Análise de casos e óbitos relacionados à esquistossomose no Brasil: padrões epidemiológicos e distribuição espaçotemporal, 2010-2022 / Analysis of schistosomiasis cases and deaths in Brazil: epidemiologic patterns and spatio-temporal distribution, 2010-2022 / Análisis de los casos y muertes relacionados con la esquistosomiasis en Brasil: patrones epidemiológión espaciotemporal, 2010-2022cos y distribuci

A esquistossomose é uma infecção parasitária causada por um grupo de vermes chatos chamados Schistosoma. A doença encontra-se, sobretudo, nos países em desenvolvimento, especialmente nas zonas rurais com más condições de saneamento e acesso limitado à água potável. A esquistossomose é transmitida através do contato com água doce contaminada, como de rios, lagos e lagoas em que vivem as larvas dos parasitas. O objetivo deste artigo foi analisar as variáveis epidemiológicas dos casos (2010-2022) e dos óbitos (2010-2020) por esquistossomose no Brasil. Trata-se de um estudo epidemiológico transversal, descritivo e quantitativo. A estratégia metodológica envolveu análise dos boletins epidemiológicos disponibilizados pelo Sistema de Informação de Agravos de Notificação (Sinan) e pelo Sistema de Informação sobre Mortalidade (SIM) no período de 2010 a 2022. Foram notificados 93.521 casos de esquistossomose e 5.495 óbitos devido a complicações dessa infecção. A forma intestinal foi a mais identificada. Minas Gerais, São Paulo, Bahia e Espírito Santo foram os estados com maior prevalência da doença. Constatou-se que homens pardos com idade entre 20 e 39 anos e com baixo nível de escolaridade são os mais afetados. Identificaram-se 732 casos da infecção em gestantes. Ademais, 62,56% dos casos evoluíram para cura e 5,88% para óbito pelo agravo notificado. Em conclusão, é crucial adotar medidas de prevenção e acesso à educação para combater efetivamente a esquistossomose.

Schistosomiasis is a parasitic infection caused by a group of flatworms called Schistosoma. The disease is primarily found in developing countries, especially in rural areas with poor sanitation and limited access to clean water. Schistosomiasis is transmitted by contact with contaminated freshwater, such as rivers, lakes, and ponds, where the parasites' larvae live. The aim of this article was to analyze the epidemiological variables of schistosomiasis cases (2010-2022) and deaths (2010-2020) in Brazil. This is a cross-sectional, descriptive, and quantitative epidemiologic study. The methodological strategy involved the analysis of epidemiological bulletins provided by the Sistema de Informação de Agravos de Notificação (SINAN) and the Sistema de Informação sobre Mortalidade (SIM) from 2010 to 2022. There were 93.521 reported cases of schistosomiasis and 5.495 deaths due to complications of this infection. The intestinal form was the most identified. Minas Gerais, São Paulo, Bahia, and Espírito Santo were the states with the highest prevalence of the disease. Males, of mixed race, aged between 20 and 39 years, and with a low level of education were the most affected. There were 732 cases of infection in pregnant women. Furthermore, 62.56% of the cases evolved to cure and 5.88% evolved to death by the notified disease. In conclusion, it is crucial to adopt prevention measures and access to education to effectively combat schistosomiasis.

La esquistosomiasis es una enfermedad parasitaria causada por un grupo de platelmintos conocidos como Schistosoma. La enfermedad es más frecuente sobre todo en países en desarrollo, especialmente en zonas rurales con saneamiento deficiente y acceso limitado al agua potable. La transmisión de la esquistosomiasis se da por el contacto con agua dulce contaminada, como ríos, lagos y lagunas donde viven las larvas de los parásitos. El objetivo de este artículo fue analizar las variables epidemiológicas de los casos (2010-2022) y muertes (2010-2020) por esquistosomiasis en Brasil. Se trata de un estudio epidemiológico transversal, descriptivo y cuantitativo. La estrategia metodológica contó con el análisis de los informes epidemiológicos que pone a disposición el Sistema de Información de Enfermedades de Declaración Obligatoria (Sinan) y el Sistema de Información sobre Mortalidad (SIM) en el período de 2010 a 2022. Se notificaron 93.521 casos de esquistosomiasis y 5.495 muertes por complicaciones de esta infección. La forma intestinal fue la más identificada. Minas Gerais, São Paulo, Bahia y Espírito Santo fueron los estados con mayor prevalencia de la enfermedad. Se constató que hombres pardos, de edad entre 20 y 39 años, y bajo nivel de escolaridad son los más afectados. Se identificaron 732 casos de infección en mujeres embarazadas. El 62,56% de los casos evolucionaron a cura; y el 5,88% tuvieron muerte confirmada por el agravio notificado. Se concluye con la necesidad de adoptar medidas de prevención y acceso a la educación para combatir eficazmente la esquistosomiasis.

Sexual Orientation Differences in Lethal Methods Used in Suicide: Findings From the National Violent Death Reporting System.

