Bruno Masquelier

Adult Mortality From Sibling Survival Data: A Reappraisal of Selection Biases

Because of incomplete registration of deaths in most countries in sub-Saharan Africa, data on the survival of close relatives constitute the cornerstone of estimates of adult mortality. Since 1990, sibling histories have been widely collected in Demographic and Health Surveys and are increasingly being relied upon to estimate both general and maternal mortality. Until recently, the use of sibling histories was thought to lead to underestimates of mortality, but a more optimistic view in the literature emerged with the development by Gakidou and King (Demography 43:569–585, 2006) of corrections for selection biases. Based on microsimulations, this article shows that Gakidou and King’s weighting scheme has been incorrectly applied to survey data, leading to overestimates of mortality, especially for males. The evidence for an association between mortality and sibship size in adulthood is reviewed. Female mortality appears to decline slightly with the number of surviving sisters, although this could be an artifact of severe recall errors in larger sibships or familial clustering of deaths. Under most circumstances, corrections for selection biases should have only a modest effect on sibling estimates.

Adult Mortality in Africa

Following an overview of the data and approaches for mortality estimation in African countries, we compare trends in estimates of 45q15 produced by the UN agencies with those derived from reports of sibling survival in the Demographic and Health Surveys. A short discussion of the distribution of causes of death is based on verbal autopsy data coming from a handful of Demographic Surveillance Sites. Despite the sometimes intriguing differences between estimates from different sources, a few general patterns of adult mortality trends are common to most sources. With the exception of northern Africa, declines in adult mortality during the last few decades have been modest, and in some populations drastic mortality reversals have been recorded. These are primarily driven by the HIV/AIDS epidemic, but the extremely high adult mortality rates in some southeastern African countries are due to the triple burden of infectious and chronic diseases and the relatively high level of deaths due to external injuries. In some countries severely affected by the HIV/AIDS epidemic, adult mortality started to decline again, and that occurred well before the large scale availability of antiretroviral therapy.

Divergences in trends in child and adult mortality in sub-Saharan Africa: Survey evidence on the survival of children and siblings.

This paper provides an overview of trends in mortality in children aged under 5 and adults between the ages of 15 and 60 in sub-Saharan Africa, using data on the survival of the children and siblings collected in Demographic and Health Surveys. If conspicuous stalls in the 1990s are disregarded, child mortality levels have generally declined and converged over the last 30–40 years. In contrast, adult mortality in many East and Southern African countries has increased markedly, echoing earlier increases in the incidence of HIV. In recent years, adult mortality levels have begun to decline once again in East Africa, in some instances before the large-scale expansion of antiretroviral therapy programmes. More surprising is the lack of sustained improvements in adult survival in some countries that have not experienced severe HIV epidemics. Because trends in child and adult mortality do not always evolve in tandem, we argue that model-based estimates, inferred by matching indices of child survival onto standard mortality schedules, can be very misleading.

The epidemiological transition in Antananarivo, Madagascar: an assessment based on death registers (1900–2012)

