Do Free and fair elections and Skilled birth attendance go together across countries?

Across 158 countries the link before adjusting for anything is r = +0.51, on a scale from -1 (opposite) to +1 (in step). A version that uses only each country's rank gives +0.42.

Does the link hold within countries over time, not just across countries?

Comparing each country only with itself across 1990-2022, and setting aside what happened worldwide in each year, the link is +0.123 (150 countries, 2,544 country-years). Using year-to-year changes, it is -0.021.

Does Free and fair elections cause Skilled birth attendance?

This analysis cannot answer that. It shows only that the two go together. A link between two country measures, adjusted or not, does not show that either one changes the other. Country figures also say nothing about individual people.

Free and fair elections vs. Skilled birth attendance

Fades after adjusting for income

Across 158 countries, Free and fair elections and Skilled birth attendance rise and fall together at r = +0.51 (on a scale from −1 to +1, where 0 means no link). Comparing only countries with similar income (GDP per person) shrinks it to +0.21, which could easily be chance (q = 0.48, allowing for the many pairs tested, and allowing for countries in the same region being alike). So the first figure mostly shows richer countries differing from poorer ones, not a link between these two things.

Comparing countries across the middle half of free and fair elections, 0.216 to 0.86 points, skilled birth attendance is better by 16% of births at the top of that range than the bottom. Comparing only countries with similar national income, the gap is 5.61% of births.

Link before adjusting (r)+0.512p = 6.2e-12 · 158 countries

After adjusting for national income+0.211p = 0.008 · likely range [+0.06, +0.36]

p, allowing for regions0.273standard error 0.175 · 7 regions

Check for luck (q)0.477across 12,497 pairs

How to read these.r runs from −1 (one goes up as the other goes down) to +1 (they rise together), and 0 means no link. Adjusting for national income means comparing countries with the same GDP per person, so differences in wealth can’t explain the link. Income is used in percentage terms, since an extra $1,000 means more to a poor country than to a rich one. p is how likely a link this strong would be if there were really none. Below 0.05 means it is unlikely to be chance. Very small values are written in short form: 1.1e-32 means a decimal point followed by 31 zeros and then 11, so very close to zero. The likely range is where the true figure probably lies, and a range that crosses zero means the link could easily be chance. Countries in the same region tend to resemble each other, so the third figure allows for that, which gives a fairer p. The standard error is the typical size of the error in r. Finally, testing this many pairs means some will look strong by luck alone. A q below 0.05 means this link is unlikely to be one of those.

Free and fair elections · index (0-1)link with income +0.61 · high

Skilled birth attendance · % of birthslink with income +0.69 · high

Both of these rise and fall closely with national income, so a strong link between them before adjusting was close to certain. Read the adjusted figure, not the first one.

“Link with income” is how closely each measure tracks GDP per person across countries, from −1 to +1.

Every country as a dot

best-fit line line after adjusting

Four ways to measure the link

Method	r	p	Countries
Standard (Pearson), not adjusted	+0.512	6.2e-12	158
By rank (Spearman), not adjusted	+0.417	5.0e-8	158
Standard (Pearson), adjusted for national income	+0.211	0.008	158
By rank (Spearman), adjusted for national income	+0.007	0.931	158

The rank version uses only each country’s place in line, from lowest to highest, so a few extreme countries count for less. The adjusted and unadjusted versions use the same 158 countries: those that report both measures and GDP per person. So the gap between them comes from the adjustment, not from a change in which countries are counted. Drop in the size of r after adjusting: +0.301 (a minus sign means it grew).

How solid is it?

Leaving out one country at a time, r ranges from +0.192 (without MWI) to +0.237 (without TLS). The bar above shows that range on a scale from −1 to +1, with the solid line at the full result. The single country that moves r most: TLS (+0.026).

Within each region

Countries are not separate, unrelated cases, and neighbors share a lot. A link that holds inside each region is far more believable than one that shows up only when comparing regions.

	n	r
East Asia & Pacific	20	+0.08
Europe & Central Asia	43	-0.03
Latin America & Caribbean	23	+0.26
Middle East, North Africa, Afghanistan & Pakistan	18	+0.27
Sub-Saharan Africa	46	+0.47

By income third

If the link shows up only in the richest third of countries, it is a feature of rich countries, not a general pattern.

	n	r
Poorest third	53	+0.34
Middle third	52	+0.22
Richest third	53	+0.04

By largest religious group

Countries grouped by a label they share, such as main religion, rather than by a number. Groups of fewer than twelve countries are not shown. These groups differ in income, region and history all at once. So a gap between them is a place to start asking questions, not an answer.

	n	r
Christians	94	+0.25
Muslims	46	+0.34

By last european coloniser

	n	r
France	23	+0.15
Never a European colony	21	+0.01
Spain	19	+0.24
United Kingdom	48	+0.42

Without outliers (countries far outside the middle half of countries on either measure, by more than one and a half times the width of that middle half): r = +0.134 after dropping 15 countries.