We examined sexual orientation and sex differences in seven methods of suicide among adult suicides reported in the United States National Violent Death Reporting System (2012-2015; N = 59,075). Overall, most sexual minorities (i.e., lesbians, gay men, bisexuals) identified in the dataset used hanging (38%) followed by firearm (30%) and drug or poison ingestion (20%). Sexual minorities were more likely than heterosexuals to be younger, female, and Black/African American. Multivariate sex-stratified analyses in the overall sample showed that strong sexual orientation differences in lethal methods existed among men but not among women. However, when we compared sex differences in lethal methods among sexual minorities only, we found that lesbian/bisexual women, as compared to gay/bisexual men, were more likely to use a firearm or drug or poison ingestion than hanging. Findings suggest that the higher rate of suicide mortality among sexual minorities is likely driven by hanging, a method of suicide that is not particularly amenable to lethal method restricted-access prevention approaches. Future research directions, clinical training recommendations, and intervention opportunities are discussed.

Excessive alcohol use and drug overdose deaths, New Mexico, 2015-2016.

BACKGROUND: Excessive alcohol use is an important component of a person's risk for drug overdose death. But alcohol's contribution to overdose death risk has not been well quantified. We aimed to quantify the role of excessive alcohol use, particularly as defined by a blood alcohol concentration (BAC) ≥0.08 g/dL, in drug overdose deaths in New Mexico (NM). METHODS: The study was conducted in 2018. We abstracted death records (scene investigation, toxicology, pathology) for all drug overdose deaths in NM during 2015-2016, information on BAC, other indications of alcohol, risk factors, comorbidities, and drug type and linked this information with demographic characteristics on death certificates. A Poisson regression model was used to determine independent associations between decedents' characteristics and alcohol involvement among drug overdose decedents. RESULTS: Approximately 18 % (n = 170) of the 946 drug overdose decedents in this study had a BAC ≥ 0.08 g/dL. After adjustment, drug overdose decedents who were American Indian/Alaska Native or had a history of alcohol use disorder were more likely to have had a BAC ≥ 0.08 g/dL at the time of death. However, decedents who had methamphetamine involved in their death or who had a history of diabetes, mental illness, or chronic pain were less likely to have a BAC ≥ 0.08 g/dL at the time of death. CONCLUSIONS: Nearly 1 in 5 overdose decedents had a BAC ≥ 0.08 g/dL at the time of death, suggesting that evidence-based alcohol prevention strategies (e.g., increasing alcohol taxes, regulating alcohol outlet density) could reduce the risk of drug overdose death.

Estimating cause-specific mortality in Madagascar: an evaluation of death notification data from the capital city.

BACKGROUND: Trends in cause-specific mortality in most African countries are currently estimated from epidemiological models because the coverage of the civil registration system is low and national statistics on causes of death are unreliable at the national level. We aim to evaluate the performance of the death notification system in Antananarivo, the capital city of Madagascar, to inform cause-of-death statistics. METHODS: Information on the sex of the deceased, dates of birth and death, and underlying cause of death were transcribed from death registers maintained in Antananarivo. Causes of death were coded in ICD-9 and mapped to cause categories from the Global Burden of Disease 2016 Study (GBD). The performance of the notification system was assessed based on the Vital Statistics Performance Index, including six dimensions: completeness of death registration, quality of cause of death reporting, quality of age and sex reporting, internal consistency, level of cause-specific detail, and data availability and timeliness. We redistributed garbage codes and compared cause-specific mortality fractions in death records and estimates from the GBD with concordance correlation coefficients. RESULTS: The death notification system in Antananarivo performed well on most dimensions, although 31% of all deaths registered over the period 1976-2015 were assigned to ICD codes considered as "major garbage codes" in the GBD 2016. The completeness of death notification, estimated with indirect demographic techniques, was higher than 90% in the period 1975-1993, and recent under-five mortality rates were consistent with estimates from Demographic and Health Surveys referring to the capital city. After redistributing garbage codes, cause-specific mortality fractions derived from death notification data were consistent with GBD 2016 for the whole country in the 1990s, with concordance correlation coefficients higher than 90%. There were larger deviations in recent years, with concordance correlation coefficients in 2015 at 0.74 (95% CI 0.66-0.81) for men and 0.81 (95% CI 0.74-0.86) for women. CONCLUSIONS: Death notification in Antananarivo is a low-cost data source allowing real-time mortality monitoring, with a potential to improve disease burden estimates. Further efforts should be directed towards evaluating data quality in urban centers in Madagascar and other African countries to fill important data gaps on causes of death.

Diabetes-attributable mortality in the United States from 2003 to 2016 using a multiple-cause-of-death approach.

