Prime-age adult mortality in sub-Saharan Africa: examining trends in Demographic and Health Surveys conducted between 1990 and 2014

Adult mortality rate is a critical indicator used to assess the level of national development in most sub-Saharan African countries. However, estimation of adult mortality rates requires comprehensive and accurate reporting of adult deaths, which is one of the challenges faced by most sub-Saharan African countries. Using data from Demographic and Health Surveys conducted between 1990 and 2014 in 25 countries in sub-Saharan Africa, we examine trends in all-cause prime adult mortality (measured by the probability of dying between exact ages 15 and 50) and sex differences in adult mortality by region. Our paper provides a basis for tracking progress in reducing adult mortality and improving overall health. The median probability of dying was 173 per 1000 for women in the latest surveys, an increase from 166 per 1000 during the initial surveys. The median value for men was 177 per 1000; a decrease from the initial surveys which was 202 per 1000. Across all countries, the average annual increase in the probability of dying was higher for women (1.08%) than men (0.49%). Intensive efforts are needed to improve adult survival and ensure that sub-Saharan Africa achieves the Sustainable Development Goals by 2030. In particular, efforts to mitigate the premature risk of dying among women need to be intensified.     

Diverging Trends in Female Old‐Age Mortality: The United States and the Netherlands versus France and Japan

In the most advanced countries, child mortality and adult mortality under age 65 years have fallen so low that further improvement in life expectancy relies almost completely on the decline of mortality at older ages. This phenomenon is particularly pronounced among women, who are far ahead of men in survival rates. Thus, to project the future of life expectancy, this study focuses on trends in female life expectancy at ages 65 and older. Four countries are selected for this analysis: the United States, Netherlands, France, and Japan. It is particularly interesting to understand why American and Dutch trends in female old‐age mortality have been diverging from those in France and Japan for two decades. It is shown here that most of the divergence derives from the fact that decline in cardiovascular mortality is more and more offset by increases in other causes of death in the United States and the Netherlands, while the other two countries are more successful in reducing mortality from all causes at increasingly older ages. This latter phenomenon could represent a new stage of the health transition.     

Geographic Divergence in Mortality in the United States

The United States trails other developed countries in adult mortality, a process that has become more pronounced over the past several decades. However, comparisons are complicated by substantial geographic variations in mortality within the United States. The second half of the twentieth century was characterized by a substantial divergence in adult mortality between the South and the rest of the United States. The article examines trends in US geographic variation in mortality between 1965 and 2004, in particular the aggregate divergence in mortality between the southern states and states with more favorable mortality experience. Relatively high smoking‐attributable mortality in the South explains 50–100 percent of the divergence for men between 1965 and 1985 and up to 50 percent for women between 1985 and 2004. There is also a geographic correspondence between the contribution of smoking and other factors, suggesting that smoking may be one piece of a more complex health‐related puzzle.     

Continued Reductions in Mortality at Advanced Ages

Mortality data for 30 mostly developed countries available in the Kannisto–Thatcher Database on Old‐Age Mortality (KTDB) are drawn on to assess the pace of decline in death rates at ages 80 years and above. As of 2004 this database recorded 37 million persons at these ages, including 130,000 centenarians (more than double the number in 1990). For men, the probability of surviving from age 80 to age 90 has risen from 12 percent in 1950 to 26 percent in 2002; for women, the increase has been from 16 percent to 38 percent. In the lowest‐mortality country, Japan, life expectancy at age 80 in 2006 is estimated to be 6.5 years for men and 11.3 years for women. For selected countries, average annual percent declines in age‐specific death rates over the preceding ten years are calculated for single‐year age groups 80 to 99 and the years 1970 to 2004. The results are presented in Lexis maps showing the patterns of change in old‐age mortality by cohort and period, and separately for men and women. The trends are not favorable in all countries: for example, old‐age mortality in the United States has stagnated since 1980. But countries with exceptionally low mortality, like Japan and France, do not show a deceleration in death rate declines. It is argued that life expectancy at advanced ages may continue to increase at the same pace as in the past.     

