Maternal mortality in South Africa: an update from the 2007 Community Survey

The 2007 Community Survey conducted in South Africa included questions on maternal deaths in the previous 12 months (pregnancy-related deaths). The Maternal Mortality Ratio (MMR) was estimated at 702 per 100,000 live births, some 30% more than at the 2001 census. This high level occurred despite a low proportion of maternal deaths (4.3%) among deaths of women aged 15–49 years, which is even lower than the proportion of time spent in the maternal risk period (7.6%). The high level of MMR was due to the astonishingly high level of adult mortality, which increased by 46% since 2001. The main reasons for these excessive levels were HIV/AIDS and external causes of death (accidents and violence). Differentials in MMR were very marked, and similar to those found in 2001 with respect to urban residence, race, province, education, income, and wealth. Provincial levels of MMR correlated primarily with HIV/AIDS prevalence. Maternal mortality defined as ‘pregnancy-related death’ appears no longer as a proper indicator of ‘safe motherhood’ in this situation.     

A method for deriving mortality estimates from incomplete vital Statistics

Summary Although they are available in many developing countries vital registration records are very little used for mortality estimation which is still mainly based on census returns. However, defective death records may yield accurate estimations of mortality. This procedure requires few data only; a sex-age distribution of the population (preferably at the middle of a period) and a sexage distribution of deaths, either derived from vital records or from census returns to questions relating to deaths during the preceding twelve months. This method is based on the observation that for a fixed age structure of the population, there is a one-one relation between the age structure of deaths (measured by the proportion of deaths at older ages) and the level of mortality (measured by the death rate above a certain minimum age). It is assumed that at ages above this minimum the rate of underregistration of deaths does not vary significantly with age. Therefore, the age distribution of registered deaths makes it possible to estimate the true proportion of deaths at older ages. This in its turn will permit the estimation of the true level of mortality, because of the relation which exists between age structure of deaths and level of mortality. The true level is then compared with the observed, to estimate the rate of underregistration, and observed age-specific death rates can be adjusted in the light of this knowledge.     

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.     

Infant Mortality and Socioeconomic Status: New Bottle,Same Old Wine

This paper presents the results of an ecological analysis of the relationship between infant mortality and economic status in metropolitan Ohio for the period 1960–2000. The data examined are centered on the five censuses undertaken during this 40-year period. The basic unit of analysis is the census tract of mother’s usual residence, with economic status being determined by the percentage of low income families living in each tract. For each of the five periods covered, census tracts were aggregated into broad income areas and three-year average infant mortality rates were computed for each area, by age, sex, race and exogenous-endogenous causes of death. The most important conclusion to be drawn from the data is that in spite of some very remarkable declines in infant mortality at all class levels since 1960, there continues to be a very clear and pronounced inverse association between income status and infant mortality. Indeed, the evidence indicates that the relationship has become stronger over the years. These observations are applicable for both sexes, for whites and nonwhites, for neonatal and postneonatal deaths, and for both major cause of death groups. It is concluded that while public health programs are important, any progress in narrowing this long-standing differential is unlikely unless ways can be found to enhance the economic well-being of the lower socioeconomic groups.     

Differences in mortality by marital status in Finland from 1976 to 2000: analyses of changes in marital-status distributions, socio-demographic and household composition, and cause of death

Being currently not married is more common today than 25 years ago. Over this period relative differences in mortality by marital status have increased in several countries, mainly as a result of a sharp decline in mortality among the married. Using Finnish census data linked with death certificates, we show that these increases are not explained by the non-married population becoming more marginalized in socio-economic status or household composition. However, the increases in marital-status differences in mortality from accidental, violent, and alcohol-related causes of death in the 30-64 age group indicate that changes in the health-related behaviour of the non-married population may play a role. The public-health burden associated with not being married has also grown. At the end of the 1990s about 15 per cent of all deaths above the age of 30 would not have occurred if the non-married population had had the same age-specific mortality rates as the married population.     