AIMS: Deaths attributable to diabetes may be underestimated using an underlying cause of death (COD) approach in U.S. death records. This study sought to characterize the burden of diabetes deaths using a multiple-cause of death approach (underlying and contributing COD) and to identify temporal changes in co-reported causes of death among those with diabetes listed anywhere on their death records. METHODS: COD were identified using data from the National Center for Health Statistics from 2003 to 2016. We calculated age-adjusted mortality rates for diabetes as the underlying or contributing COD by race/ethnicity. We used ICD-10 codes to identify leading causes of death among those with and without diabetes on their death records. We compared temporal changes in deaths due to cardiovascular disease, cerebrovascular disease, cancer, and other causes. RESULTS: The study population included 34,313,964 decedents aged ≥25 from 2003 to 2016. Diabetes was listed as an underlying COD in approximately 3.0% (n = 1,031,000) and 6.7% (n = 2,295,510) of the death records, respectively. Decedents with diabetes listed as an underlying COD experienced a 16% decline in mortality, and the race/ethnicity-specific average annual percentage changes (AAPC) showed significant declining trends for most groups (AAPC ranged from 0.18 to -2.83%). Cardiovascular disease remained the leading underlying COD among diabetes-attributable deaths, although its proportion of deaths fell from 31 to 27% over time. Co-reported COD diversified, and were more likely to include hypertension and hypertensive renal disease among those with diabetes on their death records. CONCLUSIONS: Our findings underscore the importance of using a multiple-cause-of-death approach for more completely characterizing diabetes' contribution to mortality.

Do inferences about mortality rates and disparities vary by source of mortality information?

PURPOSE: Researchers who study mortality among survey participants have multiple options for obtaining information about which participants died (and when and how they died). Some use public record and commercial databases; others use the National Death Index; some use the Social Security Death Master File; and still others triangulate sources and use Internet searches and genealogic methods. We ask how inferences about mortality rates and disparities depend on the choice of source of mortality information. METHODS: Using data on a large, nationally representative cohort of people who were first interviewed as high school sophomores in 1980 and for whom we have extensive identifying information, we describe mortality rates and disparities through about age 50 using four separate sources of mortality data. We rely on cross-tabular and multivariate logistic regression models. RESULTS: These sources of mortality information often disagree about which of our panelists died by about age 50 and also about overall mortality rates. However, differences in mortality rates (i.e., by sex, race/ethnicity, education) are similar across of sources of mortality data. CONCLUSION: Researchers' source of mortality information affects estimates of overall mortality rates but not estimates of differential mortality by sex, race and/or ethnicity, or education.

Causas de defunción mal definidas en las provincias de Argentina, 2001-2013 / Ill-defined causes of death in the provinces of Argentina,2001-2013

El objetivo fue analizar los niveles y tendencias en el porcentaje de muertes con causas mal definidas en las provincias de Argentina, durante los años 2001 a 2013. Este fue un estudio descriptivo, de tipo cuantitativo. Se utilizó la base de datos de registros de defunción de la Dirección de Estadísticas e Información en Salud. A partir del porcentaje de defunciones con causas mal definidas, se clasificó a las provincias según niveles de exactitud: alta (<5%), buena (≥ 5% <10%), regular (≥ 10% <20%) y baja (≥ 20%). Se analizó la distribución relativa de las muertes según el grupo de códigos más frecuentes: signos y síntomas (R00-R69), hallazgos anormales clínicos y de laboratorio (R70-R94) y causas desconocidas y mal definidas propiamente dichas (R95-R99). La tendencia temporal se estableció mediante el cambio porcentual. En 11 provincias la exactitud fue alta, en 5 buena y en 8 regular. En todas las jurisdicciones, los códigos más frecuentes fueron las causas desconocidas o mal definidas propiamente dichas, aunque éstas fueron proporcionalmente menos importantes en las provincias con nivel alto de exactitud. Además, en este grupo de jurisdicciones se observaron las reducciones más importantes del porcentaje de causas mal definidas. Solo dos provincias con niveles intermedios de exactitud presentaron la misma pauta. El análisis de las causas de muerte mal definidas, permitió reconocer problemas básicos en la información, y proporcionó indicios válidos para investigaciones futuras. Resulta de interés identificar las buenas prácticas implementadas en las provincias menos afectadas por este inconveniente.

The objective was to analyze levels and trends in the percentage of deaths with ill-definedcauses in the provinces of Argentina, during the years 2001-2013. This was a quantitativedescriptive study. Database of death records from the Department of Health Statistics andInformation was used. From the percentage of deaths with ill-defined causes, provinceswere classified into four accuracy levels: high (<5%), good (≥ 5% <10%), regular (≥ 10%<20%) and low (≥ 20%). The relative distribution of deaths was analyzed according to thegroup of more frequent codes: symptoms and signs (R00-R69), abnormal clinical andlaboratory findings (R70-R94) and ill-defined and unknown causes of death (R95-R99).Time trend was established with the relative variation. Eleven provinces had an excellentlevel of accuracy, five provinces had a very good level of accuracy and eight provinces had agood level of accuracy. In all jurisdictions, the most common codes were the unknown orill-defined causes, although they were proportionally less important in the provinces withhigh accuracy. Besides, the most significant reductions were observed in this group. Only two provinces with intermediate levels showed the same pattern. The analysis of the illdefinedcauses of death identified the most basic problems in the information, and providedvalid evidence to guide future research. It is interesting to analyze the good practices thathave been implemented by the provinces that are less affected by this problem.

