Dylan Thomas

And death shall have no dominion.

…Death has no territory,
no control, and no influence over
the dead ones.
All are one in death;
race and skin color have no more
meaning when skin is no more.
Dead are all united with nature….

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Measures of Mortality &
Natality

Dr. Mostafa Moin Uddin

Assistant Professor
Department of Epidemiology
NIPSOM
8th October 2024

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Learning Objectives
By the end of this class the students will be able to understand-
• Important mortality measures used in public health
• Case fatality
• Proportionate mortality
• YPLL
• Importance of mortality
• Problems with mortality data
• Direct and indirect age adjustment
• SMR
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Measuring the occurrence of Disease:
Mortality

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 Why Mortality is of great interest? For
several reasons:
1. Death is the ultimate experience that every human being is destined to have.
2. Death is clearly of tremendous importance to each person including
questions of when and how death will occur and whether there is any way
to delay it.
3. Expressing mortality in quantitative terms can pinpoint differences in the risk
of dying from a disease- between people in different geographic areas and
subgroups- in the population.
4. Mortality rates can serve as measures of disease severity.
5. Mortality rates can help us determine whether the treatment for a disease
has become more effective over time.
6. Mortality rates may serve as surrogates for incidence rates when the disease
being studied is a severe and lethal one.
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 MORTALITY RATES: How is mortality expressed in quantitative terms?

• A mortality rate is a measure of the frequency of occurrence of death in

a defined population during a specified interval. Such as

1. Age-specific death rates

2. Crude mortality/death rate
3. Proportionate mortality
4. Infant mortality rate
5. Maternal mortality ratio
6. Life Expectancy at Birth in Years

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• Annual mortality rate for all causes (per 1,000
Population)

= ꓫ 1,000

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Case fatality

• We must distinguish between mortality and case fatality.

• Case fatality is a measure of the severity of a disease.

• It is defined as the proportion of cases of a specified disease

or condition that are fatal within a specified time.

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Case-fatality

• Case-fatality (%)

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Comparison of mortality rate and case-fatality rate
in the same year
• Assume a population of 100,000 people of whom 20 are sick
with disease X, and in 1 year, 18 of the 20 die from disease X.

• Mortality rate from the disease X = = .00018 or .018%

• Case-fatality from disease X = = .9 or 90%

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 Q. What is the difference between case-fatality and a
mortality rate?

Case Fatality Mortality Rate

1. In case fatality, the denominator is 1. In a mortality rate, the
limited to those who already have denominator represents the entire
the disease. population at risk of dying from the
2. Case fatality is a measure of the disease, including both those who
severity of the disease. have the disease and those who do
3. Case fatality can be used to not have the disease.
measure any benefits of a new 2. Mortality rate identifies rare
therapy. As therapy improves, case disease(s).
fatality would be expected to 3. Can not be used to measure any
decline. benefits of a new therapy.
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Crude mortality rate:

Age-specific mortality rate

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• Crude Death Rate/ Crude Mortality Rate per 1000 population=
Total: 5.7 (Rural 6, Urban 4.8)
Life Expectancy at Birth in Years=
Both sexes: 72.3 years
• Male: 70.6 years
• Female: 74.1 years

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Proportionate mortality

• Occasionally the mortality in a population is described by

using proportionate mortality.

• Proportionate mortality is not a rate.

• Proportionate mortality does not express the risk of

members of a population dying from a disease.

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• Proportionate mortality from cardiovascular disease

= x 100

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YEARS OF POTENTIAL LIFE LOST
(YPLL)
• It is a mortality index

• Years of potential life lost (YPLL), has been increasingly used for setting
health priorities.

• YPLL is a measure of premature mortality, or early death.

• YPLL recognizes that death occurring in a person at a younger age clearly

involves a greater loss of future productive years than death occurring at
an older age.
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YPLL…2
• Two steps are involved in YPLL calculation:
• In the first step, for each cause, each deceased person’s age
at death is subtracted from a predetermined (or “average”)
age at death
• Example: In the United States, this predetermined
“standard” age is usually 75 years. Thus, an infant dying at 1
year of age has lost 74 years of life (75 to 1), but a person
dying at 50 years of age has lost 25 years of life (75 to 50).
• The younger the age at which death occurs, the more years
of potential life are lost.
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YPLL…3

• In the second step, the “years of potential life lost” for each
individual are then added together to yield the total YPLL for
the specific cause of death.