Infant mortality in the Marshall Islands

Levy and Booth present previously unpublished infant mortality rates for the Marshall Islands. They use an indirect method to estimate infant mortality from the 1973 and 1980 censuses, then apply indirect and direct methods of estimation to data from the Marshall Islands Women's Health Survey of 1985. Comparing the results with estimates of infant mortality obtained from vital registration data enables them to estimate the extent of underregistration of infant deaths. The authors conclude that 1973 census appears to be the most valid information source. Direct estimates from the Women's Health Survey data suggest that infant mortality has increased since 1970-1974, whereas the indirect estimates indicate a decreasing trend in infant mortality rates, converging with the direct estimates in more recent years. In view of increased efforts to improve maternal and child health in the mid-1970s, the decreasing trend is plausible. It is impossible to estimate accurately infant mortality in the Marshall Islands during 1980-1984 from the available data. Estimates based on registration data for 1975-1979 are at least 40% too low. The authors speculate that the estimate of 33 deaths per 1000 live births obtained from registration data for 1984 is 40-50% too low. In round figures, a value of 60 deaths per 1000 may be taken as the final estimate for 1980-1984.     

Revising Infant Mortality Rates for the Early Twentieth Century United States

Accurate vital statistics are required to understand the evolution of racial disparities in infant health and the causes of rapid secular decline in infant mortality during the early twentieth century. Unfortunately, U.S. infant mortality rates prior to 1950 suffer from an upward bias stemming from a severe underregistration of births. At one extreme, African American births in southern states went unregistered at the rate of 15 % to 25 %. In this study, we construct improved estimates of births and infant mortality in the United States for 1915–1940 using recently released complete count decennial census microdata combined with the counts of infant deaths from published sources. We check the veracity of our estimates with a major birth registration study completed in conjunction with the 1940 decennial census and find that the largest adjustments occur in states with less-complete birth registration systems. An additional advantage of our census-based estimation method is the extension backward of the birth and infant mortality series for years prior to published estimates of registered births, enabling previously impossible comparisons and estimations. Finally, we show that underregistration can bias effect estimates even in a panel setting with specifications that include location fixed effects and place-specific linear time trends.     

Maternal mortality in South Africa: lessons from a case study in the use of deaths reported by households in censuses and surveys

South Africa is unique in being a developing country which has asked questions on pregnancy-related deaths in both its 2001 census and 2007 household survey, and monitors maternal and pregnancy-related mortality through vital registration and a confidential enquiry into maternal deaths. These sources of data provide a wide range of estimates of maternal mortality for the country. This paper examines these estimates to assess to what extent the differences between them are due to data deficiencies, methodological deficiencies or definitional differences. The results show that since maternal deaths are relatively rare it is fairly difficult to establish the maternal mortality rate with a great degree of accuracy in a setting where data are less than perfect. They also show that to some extent the differences are due to differences and errors in processing of data but that pregnancy-related mortality should not be treated as synonymous with maternal mortality. However, after adjustment, pregnancy-related mortality from vital registration was comparable with the level that may be expected using several alternative approaches, while the rate reported by households in census and surveys was about double that from vital registration. Nonetheless, all the data indicate an upward trend in maternal mortality that is in keeping with the impact of the HIV/AIDS epidemic, which is likely to have contributed to the discrepancies.     

Cigarette Smoking and All-Cause and Cause-Specific Adult Mortality in the United States

This study illuminates the association between cigarette smoking and adult mortality in the contemporary United States. Recent studies have estimated smoking-attributable mortality using indirect approaches or with sample data that are not nationally representative and that lack key confounders. We use the 1990–2011 National Health Interview Survey Linked Mortality Files to estimate relative risks of all-cause and cause-specific mortality for current and former smokers compared with never smokers. We examine causes of death established as attributable to smoking as well as additional causes that appear to be linked to smoking but have not yet been declared by the U.S. Surgeon General to be caused by smoking. Mortality risk is substantially elevated among smokers for established causes and moderately elevated for additional causes. We also decompose the mortality disadvantage among smokers by cause of death and estimate the number of smoking-attributable deaths for the U.S. adult population ages 35+, net of sociodemographic and behavioral confounders. The elevated risks translate to 481,887 excess deaths per year among current and former smokers compared with never smokers, 14 % to 15 % of which are due to the additional causes. The additional causes of death contribute to the health burden of smoking and should be considered in future studies of smoking-attributable mortality. This study demonstrates that smoking-attributable mortality must remain a top population health priority in the United States and makes several contributions to further underscore the human costs of this tragedy that has ravaged American society for more than a century.     