Hacia el seguimiento de los determinantes sociales de la salud: alcances y limitaciones de las estadísticas de defunción en la Argentina (2001-2009) / Towards the monitoring of the social determinants of health: the scope and limitations of death statistics in Argentina ( (2001-2009)

OBJETIVOS: describir la precisión de las variables sobre estratificación social del fallecido y el impacto de factores personales, profesionales e institucionales en la exactitud de los datos de las estadísticas de defunción producidas entre los años 2001 y 2009 en la Argentina. METODOLOGIA: estudio descriptivo que utiliza las bases de datos de la Dirección de Estadísticas e Información de Salud de la Argentina. Se realiza un análisis estadístico descriptivo para determinar el nivel y la tendencia en la precisión de las variables seleccionadas y regresiones logísticas para determinar la influencia de diferentes factores en la exactitud de la información. RESULTADOS: se verifican niveles de precisión excelentes (dos variables), regulares (dos variables) y malos (cuatro variables). Los dos primeros grupos tienden a mantener o mejorar su situación a lo largo del tiempo, mientras que el tercero tiende a empeorarla. La inexactitud de la mayoría de las variables mostró una elevada asociación con ciertas regiones de residencia, etapas del ciclo vital, tipos de establecimientos de salud y modalidades de atención y certificación médica. DISCUSION:el uso de las estadísticas de defunción para el seguimiento de los determinantes sociales de la salud exige el mejoramiento de la exactitud de las variables sobre estratificación social del fallecido. Se recomienda implementar campañas de sensibilización, mejorar la capacitación de los médicos, actualizar los mecanismos de control de calidad e incrementar la infraestructura física y organizacional.

OBJECTIVE: To describe the accuracy of social stratification variables of the deceased, and the impact of personal, professional and institutional factors in the accuracy of the data, in death statistics from Argentina (2001-2009). METHODOLOGY: An exploratory-descriptive study, using the databases of the Department of Health Statistics and Information of Argentina. Descriptive statistic was used to determine the level and trend in the accuracy of a set of variables. Logistic regression was used to determine the influence of different factors on the accuracy of the information. RESULTS: Two variables had excellent accuracy, two variables had regular accuracy, and four variables had unsatisfactory accuracy. The first two groups of variables improve their situation. The third group makes it worse. The inaccuracy of most variables showed a high association with certain regions of residence, lifecycle stages, and certain types of health care and medical certification. DISCUSSION: The use of death statistics for monitoring the social determinants of health requires improving the accuracy of the variables on social stratification of the deceased. We recommend implementing awareness campaigns, improve training of doctors, upgrade quality control mechanisms and increase physical and organizational infrastructure.

Problemas no preenchimento da declaração de óbito: estudo exploratório / Problemas en la cumplimentación de la declaración de defunción (DO): estudio exploratorio / Problems filling out death certificates: exploratory study

Os dados do Sistema de Informação sobre Mortalidade (SIM) representam a principal fonte de informações sobre mortalidade no Brasil, embora apresentem com frequência alguma inconsistência. Uma dificuldade para a geração dos dados de mortalidade confiáveis é o correto preenchimento da Declaração de Óbito (DO), instrumento de alimentação de dados para o SIM. O artigo relata estudo exploratório sobre problemas de preenchimento da DO, utilizando abordagem semiqualitativa. A coleta dos dados foi realizada por meio de entrevistas semiestruturadas e questionários estruturados aplicados a médicos. Os resultados mostram que os principais problemas relacionados ao preenchimento da DO são o desconhecimento médico acerca da importância do correto preenchimento de todos os campos do formulário, a pouca utilização dos materiais de instrução fornecidos aos médicos pelos órgãos e instituições responsáveis, o desconhecimento sobre a importância do detalhamento e a adequação da cadeia de eventos patológicos no campo das possíveis causas de morte.

Los datos del Sistema de Información sobre Mortalidad (SIM) representan la principal fuente de información sobre mortalidad en Brasil, aunque presenten con frecuencia alguna inconsistencia. Una dificultad para la generación de datos de mortalidad fiables es la correcta cumplimentación de la Declaración de Defunción (DO), instrumento de alimentación de datos del SIM. El artículo versa sobre un estudio exploratorio acerca de problemas de cumplimentación de la DO, utilizando un enfoque semicualitativo. La recogida de datos fue realizada mediante entrevistas semiestructuradas y cuestionarios estructurados aplicados a médicos. Los resultados muestran que los principales problemas relacionados con la cumplimentación de la DO son el desconocimiento médico, acerca de la importancia de la correcta cumplimentación de todos los campos del formulario; la poca utilización de los materiales de instrucción proporcionados a los médicos por los órganos e instituciones responsables; el desconocimiento sobre la importancia de documentos detallados y la adecuación de la cadena de eventos patológicos en el campo de las posibles causas de muerte.