Background Madagascar today has one of the highest life expectancies in sub-Saharan Africa, despite being among the poorest countries in the continent. There are relatively few detailed accounts of the epidemiological transition in this country due to the lack of a comprehensive death registration system at the national level. However, in Madagascars capital city, death registration was established around the start of the 20th century and is now considered virtually complete. Objective We provide an overview of trends in all-cause and cause-specific mortality in Antananarivo to document the timing and pace of the mortality decline and the changes in the cause-of-death structure. Design Death registers covering the period 1976-2012 were digitized and the population at risk of dying was estimated from available censuses and surveys. Trends for the period 1900-1976 were partly reconstructed from published sources. Results The crude death rate stagnated around 30‰ until the 1940s in Antananarivo. Mortality declined rapidly after the World War II and then resurged again in the 1980s as a result of the re-emergence of malaria and the collapse of Madagascars economy. Over the past 30 years, impressive gains in life expectancy have been registered thanks to the unabated decline in child mortality, despite political instability, a lasting economic crisis and the persistence of high rates of chronic malnutrition. Progress in adult survival has been more modest because reductions in infectious diseases and diseases of the respiratory system have been partly offset by increases in cardiovascular diseases, neoplasms, and other diseases, particularly at age 50 years and over. Conclusions The transition in Antananarivo has been protracted and largely dependent on anti-microbial and anti-parasitic medicine. The capital city now faces a double burden of communicable and non-communicable diseases. The ongoing registration of deaths in the capital generates a unique database to evaluate the performance of the health system and measure intervention impacts.Background Madagascar today has one of the highest life expectancies in sub-Saharan Africa, despite being among the poorest countries in the continent. There are relatively few detailed accounts of the epidemiological transition in this country due to the lack of a comprehensive death registration system at the national level. However, in Madagascars capital city, death registration was established around the start of the 20th century and is now considered virtually complete. Objective We provide an overview of trends in all-cause and cause-specific mortality in Antananarivo to document the timing and pace of the mortality decline and the changes in the cause-of-death structure. Design Death registers covering the period 1976–2012 were digitized and the population at risk of dying was estimated from available censuses and surveys. Trends for the period 1900–1976 were partly reconstructed from published sources. Results The crude death rate stagnated around 30‰ until the 1940s in Antananarivo. Mortality declined rapidly after the World War II and then resurged again in the 1980s as a result of the re-emergence of malaria and the collapse of Madagascars economy. Over the past 30 years, impressive gains in life expectancy have been registered thanks to the unabated decline in child mortality, despite political instability, a lasting economic crisis and the persistence of high rates of chronic malnutrition. Progress in adult survival has been more modest because reductions in infectious diseases and diseases of the respiratory system have been partly offset by increases in cardiovascular diseases, neoplasms, and other diseases, particularly at age 50 years and over. Conclusions The transition in Antananarivo has been protracted and largely dependent on anti-microbial and anti-parasitic medicine. The capital city now faces a double burden of communicable and non-communicable diseases. The ongoing registration of deaths in the capital generates a unique database to evaluate the performance of the health system and measure intervention impacts.

Maternal mortality estimates

www.thelancet.com Vol 384 December 20/27, 2014 2211 Nicholas Kassebaum and colleagues noted that maternal deaths have decreased less rapidly worldwide between 1990 and 2010 than reported by the UN agencies. They attribute this difference partly to higher UN estimates of all-cause reproductive-age mortality, especially in west Africa. They state that the UN estimates almost exclusively uses child mortality to predict adult mortality in west Africa, whereas their estimates are based on actual data. However, this is not the case. UN adult mortality estimates for all 16 west African countries use all empirical evidence available, as publicly documented. Kassebaum and colleagues’ estimates of all-cause reproductive-age mortality (Global Burden of Disease [GBD] 2013) are not publicly available, but previous GBD 2010 estimates for sub-Saharan Africa show unexpectedly low ratios of adult-to-child mortality. This is shown in the fi gure for Nigeria, which contains roughly half the population of west Africa. In Nigeria, GBD 2010 estimates for 1970–90 suggest an adult-to-child mortality ratio well below those documented in demographic surveillance sites (DSS) in other west African countries (eg, Ghana and Senegal) where high-quality data are available. This finding suggests that GBD underestimated the baseline level of mortality in women of repro ductive age in 1990. However, the UN’s World Population Prospects (WPP) estimates for 1970–90 are consistent with the documented DSS data. Both GBD 2010 and the WPP estimates suggest sharp increases in adult mortality in the 1990s, but large diff erences between estimates remain up to 2010. GBD 2010 estimates for 1990–2010 match the adult-tochild mortality ratios observed in DSS located in Senegal and Gambia (with under-5 mortality between 125 and 200 and female adult mortality between 250 and 300), whereas the WPP ratios are slightly higher than those observed in the Ghana DSS (with under-5 mortality between 150 and 200 and female adult mortality around 350). Since the HIV For the WHO, UNICEF, UN Population Fund, World Bank estimates see http://reliefweb. int/sites/reliefweb.int/fi les/ resources/Full_Report_3984.pdf Figure: Association between under-5 mortality and women’s mortality in Nigeria and west African demographic surveillance sites The dashed lines are a prediction of mortality of women aged 15–60 years (45q15) on the basis of the information about under-5 mortality (5q0), as shown in model life tables used to synthesise the history of countries with good death registration data conforming, respectively, to northern and southern European historical age patterns of mortality. Estimates of the probabilities 5q0 and 45q15 are the two key variables that model the mortality envelope (distribution of deaths by age for each country and year) in both WPP and GBD. DSS estimates refer to a period of 7·5 years on average. DSS which have existed for many years appear more than once. GBD=Global Burden of Disease (2010). WPP=World Population Prospects (2012). DHS=demographic and health survey. DSS=demographic surveillance sites (Nouna, Ouagadougou, and Oubritenga in Burkina Faso; Bandafassi, Mlomp, and Niakhar in Senegal; Farafenni in The Gambia; Cape Coast, Navrongo, and Kintampo in Ghana). MLT=model life table. epidemic (and possibly other causes of adult mortality) is more severe in Nigeria than in other west African countries, we should expect adult-to-child mortality ratios to be higher in Nigeria too. UN estimates are in line with data for recent household deaths reported in the 2008 Nigeria demographic and health survey, whereas GBD 2010 closely match estimates from sibling histories collected in the same demographic and health survey (figure). Although sibling histories have provided invaluable retro spective mortality data in low-income countries, they are aff ected by substantial under-reporting of adult deaths in west African settings. In a validation study of sibling histories in Senegal, nearly 25% of female respondents did not report deaths of one of their adult sisters. The methods Kassebaum and colleagues use to correct this under-reporting make strong assumptions and do not account for several reasons why deaths are under-reported in sibling histories. In countries with scarce vital registration, diff erent data sources often yield very diff erent estimates of adult mortality rates. This information must therefore be triangulated and validated against high-quality independent datasets to adjust implausibly low mortality rates. Without such eff orts, we might consistently misrepresent progress towards the fi fth Millennium Development Goal.

