. maternal mortality has actually been falling. Meanwhile, a CDC report in 2020 had found the same thing as Joseph et al. (2021) — maternal mortality rose only in states that added the checkbox to death certificates.

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The CNN article is about this [1] study, which is based on OECD 2023 maternal mortality data. OECD says here [2] about "Definition and Comparability":

> Maternal mortality is defined as the death of a woman while pregnant or during childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from unintentional or incidental causes. This includes direct deaths from obstetric complications of pregnancy, interventions, omissions or incorrect treatment. It also includes indirect deaths due to previously existing diseases, or diseases that developed during pregnancy, where these were aggravated by the effects of pregnancy.

Edit: [1] Also references [3], a 2022 CDC report saying over 80% of pregnancy-related deaths were determined to be preventable.

[1] https://www.commonwealthfund.org/publications/issue-briefs/2...

[2] https://www.oecd-ilibrary.org/sites/1ea5684a-en/index.html?i...

[3] https://www.cdc.gov/maternal-mortality/php/data-research/?CD...

That may be relevant to something, but not to why the difference is so drastic between Norway and US.

It is indicative of the US healthcare system, however, that up until 2003 it wasn't even known, statistically, that women were actually dieing of childbirth.

NVSS has reported monthly updates on this since the 60s, it's wrong to say it wasn't known statistically I think. Maternal mortality review committees have existed since the 1930s also which provide extra data. Maternal mortality is one of the most important vital metrics to track for any country so it indeed would be surprising not to have more data.

It is very relevant. The US definition of maternal death is very expansive. The expanded definition counts any reason a woman who was recently pregnant and dies.

The prototypical example is murder by a spouse. While tragic and extremely important to collect for policy reasons, it is not what “maternal death rate” typically measures.

> ... murder by a spouse ... is not what “maternal death rate” typically measures

That is a good example.

While perhaps unrelated to pregnancies, it is incidentally another difference between US and Norway.

You can't say that from these statistics if the statistic in Norway does not include murder by spouse.

That is correct.

I am making that claim without backing it up by references.

My point is that there are other correlated factors that explain death rates than pregnancy.

Another one might be that the death rate in the fertile age group could simply be higher, too, although I don't know if that is true.

It is not relevant for the study cited in the article

The study cited uses OECD data. If the US does not adhere to the OECD guidelines for the data fields, for example by collecting a too broad measure and not correcting for it, studies are going to compare apples to pears. Not saying that the conclusion is false. But researchers should do their due diligence on the way international statistics are compiled.

> But researchers should do their due diligence on the way international statistics are compiled.

Do you have some evidence they didn't?

If the US collects the data in a different way and then doesn't publish anything else, there is no other data available. All you can do is include a note that explains why the numbers aren't comparable.

Sorry, the 'should' probably has an unintended negative connotation when talking about a specific study.

To delve a little deeper. They seem aware (under HOW WE CONDUCTED THIS STUDY [1]): "While the information collected by the OECD reflect the gold standard in international comparisons, it may mask differences in how countries collect their health data. Full details on how indicators were defined, as well as country-level differences in definitions, are available from the OECD."

They do not mention the specific CDC caveat mentioned above regarding the check box on US death certificates.

And then the pincher: The study points to CDC [2] where explicitly this effect is mentioned as a possible issue with the reporting via death certificates ("Efforts to improve data quality are ongoing, and these data will continue to be evaluated for possible errors.").

I'll leave the interpretation to you. They mention there is a gold standard and that some countries might not follow that gold standard. The conclusion is mainly based on US CDC data vs. OECD non-US data. They link to a CDC report mentioning this issue. Should they mention this fact in the study in the main body, or is this transparant enough?

Going back to the Noahpinion link with graph above in this discussion. For me the time series gives quite the hint that ICD-10 is not being followed appropriately and that false conclusions may arise. If this were my report, I'd take one or two paragraphs to explain why this issue doesn't affect my conclusions in the main body of text.

And then even a 'How to solve this (partially)'. As an actuary I know death is very unlikely in the childbearing age. Show a comparison table of deaths per 100k for women in the age of 20-40 between countries, including the 'US-Black' category. If that comparative line is a lot more flat (my expectation), I would really presume there is a data collection issue. The other interpretation would fail Occam's razor (that non-pregnancy death in US / US-Black categories are less likely than in other OECD-countries). First inkling: [OECD - 3], US ASMR in Women up to 20% higher than other countries.

