Pan American Health Organization

Health Status of the Population

Mortality in the Americas

  • Introduction
  • Quality of Mortality Data
  • Mortality by GBD Causes of Death
  • Mortality by Leading Causes of Death
  • Maternal Mortality by Time Period and Cause of Death
  • Infant Mortality by Time Period
  • Neonatal Mortality by Time Period
  • Conclusion
  • References
  • Full Article
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Introduction

Mortality trends and profiles in the Region of the Americas have undergone substantial changes in recent decades (). In Latin America and the Caribbean (LAC), demographic changes coupled with evolving lifestyle, environmental, behavioral, and economic factors have led to noncommunicable diseases (NCDs) replacing or, in some settings, co-existing with the burden of communicable diseases (CDs) (). This epidemiological transition helps explain the particularly heterogeneous mortality trends in LAC countries (), where the double burden of CDs and NCDs is common and takes a tremendous toll on the health system (). However, improvements in primary health care () and disease control and surveillance have reduced the risk of death from vaccine-preventable diseases () and complications during pregnancy and childbirth ().

In the Americas overall, the past decade has been characterized by an increase in deaths resulting from external causes such as road traffic injuries and suicides, which have contributed to changes in the Region’s mortality profile (). These changes have not occurred uniformly across different subregions, countries, populations, age groups, and genders (). For example, declines in mortality rates among indigenous populations in LAC countries have generally lagged compared to those in other groups ().

The analysis of mortality trends is crucial for developing effective health, social security, and other types of policies (). This chapter describes the trend and magnitude of mortality in the Americas between 2002 and 2013, by main causes of death, time period, and age group, and the heterogeneous patterns of mortality across subregions of the Americas in different stages of the epidemiological transition.

The LAC region has been recognized as having the highest socioeconomic disparities in the Americas, a status that has inevitably translated into high mortality due to NCDs, including cardiovascular diseases, diabetes, and cancer (). Reversing mortality trends due to NCDs in these subregions may be the Region’s biggest challenge as well as its greatest opportunity to meet the Sustainable Development Goals (SDGs) ().

Aging, globalization, urbanization, and the rise in obesity and physical inactivity in the Region have made cardiovascular diseases the leading cause of death and disability in the Americas (), accounting for almost one-third of all Regional mortality, with the risk generally higher in men compared to women.

The Region of the Americas also suffers from a high burden of diabetes mellitus, which is known to increase the risk of cardiovascular diseases two- to fourfold, and is among the top five causes of death in the LAC region, according to the 2010 Global Burden of Disease Study (GBD) (). Based on current trends, mortality from diabetes in the LAC region is projected to be 1.6 times higher than the SDG target (). In addition, cancer contributes to one-third of the NCD burden in the Region, according to the World Health Organization (WHO), with demographic, social, economic, and environmental factors, as well as changes in reproductive patterns, as the main drivers of the patterns of cancer mortality ().

Over the last decade, the Americas has experienced a decline in mortality from CDs resulting from improvements in access to water and sanitation services, micronutrient supplementation, primary care, and vaccination, among other areas (). Between 2007 and 2009, 12.5% of all deaths in the Region were attributed to CDs, with the highest mortality rates observed in Guatemala and Peru (). Despite favorable trends in CD mortality overall, challenges such as antibiotic resistance and emerging and reemerging infectious diseases will require continued and constant surveillance (). A better understanding of the link between climate change and infectious diseases will also be crucial given the predicted climatic effects on vector-borne and zoonotic diseases ().

Maternal mortality reduction remains an unfinished agenda in the Americas. No country in the Region achieved Millennium Development Goal 5 (MDG 5) (“Reduce maternal mortality”). In fact, from 1999 to 2013, an increase in maternal mortality was reported in the Americas (). This increase may be at least partially attributable to the enhanced identification of direct and indirect maternal deaths; the addition of a pregnancy checkbox in U.S. death certificates in 2003 (); the inclusion of late maternal deaths in the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10); active surveillance of maternal deaths in Brazil and Mexico since 2002 (); and an increasing prevalence of chronic conditions and risk factors such as obesity, hypertension, diabetes mellitus, and heart disease among pregnant women, along with the obstetric transition ().