Data from the Brazilian Mortality Information System (SIM, in Portuguese) represent the main source of information on mortality in Brazil, even though the system contains many inconsistencies. One difficulty in generating reliable data on mortality is the correct filling out of death certificates (DOs), which are source instruments for the SIM system. This article describes an exploratory study on problems related to the filling out of DOs, using a semi-qualitative approach. The data was collected in semi-structured interviews and questionnaires with medical doctors. The results show that the main problems related to filling out DOs are lack of medical information regarding the importance of the correct filling out of all the fields on the form, the limited use of the instructions issued by responsible organs and institutions, and lack of knowledge as to the importance of certain details and descriptions of the chain of pathological events in the field of possible causes of death.

Lung cancer deaths in the United States from 1979 to 1992: an analysis using multiple-cause mortality data.

BACKGROUND: We sought to describe trends in the presence of lung cancer at the time of death in the United States from 1979 to 1992. METHODS: We analysed death certificate reports in the Multiple-Cause Mortality Files compiled by the National Center for Health Statistics, searching for any mention of lung cancer, lung cancer as the underlying cause of death, and comorbid conditions. RESULTS: Of the 29,042,213 decedents in the study period, 1,892,129 (6.5%) had a diagnosis of lung cancer listed on their death certificates; of these 1,892,129 decedents, 1,734,767 (91.7%) had lung cancer listed as the underlying cause of death. Decedents with lung cancer listed as being present but not the underlying cause of death were more likely to be male (relative risk [RR] 1.16, 95% confidence interval [CI]: 1.15-1.17), and older (RR 4.61, 95% CI: 4.35-4.88 for decedents older than 85 compared to those aged less than 44), but less likely to be black than white (RR 0.88, 95% CI: 0.87-0.90). The mortality rate, age-adjusted to the 1980 population, increased 23.0%, from 47.9 per 100,000 in 1979 to 58.9 per 100,000 in 1992. Over the study period, black men had the highest mortality rates (117.3-125.2 per 100,000), followed by white men (81.7-88.7 per 100,000), men of other races (37.4-46.7 per 100,000), white women (22.1-39.1 per 100,000), black women (21.4-38.2 per 100,000), and women of other races (12.6-18.1 per 100,000). Age-adjusted, state specific rates varied threefold, from 30.4 per 100,000 in Utah to 93.9 per 100,000 in Nevada. CONCLUSIONS: We conclude that the underlying cause of death data base, which captures almost 92% of decedents with lung cancer present, accurately tracks lung cancer mortality trends in the US. Mortality rates of lung cancer, which are decreasing among men, continue to increase among women.

The validity of verbal autopsies for assessing the causes of institutional maternal death.

This report presents data from a study carried out in three African countries to assess the validity of verbal autopsies--based on information about symptoms and signs observed antemortem by relatives or associates of deceased individuals--for determining the causes of institutional maternal death. The validity of the verbal autopsy was assessed for each cause of death; and for groups of "direct" and "indirect" maternal causes, by comparing the verbal autopsy diagnoses with the reference diagnoses and calculating their sensitivity, specificity, and positive predictive value. Verbal autopsies were found to be highly specific (98 percent specificity for all causes of maternal death) but not very sensitive (< or = 60 percent sensitivity for all causes except ante/postpartum hemorrhage). Verbal autopsy estimates of cause-specific mortality were comparable to expected values for most of the causes. The study shows that certain direct causes of hospital-based maternal mortality can be determined by means of verbal autopsies with a reasonable level of confidence.

PIP: This study shows that certain direct causes of hospital-based maternal mortality can be validly determined by verbal autopsies. Data were obtained during 1993-95 from a rural district hospital in Kilombero District, Tanzania; a rural teaching hospital in Oromiya Region, Ethiopia; and a rural district hospital in Bawku District, Ghana. Hospital deliveries averaged 1200-1500/year. Maternal deaths averaged 20-30/year. The study population included all adults aged over 15 years dying at ages 15-49 years in the specified hospitals and who lived within 60 km. Data also included hospital records and death certificates. Findings among physicians indicate that direct maternal causes (DMCs), including abortion, had a sensitivity of 82% and a specificity of 93%. For indirect maternal causes (IMCs), the specificity was 97% and the sensitivity was 38%. The positive predictive value (PPV) was 70% for DMCs and 67% for IMCs. Sensitivity was the lowest measure of reliability for all causes. Sensitivity was higher than 60% for all DMCs, with the exception of eclampsia (40%), and lower than 50% for common IMCs. IMCs had a specificity over 98%. The PPV was under 60% for most IMCs and DMCs, except obstructed labor (80%), abortion (64%), and hepatitis (100%). Findings using the algorithm showed lower specificities (93% for DMCs and IMCs). Sensitivity was 60% for DMCs and 68% for IMCs. There was reasonable agreement between physician diagnoses and algorithms. Individual misclassifications of causes were higher in algorithm-based verbal autopsies. False nonmaternal causes were greater among algorithm-based verbal autopsy diagnoses.

Is length of life predictable?