Age patterns and sex ratios of adult mortality in countries with high HIV prevalence

Objective: To compare the 2016 United Nations Programme on HIV/AIDS (UNAIDS) modelled estimates of adult mortality in sub-Saharan Africa to empirical estimates. Design: Age-specific mortality rates were obtained from nationally representative sibling survival data, recent household deaths and vital registration, and directly compared with UNAIDS estimates. Orphanhood prevalence derived from UNAIDS mortality estimates was compared with survey and census reports on the survival of childrens parents. Methods: Age-specific mortality rates for adults aged 15–59 years were calculated from Demographic and Health Surveys and deaths reported in censuses or vital registration, adjusted for underreporting, whenever possible. Proportions of orphans were extracted from censuses and surveys for children aged 5–9 years. Results: UNAIDS estimates were significantly higher than sibling mortality estimates, except among men in countries with very high HIV prevalence. There was a better agreement between rates based on household deaths or vital registration and model outputs. Sex ratios (M/F) of adult mortality were lower in UNAIDS estimates. The modelled orphan prevalence was significantly higher than in surveys and censuses, again with the exception of paternal orphans in countries with very high HIV prevalence. Ratios of paternal-to-maternal orphans were lower in the UNAIDS model than surveys and censuses. Among women, increases in mortality due to AIDS were more concentrated in the age range 25–50 years in model outputs, as compared with empirical estimates. Conclusion: Discrepancies in levels, sex ratios and age patterns of adult mortality between empirical and UNAIDS estimates call for additional data quality assessments and improvements in estimation methods.