The lowest rate of decline in maternal mortality during the 1990–2015 period was observed in the Caribbean, which reported a 1.8% reduction (). Maternal mortality reporting in the Region continues to be challenged by misclassification and under-reporting ().

Despite an overall decline in complications during pregnancy and childbirth across the Region (), direct obstetric causes still accounted for 75.0% of Regional maternal deaths in 2007 (). Improvements in fighting CDs and perinatal complications in children over the last few decades have led to marked reductions in deaths in neonates and children under 5 years old, which enabled the LAC region to meet MDG 4 (“Reduce child mortality”) (). Nevertheless, striking disparities remain within LAC countries. For example, despite major improvements in preventing maternal, newborn, and child mortality, Mexico’s neonatal mortality rate is still twice as high as the United States’ (8.2 compared to 3.6 deaths per 1,000 live births) ().

Youth and adolescents, representing about 26% of the total population of the Region, comprise the largest cohort in the Americas (). This population is also the most affected by external causes of mortality, which accounted for 64.7% of deaths in the 10–24 year age group and 11.1% of all deaths in the Region between 2007 and 2009 (). The largest contributors to external causes of death include road traffic injuries, which are among the leading causes of death in the 5–14 and 15–44 year age groups (), followed by accidental injuries, assaults, and suicides. Global estimates predict that by 2020 road traffic injuries will rank third in the causes of disability-adjusted life years (DALYs) lost (). External causes of death thus remain a major concern given the increasing proportional mortality they represent in the Region of the Americas.

The differences in mortality due to external causes by sex are striking, disproportionately affecting men more compared to women (). For example, deaths from assaults account for up to 30.0% of total deaths from external causes among males but only 10–12% of total deaths among females, and the risk of death from road traffic injuries was 3–4 times higher in men than in women in 2007 ().

To assess mortality in the Americas, an ecological study was conducted using data from () the Pan American Health Organization (PAHO) mortality database for 2002–2013 and () estimated maternal and infant mortality indicators obtained from interagency groups. This chapter describes the magnitude, distribution, and trends of mortality data across the Americas and its subregions over three time periods (2002–2005, 2006–2009, and 2010–2013). The countries are grouped according to PAHO’s Regional Core Health Data Initiative (RCHDI), with Mexico and Brazil listed separately as subregions due to their population size. Age-adjusted mortality rates were calculated for comparison across subregions, using the WHO world population age structure constructed for the period 2000–2025 as the standard population. Relative risk (RR) of mortality was calculated by sex and each of the 3-year time periods, along with the percentage of change in mortality between the time periods, using the latest interval as the reference variable.

Quality of Mortality Data: Under-registration, Ill-defined Causes of Death, and Garbage Codes

Data quality was assessed for proportions of under-registration, ill-defined causes of death, and garbage codes. For under-registration, the analysis indicated that the Region of the Americas mortality data for 2010–2013 had 5.9% under-registration, compared to 7.2% for 2002–2005 and 2006–2009. A total of 3.4% of the data for 2010–2013 were considered ill-defined causes of death, compared to 4.7% of the data in 2002–2005 and 3.6% in 2006–2009. On the other hand, the proportion of garbage codes increased to 15.2% for 2010–2013, compared to 14.8% for 2002–2005 and 15.0% for 2006–2009. Therefore, the quality of mortality data for the Region improved in terms of under-registration and ill-defined causes of death but dropped in terms of the proportion of garbage codes.

There was wide variability in the quality of mortality data by subregion (Figure 1). For example, in 2010–2013, the Andean Area had 24.9% under-registration, 2.2% ill-defined causes of death, and 17.2% garbage codes, whereas the Southern Cone reported 2.5%, 7%, and 24.7% for the same respective categories. In 2010–2013, the highest and lowest proportions of under-registration were observed in the Andean Area (24.9%) and in Mexico (near 0%), respectively. During the same period, the highest and lowest proportions of ill-defined causes of death were in the Southern Cone (7.0%) and North America (1.5%), respectively, whereas the highest and lowest proportions of garbage codes were in the Southern Cone (24.7%) and in Mexico and the Latin Caribbean (13.5%).