A random sample of death records of adult males from the period 1967 to 1970 was chosen from the South Australian Registry of Births, Deaths, and Marriages. The natural parents of these individuals were identified by cross-referencing to birth certificates, and an extensive search was made of the death records for these parents. In this manner random families were selected for which, where possible, the cause of death and length of life of each family member were determined. Here, we analyze the association between sons and their parents in length of life and report the statistically useful correlations that were found. These correlations enable the calculation of a life table for a male conditional on his current age and the lifetimes of his parents. Comparisons are made with the uninformed population life table based solely on sex and year of birth.

Underreporting and misclassification of maternal mortality in Taiwan.

BACKGROUND: Underreporting and misclassification of maternal deaths are universal. The purposes of this study were to quantify the level of underestimation of maternal mortality and to analyze possible factors that contribute to underreporting and misclassification of maternal mortality. METHODS: An interview census of all registered deaths that occurred during 1984-1988 in women of reproductive age was undertaken in Taiwan. Pregnancy-related deaths were screened from all collected questionnaires and death certificates by the researchers. The screened pregnancy-related deaths were then reviewed and evaluated by obstetrician-gynecologists; a cause of each death was assigned. RESULTS: For the five years, on average, the rate of underreporting of maternal mortality is 58.38% and the correct/confirmed rate of classification is 53.28%. Underreported and misclassified maternal deaths are more likely for women aged 20-24, with stillbirth and fetal death, care sought for non-obstetric reasons, care received in private hospitals and clinics, occurrence in the home, certification by non-obstetrician-gynecologists and court doctors, and death from non-obstetric causes. CONCLUSIONS: This study shows the limitations of official vital registration and concludes that dependence on death certificates alone to identify maternal deaths is incomplete and incorrect.

PIP: This study determines the reliability of death certificate information on maternal mortality in Taiwan. A file was constructed of death certificates of all females 10-49 years old who died during 1984-88 in Taiwan. Trained public health nurses and midwives interviewed family members of deceased persons. Cause of death was taken from the death certificate. Obstetricians-gynecologists determined whether a pregnancy-related death was due to obstetric or unrelated causes, according to the International Classification of Disease-9, Clinical Modification codes. Based on the physicians reviews, 520 women died during pregnancy or within 42 days postpartum, of which 246 were nonmaternal deaths. 173 of the 274 deaths were previously determined by the routine procedure of death certificate reporting to be maternal deaths. Obstetrician-gynecologists identified 101 deaths as maternal deaths. 146 of the 173 certificate maternal deaths were verified as maternal deaths. 27 deaths were minor misclassifications. The adjusted proportion of maternal deaths was 54.8% rather than 34.6%. The greatest rate of underreporting was 86.59% in 1988. The smallest rate of underreporting was 39.29% in 1987. The official death certificate maternal group had a significantly higher percentage of women 30-34 years old. The underreported group had a significantly higher percentage of women 20-24 years old. The underreported group had a higher proportion of stillbirths and fetal deaths among mothers who died. The reported group had higher proportions of deaths from hypertension, embolism, hemorrhage, and more mothers who sought care at clinics and hospitals. The misclassified group had more information provided by physicians and family. Underreporting is attributed to confusing coding criteria, neglect of physicians, incomplete information, specific indicators, and avoidance of blame.

Recent fertility and mortality trends among aboriginal and nonaboriginal populations of central Siberia.

We examine mortality and fertility patterns of aboriginal (primarily Evenki and Keto) and Russian (i.e., nonaboriginal) populations from the Baykit District of Central Siberia for the period 1982-1994. Mortality rates in the aboriginal population of Baykit are substantially greater than those observed in the Russians and are comparable to levels recently reported for other indigenous Siberian groups. Infant mortality rates average 48 per 1000 live births among Baykit aboriginals, three times greater than the Russians of the district (15 per 1000 births) and more than double the rates for Inuit and Indian populations of Canada. Similarly, crude death rates of the Baykit aboriginals are twice as high as those observed in either the Baykit Russians or the Canadian aboriginal populations (13 vs 6-7 deaths per 1000 individuals). Birth rates of the indigenous population of Baykit are higher than those of the Russians (33 vs. 15 births per 1000 individuals) but are comparable to those of Canadian aboriginal groups. Violence and accidents are the leading causes of adult male mortality in both ethnic groups, whereas circulatory diseases have emerged as the prime cause of death in women. The greater male mortality resulting from violence and accidents is a widely observed cross-cultural phenomenon. The emergence of circulatory diseases as a major mortality risk for women, however, appears to be linked to specific lifestyle changes associated with Soviet reorganization of indigenous Siberian societies. Marked declines in mortality and increases in fertility were observed in the Baykit aboriginal population during the mid to late 1980s with the government's implementation of anti-alcohol policies. The decline in mortality, however, was largely erased during the early 1990s, as the region became increasingly isolated and marginalized following the collapse of the Soviet Union. Demographic trends in the Baykit District suggest that because the indigenous groups have become more isolated, many are returning to a more traditional subsistence lifestyle.