Health at the borders: Bayesian multilevel analysis of women’s malnutrition determinants in Ethiopia

Background Womens malnutrition, particularly undernutrition, remains an important public health challenge in Ethiopia. Although various studies examined the levels and determinants of womens nutritional status, the influence of living close to an international border on womens nutrition has not been investigated. Yet, Ethiopian borders are regularly affected by conflict and refugee flows, which might ultimately impact health. Objective To investigate the impact of living close to borders in the nutritional status of women in Ethiopia, while considering other important covariates. Design Our analysis was based on the body mass index (BMI) of 6,334 adult women aged 20-49 years, obtained from the 2011 Ethiopian Demographic and Health Survey (EDHS). A Bayesian multilevel multinomial logistic regression analysis was used to capture the clustered structure of the data and the possible correlation that may exist within and between clusters. Results After controlling for potential confounders, women living close to borders (i.e. ≤100 km) in Ethiopia were 59% more likely to be underweight (posterior odds ratio [OR]=1.59; 95% credible interval [CrI]: 1.32-1.90) than their counterparts living far from the borders. This result was robust to different choices of border delineation (i.e. ≤50, ≤75, ≤125, and ≤150 km). Women from poor families, those who have no access to improved toilets, reside in lowland areas, and are Muslim, were independently associated with underweight. In contrast, more wealth, higher education, older age, access to improved toilets, being married, and living in urban or lowlands were independently associated with overweight. Conclusions The problem of undernutrition among women in Ethiopia is most worrisome in the border areas. Targeted interventions to improve nutritional status in these areas, such as improved access to sanitation, economic and livelihood support, are recommended.Background Womens malnutrition, particularly undernutrition, remains an important public health challenge in Ethiopia. Although various studies examined the levels and determinants of womens nutritional status, the influence of living close to an international border on womens nutrition has not been investigated. Yet, Ethiopian borders are regularly affected by conflict and refugee flows, which might ultimately impact health. Objective To investigate the impact of living close to borders in the nutritional status of women in Ethiopia, while considering other important covariates. Design Our analysis was based on the body mass index (BMI) of 6,334 adult women aged 20-49 years, obtained from the 2011 Ethiopian Demographic and Health Survey (EDHS). A Bayesian multilevel multinomial logistic regression analysis was used to capture the clustered structure of the data and the possible correlation that may exist within and between clusters. Results After controlling for potential confounders, women living close to borders (i.e. ≤100 km) in Ethiopia were 59% more likely to be underweight (posterior odds ratio [OR]=1.59; 95% credible interval [CrI]: 1.32-1.90) than their counterparts living far from the borders. This result was robust to different choices of border delineation (i.e. ≤50, ≤75, ≤125, and ≤150 km). Women from poor families, those who have no access to improved toilets, reside in lowland areas, and are Muslim, were independently associated with underweight. In contrast, more wealth, higher education, older age, access to improved toilets, being married, and living in urban or lowlands were independently associated with overweight. Conclusions The problem of undernutrition among women in Ethiopia is most worrisome in the border areas. Targeted interventions to improve nutritional status in these areas, such as improved access to sanitation, economic and livelihood support, are recommended.Background Womens malnutrition, particularly undernutrition, remains an important public health challenge in Ethiopia. Although various studies examined the levels and determinants of womens nutritional status, the influence of living close to an international border on womens nutrition has not been investigated. Yet, Ethiopian borders are regularly affected by conflict and refugee flows, which might ultimately impact health. Objective To investigate the impact of living close to borders in the nutritional status of women in Ethiopia, while considering other important covariates. Design Our analysis was based on the body mass index (BMI) of 6,334 adult women aged 20–49 years, obtained from the 2011 Ethiopian Demographic and Health Survey (EDHS). A Bayesian multilevel multinomial logistic regression analysis was used to capture the clustered structure of the data and the possible correlation that may exist within and between clusters. Results After controlling for potential confounders, women living close to borders (i.e. ≤100 km) in Ethiopia were 59% more likely to be underweight (posterior odds ratio [OR]=1.59; 95% credible interval [CrI]: 1.32–1.90) than their counterparts living far from the borders. This result was robust to different choices of border delineation (i.e. ≤50, ≤75, ≤125, and ≤150 km). Women from poor families, those who have no access to improved toilets, reside in lowland areas, and are Muslim, were independently associated with underweight. In contrast, more wealth, higher education, older age, access to improved toilets, being married, and living in urban or lowlands were independently associated with overweight. Conclusions The problem of undernutrition among women in Ethiopia is most worrisome in the border areas. Targeted interventions to improve nutritional status in these areas, such as improved access to sanitation, economic and livelihood support, are recommended.