Figure 1. Mortality data quality by subregion and time period, Region of the Americas, 2002–2013

Source: PAHO Health Information Platform for the Americas (Plataforma de Información de Salud de la Organización Panamericana de la Salud, PLISA; https://www.paho.org/plisa).

Analysis of data quality across subregions over time (Figure 1) shows that Brazil and Mexico had the largest decline in under-registration between 2002–2005 and 2010–2013. During the same period, in Mexico the proportion declined from 4.5% to near 0%, whereas in Brazil it declined from 7.6% to 3.1%. Brazil also had the largest reduction in ill-defined causes of death (from 12.4% in 2002–2005 to 6.5% in 2010–2013), whereas North America experienced a slight increase for that category (from 1.3% in 2002–2005 to 1.5% in 2010–2013). The LAC region experienced a decrease in garbage codes followed by an increase (from 14.3% in 2002–2005 to 12.9% in 2006–2009 and 13.5% in 2010–2013), whereas in Mexico, this category increased from 12.6% (2002–2005) to 13.5% (2010–2013).

Mortality by GBD Causes of Death: CD, NCD, and External

Mortality by main causes of death according to the GBD 2010 categories (CDs, NCDs, and external) is shown in Table 1. The results show that in the Region of the Americas in 2010–2013, NCDs were the largest contributor to mortality. The age-adjusted mortality rate due to CDs was 59.7 deaths per 100,000 population compared to 441.3 deaths per 100,000 due to NCDs and 62.7 deaths per 100,000 due to external causes.

Table 1. Age-adjusted mortality rate by Global Burden of Disease (GBD)a cause of death, time period, and sex, Region of the Americas, 2002–2013

GBD cause of death Period Rate Variation
(%)b
Relative
riskc
Male Female Total
Communicable disease 2002–2005 74.8 58.1 66.2 –9.9 1.3
2006–2009 71.9 56.6 64.1 –6.9 1.3
2010–2013 66.7 53.0 59.7 1.3
Noncommunicable disease 2002–2005 539.3 436.0 483.4 -8.7 1.2
2006–2009 521.9 422.7 468.7 –5.8 1.2
2010–2013 490.7 398.1 441.3 1.2
External 2002–2005 98.8 27.2 62.4 0.5 3.6
2006–2009 101.2 27.9 64.0 –2.0 3.6
2010–2013 98.9 27.5 62.7 3.6
Source: PAHO Health Information Platform for the Americas (Plataforma de Información de Salud de la Organización Panamericana de la Salud, PLISA; https://www.paho.org/plisa).

a) Global Burden of Disease Study 2010 ().
b) Reference variable: period 2010–2013.
c) Reference variable: female.

Over the three time periods, CD age-adjusted mortality rates dropped from 66.2 per 100,000 (in 2002–2005) to 59.7 deaths per 100,000 (in 2010–2013), a 9.9% reduction. Similarly, the NCD age-adjusted mortality rates fell steadily from 483.4 per 100,000 in 2002–2005 to 441.3 deaths per 100,000 in 2010–2013. External causes of mortality rates rose from 62.4 to 64.0 per 100,000 between 2002–2005 and 2006–2009 and dropped to 62.7 deaths per 100,000 for 2010–2013.

An analysis of GBD causes of death in the Americas (stratified by sex) was carried out to assess the disparities between men and women regarding the risk of CD, NCD, and external causes of death over time (Table 1). The results indicated a constant RR for CD deaths of 1.3 over time, with a 30% higher risk for men, throughout the three time periods. Similarly, men had a 20% higher risk of NCD deaths throughout the study period (RR = 1.2). For external causes of death, disparity by sex was much larger: men had a 3.6-fold higher risk of death compared to women, and the disparity remained constant between 2002–2005 and 2010–2013. There were disparities in risk of death due to CDs, NCDs, and external causes for all subregions of the Americas, with the RR for the first two causes ranging from 1.2 to 1.4 for men compared to women for 2010–2013 and the RR for external causes ranging from 2.3 to 5.2 for men compared to women for the same period of time.