The role of smoking in the explanation of the Israeli Jewish pattern of sex differentials in mortality

The difference in life expectancy between women and men among Israeli Jews is very low relative to the difference in other developed countries, and the reasons for this are not fully understood. This paper explores the contribution of smoking to the observed patterns of sex-specific mortality among Israeli Jews, and to the sex difference in mortality exhibited by this population. The results show that the mortality of Israeli Jewish men is low owing to the relatively weak impact of smoking-related mortality, and that this also contributes to an explanation of the small sex difference. The result is explained by the high level of health-protective behaviour of Israeli Jewish men, including a low intensity of smoking (though not a low prevalence). The findings could have implications for some debates on the determinants of divergences and convergences in mortality, and research into the relationship between mortality and the Mediterranean diet.     

Russian Mortality Crisis and the Quality of Vital Statistics

Mortality from ill-defined conditions in Russia has the fastest rate of increase compared to all other major causes of death. High proportion of deaths in this category is indicative for low quality of mortality statistics. This article examines the trends and possible causes of mortality from ill-defined conditions in Russia. During 1991–2005, mortality from ill-defined conditions in Russia increased in all age groups. The pace of increase was particularly high at working ages and the mean expected age at death from ill-defined conditions has shifted to younger ages, particularly for men. The analysis of individual medical death certificates issued in Kirov and Smolensk regions of Russia demonstrate that 89–100% of working-age deaths from ill-defined conditions correspond to human bodies found in a state of decomposition. Data from Smolensk region shows that over 60% of these decedents were unemployed. Temporal trends of mortality from ill-defined conditions and injuries of undetermined intent in Moscow city suggest that deaths from the latter cause were probably misclassified as ill-defined conditions. This practice can lead to underestimation of mortality from external causes. Growing number of socially isolated marginalized people in Russia and insufficient investigation of the circumstances of their death contribute to the observed trends in mortality from ill-defined conditions.     

Changing sex differences in life expectancy in Australia between 1970 and 1990

Between 1970 and 1990, Australia experienced a narrowing of its sex difference in life expectancy by just over one year, which is a substantial amount when compared to the experience of other industrialized nations. Most of this reduction materialized in the decade between 1980 and 1990. In this study we decompose the gender based survival difference in 1970, 1980 and 1990 into components that can be attributed to different causes of death. Our analysis indicates that a significant component of the constriction in the differential was due to males having made larger gains than females over time with respect to heart disease, accidents and violence excluding suicide, and lung cancer. A large part of the narrowing in female-male difference in life expectancy can be attributed to narrowing sex differences in mortality in the older ages. We discuss these findings in the context of emerging epidemiological trends in the industrialized world, and the implications these have for the future of the sex differential in survival.     

Lifespan Dispersion in Times of Life Expectancy Fluctuation: The Case of Central and Eastern Europe

Central and Eastern Europe (CEE) have experienced considerable instability in mortality since the 1960s. Long periods of stagnating life expectancy were followed by rapid increases in life expectancy and, in some cases, even more rapid declines, before more recent periods of improvement. These trends have been well documented, but to date, no study has comprehensively explored trends in lifespan variation. We improved such analyses by incorporating life disparity as a health indicator alongside life expectancy, examining trends since the 1960s for 12 countries from the region. Generally, life disparity was high and fluctuated strongly over the period. For nearly 30 of these years, life expectancy and life disparity varied independently of each other, largely because mortality trends ran in opposite directions over different ages. Furthermore, we quantified the impact of large classes of diseases on life disparity trends since 1994 using a newly harmonized cause-of-death time series for eight countries in the region. Mortality patterns in CEE countries were heterogeneous and ran counter to the common patterns observed in most developed countries. They contribute to the discussion about life expectancy disparity by showing that expansion/compression levels do not necessarily mean lower/higher life expectancy or mortality deterioration/improvements.     