Improving survey data on pregnancy-related deaths in low-and middle-income countries: a validation study in Senegal

In low‐ and middle‐income countries (LMICs), siblings’ survival histories (SSH) are often used to estimate maternal mortality, but SSH data on causes of death at reproductive ages have seldom been validated. We compared the accuracy of two SSH instruments: the standard questionnaire used during the demographic and health surveys (DHS) and the siblings’ survival calendar (SSC), a new questionnaire designed to improve survey reports of deaths among women of reproductive ages.

Global, regional, and national mortality trends in older children and young adolescents (5–14 years) from 1990 to 2016: an analysis of empirical data

Summary Background From 1990 to 2016, the mortality of children younger than 5 years decreased by more than half, and there are plentiful data regarding mortality in this age group through which we can track global progress in reducing the under-5 mortality rate. By contrast, little is known on how the mortality risk among older children (5–9 years) and young adolescents (10–14 years) has changed in this time. We aimed to estimate levels and trends in mortality of children aged 5–14 years in 195 countries from 1990 to 2016. Methods In this analysis of empirical data, we expanded the United Nations Inter-agency Group for Child Mortality Estimation database containing data on children younger than 5 years with 5530 data points regarding children aged 5–14 years. Mortality rates from 1990 to 2016 were obtained from nationally representative birth histories, data on household deaths reported in population censuses, and nationwide systems of civil registration and vital statistics. These data were used in a Bayesian B-spline bias-reduction model to generate smoothed trends with 90% uncertainty intervals, to determine the probability of a child aged 5 years dying before reaching age 15 years. Findings Globally, the probability of a child dying between the ages 5 years and 15 years was 7·5 deaths (90% uncertainty interval 7·2–8·3) per 1000 children in 2016, which was less than a fifth of the risk of dying between birth and age 5 years, which was 41 deaths (39–44) per 1000 children. The mortality risk in children aged 5–14 years decreased by 51% (46–54) between 1990 and 2016, despite not being specifically targeted by health interventions. The annual number of deaths in this age group decreased from 1·7 million (1·7 million–1·8 million) to 1 million (0·9 million–1·1 million) in 1990–2016. In 1990–2000, mortality rates in children aged 5–14 years decreased faster than among children aged 0–4 years. However, since 2000, mortality rates in children younger than 5 years have decreased faster than mortality rates in children aged 5–14 years. The annual rate of reduction in mortality among children younger than 5 years has been 4·0% (3·6–4·3) since 2000, versus 2·7% (2·3–3·0) in children aged 5–14 years. Older children and young adolescents in sub-Saharan Africa are disproportionately more likely to die than those in other regions; 55% (51–58) of deaths of children of this age occur in sub-Saharan Africa, despite having only 21% of the global population of children aged 5–14 years. In 2016, 98% (98–99) of all deaths of children aged 5–14 years occurred in low-income and middle-income countries, and seven countries alone accounted for more than half of the total number of deaths of these children. Interpretation Increased efforts are required to accelerate reductions in mortality among older children and to ensure that they benefit from health policies and interventions as much as younger children. Funding UN Childrens Fund, Bill & Melinda Gates Foundation, United States Agency for International Development.

Mortality, Health, and Aging in Sub-Saharan Africa

Low survival prospects, especially among adults, are holding back African development and reducing the chance of reaping a demographic dividend. Gains in life expectancy have lagged far behind those experienced in other regions, despite impressive mortality declines among children under age five in the last decade. With a life expectancy still below 60 in 2015, sub-Saharan Africa is also the region where uncertainty about levels and trends in mortality is the greatest. This is because the vital registration systems operating in the vast majority of countries fail to provide full national coverage. Few deaths have a cause certified by a medical practitioner, and there is limited evidence on the leading causes of death to make informed decisions about how to spend scarce human and financial resources. This chapter provides a cursory overview of the different data sources, and present trends in mortality among children and adults, using survey reports on the survival of close relatives. The chapter then describes major changes in the leading causes of death and highlights specific characteristics of the process of demographic aging in SSA.