PIP: This study compares fertility and mortality patterns among the aboriginal and Russian population in the Evenk Autonomous Region in Siberia. Data were obtained from birth and death records at Baykit Hospital during 1982-94 for the population of the district capital at Baykit and nine isolated rural villages. The indigenous population are semi-subsistence reindeer herders. Cause of death data were obtained from a subsample of 164 persons (101 aboriginals and 24 Russians) from Surinda, Poligus, and Sulamai villages. Findings indicate that aboriginal populations had higher mortality rates. Infant mortality was three times higher than in the Russian population at 48.2 infant aboriginal deaths per 1000 births. The crude death rate among aboriginals was double that of Russians at 12.9 deaths per 1000 aboriginals. The crude birth rate was 33 per 1000 aboriginals. The rate of natural increase was an estimated 2% annually among aboriginals and 1% among Russians. Infant mortality and crude death rates among aboriginals were twice as high as among aboriginals in Canada. Canadian and Siberian aboriginal crude birth rates were similar. In both Russian and aboriginal groups, violent and accidental deaths showed strong gender differences. 56% of male aboriginals and 59% of male Russians died from accidents and violence, while only 31% of aboriginal women and 29% of Russian women did. Most Russian accidental and violent deaths were due to asphyxia and poisoning, while most aboriginal accidental and violent deaths were due to gunshot trauma, in part due to alcohol consumption. About 33% of deaths among aboriginal women and 29% among Russian women were due to circulatory diseases. Russian mortality has remained stable over the last 13 years. Aboriginal mortality and fertility fluctuated. The Russian population grew more rapidly over the past 13 years, but levels varied between villages and between villages and Baykit.

Trends of infant mortality in Hong Kong (1956-90) and evaluation of preventable infant deaths.

OBJECTIVE: This study describes the time trends for infant mortality in Hong Kong and aims to develop statistical models that can be used to predict changes of infant mortality in places already having low levels of infant mortality. METHODOLOGY: Data on births and deaths of infants in Hong Kong during the years 1956-90 were analysed annually as well as by aggregating the data into seven consecutive quinquennia. To assess the contribution of preventable infant deaths, causes for infant deaths were classified into two broad categories: (i) congenital anomalies; and (ii) preventable diseases. A simple linear regression model was used to analyse the time trend of the mortality rate of the preventable diseases (PIMR) over the seven quinquennia. RESULTS: During the period 1956-90, the infant mortality rate fell from 60.9 in 1956-5.9 per 1000 in 1990 and the neonatal mortality rate fell from 24.2-3.8 per 1000. There was no clear time trend observed for infant mortality of congenital anomalies. However, the time trend for PIMR (log scale) was very close to a straight line and simple linear regression modelling showed a R2 of 0.9970. CONCLUSION: As the infant mortality rate (IMR) falls to below 30 per 1000, the further rate of decrease becomes less predictable from the regression model of the IMR. By removing the portion of deaths attributable to congenital anomalies, the further decrease in infant mortality became more predictable down to very low levels of IMR.

PIP: This study determines the pattern of reliability of infant mortality reports in Hong Kong. Data are obtained from annual reports of the director of Medical and Health Services during 1956-88 and the director of Health during 1989-90. Deaths were grouped in 5-year age periods during 1956-90. Infant deaths were registered according to cause based on 3 different versions of the International Classification of Disease into 4 major groups: congenital anomalies, conditions originating in the perinatal period, pneumonia, and all other causes. Preventable infant deaths were grouped into 2 categories based on Bourgeois-Pichat's classification: congenital causes and preventable ones. These 2 causes were plotted on a line chart by quinquennial period. Infant mortality rates (IMR) declined from 60.9/1000 in 1956 to 5.9/1000 in 1990. The neonatal mortality rate declined from 24.2 to 3.8/1000 in the same period. Postneonatal mortality rates declined the most from 36.7 to 2.2/1000. The 3 mortality trends were mostly linear. All 3 rates were highly correlated with each other. Major decreases occurred for pneumonia and other. The other group of infectious diseases that included tuberculosis, tetanus, gastroenteritis, and other diarrheal diseases declined the most rapidly by as much as 66 times. Mortality rates by congenital causes increased during the early period and declined slowly during the 1980s, while proportional mortality continued to increase. 84.6% of all infant deaths during 1986-90 were congenital deaths and deaths occurring in the perinatal period. The authors suggest reducing congenital deaths by imposing public health measures, raising the medical knowledge of the public, and improving the use of modern technology. Conditions originating in the perinatal period could be reduced by addressing intrauterine hypoxia, birth asphyxia, and other respiratory conditions.

An evaluation of the 1993-94 Bangladesh Demographic and Health Survey within the Matlab area.