The narrowing sex differential in life expectancy in high-income populations: effects of differences in the age pattern of mortality

Using data from the Human Mortality Database for 29 high-income national populations (1751-2004), we review trends in the sex differential in e(0). The widening of this gap during most of the 1900s was due largely to a slower mortality decline for males than females, which previous studies attributed to behavioural factors (e.g., smoking). More recently, the gap began to narrow in most countries, and researchers tried to explain this reversal with the same factors. However, our decomposition analysis reveals that, for the majority of countries, the recent narrowing is due primarily to sex differences in the age pattern of mortality rather than declining sex ratios in mortality: the same rate of mortality decline produces smaller gains in e(0) for women than for men because women's deaths are less dispersed across age (i.e., survivorship is more rectangular).     

A note of correction with reference to parameters of the menstrual cycle and the efficiency of rhythm methods of contraception

It is known that further mortality reductions in industrialized countries depend heavily on trends in mortality rates at the oldest ages. In this article, a model proposed by Coale and Kisker is used to investigate mortality trends at the extreme old age of 110 years. The most important conclusions are that (1) the form of the model proposed by Coale and Kisker fits observed mortality schedules very well indeed, and (2) the trend in mortality rates at extremely high ages has apparently been flat for men, but may have declined slightly for women during this century.     

近50年来世界人口期望寿命的演变轨迹

进入21世纪以来,全球人口已经突破60亿,但是人口增长速度明显减慢。许多国家已经完成了人口转变,其总和生育率在更替水平以下。与此同时,人口健康状况得到明显改善,死亡水平显著降低,期望寿命在不断提高。本文利用联合国人口司发布的192个国家人口死亡信息,系统分析了世界人口平均期望寿命在过去50年里的演变态势、区域差异以及演变模式。结果显示世界人口期望寿命经历了半个多世纪的持续增长,有50%以上的人口或国家平均期望寿命达到了70岁。演变轨迹呈多样化的发展模式,区域发展不平衡。欠发达地区总体上较发达地区增幅大,人口比重上升幅度也很显著。人均期望寿命增幅最大的是亚洲国家,非洲国家与世界不同步,而且区域内差异较大。     

The narrowing sex differential in life expectancy in high-income populations: Effects of differences in the age pattern of mortality

Using data from the Human Mortality Database for 29 high-income national populations (1751–2004), we review trends in the sex differential in e(0). The widening of this gap during most of the 1900s was due largely to a slower mortality decline for males than females, which previous studies attributed to behavioural factors (e.g., smoking). More recently, the gap began to narrow in most countries, and researchers tried to explain this reversal with the same factors. However, our decomposition analysis reveals that, for the majority of countries, the recent narrowing is due primarily to sex differences in the age pattern of mortality rather than declining sex ratios in mortality: the same rate of mortality decline produces smaller gains in e(0) for women than for men because women's deaths are less dispersed across age (i.e., survivorship is more rectangular).     

Falling Short of Highest Life Expectancy: How Many Americans Might Have Been Alive in the Twentieth Century?

Life expectancy at birth in the United States during the twentieth century was lower than in many other highly developed countries. We investigate how this mortality disadvantage in the last 100 years translates into the number of hypothetical lives lost and their sex and age structure. We estimate the hypothetical US population if it had experienced in each decade since 1900 the mortality level of the country with the then highest life expectancy and compare the results to the actual figures in 2000. By 2000, the number of additional people who could have been alive had the mortality levels in the United States been as low as those in countries with the highest life expectancy was 66 million. This number is distributed equally between males and females. Suboptimal mortality at reproductive ages is crucial for the cumulative effect of potential lives lost, resulting from premature deaths of women who could still become first‐time mothers or bear additional children. Out of the 66 million additional persons who could have been alive in 2000, 45 million are attributable to those indirect deaths. Although the differences in the composition of the population by sex and age under the two mortality regimes are minor, the majority of people who might have been alive—54 million—were of working age or younger.     

Differences in life expectancy by education and occupation in Italy, 1980-94: indirect estimates from maternal and paternal orphanhood

In the present study, we use the modified orphanhood method to analyse mortality differences by socio-economic status in Italy. This technique permits the indirect estimation of adult mortality from survey-based information on parents' survival in developed populations and helps to overcome several limitations of conventional studies on mortality differences by social class. We estimate a time series of life tables by education and occupation and analyse the differences in life expectancy by socio-economic status along with their changes between 1980-84, 1985-89, and 1990-94. Whereas mortality differences between the highest social class and the other socio-economic status groups increased among men, they decreased among women. We speculate about the reasons for these sex-specific trends and evaluate the application of indirect estimation techniques to the populations of developed countries.     

