MEASURES OF

MORTALITY

Kennedy Muthoka, PhD

Public Health, JKUAT
 Definition
 Death: “the permanent disappearance of all
evidences of life at any time after birth”
(WHO)
 Definition
 Mortality
 Is a term which means “death” or describes
death and related issues
 A demographic event – Average risk of dying of
a person in the group during a time span
 This is one of the three determinants of
population change i.e. fertility, mortality and
migration
 Uses of mortality data
 Explaining trends in overall mortality
 Indicating priorities for health action and
resource allocation
 Designing intervention programs
 Assessment of public health problems and
programs
 Give important clues for epidemiological
research
 Cont’d
 Useful for projecting the future size of the
population
 Identify population groups that are at high
risk and in need of health service
 Indicative of quality of life and expectation
of life at birth
 Useful guides to planners
 Helpful to insurance companies
 MEASURES OF MORTALITY
600

500
Thousands of deaths

400

300

200

100

0
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000
Years
 Mortality…

 Cancer death numbers over the years

 HERE HAVE ONLY NUMBERS OF DEATH
(NUMERATOR)
 Cant say this is risk of dying
 If rate of pop. increase is same as the trend
in deaths, then risk of death from cancer
remains same throughout
 To address risk of dying, must use rates
 Types of Mortality Rates/Ratio
 Annual death rate
 Crude death rates
 Infant mortality rates
(ratio)
 Neonatal mortality rates
 Postneonatal mortality
rates
 Perinatal mortality rates
 Fetal death rates
 Fetal death ratios
 Abortion rates
 Maternal mortality ratio
 Maternal mortality rates
 Adjusted mortality rates
 Standardized mortality
ratio
 Specific death rates
 Proportionate mortality
rate
 Case fatality rate
 Three Levels of Rates
 Crude rates
 Adjusted rates
 Specific rates/ratios
 Crude rates
 One giving the total number of events
occurring in an entire population over a
period of time, without reference to any of
the individuals or subgroups within the
population
 These don’t take into account of the
composition of the pop. or consideration of
certain crucial factors that influence the
measure of rate E.g. Age, sex, place
 Adjusted rates
 A fictitious summary rate statistically
adjusted to remove the effect of a variable,
such as age or sex, to permit unbiased
comparison between groups having different
compositions with respect to these variables
 Specific rates/ratios
 A rate that applies to a specific demographic
subgroup,
 E.g., individuals of a specific age, sex, or race,
 Gives the total number of events in relation only
to that subgroup
 Annual Death Rates
 “General” (crude) mortality rate
 A population group exposed to risk of death
 A time period
 Crude Mortality Rate = # of deaths occurring
in that population during that period of time
 Crude Death Rates
 Does NOT account for differences of age,
sex, etc. in any aspect of death
 Info needed:
 total deaths
 total population
 a given period of time
 Crude Death Rates (cont’d)

Death rate - crude (per 1,000 people) in Kenya

Years 1990 2000 2010
Crude Rate 9.5 12.5 10.5
 Crude mortality rate
 Counts all deaths
 All causes
 All ages and both sexes
 Denominator includes entire population
 All ages and both sexes
 Summarizes population composition &are
specific death rates
 Lack comparability if populations differ in
age composition
 Cause Specific Mortality Rate
 This is the mortality rate from a specified cause for
a population during a specified time period
 The numerator is the number of deaths from that
cause
 The denominator remains the size of the
population at the mid-point of the time period
 For example, the tuberculosis death rate for the US
in 2002 was 0.3 per 100,000
Cause Specific Mortality Rate
 Case Fatality Rate
 Is the proportion of deaths within a designated
population of "cases" (people with a medical
condition), over the course of the disease
 The % of persons diagnosed as having a specified
disease who die as a result of that illness within a
given period
 CFRs are most often used for diseases with
discrete, limited time courses, such as outbreaks of
acute infections
 Cont’d
 Technically, CFRs are actually risks (or
"incidence proportions") and take values
between 0 and 1
 They are not rates coz the time from
disease onset to death is not taken into
account
Case Fatality Rate
 Case Fatality Rate: Ebolavirus