[1] https://www.commonwealthfund.org/publications/issue-briefs/2...

[2] https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2022...

[3] https://stats.oecd.org/Index.aspx?DataSetCode=HEALTH_MORTAN#

Reporting differences don’t fix the fact that they also claim that 80% of these deaths are preventable.

The US healthcare system is always being designed around profit requirements and care constraints, and not vice versa. Nobody here (save for Medicare) really knows what the proper reimbursement is for care, and we waste needless amounts of time and money on quackery (naturopaths, supplements, chiropractic) instead. The reason why we open more “cancer centers” rather than adequate emergency or trauma care is because these hospital systems want to sell a Veblen good to wealthy people with cancer. There’s hope though, if we erase the weird private insurance industry we might start seeing prices and care reflect needs vs. means.

Additional info here: https://foreignpolicy.com/2024/01/31/united-states-maternal-...

It’s amazing how often you find out the differences in metrics are due to how data is collected not due to actual differences.

I read a good paper(1) about newborn deaths rates in Cuba. It’s often touted that Cuba has amazingly low newborn death rates which obvious means communism has far better healthcare than capitalist systems.

Turns out it’s a reporting artifact. If you correct for it, they have the same death rate as other Central American countries with similar GDP per capita.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6681443/

Can you please explain the different data collection of norway to reach almost zero?

I just finished this comment before reading yours.

https://news.ycombinator.com/item?id=40607378

It's explained in another comment. The US tracks it by asking "is this person who died, pregnant?". If the answer is yes, then it's a "maternal death".

Norway only counts pregnant women who died because of their pregnancy.

This implies the US data collection does not gather cause of death, with which a normalization before comparison would be harder.

Ill check now for this and edit this comment.

Edit:

> https://www.cdc.gov/maternal-mortality/php/data-research/?CD...

> Among the 525 pregnancy-related deaths, an underlying cause of death was identified for 511 deaths. In 2020, the six most frequent underlying causes of pregnancy-related death—mental health conditions, cardiovascular conditions, infection, hemorrhage, embolism, hypertensive disorders of pregnancy—accounted for over 82% of pregnancy-related deaths (Table 4).

> Among the 525 pregnancy-related deaths, a preventability determination was made for 515 deaths. Among these, 430 (84%) were determined to be preventable (Table 6).

This shows they didnt just take a yes\no for pregancy and +1ed the statistic, like you suggested. They reasoned about the causality and preventability.

> This shows they didnt just take a yes\no for pregancy and +1ed the statistic, like you suggested.

I didn't suggest that.

What I said was how numbers were reported. The US reports all deaths in pregnant women, regardless of cause. Norways only reports maternal deaths when the cause is pregnancy complications.

In the same direction: https://ourworldindata.org/rise-us-maternal-mortality-rates-...

World in Data's stats from before this 2003 statistical change happened:

https://ourworldindata.org/grapher/number-of-maternal-deaths...

Note that this data is the absolute number of deaths, not accounting for population size. This is what it looks like when you add "Europe":

https://ourworldindata.org/grapher/number-of-maternal-deaths...

That's still apples and oranges because that's based on the WHO European Region which includes all these countries:

https://who-sandbox.squiz.cloud/en/countries

Uzbekistan - GDP per capita $2,667

Tajikistan - GDP per capita $1,271

Kyrgyzstan - GDP per capita $1,922

Ukraine - GDP per capita $5,663

Meanwhile:

US - GDP per capita $85,373 (LOL)

To compare apples to apples you'd want:

US vs EU

to make it somewhat comparable, or maybe even better:

US (334m) vs Germany (83m) + France (67m) + UK (67m) + Italy (59m) + Spain (48m) = 324m people

So you want to use only the richest and most sophisticated EU countries but then compare them against a federation of US states that includes the likes of Mississippi and West Virginia?

LOL, of course.

If you don't believe me, compare the GDPs per capita of "the richest and most sophisticated EU countries" versus Mississippi and West Virginia.

Hint: the "sophisticated" EU countries are poorer.

Comparing ANY US state (average: $85,373) with Tajikistan ($1,271) would be a travesty.