The increase in marital status differences in mortality up to the oldest age in seven European countries, 1990–99

We investigate mortality differentials by marital status among older age groups using a database of mortality rates by marital status at ages 40 and over for seven European countries with 1 billion person-years of exposure. The mortality advantage of married people, both men and women, continues to increase up to at least the age group 85–89, the oldest group we are able to consider. We find the largest absolute differences in mortality levels between marital status groups are at high ages, and that absolute differentials are: (i) greater for men than for women; (ii) similar in magnitude across countries; (iii) increase steadily with age; and (iv) are greatest at older age. We also find that the advantage enjoyed by married people increased over the 1990s in almost all cases. We note that results for groups such as older divorced women need to be interpreted with caution.     

The increase in marital status differences in mortality up to the oldest age in seven European countries, 1990-99

We investigate mortality differentials by marital status among older age groups using a database of mortality rates by marital status at ages 40 and over for seven European countries with 1 billion person-years of exposure. The mortality advantage of married people, both men and women, continues to increase up to at least the age group 85-89, the oldest group we are able to consider. We find the largest absolute differences in mortality levels between marital status groups are at high ages, and that absolute differentials are: (i) greater for men than for women; (ii) similar in magnitude across countries; (iii) increase steadily with age; and (iv) are greatest at older age. We also find that the advantage enjoyed by married people increased over the 1990s in almost all cases. We note that results for groups such as older divorced women need to be interpreted with caution.     

Trends in senescent life expectancy

The distinction between senescent and non-senescent mortality proves to be very valuable for describing and analysing age patterns of death rates. Unfortunately, standard methods for estimating these mortality components are lacking. The first part of this paper discusses alternative methods for estimating background and senescent mortality among adults and proposes a simple approach based on death rates by causes of death. The second part examines trends in senescent life expectancy (i.e., the life expectancy implied by senescent mortality) and compares them with trends in conventional longevity indicators between 1960 and 2000 in a group of 17 developed countries with low mortality. Senescent life expectancy for females rises at an average rate of 1.54 years per decade between 1960 and 2000 in these countries. The shape of the distribution of senescent deaths by age remains relatively invariant while the entire distribution shifts over time to higher ages as longevity rises.     

Causes of Male Excess Mortality: Insights from Cloistered Populations

The degree to which biological factors contribute to the existence and the widening of mortality differences by sex remains unclear. To address this question, a mortality analysis for the years 1890 to 1995 was performed comparing mortality data on more than 11,000 Catholic nuns and monks in Bavarian communities living in very nearly identical behavioral and environmental conditions with life table data for the general German population. While the mortality differences between women and men in the general German population increased considerably after World War II, they remained almost constant among the members of Bavarian religious orders during the entire observation period, with slight advantages for nuns. Thus, the higher differences observable in the general population cannot be attributed to biological factors. The different trends in sex‐specific mortality between the general and the cloistered populations are caused exclusively by men in the general population who were unable to follow the trend in mortality reduction of women, nuns, and especially monks. Under the special environmental conditions of nuns and monks, biological factors appear to confer a maximum survival advantage for women of no more than one year in remaining life expectancy at young adult ages.     

The choice among past trends as a basis for the prediction of future trends in old-age mortality

We explored the extent to which projections of future old-age mortality trends differ when different projection bases are used. For seven European countries, four alternative sets of annual rates of mortality change were estimated with age-period log-linear regression models, and subsequently applied to age-specific all-cause mortality rates (80+) in 1999 to predict mortality levels up to 2050. On average, up to 2050, e80 is predicted to increase further by 2.33 years among men and 4.03 years among women. Choosing a historical period of 25 instead of 50 years results in higher predicted gains in e80 for men but lower gains for women. Choosing non-smoking-related mortality instead of all-cause mortality leads to higher gains for women and mixed results for men. In all alternatives there is a strong divergence of predicted mortality levels between the countries. Future projections should be preceded by a thorough study of past trends and their determinants.