Two series, one country

Both measures over the years for one country you pick. The two charts are stacked so they share only the years along the bottom.

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Over time, within countries

Everything above compares countries with each other at one moment. This section compares each country only with itself over 33years. So a link here can’t come from anything about a country that stays the same, such as its history, geography, institutions or culture.

Within countries over time, there is no link that is clearly more than chance (r = +0.123, comparing each country only with itself over the years, and each year only with the same year elsewhere). Whatever the cross-country picture shows, countries whose free and fair elections moved did not tend to see their skilled birth attendance move with it.

Across countries (adjusted)+0.211for comparison

Within countries+0.185each country vs itself

…and vs the same year elsewhere+0.123q = 0.302 · 150 countries

Year-on-year changes-0.021q = 0.624

2,544 country-years (one country in one year), 150 countries, 1990–2022, about 17 years each on average. Share of the variation that happens within countries over time: 13% for Free and fair elections, 13% for Skilled birth attendance. The margins of error allow for each country appearing many times, and for each year’s value being close to the year before.

Year-to-year changes are a cautious test, not a final answer. Looking only at changes from one year to the next removes each country’s own trends. But it also makes measurement mistakes louder, which pulls the results toward zero. A near-zero result here is weak evidence of no link, not proof.

With one measure years behind the other

Same year (lag 0): +0.123. A peak away from zero does not show which comes first. These series change slowly — this year’s value is close to last year’s. That makes the curve smooth and nearly symmetric, whatever produced the data. Even a sharp peak at one lag (a gap of some years) would not prove that one measure changes the other.

The data

	index (0-1)	% of births	Years
Norway NOR	0.966	99.2%	2025, 2021
Australia AUS	0.962	96%	2025, 2020
Finland FIN	0.961	99.5%	2025, 2021
Denmark DNK	0.961	95.3%	2025, 2018
Germany DEU	0.957	96.2%	2025, 2019
Spain ESP	0.956	99.9%	2025, 2020
Chile CHL	0.956	99.8%	2025, 2019
New Zealand NZL	0.954	96.5%	2025, 2019
Estonia EST	0.952	99.6%	2025, 2020
Uruguay URY	0.947	100%	2025, 2020
Italy ITA	0.945	99.8%	2025, 2020
Ireland IRL	0.945	99.7%	2025, 2017
Greece GRC	0.944	99.9%	2025, 2018
Costa Rica CRI	0.944	99%	2025, 2019
Canada CAN	0.944	98%	2025, 2020

Coppedge, M. et al., V-Dem Dataset, Varieties of Democracy (V-Dem) Project
World Bank, World Development Indicators

Sources

Free and fair elections

Free and fair elections index

V-Dem Institute, University of Gothenburg · via Our World in Data · CC BY 4.0 · updated annual

Whether elections are run without voter-registration fraud, widespread irregularities, government threats against the opposition, vote buying or election violence. This asks a narrower question than whether a country is a democracy, and one that is easier to answer. A state can run clean elections while barring the opposition from standing. It can also run dirty elections and still change government. It is the clean-elections part of the electoral democracy index. So its pair with that index, and with liberal and participatory democracy, is built from the same numbers and flagged as such.

Skilled birth attendance

Births attended by skilled health staff (% of total)

UNICEF and WHO · CC BY 4.0 · updated quarterly

Based on surveys, so a country reports it every few years rather than yearly.

How this was computed

Data used: most recent value in 2010-2025; values come from 2011–2025. To adjust for income, each measure is first predicted from GDP per person (in percentage terms, on a log scale) with a straight-line fit. Only what is left over is then compared. This is called a partial correlation. The line is drawn the standard way (ordinary least squares), which picks the line that comes closest to all the countries at once. The error margins allow for countries in the same region resembling each other, using 7 World Bank regions. The q-value corrects for testing all 12,497 pairs at once, using the Benjamini–Hochberg method. Underlying data last updated DYB 2024. How the country data works · explore Free and fair elections and Skilled birth attendance

This page shows that two measures go together. It does not show that Free and fair elections changes Skilled birth attendance, or the reverse. These figures also describe countries, not individual people. See the ecological fallacy.