Chapter 7

7.0 Mortality
At the end of the module the student should be able to:
a) Define mortality
b) Calculate various measurements in mortality
c) Calculate the standardization of death rates
7.1 Introduction

The acceleration of population growth in the developing countries of the world has not
been due to a change in the birth rates; but to the great reduction in death rate following
improvements life in the developing countries, the rate of natural increase was most
unlikely to have been more, and may indeed have been much less than that of the more
developed countries.

There is still considerable scope for reduction in death rates in the developing countries.
If this should occur unaccompanied by any fall in birth rates; the populations of these
countries would grow at even faster rates than at present. In short, there is no hope of any
reduction in the rates of population growth until the fall in birth rates is faster than
that of the rates of death. In any case, the population will go on increasing until or
unless the Crude Birth Rate (CBR) = Crude Death Rate (CDR) when the natural
increase becomes zero.

7.2 Measurements of Mortality

To study mortality, it is necessary to use comparative measures or indices of mortality

for periods and areas under consideration. The basic measures are essentially rates of
incidence relating to the number of death to a unit of population, commonly 1,000, in a
particular interval of time. The interval is invariably one year, to avoid the complicated
effect of seasonal mortality variations on comparability of rates.

7.2.1 Crude Death Rate

This is the simplest measure, indicating the number of deaths in a particular year per
1,000 of the population.
Formula: - CDR = D x 1,000
P
Where D = Deaths in a year
P = population at mid- year

The mid- year population is used, ideally, as the best available approximate of the
average number of people exposed to death, or “at risk”, during the year. The term
“crude” is used simply, since no allowance is made for often considerable differences
between populations in those aspects of composition in particular age and rates increase
with age from late childhood, and that at nearly all ages mortality is higher for males than
females. Consequently, age and sex structure plays an important role in influencing crude
death rates, regardless of factors like living standards and health programmes. This is
why care has to be taken in interpreting international difference in crude death rates.
There are some less developed countries (e.g. Costa Rica, Guyana, Jamaica, Malaysia,
Sri Lanka) which have lower crude death rates (about 5-7 per 1,000), countries of North
America and North Western Europe ( about 9-12 per 1,000). Clearly, this is due to much
younger age structures in less developed countries, resulting from their high fertility in
the immediate past.

7.2.2 Age and sex – specific Death Rates

A more critical appreciation of mortality level can be derived from a table of mortality
desegregated by age and sex. An age and sex specific death rate is the number of deaths
during the year of persons of a given age and sex per 1,000 people of that age group and
sex category.

Formula: A and SSDR = D (A&S) x 1,000

P (A&S)

D (A&S) = Deaths of a given age and sex in a year

P (A&S) = population of a given age and sex in the middle of the year.

It is conventional to use five year or ten year age groups, as a compromise between
unnecessarily detailed and tediously compiled larger age groups. However, because
of the importance of infant mortality, separate rates are usually calculated for the
under one and 1-4 age groups.

Examples of age and sex- specific death rates are given in the following table and
figures for a developed and a less developed country. Although levels of mortality differ
between England and Wales, and Mauritius, the overall pattern of mortality by age and
sex is very similar. Mortality rates fall from high levels in the first one year of life to a
minimum in 5-14 age group and then rise in successive age groups, although the
mortality level in the first one year is not exceeded until old age. The lower mortality rate
for females is found in all the England and Wales age groups and almost all in Mauritius.
Traditional explanations include the greater exposure of men, in general to warfare,
occupational and recreational hazards and to occupational stress. The excess male
mortality at infant and even fetal stages suggests that biological difference is the decisive
factor.

Table 5 Age Specific Mortality Rate in a District in Kenya

Age group Population No. of Deaths ASDR

0–4 155,900 4108 26.35
5 – 14 498,100 6566 13.18
15 – 24 495,000 5252 10.61
25 – 34 487,400 1418 2.91
35 – 44 381,500 1823 4.78
45 – 54 322,300 3408 10.57
55 – 64 266,800 7022 26.32
65 – 74 143,300 9298 64.88
75 + 84,500 1325 15.68
2,834,800 40220

Crude Death Rate = Deaths occurring during a calendar period x 1000

Mid year population
CDR = 40220 x 1000 = 14.18795

2834800

7.2.3 Overall pattern of mortality rates

Sets of age – and sex specific rates represent refined measures of mortality, but they are
cumbersome and difficult to assimilate. It is desirable, therefore to have a summary
measure which epitomizes a whole set of rates but which avoids the crudity of the crude
death rate. Demographers have used their technical skills to produce several measures
and two of the most widely used will now be discussed to illustrate the procedure known
as standardization. By this procedure, death rates are adjusted or standardized for the
age and sex composition of the population. Standardization can be regarded as a means
of holding age and sex constant.