Measures and effectiveness in controlling omission of reports on infant deaths in Shanghai metropolitan areas]

The infant mortality rate is a sensitive indicator of a country's or area's economic, cultural, and health care conditions, and in particular, it reflects the quality of health care for women and young children. Since liberation, great progress has been achieved in Shanghai's health and medical care in general as well as in health care for women and young children, and the infant mortality rate has dropped notably. However, the omission of reports on infant deaths is still a very serious problem. In order to control such omissions in reporting, the Shanghai municipal government and Department for Public Health have improved the methods of reporting deaths. Health care units are required to fill out a report on births and deaths, and census registers in the city government are responsible for registering all new births and deaths and preparing complete statistics on new births and deaths. At the end of each year, special investigators are sent to various hospitals to check on omissions of reports on infant deaths and they also help households to report infant deaths to census registers. The new measures have proved to be very effective. According to a new report released in 1980, the omission of reports on infant deaths has been reduced by 94.01% as compared with the 1972 statistics.     

The Effect of Age Misreporting in China on the Calculation of Mortality Rates at Very High Ages

When mortality rates by age are calculated from recorded deaths and enumerated populations, rates at higher ages are typically in error because of misstated ages. Mortality rates for China in 1981 have been calculated from the number of deaths in 1981 in each household recorded in the 1982 census, and from the census population back-projected one year. Because age was determined from date of birth, and because persons of the Chinese culture have very precise knowledge of date of birth, the mortality rates even at high ages should be unusually accurate. This expectation is fulfilled for most of China, but severe misreporting of age is found in a province that contains a large minority of a non-Han nationality, which lacks precise knowledge of date of birth. Although the province contains only 1.3% of China's population, male death rates above age 90 for all of China are distorted seriously by the erroneous data from this location.     

New african American life tables from 1935–1940 to 1985–1990*

New life tables for African Americans are presented from 1935 through 1990. They are based on a historical series of vital statistics data on deaths that have been corrected for age misreporting, on reconstructed population counts that have been adjusted for census underenumeration, and on births that have been corrected for underregistration. The new life tables show rapid mortality declines for both African American males and females from 1935 to 1950, and relatively steady reductions thereafter for females. The smaller declines in male mortality in young adulthood and middle age since the 1950s have led to exceptionally high ratios of male to female mortality at these ages. Corrections for census undercounts lead to higher values of life expectancy than in official life tables, but to less improvement over time. Official estimates of life expectancy at age 65 appear to be about 10% too high around 1940 but only about 1.5% too high in the late 1980s.     

Estimation of vital rates for Ghana

Abstract A complete and efficient registration system, of the type which would provide good data on births and deaths, does not exist in Ghana. However, registration of vital events is supposed to be compulsory in 39 towns in the country but the data collected in these areas are too inadequate and defective to provide a sound basis for the analysis of the dynamics of population growth. The results of the censuses conducted by the colonial governments are so defective and unreliable that they do not allow scientific research in the field of population analysis. Before 1960, therefore, when the national census and the post-enumeration survey (based on a 5% sample of the population) were carried out, estimates of fertility and mortality levels were little more than guesses. In this study an attempt has been made to utilize the information on the age-sex composition provided by the 1960 census and post-enumeration survey data on births and deaths to determine, as far as possible, the levels of fertility and mortality and the rates of population growth in Ghana. The fertility estimates-i.e. a crude birth rate of 50, total fertility rate of 6.9 and a gross reproduction rate of 3.4-show that Ghana's fertility is one of the highest in the world. An expectation of life at birth of 40 years, an infant mortality of 160 and a crude death rate of 23 appear to be the most plausible estimates. These estimates yield a rate of natural increase of 2.7% and a growth rate of 3.0% per annum.     

Altitude, fertility and mortality in Andean countries

Abstract Using the census data for Peru, Bolivia and Ecuador, previous writers have investigated some possible determinants of inter-regional differences in fertility; language spoken, female participation rates, and altitude. This paper points out the many sources of inaccuracy in the census data used. It argues that the indicators of unusually low fertility in the highland, predominantly Indianspeaking areas fail to control effectively for the very high levels of infant mortality in these regions. Fragmentary survey results give some indication of the scale of infant mortality, and appear to refute the idea that fertility is exceptionally low in areas of high altitude. In an attempt to explain why such high mortality rates persist in the Andean region the main health problems of Bolivia are examined. It seems that the causes are economic and social, rather than physiological. Unfortunately a change of policy which reduced death rates would produce grave new social problems.     

Neo-natal mortality in South Asia: The special role of tetanus

First-year mortality in rural Uttar Pradesh is characterized by a predominance (60 per cent) of deaths during the first month of life, of which 66 per cent are reported to be due to tetanus. This pattern is not typical of the historical experience of many developed countries and the current experience of some less developed countries where post-neo-natal mortality predominates. To examine this phenomenon, two causal models of neo-natal mortality (one for tetanus and one for all other diseases) are developed and tested using retrospective survey data from 2000 couples living in rural Uttar Pradesh.

