Guide on Gender Analysis of Census Data Full Draft of 6 December 2012 Contents

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Recommended census questions to estimate maternal deaths

Chapter 4:
Mortality

1. What is it?
119. Mortality is the one major demographic variable in which men are almost universally at a disadvantage compared to women. The one major exception to this is the Indian sub-continent (specifically, India, Bangladesh and Nepal) where, prior to the 1990s, the life expectancy at birth for males exceeded that of females. Up to this day, the male-female life expectancy difference in this part of the world, now favourable to women, is still relatively small by world standards. The opposite situation exists in the countries that make up the former Soviet Union, some of which (e.g. Belarus, Russia and Ukraine) have life expectancy gaps of more than 10 years between and women.
120. Life expectancy (at birth) refers to the number of years that an average person can expect to live, provided that at each age he or she is exposed to the current age specific mortality rates for that age. For the world as a whole, it is currently about 71.6 years for women and 67.1 years for men. The Age-Specific Mortality Rate or age-specific death rate, in turn, is the number of person of a given age that die during a year, divided by the average population of that age during the year. The most significant age-specific mortality rate is the Infant Mortality Rate, which differes from other age-specific mortality rates in that it uses the number of births, rather than the average population under age 1, as its denominator. For the world as a whole, its present value is 43.3 (per 1,000 births) for boys and 40.3 for girls. The Crude Death Rate, finally, is the total number of deaths divided by the average population during the year, regardless of age. It is basically a measure of how much populations diminish as a result of mortality, but it is not a good measure of risk as it is greatly affected by the age structure of the population. Finally, mortality can be analysed by cause. The most common cause-specific mortality measures are analogous to the crude or age-specific death rates, but limited to a specific cause. Because of the smaller numbers, they are generally expressed as fractions of 100,000, rather than 1,000.
121. Maternal mortality refers to the phenomenon of deaths caused by pregnancy-related factors. It is typically measured by three indicators:

The Maternal Mortality Ratio - the number of women who die while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes, per 100,000 live births¹⁴. This is the indicator used with MDG goal 5B.

The Maternal Mortality Rate – this indicator uses the same numerator, but measures it per 1,000 women of reproductive age in the population. One important implication of this definition is that this indicator is sensitive to the level of fertility in the population, unlike the MMRatio.

There is widespread confusion about the difference between the Maternal Mortality Ratio and the Maternal Mortality Rate, and often these terms are used interchange-ably.
In terms of statistical practice, a ratio is a division of things that have the same unit of measurement: for instance, the sex ratio divides the number of men by the number of women. A rate, on the other hand, measures the relationship of two things that have different units of measurement: for instance, the Infant Mortality Rate measures the relationship between number of infant deaths and numbers of births. According to this practice, the Maternal Mortality Ratio is actually a rate. Nevertheless, it is called a ratio to distinguish it from the existing concept of Maternal Mortality Rate, as defined above.

122. Less commonly used is a third indicator called Lifetime Risk of Maternal Mortality. This indicator refers to the probability of maternal death, conditional on survival to age 15 years (Wilmoth, 2009).
123. Although the best and most detailed mortality information depends on civil registration data, censuses can measure mortality in a number of ways. The most common census questions are part of the same cluster that is used to measure fertility (see the previous chapter). It consists in asking women between the ages of 15 (sometimes 12) and 50 about: 1) Their number of Children Ever Born alive (CEB); 2) Children born during the past 12 months before the census; and 3) Survival of children ever born and/or children born in the past 12 months. Combining the information from 1) and 3) - and more rarely 2) -, it is possible to derive estimates of infant and child mortality by using indirect estimation techniques (United Nations, 1983). Some censuses also ask for the survival of the last birth or the children born during the past 12 months, in addition to the survival of all Children Ever Born. Other common census questions regarding mortality include orphanhood questions, questions about members of the household that died in the recent past and questions about the survival of the sisters of adult household members, to measure maternal mortality.
2. Why is it important ?