Within the Region of the Americas, there was variability in the patterns and trends of mortality rates for CDs, NCDs, and external causes (Figure 2). In the most recent time period (2010–2013), the subregions with the highest and lowest mortality rates due to CDs were Central America (111.8 deaths per 100,000) and North America (32.8 deaths per 100,000), respectively. NCD mortality rates were highest in Central America (454.2 deaths per 100,000) and lowest in the Non-Latin Caribbean (297.3 deaths per 100,000). Mortality rates for deaths due to external causes within the same period were the highest in Central America (90.2 deaths per 100,000) and lowest in the Non-Latin Caribbean (38.7 deaths per 100,000). Hence, the analysis by subregions suggests that Central America had the highest mortality rates for CDs, NCDs, and external causes in 2010–2013.

Analysis of the trend across the three time periods (Figure 2) shows that all subregions experienced a continuous decline in CD mortality rates with the exception of Brazil and Central America. In Central America, a steep rise was reported between 2002–2005 and 2006–2009 (from 80.7 to 131.9 deaths per 100,000), followed by a steady decline in 2010–2013 to 111.8 deaths per 100,000. Similarly, all subregions except Brazil, Central America, and Mexico experienced a continuous decline in NCD mortality rates. In Central America, a pattern resembling that for CDs was observed, with a sharp increase in the NCD death rate (from 351.0 to 454.8 deaths per 100,000) between 2002–2005 and 2006–2009, followed by a steady drop in magnitude to 454.2 deaths per 100,000 in 2010–2013. The Non-Latin Caribbean had the largest decline in NCD mortality rates, with 475.7 deaths per 100,000 in 2002–2005 and 297.3 deaths per 100,000 in 2010–2013 (a 37.5% reduction).

Figure 2. Trends in mortality rates for Global Burden of Disease (GBD)a causes of death by time period and subregion, Region of the Americas, 2002–2013

Source: PAHO Health Information Platform for the Americas (Plataforma de Información de Salud de la Organización Panamericana de la Salud, PLISA; https://www.paho.org/plisa).

a) Global Burden of Disease Study 2010 ().

Different trends were observed across the subregions for deaths by external causes: North America, the Latin Caribbean, and the Non-Latin Caribbean had a similar pattern, with a slight increase between 2002–2005 and 2006–2010, followed by a decline in 2010–2013. In Mexico, mortality due to external causes continued to increase in 2010–2013, whereas in Brazil it declined between 2002–2005 and 2006–2009 and then increased in 2010–2013. The Andean Area was the only subregion with a steady and continuous decline in mortality due to external causes throughout the study period (from 98.6 deaths per 100,000 in 2002–2005 to 89.1 deaths per 100,000 in 2010–2013). Central America had the largest increase in mortality from external causes (from 65.0 in 2002–2005 to 98.5 deaths per 100,000 in 2006–2009), followed by a decline to 90.2 in 2010–2013.

Mortality by Leading Causes of Death

Leading causes of death were analyzed by age group (10–24, 25–64, and 65+ years) and the three designated time periods. Figure 3 shows the five leading causes of death and associated mortality rates for the Region by age group and time period. Results for the Region overall for 2010–2013 indicated homicide was the leading cause of death among the 10–24 year age group, with a death rate of 20.4 per 100,000, followed by land transport accidents, with a rate of 13.4 per 100,000, and suicide, with a rate of 5.7 deaths per 100,000. In the 25–64 year age group, for the same period, ischemic heart diseases were the leading cause of death (35.9 deaths per 100,000), followed by diabetes mellitus (19.1 deaths per 100,000); homicides were on par with cirrhosis and other liver diseases, with a rate of 18.3 deaths per 100,000. Land transport accidents had a rate of 17.0 per 100,000. Homicide and land transport accidents were among the top five leading causes of death in both the 10–24 and 25–65 year age groups for both the 2002–2005 and 2002–2005 time periods (and for the 2006–2009 time period as well, for the younger age group). Among people 65 years old and older, ischemic heart diseases remained the leading contributor to mortality for 2010–2013, with a rate of 620.6 deaths per 100,000, followed by cerebrovascular disease deaths, dementia and Alzheimer’s disease deaths, chronic lower respiratory disease deaths, and diabetes mellitus.