PIP: The 1993-94 Bangladesh Demographic and Health Survey (DHS) reported substantial declines in vital rates, especially the fertility rate, which needed confirmation. The demographic database of the International Center for Diarrheal Disease Research, Bangladesh (ICDDR,B) contains the birth and death records for 200,000 people whose households have been visited every 2 weeks since 1966. In addition, the system kept records on the pregnancy and contraceptive use status of women of reproductive age since 1977. A validation study was conducted, which entailed the comparison of fertility and infant mortality rates from a special DHS survey conducted in the Matlab treatment area in 1994, with rates obtained by the Demographic Surveillance System (DSS) over the 5 years prior to the survey and also the comparison of the current contraceptive use rate. The records of 2628 women were examined. The Matlab DHS was found to be accurate in estimating fertility both in the treatment and comparison areas. The Matlab DHS infant mortality rates for the 5 years prior to the survey were also consistent with the estimates derived from the DSS. However, the Matlab DHS seemed to have underestimated contraceptive prevalence, which underestimate was substantial for modern temporary methods, especially pills and injectables. Since contraceptive prevalence may also be higher at the national level as a result of this, the total fertility rate for Bangladesh of 3.4 children/woman may be plausible. Although the Matlab DHS figures on vital rates seem to be reliable, the national level DHS estimates may not be as reliable, because women elsewhere in the country may not have reported their children's births and deaths as accurately as did women in the Matlab area.^ieng

Constructing reproductive histories by linking vital records.

Certificates of 1,449,287 live births and fetal deaths filed in Georgia from 1980 through 1992 were linked to create chronologies that, excluding induced abortions and ectopic pregnancies, constituted the reproductive experience of individual women. The authors initially used a deterministic method (whereby linking rules were not based on probability theory) to link as many records as possible, knowing that some of the linkages would be incorrect. They subsequently used a probabilistic method (whereby evaluation of linkages was developed from probability theory) to evaluate each linkage, and they broke those that were judged to be incorrect. Of the 1.4 million records, 38% did not link to another record. From the remaining records, 369,686 chains of two or more events were constructed. The longest chain included 12 events. Of the chains, 69% included two events; 22% included three events. Longer chains tended to have lower scores for probable validity. The probability-based evaluation of chains affected 3.0% of the records that had been in chains at the end of the deterministic linkage. A greater percentage of records in longer chains were affected by the evaluation. Unfortunately, the small subset of records that were the most difficult to link tended to overrepresent groups with the greatest risk of adverse pregnancy outcomes. Researchers contemplating a similar linkage can anticipate that, for the majority of records, linkage can be accomplished with a relatively straightforward, deterministic approach.

[Correction of underregistration of general mortality]. / Correccion del subregistro de mortalidad general.

PIP: The authors evaluate the underregistration of mortality in Latin America, using the example of Ecuador. Underregistration by province, age groups, sex, and cause of death is investigated.^ieng

Cause-specific mortality among older African-Americans: correlates and consequences of age misreporting.

This paper examines the quality of age reporting on death certificates of elderly African-Americans by major causes of death. We utilize a sample of death certificates linked to early census records and to Social Security Administration records to establish a "true" age at death. We then examine the patterns, predictors, and consequences of age misreporting for major causes of death. We find a pattern of greater age misreporting among females, identify educational background as a key predictor of accurate age reporting, and show that mortality crossovers are eliminated for most causes of death when more accurate age data are used.

Sex ratio at birth deviations in modern Venezuela: the Trivers-Willard effect.

This study evaluates the impact of the Trivers-Willard (T-W) effect on human populations, using demographic data collected from vital registration data in Venezuela. The evaluation of the sex ratio at birth (SRB) and of fetal and infant deaths supports the existence of T-W effect in the Venezuelan population in extreme conditions. This T-W effect was observable in the SRB but not at later ages and is related to the marital status of the mother. The results indicate that the investment in females associated with environmental adversity is greater than the investment in males associated with good environmental conditions.

PIP: This study relies on stepwise discriminant analysis to evaluate the influence of socioeconomic status (SES) factors according to marital status on the probability of the child being born a male or a female. Data were obtained from the 1988 and 1990 Venezuelan death and birth registers in the Central Office of Statistics and Information. Fetal and infant deaths numbered 87,229. Births numbered 577,976 and were reported for a variety of demographic/socioeconomic variables. The study evaluates the Trivers and Willard (1973) hypothesis that the sex ratio at birth is correlated with socioeconomic status. The focus is on the deviations in the sex ratio at birth (SRB) in Venezuela. The authors refer to studies confirming sex biases in mortality and sex biases in allocating resources and care and refuting the Trivers-Willard (T-W) effect. Findings indicate that the SRB was 0.5124 and confirms other estimates. The SRB for married and cohabiting couples was 0.512 and 0.514, respectively. The SRB was lower for single women (0.508). Differences were all statistically significant. Findings suggest that the T-W effect may be stronger in women who do not live with a male partner. Sex ratio deviations varied by SES. Higher educational status was associated with a higher SRB. Extreme poverty was associated with lower SRB and had a stronger impact on SRB than high SES. The T-W effect appeared stronger prior to conception. The T-W effect varied by maternal marital status. Females were more advantaged when mothers were unmarried. The sex ratio of neonatal deaths was 0.562; that for infant deaths was 0.574. The sex ratios for mortality did not differ for any of the SES indicators. There were differences by type of births and gestation time. Single births and early gestational times had higher male mortality. Infant deaths among mothers aged 30-34 years showed a higher sex ratio.