124. Apart from aggregate differences between the mortality of men and women, there are also major differences in the structure of mortality by cause. To do this requires death registration data which are not available from censuses, but it may be worthwhile to show where the major differences are found. Table 7, which is based on global WHO estimates for 2002, summarizes the causes of death in which female death rates (per 100,000 population, not standardized by age) were at least 20 per cent higher than male death rates or, conversely, in which male death rates exceeded female death rates by at least 20 per cent.

125. The most important causes in which women face a disadvantage are those that, by definition, are exclusive (or almost exclusive) to women: maternal mortality (16.5 per 100,000 in 2002), breast cancer (15.3), cervical cancer (7.7), ovarian cancer (4.4) and uterine cancer (2.3). Because women live longer, they are also more prone to develop diabetes (17.7, compared to 14.1 per 100,000 in men), and Alzheimer’s disease and other dementias (8.1, compared to 4.7 per 100,000 in men). Maybe less obviously, because women spend more time at home, in constructions that are often unsafe, they are at greater risk to die in fires (6.2, compared to 3.8 per 100,000 in men). Finally, women have higher mortality due to some nutritional deficiencies, especially iron deficiency anemia, and also endocrine/nutritional disorders, rheumatic heart disease, musculoskeletal diseases, and skin diseases.
126. Men, on the other hand, have considerably higher mortality rates due to most cancers, especially lung cancer, stomach cancer, liver cancer and – of course – prostate cancer. Together, these types of cancer are associated with a male death rate of 67.3, compared to a female death rate of 28.1 per 100,000. In addition, men are much more likely to die of most types of injury, both intentional and non-intentional. Road traffic accidents, falls, drowning and poisoning jointly represent a male death rate of 50.9, compared to a female rate of 23.3 per 100,000. The male suicide rate in 2002 was estimated at 17.4 per 100,000, compared to 10.6 for women. Acts of war and violence resulted in 19.2 male, compared to 4.2 female deaths per 100,000. Finally, male death rates are significantly higher with respect to tuberculosis (32.9, compared to 17.3 per 100,000 in women), alcohol-induced conditions and drug abuse, perinatal conditions, hepatitis B and C and some tropical diseases (not including malaria).
Table 7: Estimated global male and female death rates (per 100,000) by cause of death in 2002

Female disadvantage		Male	Female

–	Diabetes mellitus	14.1	17.7
–	Maternal conditions	0	16.5
J	Nutritional deficiencies	6.9	8.7
J.2	Iron deficiency anemia	1.5	2.9
C.5	Breast cancer	0.1	15.3
H.1	Alzheimer's disease and other dementias	4.7	8.1
A.5	Rheumatic heart disease	4.4	6.1
E.5	Fires	3.8	6.2
–	Endocrine/nutritional disorders	3.4	4.4
C.11	Cervical cancer	0	7.7
C.14	Ovarian cancer	0	4.4
–	Musculoskeletal diseases	1.2	2.2
C.15	Uterine cancer	0	2.3
–	Skin diseases	0.8	1.4

Male disadvantage

C	Malignant neoplasms (cancers)	126.9	101.7
C.1	Lung cancers	28.4	11.4
C.2	Stomach cancer	16.7	10.5
C.4	Liver cancer	13.6	6.2
C.6	Esophageal cancer	9.1	5.2
C.8	Oral and oropharynx cancers	7.1	3.1
C.9	Prostate cancer	8.6	0
C.10	Leukemia	4.7	3.8
C.13	Bladder cancer	4.0	1.7
E	Unintentional injuries	73.7	40.2
E.1	Road traffic accidents	27.8	10.4
E.2	Falls	7.5	5.0
E.3	Drowning	8.4	3.9
E.4	Poisoning	7.2	4.0
–	Perinatal conditions	43.7	35.4
F	Digestive diseases	34.9	28.2
F.1	Cirrhosis of the liver	16.1	9.1
F.2	Peptic ulcer disease	5.0	3.5
G	Intentional injuries (Suicide, Violence, War, etc.)	37	14.9
G.1	Suicide	17.4	10.6
G.2	Violence	14.2	3.7
G.3	War	5.0	0.5
B.4	Tuberculosis	32.9	17.3
B.9	Tropical diseases excluding malaria	2.5	1.6
B.9.1	Leishmaniasis	1.0	0.7
B.9.2	Trypanosomiasis	1.0	0.5
H.2	Epilepsy	2.2	1.8
B.10	Hepatitis B	2.3	1.0
H.4	Alcohol use disorders	2.5	0.4
H.5	Drug use disorders	2.2	0.5
B.11	Hepatitis C	1.1	0.6
I.2	Benign prostatic hyperplasia	1.0	0