Figure 3. Leading causes of death by age group and time period, Region of the Americas, 2002–2013 FMaterna;

Source: PAHO Health Information Platform for the Americas (Plataforma de Información de Salud de la Organización Panamericana de la Salud, PLISA; https://www.paho.org/plisa).

There was little heterogeneity in the leading causes of death over time in the Americas among the 10–24 year age group: homicide, land transport accidents, and suicide remained the top three causes of death between 2002–2005 and 2010–2013. For the 25–64 year age group, throughout all three time periods, ischemic heart disease remained the top cause of death and land transport accidents remained in the top five leading causes of death. Conversely, diabetes mellitus was not among the five leading causes of death in 2002–2005 but was the second leading cause of death for the periods 2006–2009 and 2010–2013. Also, cerebrovascular diseases, which were a leading cause of death in 2002–2005, were no longer a cause of death in the last two study periods, when cirrhosis and other liver diseases became a leading cause of death for the first time in the study period.

Among people 65 years old and older, a similar homogenous trend across subregions was observed for the leading causes of death over time. Ischemic heart diseases, cerebrovascular diseases, chronic lower respiratory diseases, and diabetes mellitus remained among the top five contributors to mortality in this age group. The category of dementia and Alzheimer’s disease was not one of the five leading causes in the first time period but increased from the fourth leading cause in 2006–2009 to the third leading cause in 2010–2013.

The data for the Americas overall suggest variability between subregions and countries in the leading causes of death by age group. Subregional and country data can be accessed from the mortality database of PAHO’s Health Information Platform for the Americas (Plataforma de Información de Salud de la Organización Panamericana de la Salud, PLISA).

Maternal Mortality by Time Period and Cause of Death

For the period 2010–2013, the maternal mortality ratio (MMR) Region-wide was 58.2 deaths per 100,000 live births, a decline from MMRs of 68.4 for 2002–2005 and 64.6 for 2006–2009 (a reduction of 14.9% and 9.9%, respectively) (Table 2). The highest subregional MMR recorded for 2010–2013 was in the Latin Caribbean, which experienced 192.2 deaths per 100,000 live births. Haiti had the highest MMR (375.0) in the Latin Caribbean for that period. The subregion with the lowest MMR for 2010–2013 was North America, which reported 13.5 deaths per 100,000 live births; at the country level in North America, for the same period, Canada had the lowest reported MMR (7.7).

Table 2. Maternal mortality ratio (MMR) by region/subregion and time period, Region of the Americas, 2002–2013

Region/subregion Period MMR Variation
(%)a
Americas 2002–2005 68.4 -14.9
2006-2009 64.6 -9.9
2010–2013 58.2
Andean Area 2002-2005 118.4 -19.2
2006–2009 104.8 -8.7
2010–2013 95.7
Brazil 2002–2005 64.5 -10.1
2006–2009 66.5 -12.8
2010–2013 58.0
Central America 2002-2005 126.9 -15.8
2006–2009 115.8 -7.7
2010–2013 106.9
Latin Caribbean 2002–2005 219.1 -12.3
2006–2009 214.8 -10.5
2010–2013 192.2
Mexico 2002–2005 56.5 -24.8
2006–2009 51.0 -16.7
2010–2013 42.5
Non-Latin Caribbean 2002–2005 114.1 -5.7
2006–2009 107.3 0.3
2010–2013 107.6
North America 2002–2005 12.7 6.3
2006–2009 13.8 -2.2
2010–2013 13.5
Southern Cone 2002–2005 64.2 -10.0
2006–2009 62.1 -6.9
2010–2013 57.5
Source: PAHO Health Information Platform for the Americas (Plataforma de Información de Salud de la Organización Panamericana de la Salud, PLISA; https://www.paho.org/plisa).

a) Reference variable: period 2010–2013.