7.3 Standardized Death Rates and Indices

A legitimate desire is often felt for a single mortality rate, summing up the rates to be
made between one rate and another. For this purpose, standardized death rate is generally
used. This is a hypothetical figure which indicates what the crude death rate would be if
the population being studied had the same age and sex composition as a population (any
real or assumed population).
You will find that while comparing rates between different geographical areas,
different hospitals, population or experimental groups; there are other factors which
should be considered in assessing the reliability of a crude death rate e.g. many
diseases, age specific death rates are higher for infants and very old people and low for
children and young adults as already shown. Therefore, if one population has a high
proportion of very old and very young persons, the crude death rate will usually be
higher than that of a population consisting of mainly children and young adults.
The following data shows the number of deaths in males by age of a population in
country A and the resultant death rates (hypothesized) and her immigrants in a particular
year.

Table 6 Population of country A and Immigrants to country A (Males)

AGE MALES NO. OF MALES OF NO. OF

GROUP POPULATION DEATHS IMMIGRANTS DEATHS
0-4 1,900,000 1,406 26,000 21
5 -14 3,100,000 186 30,000 2
15 - 44 9,400,000 1,786 127,000 27
45 - 64 4,900,000 7,350 25,000 42
65 + 2,000,000 17,400 5,000 48
TOTAL 21,300,000 28,128 213,000 140

Table 7 Age Specific Death Rates for country A and Immigrants

AGE DEATH RATE DEATH RATE

GROUP MALES OF COUNTRY OF IMMEGRANTS
A PER 100,000 PER 100,000
0-4 74.0 80.8
5 -14 6.0 6.7
15 - 44 19.0 21.3
45 - 64 150.0 168.0
65 + 870.0 960.0
C.D.R. 132.1 65.7
The crude death rate for country A is 132.1/100,000, and that of the immigrants is
65.7/100,000, although at every age group, age specific death rates were higher for
immigrants than for country A. These results are explained by the relatively small
number of people aged over 45 in country A, which gives much weight to the crude
death rate. Here then is an example of crude death rate
being a sample of misleading index of comparing the levels of death in these two
populations. Death rates vary with many social conditions, age and many others. To make
a single figure index of reliable we must take account of the different population
structures. This is what we have called a “standardized death rate”.
There are two common methods of deriving standardized rates, known as direct and
indirect standardization.

7.4 Direct Method of the Standardization

In order to get over the problem of different population structure of the two populations
to be compared, we choose a standard comparison.
This we call the standard. The population to be standardized we call it the index
population.
We then apply the age (or characteristics) specific rates of the index population to the
standard population.
This gives us the number of cases for each age group that we would expect if the index
population rates applied in the standard population.
Adding these cases over the age groups and dividing by the number of persons in the
standard population gives the standardized death rate for the index population.
In detail the steps involved in calculating the direct standardized death rate for the
index population.

Define the standard population

Apply the Age Specific Death Rates for the index population to the numbers in each age
group of the standard population to obtain the deaths we would expect in the population if
the index rates applied.
Add these expected deaths over the age groups to obtain the total number of the expected
deaths.
The crude rate obtained by dividing the total expected deaths by the total in the standard
population; gives the standardized death rate for the index population.

Table 8 Standard Population and Expected Deaths of Country A against the Immigrants
(per 100,000)
 AGE STANDARD INDEX RATES EXPECTED
GROUP POPULATION IMMIGRANTS DEATHS
COUNTRY A PER 100,000
0-4 1,900,000 80.8 1,536
5-14 3,100,000 6.7 208
15-44 9,400,000 21.3 2,002
45-64 4,900,000 168.0 8,232
65+ 2,000,000 960.0 19,200
CDR 21,300,000 146.4 31,177

Table 9 Immigrants Population and Expected Deaths

AGE IMMIGRANTS INDEX RATES EXPECTED

GROUP IMMIGRANTS DEATHS
PER 100,000
0-4 26000 74 19.24
5 -14 30000 6 1.8
15 - 44 127000 19 24.13
45 - 64 25000 150 37.5
65 + 5000 870 43.5
CDR 213000 59.2 126.17

The expected deaths are obtained by multiplying the standard population in each age
group by the age specific death rate of the index population, e.g.

1,900,000 x 80.8=1,535
100,000

The total expected deaths are 1,535+208+2,002+8,232

+19,200 = 31,177
The standardized death rate for the immigrants is therefore:

31,177 x100, 000= 146.4/100,000

21,300,000

The standardized death rate for country a is equal to the crude death rate which is 132.1
per 100,000.

In the following table are the standardized age- sexes – specific death rates for England
and Wales, and Mauritius, which we came across earlier in table 4 using the population
of Japan as a standard population to calculate the direct method of standardization.