• When looking at reports that use YPLL, it is important to note

what assumptions the author has made, including what
predetermined standard age has been selected.
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WHY LOOK AT MORTALITY?
• Mortality is an index of the severity of a disease from both clinical
and public health standpoints, but mortality can also be used as an
index of the risk of disease.

• In general, mortality data are easier to obtain than incidence data

for a given disease, and it therefore may be more feasible to use
mortality data as a proxy indicator for incidence.

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 WHY LOOK AT MORTALITY?
• When a disease is mild and not fatal, mortality may not be a
good index of incidence.
• A mortality rate is a good reflection of the incidence rate under
two conditions:
 when the case-fatality rate is high (as in untreated Rabies),
and
 when the duration of the disease (survival) is short.
Under these conditions, mortality is a good measure of
incidence, and thus a measure of the risk of disease.

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• For example, Cancer of the Pancreas is a highly lethal
disease: death generally occurs within a few months of
diagnosis, and long-term survival is rare. Thus, unfortunately,
mortality from pancreatic cancer is a good surrogate for
incidence of the disease.

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Probable Question?

“Mortality is a good measure of incidence”-please briefly

explain the statement.

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PROBLEMS WITH MORTALITY
DATA
• By international agreement, deaths are coded according to the
underlying cause.
• In the death certificate the underlying cause of death “excludes
information pertaining to the immediate cause of death, contributory
causes and those causes that intervene between the underlying and
immediate causes of death.”
• The total contribution of a given cause of death may not be reflected
in the mortality data as generally reported; this may apply to a greater
extent in some diseases than in others.

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PROBLEMS WITH MORTALITY
DATA
• Deaths are coded according to the International
Classification of Diseases (ICD), now in its 10th revision.
• Because coding categories and regulations change from one
revision to another, any study of time trends in mortality that
spans more than one revision must examine the possibility
that observed changes could be due entirely or in part to
changes in the ICD.

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SOME CAUSES OF DEATH THAT WERE REPORTED
ON DEATH CERTIFICATES IN THE EARLY 1900S

• “Died suddenly without the aid of a physician”

• “A mother died in infancy”
• “Deceased had never been fatally sick”
• “Died suddenly, nothing serious”
• “Went to bed feeling well, but woke up dead”

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Comparing Mortality in Different
Populations
• An important use of mortality data is to compare two or more
populations, or one population in different time periods.
• Such populations may differ with regard to many
characteristics that affect mortality, of which the age
distribution is the most important.
• Age is the single most important predictor of mortality.
• Therefore methods have been developed for comparing
mortality in such populations while effectively holding
constant characteristics such as age.
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• The overall mortality also called crude or unadjusted mortality
reflects both
differences in the force of mortality and

differences in the age composition of the population.

• For dealing with this problem: direct age adjustment and indirect
age adjustment is used.
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• In Direct Age Adjustment, a standard population is used in order
to eliminate the effects of any differences in age between two or
more populations being compared.
• A hypothetical “standard” population is created to which we apply both
the age specific mortality rates from the early period and the age-specific
mortality rates from the later period. By applying mortality rates from
both periods to a single standard population, we eliminate any possibility
that observed differences could be a result of age differences in the
population.
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INDIRECT AGE ADJUSTMENT
(STANDARDIZED MORTALITY RATIOS)
• Indirect age adjustment is often used when numbers of deaths for
each age-specific stratum are not available.
• It is also used to study mortality in an occupationally exposed
population
Example:
Do people who work in a certain industry, such as mining or
construction, have a higher mortality than people of the same age in
the general population?
Is an additional risk associated with that occupation?

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INDIRECT AGE ADJUSTMENT
(STANDARDIZED MORTALITY RATIOS-
SMR)
• To answer the question of whether a population of workers has a higher
mortality than we would expect in a similar population that is not engaged in
the occupation being observed, the age-specific rates for a known population,
such as all men of the same age, are applied to each age group in the
population of interest.
• This will yield the number of deaths expected in each age group in the
population of interest, if this population had had the mortality experience of
the known population.
• Thus, for each age group, the number of deaths expected is calculated, and
these numbers are totaled or added up to.
• The numbers of deaths that were actually observed in that population are
also calculated and totaled.
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standardized mortality ratio (SMR)
• The ratio of the total number of deaths actually observed to
the total number of deaths expected, if the population of
interest had had the mortality experience of the known
population, is then calculated.
• This ratio is called the standardized mortality ratio (SMR).
• SMR = Observed no of deaths per year/ Expected no of
deaths per year

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Civil Registration and Vital Statistics
(CRVS) in Bangladesh
• The United Nations General assembly in 1979 declared that most
countries have a legal requirement for relevant authorities to be
notified of certain life events (birth, marriage, divorce, adoption, and
death) which are known as vital events.
• Complete coverage, accuracy and timeliness of civil registration are
essential to ensure the quality of vital statistics.