Between 2002–2005 and 2010–2013, there was an overall trend of decline in maternal mortality in all subregions except North America, where there was a 5.7% increase in the MMR. The United States was the largest contributor to the rise in MMR in North America. Despite having the lowest MMR in the Region of the Americas, North America was the only subregion with an increase in MMR over the past decade (Table 2). In the other subregions, the largest decline over time was recorded in Mexico, where there was a 24.8% drop between 2002–2005 (MMR = 56.5) and 2010–2013 (MMR = 42.5).

Causes

Causes of maternal death were divided into four categories: (1) direct obstetric causes; (2) indirect obstetric causes; (3) obstetric deaths of unspecified causes; and (4) late maternal deaths and deaths from sequelae of obstetric causes. The distribution of maternal mortality causes for the Americas over time, by subregion, is shown in Figure 4. In 2010–2013, 66.4% of maternal deaths in the Americas were direct obstetric deaths, 23.5% were indirect obstetric deaths, 7.4% were late and obstetric sequelae deaths, and 2.8% were obstetric deaths of unspecified causes. When mortality was analyzed by these categories, within the overall declining trend, the largest contributor over all three time periods was direct obstetric causes, which accounted for 77.2%, 71.3%, and 66.4% of maternal deaths in 2002–2005, 2006–2009, and 2010–2013, respectively, followed by the rising proportion of indirect obstetric causes, which led to 16.3%, 20.4%, and 23.5% of maternal deaths, respectively. Late and sequelae maternal deaths also increased over the study period, representing 4.0%, 6.0%, and 7.4% of maternal deaths across the three time periods. Obstetric deaths from unspecified causes made up the smallest proportion of maternal deaths in the Americas (2.6%, 2.4%, and 2.8%, respectively, of total maternal deaths).

Figure 4. Causes of maternal mortality by region/subregion and time period, Region of the Americas, 2002–2013

Source: PAHO Health Information Platform for the Americas (Plataforma de Información de Salud de la Organización Panamericana de la Salud, PLISA; https://www.paho.org/plisa).

In the subregions, the proportional distribution of causes of maternal deaths varied. The Andean Area and Latin Caribbean followed a pattern similar to that of the Region in 2010–2013, with the largest contributor being direct obstetric deaths (68.1% and 63.5%, respectively) compared to indirect obstetric deaths (26.6% and 27.4%, respectively) and late and obstetric sequelae deaths (1.7% and 5.1%, respectively). Central America and the Non-Latin Caribbean had a similar distribution but with a much larger contribution from direct obstetric deaths (87.5% and 87.2%, respectively). North America had a more even distribution of maternal death causes, with 52.2% direct obstetric deaths, 24.2% indirect obstetric deaths, and 20.3% late and obstetric sequelae deaths in 2010–2013.

These data suggest an overall increase in the proportion of both indirect obstetric deaths and late and obstetric sequelae deaths, and a decline in the proportion of direct obstetric deaths. In the North American subregion, the proportion of direct obstetric maternal deaths declined from 62.5% in 2002–2005 to 53.7% and 52.2% in 2006–2009 and 2010–2013, respectively, and the proportion of obstetric deaths from unspecified causes declined from 4.1% in 2002–2005 to 3.2% in 2010–2013. Conversely, in the same subregion, indirect obstetric causes increased (from 18.6% in 2002–2005 to 24.3% in 2010–2013), and there was a sharp increase in late and obstetric sequelae maternal deaths (from 15.0% to 24.3%) between 2002–2005 and 2006–2009, which then declined slightly in 2010–2013 (to 20.3% of maternal deaths). Since 2002–2005, North America has had the highest subregional proportion of late maternal deaths and deaths from sequelae of obstetric causes in the Americas. In Mexico, there was an increase in indirect obstetric maternal deaths (from 15.3% in 2002–2005 to 23.5% in 2010–2013) and in late obstetric sequelae causes deaths (from 2.3% in 2002–2005 to 8.0% in 2010–2013) simultaneous with a decline in the proportion of direct obstetric causes (from 82.1% in 2002–2005 to 68.3% in 2010–2013). This pattern was also observed in both the Andean Area and the Latin Caribbean. In the Latin Caribbean, between 2002–2005 and 2010–2013, the proportion of direct obstetric causes declined from 74.5% to 63.5%, while the proportion for indirect obstetric causes rose from 19.2% to 27.4%. The proportional mortality for that subregion from late and sequelae maternal deaths remained relatively constant (approximately 5% over time), while obstetric deaths from unspecified causes rose from 1.7% in 2006–2009 to 4.0% in 2010–2013.