Mississippi: ~$39,000

GDP per capita, PPP[0]:

  Turkey: $41,881
  Spain: $50,472
  Slovenia: $51,407
  UK: $56,836
  Germany: $66,038 
  Denmark: $74,958 
  Norway: $82,264
  Ireland: $137,638
  Luxembourg: $143,304

[0] https://en.wikipedia.org/wiki/List_of_sovereign_states_in_Eu...

The difference between New York (the highest US state by per capita GDP, ~$91,000) and Ireland is larger than the difference between Mississippi and a per-capita GDP of literally zero.

Pretty sure we can´t divide Mississippi by zero

It's an average. You can average zero in with 140 and still have a higher average than the average of 90 and 40. And what do you expect if you don't average in the zero?

GDP per capita PPP can't buy you many things. It's a disingenuous comparison.

You also didn't address my Tajikistan comment, because you know you're but won't admit it.

*you're wrong but won't admit it

Also, I forgot, it's a disingenuous comparison if you know anything about how life, subsistence, marginal savings rate & co work, which I assume you do if we're discussing these kinds of topics.

The scale of "GDP per capita and how people are living" is roughly this:

At a "GDP of literally zero" you're DEAD.

At a GDP of 1k, you can afford a cheap bicycle.

At a GDP of 10k, you can afford small, old, beat up and unsafe cars.

At a GDP of 30k, you can afford almost all modern amenities, they'll just be smaller, older, have fewer features.

At a GDP of 80k you can do whatever the hell you want if real estate expenses aren't killing you.

So no, you can't freely compare a country at 10k with one at 80k and try to bail out the comparison with PPP.

And the difference between 1 billion and 1 billion 30k is 1 billion. Percentages matter, thresholds matter. The person having 1 billion 30k doesn't have a materially different life to the person having 1 billion. The person having 30k is reasonably well off, the person having 0 is dead. The person having 40k is also reasonably well off while the person having 10k is poor (and NOT US poor, world standards poor; which BTW, is about the global average, which makes the average person in the world poor by modern development standards).

Compare like with like:

https://en.wikipedia.org/wiki/Developed_country#Comparative_...

Good spot, same period by deaths per 100,000 births:

https://ourworldindata.org/grapher/maternal-mortality?tab=ch...

How does moving the discussion to the legibility of the rate of change help us understand why large numbers of women are still dying from pre-industrial causes in the richest nation?

Yea, US americans in here try really hard to reason their numbers away and ignore the comparand.

Man! this plus the teenage suicide/mental health rate stats also possibly being an illusion (Obamacare changed data rules the same time mobile social media was taking off, obfuscating everything) has really thrown me for a loop. Not sure what to believe!

A related effect is there is a real tendency in online debates to use countries that speak exotic foreign languages as examples. So there is no way of working out what the data actually represents, what the known strengths and weaknesses are or what they are trying to measure. Or what the legal framework is.

Most statistical data in Norway is also available in English: https://www.ssb.no/en

I got a great laugh out of that, they've done an impressive job anglicising their website. But it doesn't really change the fundamental point. It doesn't take long to get to "Most of the content here is only available in Norwegian" [0]. And the articles on the Norwegen version of the site seem to be different to the English.

It can take a surprising amount of research sifting through who-knows-what to figure things out. One fun introductory challenge I recommend is figuring out what the components of the inflation index actually are; it usually takes a few rounds of sleuthing unless you have a muscle memory of where the right manual is. It is hard enough in the same language and with a familiar government. It isn't easy to do in a foreign language and unfamiliar government.

[0] https://www.ssb.no/en/innrapportering

> It isn't easy to do in a foreign language and unfamiliar government

The IMF does this.

If your're most interested in blog posts google translate is great for exotic languages.

But for the data they're all there in English [0].

And if you're after methodology, analysis or understanding medical data, they follow WHO standards and publications are all in English on pubmed.gov [1] for the explicit purpose of international collaboration (which is the norm in medicine and public health for most developed nations).

[0] https://www.ssb.no/a/en/histstat/ [1] https://pubmed.ncbi.nlm.nih.gov/24780982/

I applaud the enthusiasm but I'm not that interested in Norway's medical system. I'm making a point about the larger issue of using foreign data. I spend a lot of time arguing with people on the internet for fun and education; and it is extremely common to get a cheerful comment which - after a few hours of investigation - appears to be an incorrect interpretation of data.