Neo-natal tetanus mortality is found to be primarily a function of opportunities for exposure to the disease (e.g. lack of antiseptic birth practices, ownership of large animals) rather than of socio-economic status or demographic variables. The importance of examining neo-natal mortality by cause, and the shortcomings inherent in making inferences from the historical experiences of Western nations are emphasized.     

A preliminary analysis of mortality in China]

An analysis of mortality trends in China, based on data from the 1982 census, is presented. It shows that the mortality rate has gradually declined since 1949, but has recently leveled off and is now on the rise again. The main reasons for this decline were fewer deaths from disease and the changing age structure of the population. It is noted that the mortality rate varies from region to region, with infant mortality in border areas accounting for a large portion of total deaths. An increase in life expectancy has occurred as a result of declining mortality.     

Estimating Indigenous life expectancy: pitfalls with consequences

The methods used by the Australian Bureau of Statistics (ABS) to estimate life expectancies of Aboriginal and Torres Strait Islander peoples in 2009 have been controversial and require critical and sensitive analysis. The introduction by ABS of the direct method for estimating Indigenous life expectancies, based on estimated deaths and populations, has been generally welcomed. But the way this method has been applied and, in particular, death estimates used by the ABS, warrant scrutiny. These estimates were based on a first ever linkage between Indigenous deaths and census records following the 2006 census. Census-based identification was used in place of identification in the death registrations, rather than as a supplementary data source. The various national, state and regional life expectancy estimates published may have been biased upwards by this process. Because the impact of the methodology varies across Australia, regional differentials reported appear substantial but are not soundly based. The questionable ABS results are highlighted and discussed. Analysis based on more comprehensive linkage of death records in New South Wales over 5?years suggests that the ABS methods have understated Indigenous deaths and so overstated life expectancy. The effect of an alternative ABS approach is also discussed. ABS estimates published in 2009 are not necessarily definitive and may well overestimate Aboriginal and Torres Strait Islander life expectancy and underestimate the life expectancy gap. Estimates should be based on accurate estimates of deaths and population. Consultation and a thorough review are essential before the next round of estimates following the findings of the 2011 population census. Closing the Gap commitments focus on eliminating the life expectancy gap between Aboriginal and Torres Strait Islander peoples and other Australians. Life expectancy estimates need to be based on methods and data that are well understood and broadly supported. The alternative is unproductive debate about statistics rather than the range of policies and resourcing issues needed to improve Indigenous health.     

High-risk families: the unequal distribution of infant mortality in nineteenth-century Sweden

An analysis of infant mortality (based on 133,448 births) in two regions, Sundsvall and Skellefte?, in north-eastern Sweden during the nineteenth century shows that infant mortality was highly clustered with a relatively small number of families accounting for a large proportion of all infant deaths. Using logistic regression, two important factors were found to be associated with high-risk families: (i) a biological component evidenced by an over-representation of women who had experienced stillbirths, and (ii) a social component indicated by an increased risk among women who had remarried. The results strengthen the argument for using the family rather than the single child as the unit of analysis. The clustering of infant deaths points to the need to re-evaluate our interpretations of the causes of infant mortality in the past.     

The 1918 Influenza Epidemic's Effects on Sex Differentials in Mortality in the United States

The 1918 influenza epidemic had a marked and fairly long‐lasting effect on the sex differential in mortality in the United States. After 1918 women lost most of their mortality advantage over men and the female/male gap did not regain its pre‐epidemic level until the 1930s. An analysis of causes of deaths shows a link with tuberculosis. We conjecture the existence of a selection effect, whereby many 1918 influenza deaths were among tuberculous persons, so that tuberculosis death rates dropped in later years, disproportionately among males. Age‐ and sex‐specific data by cause of death corroborate this hypothesis.     

Premature birth and the changing composition of newborn infectious disease mortality: Reconsidering “exogenous” mortality

Linked death and birth records from San Antonio, Texas reveal that infectious infant mortality is increasingly a function of premature birth and low birth weight. Between 1935 and 1944, 4% of infectious infant deaths had associated causes involving prematurity and related conditions; by 1980, 25% of infectious infant deaths involved prematurity and more than 40% of those infants weighed less than 2,500 grams. The shift in birth-weight composition results almost entirely from an increase in very low-weight births. Under conditions of advanced perinatal technology, infectious infant mortality should no longer be viewed as wholly exogenous. These findings further undermine the contemporary relevance of the exogenous-endogenous distinction.