In both the Southern Cone and Brazil, the rise in proportional mortality from late and obstetric sequelae causes was not as striking as what was reported for North America and Mexico. For example, in Brazil, this value only increased from 4.1% in 2002–2005 to 6.4% in 2010–2013. However, both the Southern Cone and Brazil followed the same pattern as the rest of the Americas with regard to the interchanging contributions of direct and indirect obstetric causes of maternal death over time. In Central America and the Non–Latin Caribbean, a somewhat different scenario was observed in which the proportion of direct obstetric deaths rose between 2002–2005 and 2006–2009 while indirect obstetric deaths declined, followed by a reverse trend in 2010–2013. For example, in Central America, the contribution of direct obstetric causes increased from 86.0% to 89.1% from 2002–2005 to 2006–2009, and then declined to 87.5% in 2010–2013. This trend was reversed for indirect obstetric causes, whose contribution to maternal deaths declined from 10.9% to 7.5% between the first two time periods and then rose again to 10.2% in 2010–2013.

Infant Mortality by Time Period

Infant mortality rates (IMRs), defined as deaths in children under 1 year old per 1,000 live births, are presented in Table 3. In 2010–2013, the IMR in the Americas was 13.6 deaths per 1,000 live births, a decline from 17.9 and 15.2 deaths per 1,000 live births in 2002–2005 and 2006–2009 (a 24.0% and 10.5% reduction), respectively. Within the region, the IMR ranged between 6.0 and 38.7 deaths per 1,000 live births in North America and the Latin Caribbean, respectively, in 2010–2013.

Table 3. Infant mortality rate (IMR) by region/subregion and time period, Region of the Americas, 2002–2013

Region/subregion Period IMR Variation
(%)a
Relative
riska
Americas 2002–2005 17.9 –24.0 1.3
2006–2009 15.2 –10.5 1.1
2010–2013 13.6
Andean Area 2002–2005 23.4 –25.2 1.3
2006–2009 20.0 –12.5 1.1
2010–2013 17.5
Brazil 2002–2005 21.9 –33.8 1.5
2006–2009 16.7 –13.2 1.2
2010–2013 14.5
Central America 2002–2005 28.1 –23.1 1.3
2006–2009 24.4 –11.5 1.1
2010–2013 21.6
Latin Caribbean 2002–2005 41.2 –6.1 1.1
2006–2009 38.3 1.0 1.0
2010–2013 38.7
Mexico 2002–2005 17.9 -24.6 1.3
2006–2009 15.6 –13.5 1.2
2010–2013 13.5
Non-Latin Caribbean 2002–2005 21.4 –14.0 1.2
2006–2009 19.9 –7.5 1.1
2010-2013 18.4
North America 2002–2005 6.7 –10.4 1.1
2006–2009 6.4 –6.3 1.1
2010–2013 6.0
Southern Cone 2002–2005 15.4 –20.8 1.3
2006–2009 13.5 –9.6 1.1
2010–2013 12.2
Source: PAHO Health Information Platform for the Americas (Plataforma de Información de Salud de la Organización Panamericana de la Salud, PLISA; https://www.paho.org/plisa).

a) Reference variable: period 2010–2013.

Analyses of the IMRs over time suggest all subregions had a declining trend in infant mortality since 2002–2005. Within the overall decreasing trend Region-wide, the Latin Caribbean subregion had the highest IMR, with 41.2, 38.3, and 38.7 deaths per 1,000 live births for the three time periods. In both the Latin Caribbean subregion and the Region of the Americas as a whole, Haiti’s IMR was consistently the highest, ranging from 68.0 to 63.5 deaths per 1,000 live births between 2002–2005 and 2010–2013. At the subregional level, North America had the lowest IMR throughout the respective time periods (6.7, 6.4, and 6.0 infant deaths per 1,000 live births). At the country level, for 2010–2013, Cuba’s IMR was lowest (4.7 deaths per 1,000 live births). The Latin Caribbean subregion had the greatest disparity in infant mortality, with both the highest and lowest IMRs at the country level. The largest decline in infant mortality over time was in Brazil (followed by the Andean Area), with a 33.8% reduction (RR = 1.5) between 2002–2005 and 2010–2013 and a 13.2% reduction (RR = 1.2) between 2006–2009 and 2010–2013.