Source: WHO (2004): Annex Table 2

127. Out of all of the differences that stand out from the previous listing, two have been of special concern: violence and accidents, as a major cause of male over-mortality, and maternal mortality as a cause of mortality that is specific to women. Worldwide, intentional injuries make about 750,000 more male than female victims annually; the difference with respect to unintentional injuries (accidents) is 1.2 million. Male disadvantage with respect to violent deaths is particularly evident in the countries of the former Soviet Union and in much of Latin America. Gavrilova et al. (2000) comment, for instance, on the overall rise of mortality that took place in Russia between 1991 and 1994 as a result of the tumultuous transition from a socialist to a market economy and the devastating effect that this had on male mortality rates from violent causes. Female mortality from these causes also increased, but to a lesser extent, thereby exacerbating a male-female difference which was already among the largest in the world at the time. In particular, male suicide rates increased from 47.7 in 1991 to 76.9 per 100,000 in 1994, as the corresponding female rates increased from 11.2 to 13.6. What this suggests is that men were more psychologically affected by the uncertainties surrounding the economic transition than women. Similarly, deaths due to alcohol poisoning - always a problem in the former Soviet Union (see Simpura et al., 1998, for an account on the Baltic states) - multiplied, from 19.4 to 61.2 per thousand, in the case of men, and from 4.2 to 15.8 in the case of women, whereas male homicide rates increased from 25.1 to 52.8 per thousand, as female rates went up from 6.9 to 13.6.
128. Male over-mortality from violent causes, particularly homicides, has also been a major issues in some Latin American countries, such as Brazil. In 2007, there were 45,554 registered homicides in Brazil, 92.1 per cent of which were of male victims, especially men between the ages of 15 and 40 (Isfeld, 2010). In some more developed countries (Croatia, Germany, Hungary, Japan, Republic of Korea, Slovenia, Switzerland), on the other hand, the number of male and female victims is roughly equal. There is a moderately strong positive relationship between the level of the overall homicide rate in a country and the percentage of victims that are male. In those countries in which data exist, there is also evidence that the majority (about 90 per cent globally) of perpetrators of homicides are males (UNODC, 2011: Fig. 5.12). Homicides in which both the victim and the perpetrator are female are quite rare, e.g. 2.6 per cent in the US (UNODC, 2011: 72). Whereas men are likelier to be killed in a public place, female victims are murdered mainly at home, as is the case in Europe, where half of all female victims were killed by a family member. The overwhelming majority of victims of violence committed by partners and family members are women. In Europe, for example, women accounted for almost 80 per cent of the total number of persons killed by a current or former partner in 2008. There is a general sense in the literature that the gender determinants of violent cause of death are under-studied and that they are too easily attributed to the innate aggressiveness of males. However, advancing in this area based on census data is difficult due to the fact that censuses provide no or only minimal cause-specific mortality data. Two censuses that did attempt to obtain some level of cause-specific mortality data are the 2008 census of Cambodia and the 2010 census of Zambia. The latter included the following cause categories: a) Accident; b) Injury; c) Suicide; d) Spousal violence; e) Other violence; f) Sickness/disease; g) Witchcraft; and h) Other.
129. Studying maternal mortality based on census data, while not ideal, is more viable. Globally, an estimated 287,000 maternal deaths occurred in 2010 (WHO/UNICEF/UNFPA/World Bank, 2012). Although maternal mortality is only the 20th most common cause of death for women of all ages worldwide, it is the most important cause of death for women of reproductive age (usually taken as the age range 15-49) in many developing countries. In addition, like violent causes of death, it is eminently amenable to prevention. Maternal mortality by itself is not considered a gender indicator. That does not mean that it has no linkages with gender, but rather that it is an outcome to which gender factors contribute¹⁵. One publication on UNFPA’s website states: “Preventable maternal mortality occurs where there is a failure to give effect to the rights of women to health, equality and non-discrimination. Preventable maternal mortality also often represents a violation of a woman’s right to life” (Hunt and Bueno de Mesquita, xxxx). Yet, there is little empirical evidence on the extent to which gender factors contribute to maternal mortality. A detailed discussion on this subject is beyond the scope of this manual, but one set of results may serve to illustrate the nature of the relationships.
Table 8: Strength and significance of trends calculated using polynomial regression analysis for all variables in the study