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Birth registration
• Only legal way for a child to get a birth certificate.
• This legal proof of identity can help protect children from violence,
abuse and exploitation.
• Without a birth certificate, children are unable to prove their age,
which puts them at a much higher risk of being forced into early
marriage or the labor market, or recruited into the armed forces.
• It can also help protect migrant and refugee children against family
separation, trafficking and illegal adoption.

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Registration of death and cause of
death
• It provides legal rights to the family, for example, in conferring property
or other individual or personal transfer rights to remaining family
members.
• It is also central to keeping the civil registry up to date.
• Some countries might have good death registration coverage, but little or
no information on causes of death. This may be because there are no
processes or resources in place to determine these, such as verbal
autopsy or adequately trained medical staffin health facilities.
• Cause of death registration provides critical information about infant,
child, and adult mortality and the burden of disease in communities,
and contributes to the calculation of population statistics and dynamics.
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Medical Certificate of Cause of
Death (MCCoD)
• MCCoD are assigned according to International Statistical
Classification of Disease and Health Conditions (ICD) rules and
guidelines.
• In case of hospital death, a registered doctor has to fill out the
international medical certificate form stating the cause of death.
• Then this data is entered into DHIS2 by a senior staff nurse.
• The best way to obtain a good-quality mortality statistics is to have
death certificates by medically certified doctors.

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Verbal Autopsy (VA)
• VA is a technique for determining the cause of death (COD) in case of
death in a community, based on interviewing a family member close
to the decedent.
• This involves collecting information on the signs and symptoms
experienced by the deceased prior to death using a specific,
structured set of questions.

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• This has been demonstrated to yield useful policy-relevantt
information on the leading causes of deaths, particularity for home
deaths.
• It is the only available method to obtain a probable COD where no
opportunity exists for a physician to assign a medically certified COD.
• Automated VA is the application of VA using a tablet to collect data
and a computer algorithm to assign the COD based on the signs and
symptoms elicited from the questionnaire. (Health Bulletin 2021,
p233)

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• Infant mortality rate

1000

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In Bangladesh: SVRS 2021
1. Crude Death Rate per 1000 population= 5.7 or 6
2. Neonatal Mortality Rate per 1000 live births (both sexes)= 16
3. Infant Mortality Rate per 1000 live births (both sexes)= 22
4. Under -5 Mortality rate per 1000 live births (both sexes)=28

 Neonate: a child under 28 days of age.

 Infant: a child in the first year of life.
Bangladesh Bureau of Statistics (BBS) introduced Sample Vital Registration System
(SVRS) in 1980 to study the changes in the demographic scenarios of Bangladesh during
the intercensal periods.
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Maternal Mortality Ratio (MMR)
• MMR=
No. of MDs during a given time period x100,000 live births/ No. of LBs
in the same period
No. of MDs in 12 months x100,000 live births / No. of LBs in the same
12 months

• Maternal Mortality Ratio per 100,000 live births in Bangladesh =

168 per 100,000 live births (Rural: 176, Urban: 140)

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Maternal Mortality Rate
• Maternal Mortality Rate=
• No. of MDs in 12 monthsx 100,000/ Average number of women in the
reproductive age in the same 12 months.

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Natality:
• Natality in population ecology is the scientific term for birth rate.
• Along with mortality rate, natality rate is used to calculate the
dynamics of a population.
• They are the key factors in determining whether a population is
increasing, decreasing or staying the same in size.
• It shows a positive effect on population density because it results in
adding the number of individuals to a population.
• Natality is the greatest influence on a population's increase.

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• Natality is shown as a crude birth rate or specific birth rate.
• Crude birth rate per 1000 population in Bangladesh: 18.8 per 1000
population/year)
• Natality is defined as the ratio of the number of births to the size of
that population.
• The formula for calculating Natality for a growing population:
• Natality= Number of Birth per yearx100/Total Population
• Total Fertility Rate per woman aged 15-49 : 2.05 (SVRS 2021)

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• Do you have any questions/comments/observation?

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Thank you

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