Total number of EVD confirmed deaths and cases

up to the 26th August 2014

Country Deaths Cases Ratio

Guinea 287 482 0.59

Liberia 225 322 0.70
Sierra Leone 380 935 0.41

http://epidemic.bio.ed.ac.uk/ebolavirus_fatality_rate
 DIFFERENCE BETWEEN MORTALITY RATES AND
CASE FATALITY RATES

Mortality Rates
 Denominator is of entire pop. at risk of

dying
- It includes those with and without disease
(but at risk of dying)
Case Fatality Rates
 Denominator only those with disease

 Thus measures severity of disease

 DIFFERENCE IN MORTALITY RATES AND CASE
FATALITY RATES Cont…:

 Numerator has only those dying from

specific disease.

(However this sometimes not completely

possible to distinguish e.g. HIV dies from
TB)
 DIFFERENCE IN MORTALITY RATES AND CASE
FATALITY RATES Cont…..:

 Hypothetical example of mortality and case fatality

- Assume in pop of 1,000.
- 20 have disease X in 1 yr
- 18 people die
Mortality rate = 18 X 100 = 1.8%
1000
Case fatality = 18 X 100 = 90%
20
(Suggests once person gets disease has high
chance of dying)
 Specific Death Rates
Early life mortality measures
 Specific Death Rates:
Infant Mortality Rate (IMR)
 Counts deaths in children less than 12 months of
age, divides by number of live births in same time
period
 Compares the number of deaths of infants under
one year old in a given year per 1,000 live births in
the same year
 Is often used as an indicator of the level of health
in a country
 40.71 IMR in Kenya (2014 CIA Factbook)
 Specific Death Rates:
Infant Mortality Rate

= # of deaths under one year of age X 1,000

# of live births
 Neonatal mortality rate (NMR)

 A neonatal death is defined as a death during

the first 28 days of life (0-27 days)
 NMR is the number of neonates dying before
reaching 28 days of age, per 1,000 live births in
a given year
 # of neonatal deaths x 1,000
Total # of live births in the same year
 An indicator for newborn care and directly
reflects prenatal, intrapartum, and neonatal care
 Early and late neonatal mortality
rates

Early Neonatal Mortality rate (ENMR)

 # of neonatal deaths 0-7 days x 1,000
Total # of live births in the same year
Late neonatal mortality rate (LNMR)
 # of neonatal deaths 8-27 days x 1000
Total # of live births in the same year
 Postneonatal mortality rate

 Is a subset of infant mortality

 Is defined as those infant deaths in which the
infant is more than 27 days and less than one year
of age
 • Postneonatal
Sometimes mortality
approximated as rate
the difference
between the infant mortality rate and the neonatal
mortality rate
 Perinatal mortality rates
 The # of stillbirths and deaths in the first week of life per
1,000 live births
 The perinatal period commences at 22 completed weeks
(154 days) of gestation and ends seven completed days
after birth
 Indicator to assess the quality of health care delivery
 Stillbirth:
 Deaths of fetuses weighing at least 500g, or of 22-weeks gestation
or more if weight is unavailable (ICD 10)
 Deaths of fetuses weighing at least 1000g, or of 28-weeks gestation
or more if weight is unavailable (WHO)
Perinatal mortality rates: Limitations