Variables	Number of observations with all variable data	R-squared value	P
Infant mortality rate	148	77.0	0.002
Total fertility rate	144	65.4	0.424
Female literacy rate	114	48.6	0.039
Combined enrolment ratio	148	48.0	0.004
Year of suffrage	142	18.1	0.574
Seats in parliament held by women	142	2.0	0.750
Female professional and technical workers	65	16.5	0.111
Ratio of estimated female to male earned income	62	7.6	0.075
Female economic activity	142	4.6	0.634
Human development index	148	81.2	0.000
Gender-related development index (Figure 2)	125	82.9	0.000
Gender empowerment measure (Figure 3)	62	25.0	0.187

Source: McAlister and Baskett (2006)

130. The element to note in the above table is the relatively poor performance of “pure” gender indicators as predictors of maternal mortality, as compared to indicators that reflect overall level of development. Of particular note is the finding that the Human Development Index scores very high, with an R² of 81.2, and that this improves to 82.9 with the Gender-related Development Index. Thus, gender is shown to be a dimension of maternal mortality, but not the principal one.

131. A different perspective, but resulting in similar conclusions, is provided through the ”Three Delays” model. This model proposes that pregnancy-related mortality is overwhelmingly due to delays in:

1) Deciding to seek appropriate medical help for an obstetric emergency;

2) Reaching an appropriate obstetric facility; and

3) Receiving adequate care when a facility is reached.
Out of these three delays, it is mainly the first one where gender plays an important role, the other two are more dominated by factors of general development (transport issues) and development of the health care system (quality and availability of obstetric care).
3. Data issues
132. As was indicated in the first section, censuses can measure mortality in a variety of ways. The first and most common is through questions to women of reproductive age about

1) Their number of Children Ever Born alive (CEB);

2) Children born during the past 12 months before the census; and

3) Survival of Children Ever Born alive.