It is hard enough to do for systems that are part of the English speaking world or big, easy to track metrics. It is substantially harder to do for fiddly data series from foreign systems where the primary source material is in a different language.

> And if you're after methodology, analysis or understanding medical data, they follow WHO standards and publications are all in English on pubmed.gov

This goes to the main point - if it turns out that they don't follow WHO standards in an area or there is critical data not on pubmed.gov, what is the expected path for finding that out?

Because in English I have a much better chance of being able to figure that out. The countries are familiar and there is a better chance that the criticisms of the major institutions are well known. In a Norwegian context that already rather challenging task is even harder.

EDIT

An example occurs to me a few minutes later; there was an interesting theory that Japan had a lot of old people because there were unusually strong pension & tax incentives to lie about elderly relatives being alive when they were in fact dead.

The Japanese stats office could be following WHO standards and publishing all their information on pubmed.gov and the series would still be incomparable with other countries if there is an unusual incentive for the stats to deceive coming form an unexpected angle.

Keeping on top of that sort of thing in foreign legal systems is simply hard.

For the point of arguing with strangers, yes, I agree that neither PubMed nor any other entities will provide you with what you need. I don't think that it is possible to acquire an understanding of an issue without some domain knowledge, at least on how to get the data.

But to gain a deeper understanding of the flaws of any country's health (or any) system, there is no way around that except by comparing it with data from other countries. And that might be hard, which is why professionals spend a lot of time on it.

Are saying that Norway speak an exotic foreign language, so we should ignore their results because some people feel that we cant trust their information? Does that mean that we should not compare the US system to these other nations? Who can we compare it to in that case, UK, Australia and New Zealand?

You can make judgements on uncertain data. It is a reasonable thing to do. It just happens that, given the number of people who muck up data that should be familiar to them, I say there is a lot of misplaced confidence in how well people understand other countries - confidence that often grows because the average person has very limited material to cross-reference with because they can't read a lot of publicly available stuff.

> Who can we compare it to in that case, UK, Australia and New Zealand?

Australia and New Zealand live upside down, you can not trust any of their data.

And google translate can help with exotic languages, here's an in depth on methodology:

https://www-ssb-no.translate.goog/helse/artikler-og-publikas...

I don't think that is an in-depth on methodology, they seem to be talking about how the WHO does things. And that doesn't seem to translate the graphs.

But regardless, the bigger point is that the default position isn't that Stats Norway data is automatically comparable with everyone else's data. The world is large and complicated; it is quite easy for small details between systems to do surprising things.

> exotic foreign languages

> Norwegian

Come on, it's in the same writing system, runs through google translate, and there are plenty of English speaking Norwegians.

Nah don't bother - if one's only argument is that the US is The Incomparable Outlier, no logic will ever help.

Yeah this roenxi user is one of the most talented mental gymnasts on HN. In past arguments I have been honestly suspicious that I was taken in by a performance artist.

I thought you'd made a bad point. Is that so hard to believe?

Oh no, I have no problem with that. The repeated (willful?) misreading was the confusing bit.

Apart from the bit where Norwegians speak better English than Brits and Americans

Yeah, Norway is conspiring to dethrone the mighty US through crooked statistics, we all know that Norwegians are infamous scoundrels! :-D

Norwegian and English is even in the same language group.

OK thats all fine, this kind of discrepancies/errors happen all the time in statistics. You for some reason completely avoid massive discrepancy between 0 and what US reports. The fact that its slowly falling from relative stratospheric heights gives no comfort to common US citizens, when clearly it can be done much, much better.

I think we all know most probably the main reason - US healthcare is a business with huge prices compared to anywhere else in the world including nations with higher salaries, not public service. So its all nice and top notch if you have millions in some form, not if you are remaining 95% of the country. General compassion to fellow citizens in need is not a strong point of US in general, is it.

People like me could move literally anywhere in the world if wanted. I moved to Switzerland from my crappy home country for example. But hell will freeze sooner than I would want to raise my kids or get old in US, no thank you for many reasons and this being one of biggest.

> OK thats all fine, this kind of discrepancies/errors happens all the time in statistics.

That's not what the article is tackling. Rather, it's quite literally about what types of deaths get categorized as "maternal mortality."

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