The standardized death rates are as follows:

Mauritius

SIR = Expected deaths x 1,000

Standard population

= 518,314+445,676 x1, 000

121,008,000
= 7.97 per 1,000

7.5 Choice of the Standard Population

Whatever considerations are made in the choice of a standard population for application
of the direct method, the final decision as to which population is used must be to some
extent arbitrary. However, provided the standard population is in some sense
appropriate for the problem at hand, the precise structure of the
population is unlikely to affect the results of comparisons of an index population to a
market extent. For example, if the problem is to compare several occupational groups in
England and Wales an appropriate standard might be the adult population of Kenya. On
the other hand, there is no good reason why the adult population of Kenya should be
chosen as a standard if the problem is to compare several occupational groups in
England and Wales an appropriate standard might be the adult population of Kenya. On
the other hand, there is no good reason why the adult population of Kenya should be
chosen as a standard if the problem is to make international comparisons, various
suggestions have been made for the choice of standard populations and these are shown
in the following table.
These standards vary from an African country with a low proportion of old people
through an intermediate world population to a European population with a high
proportion of old people.
Table 10 Standard Population used for International comparison

Age Group Africa World Europe Truncated

0 2000 2400 1600
1–4 2000 9600 6400
5–9 10000 10000 7000
10 – 14 10000 9000 7000
15 – 19 10000 9000 7000
20 – 24 10000 8000 7000
25 – 29 10000 8000 7000
30 – 34 10000 6000 7000
35 – 39 10000 6000 2000 6000
40 – 44 5000 6000 2000 6000
45 – 49 5000 6000 2000 6000
50 – 54 3000 5000 7000 5000
55 – 59 2000 4000 6000 4000
60 – 64 2000 4000 5000 4000
 65 – 69 1000 3000 4000
70 – 74 1000 2000 3000
75 – 79 500 1000 2000
80 – 84 300 5000 1000
85 + 200 5000 1000

7.5.1 Indirect standardization

The direct method of standardization uses the population of each age group as the
standard. The indirect method of standardization uses the age specific rates as the
standard.
In detail, the procedure is as follows:
 Define the standard age specific mortality rates.
 Apply the standard age specific rates to the index population to get the expected
deaths in each age group.
 Add the expected deaths of all the age groups to get the sum of the expected deaths.
 Divide the total observed deaths (real) by the total of the expected deaths to get the
standardized mortality ratio
 Multiply the standardized mortality ratio by the crude death rate of the standard
population.

Applying the procedure mentioned above to the data shown in the following table
the calculation would be as follows:
Table 11 Indirect Standardization of the Immigrants to Country A

Age Standard Immigrant Expected

Group Rate/1000 population Cases
0–4 74.0 26000 19.2
5 – 14 6.0 30000 1.8

15 – 44 19.0 127000 24.1

45 – 64 150.0 25000 37.5
65 + 870.0 5000 43.5
126.1

The expected cases are obtained by multiplying the age specific rates by the number of
persons in the immigrants (index) population e.g. (74.0 x 26,000) divide by 100,000 =
19.2.

The standard rates are the age specific rates for country A. The total expected cases are
arrived at by adding 19.2+ 1.8+ 24.1+ 37.5 + 43.5= 126.1, and hence the standard
mortality ratio

(SMR) is 140 =1.11 or 111%

126.1

Where 140 are the actual or observed total number of deaths in the immigrants population. Refer (Table 6
Population of country A and Immigrants to country A (Males))

The indirectly standardized rate for the immigrants is then obtained by multiplying the
crude rate of the standard population by the standard mortality ratio that is
132.1 x 1.11 = 146.6 per 1,000. The indirect standardized rate for country A remains
132.1 for purposes of comparison, because we chose country A’s rates as the standard.

7.5.2 Choice between the Direct and Indirect Methods

Advantages of the direct method:

The method is simple to understand and apply

If it is necessary to compare one index population with another index population, it is
possible to simply take the ratio of the two comparative mortality indices, to obtained
comparative mortality index

CMI = DIRCTLY STANDARDIXED RATE 1

DIRECTLY STANDARDIZED RATE 2

The ratio of the two SMR obtained through indirect standardization does not simplify to
any meaningful expression. Indeed in extreme situations the ratio of the two
Standardized Mortality Rates (SMRs) could yield a totally misleading comparison of the
incidence/mortality in the two index population.
Advantages of the indirect method:
It can be shown that assuming the index rates are small as indeed they are in most
studies of mortality and incidence the standard error of indexing the indirectly
standardized rates is less than the directly standardized rate. Thus, if the sample sizes in
the index population are small, there may be an important gain in precision if the
indirect method is used rather than the direct method.

In many situations, it may be impossible to apply the direct method because the
distribution of cases or deaths in the index population is unknown. The indirect method
does not require this information.

In summary, the indirect method is preferred because of its consistency provided the
sample sizes in the index population are small.
Questions for the module
1. The following information was collected from Meru District in 1997

Age group Population No. of Deaths

0–4 157,900 3108
5 – 14 598,100 5566
15 – 24 475,000 4252
 25 – 34 387,400 1383
35 – 44 281,500 1623
45 – 54 212,300 2408
55 – 64 176,800 6022
65 – 74 133,000 8298
75 + 74,500 1225

Using the information provided in the table, calculate: -

i) Crude death rate ii) Age specific death rate
iii) Graph the age specific death rate iv) Comment on the graph.
2) Briefly describe the following rates commonly used in demography
i) Infant Mortality Rate ii) Neonatal Mortality Rate
iii) Post neonatal Mortality Rate iv) Fetal Death Rate
v) Maternal Mortality Rate vii) Case Fatality Rate