133. As was indicated in the previous chapter, most countries ask for this information disaggregated by sex of the child, but there are still a few countries where this information is not available. In countries that disaggregate the basic fertility and mortality data by sex, important information can be obtained about the sex ratio at birth and on differential mortality between young girls and boys. This issue, although directly related to fertility, will be discussed in the next sub-chapter. Typically, the information from questions 1) and 2), disaggregated by the age of the mother, is combined to estimate fertility, whereas 1) and 3) (more rarely 2) are combined for the purpose of mortality estimation. In addition, some censuses ask about the survival of the last child born or children born in the past 12 months.
134. A limitation of this method is that it can only provide information for mortality levels up to age 15 or 20. That means that mortality levels at higher ages (including the life expectancy) have to be estimated based on extrapolations, using typical relations between the mortality under age 20 and at higher ages. Such extrapolations contain a good deal of uncertainty and consequently the life expectancy estimates for many developing countries (including the sex differential) need to be treated with caution.
135. Some censuses have additional questions that serve primarily to complement the information on early mortality by adult mortality estimates. One such question is the orphanhood question, which asks members of the household whether their mother, father or both are still alive. Based on the age of the respondent and typical fertility patterns in the country, this allows the estimation of probabilities of death for the parents. A limitation of this method is that the estimates obtained in this manner refer to deaths that occurred at any time during the birth of the respondent and the present. Especially in the case of older respondents, these estimates can be quite distinct from current mortality levels. There is also the possibility that parents live in unspecified areas different from the current residence of the respondent, thereby making it difficult to use the information for sub-national mortality estimates. This limitation also applies to the infant and child mortality estimates of the previous paragraph, but the potential bias is more serious in the case of adult mortality. For all of these reasons, the questions on orphanhood are generally not considered very effective and only about 25 countries currently include them in their censuses.
136. Rather than asking about the parents, another option is to ask about the survival of sisters of adult members of the household. There are two variants if this method. In the direct sisterhood method, which is the standard method used in the DHS, the detection of deaths of sisters is followed up by more detailed questions about the year in which the date occurred and the age of the sister at the time. This method, however, is too laborious for most censuses which use the indirect sisterhood method, in which only the age of the respondent is used and the remaining information is attributed based on averages. This makes the indirect variant much less efficient than the direct variant. Although the sisterhood method can be used to estimate adult (female) mortality in general, its more typical use is the estimation of maternal mortality, in which it has to be combined with follow-up questions about the likely cause of death. However, as will be explained below, its use in censuses for this purpose is generally not recommended.
137. The other major type of question that can be used to measure adult mortality is the one that asks about the age and sex of members of the household that died during the past 12 months or another appropriate reference period. The most common problem with this question is that it tends to systematically under or (more rarely) over-estimate mortality due to factors such as the following:

Confusion about the reference period (e.g. current calendar year, rather than past 12 months);
Confusion about the meaning of “household”, as opposed to “family” or “community”; or
Confusion about the meaning of “belonging to this household”, especially in the case of prolonged hospitalization prior to death.

However, to the extent that these errors affect all age groups more or less equally, the results can still be used to determine a mortality pattern. In addition, there are methods (see Hill et al., 2011) to estimate correction factors, based on the observed population sizes by age and sex, to correct for the systematic errors in estimated mortality levels. By asking appropriate follow-up questions (see below), this question can also be used to measure maternal mortality. In the 2010 census round, this method for measuring maternal mortality has been followed in more than 30 countries that do not have reliable registration data.
138. Measurement of maternal mortality through a population census is recommended for countries where other sources of maternal mortality information such as the vital registration system are deficient. In practice this recommendation only applies to countries with at least 500,000 population because of the need to have sufficiently large denominators to reliably measure this event. In this context it is important to realize that maternal deaths are relatively rare events and in order to measure them through a sample survey the sample size needs to be very large, often resulting in prohibitive costs.
139. Questions on maternal mortality in a census typically result in information on pregnancy related deaths, which is not the same as maternal deaths (see also the definition in an earlier paragraph). Pregnancy related deaths include deaths from any cause, occurring while a woman was pregnant or within 42 days after delivery. Using this data for analysis of maternal mortality results in a measure called the Pregnancy-Related Mortality Rate (PRMR). Comparisons of census-based estimates of the PRMR with survey-based estimates of MMR found that approximately 85% of pregnancy related deaths are maternal deaths. It is believed that the correspondence between PRMR and MMR is quite close since the number of pregnancy related deaths tends to be under-reported in censuses (Hill, 2009; NIPORT; ORC Macro; Johns Hopkins and ICDDR.B, 2001). Nevertheless, the results from census-based maternal mortality questions should not be taken at face value and should ideally be followed up by a survey among the reported pregnancy related deaths to empirically establish the proportion of pregnancy related deaths that are maternal.

Guide on Gender Analysis of Census Data Full Draft of 6 December 2012 Contents

Chapter 4: Mortality

Recommended census questions to estimate maternal deaths:

Chapter 4:
Mortality