 Great variation between and within countries on how the

stillbirth is recorded
 Difficulty in obtaining accurate information on gestational
age or birth weight leading to the misclassification of
stillbirths as late spontaneous abortions
 Registration bias – age heaping on day 7, misclassification
as late neonatal
 Omission of stillbirths and early neonatal deaths
 Formula;
# of perinatal deaths x 1,000
Total # of births (still births + live births) in the same period
 Fetal death rate
 Fetal death
 Is the spontaneous intrauterine death of a fetus at any
time during pregnancy
 Death prior to the complete expulsion or extraction from
its mother of a product of human conception,
irrespective of the duration of pregnancy and which is
not an induced termination of pregnancy
 Maternal Mortality Ratio
 Is the annual number of female deaths per 100,000
live births from any cause related to or aggravated
by pregnancy or its management while pregnant or
within 42 days of pregnancy termination (excluding
accidental or incidental causes)
 It depicts the risk of maternal death relative to the
frequency of childbearing
 Maternal Mortality Ratio
Maternal mortality ratio (modeled estimate,
per 100,000 live births) [World bank 2013]
 Burundi - 740

 Kenya – 400

 Afghanistan – 400

 Canada - 11

 USA - 28
 Maternal Mortality Rate
 Found by dividing the average annual number of
maternal deaths in a population by the average
number of women of reproductive age (typically
those aged 15 to 49 years) who are alive during
the observation period
 The MMRate reflects;
 The risk of maternal death per pregnancy or per birth
 The level of fertility in a population
 PROPORTIONATE MORTALITY

 This is not a rate

 Proportionate mortality from particular disease
(percent) =
No. of deaths from given disease in year X 100
Total deaths in same year
i.e. % of all deaths in given place and year that are
due to given disease
- Provides quick idea of major causes of death
- However doesn’t give risk of dying from
disease
 ADJUSTED RATES:

 Undergo statistical transformation to permit

fair comparison between grps which differ
in some characteristic that may affect risk
of disease.
 Transformation is carried out on crude rates
to remove the effect of differences in
composition of the various pops
 ADJUSTED RATES:
 Adjustment is done coz pop. compositions
in two different periods of same population
may differ
 One may have older people which affects
mortality
 Adjustment removes the influence of age
on rates being compared
 ADJUSTED RATES:
 Adjustment or standardization refer to
procedures for facilitating comparison of
summary measures across population
groups
 ADJUSTED RATES: Example

 Crude mortality rate from cancer in USA in 1940 was 120.2 per
100,000 and in 1980, rate was 183.8 per 100,000.
 When compare the 2 rates it suggests that, the rate increased
alarmingly by 53% (This is an epidemic)

(183.8 – 120.2 = 63.2 X 100 )

120.2
 Problem of comparing the 2 directly is that;
In 1980, 11% of the population was 65 years or older while in
1940, this proportion was 6.9%. (i.e. the population in 1980 is
older
 Mortality rates from most cancers increase dramatically with age.
 The higher crude cancer mortality rates are attributed in part, at
least, to ageing of the population
 ADJUSTED RATES

 However must examine large numbers, each age

group has to be scrutinized and compared with
another
 It becomes easier to have a summary rate to
compare with another
 Summary takes into account any differences in the
structure of a population
 The procedure used to do this is called Adjustment
or Standardization
 ADJUSTED RATES:
 Adjusted rates are also standardized rates
 Age is variable for which most adjustment
or standardization is required
 2 ways of removing effect of differences in
pop (Standardization) are:
- Direct method
- Indirect method
 DIRECT METHOD Cont..:

 Select standard Pop.

 The standard pop. is arbitrarily selected
 Identify two grps being compared
 Then apply age specific mortality rates of each grp
to the pop. in same age grp of the standard pop
 This gives number of deaths that can be expected
if these age specific rates prevailed on the
standard pop
 Adjusted Death Rates
Age Adjusted Rates
 Direct Method
 Adjusted Death Rates
Age Adjusted Rates
 Direct Method
 Adjusted Death Rates
Age Adjusted Rates
 Direct Method
 Adjusted Death Rates
Age Adjusted Rates

 Indirect Method
 Standard Mortality Ratio
 INDIRECT METHOD: (SMR)
 Select a standard Pop. whose age specific
death rates are known
 Use this to calculate expected death rates in
pop. being compared
 Calculate S.M.R.
= Observed deaths X 100
Expected deaths
Standardized Mortality Ratio
(SMR)
Standardized Mortality Ratio
(SMR)