Neonatal Mortality by Time Period

Neonatal mortality, defined as deaths occurring during the first 28 days of life per 1,000 live births, was analyzed by principal causes and time period. The principal cause was “certain conditions originating from the perinatal period,” and consistently accounted for more than 70.0% of all neonatal deaths in the Americas during all time periods. Therefore, the analysis reported here focused on this cause of death among neonates. Within this category, the leading specific causes of neonatal mortality in the Americas were respiratory distress of newborns, which accounted for 18.2–20.4% of neonatal deaths between 2002–2005 and 2010–2013, followed by disorders related to length of gestation and fetal growth (14.3–15.8%); bacterial sepsis in newborns (13.5–14.9%); and fetus and newborn affected by maternal factors and complications of pregnancy and labor and delivery (11.5–12.8%). In North America and the Southern Cone, disorders related to the length of gestation and fetal growth remained the leading cause of neonatal deaths throughout the three time periods, whereas in the Andean Area, Brazil, Central America, the Latin Caribbean, Mexico, and the Non-Latin Caribbean, respiratory distress of the newborn was the leading cause. In addition to “certain conditions originating from the perinatal period,” intrauterine hypoxia and birth asphyxia, hemorrhagic and hematological disorders of the fetus and newborn, and congenital pneumonia were the top causes of neonatal mortality in certain subregions.

Conclusion

Despite major improvements since 2002–2005 for the Americas in both the overall health indicators and the quality of mortality data (i.e., the proportion of under-registration, ill-defined causes, and garbage codes), important challenges remain to sustain progress and further improve quality (e.g., continued reduction of the proportion of garbage codes). Suggested changes include a reduction in the disparities among health indicators across regions and countries.

Trends for the GBD causes of death were mixed. Between 2002–2005 and 2010–2013, risk decreased by 10.0% and 9.0% for CDs and NCDs, respectively, but risk of death from external causes remained relatively constant.

Based on the analysis of leading causes of death in the Region by age group, mortality trends across the Americas subregions were heterogeneous. However, there were some similarities Region-wide. For example, across all countries, homicide and land transport accidents were among the leading causes of death in the 10–24 year age group; ischemic heart diseases, cerebrovascular diseases, and diabetes were common leading causes of death in the 25–64 year age group; and chronic lower respiratory diseases and dementia and Alzheimer’s disease were common leading causes of death in people 65 years old and older.

Despite general declines in the risk of maternal mortality across subregions of the Americas, a rising trend was observed in North America. Regarding the causes of death, a declining proportion of direct obstetric causes and a rising proportion of indirect obstetric causes, late maternal deaths, and deaths from sequelae of obstetric causes were recorded throughout the Region. Infant mortality data indicate a declining trend in infant deaths across the Region, with the largest decline reported in Brazil since the period 2002–2005. The majority of deaths among neonates across the Americas were uniformly attributed to conditions originating from the perinatal period, including (1) newborn respiratory distress; (2) disorders related to length of gestation and fetal growth; (3) bacterial sepsis in newborns and fetus and newborn affected by maternal factors and by complications of pregnancy, labor, and delivery; and (4) other newborn respiratory conditions.

Technical notes

Mortality in the Americas was assessed through an ecological study using two sources: PAHO mortality data for the period 2002–2013 and estimated maternal and infant mortality indicators obtained from interagency groups (). The 2002–2013 study period was selected to capture at least a decade of data and because that period included the most complete information from PAHO’s mortality database.

PAHO data are collected on an annual basis from the national statistics institutes and ministries of health of all PAHO Member States. Each Member State documents deaths by year with ICD-10 coding. The data in the PAHO mortality database include at least five variables consistently reported by all countries: country name, year of death, age, sex, and underlying cause of death—all of which are used in the analyses reported here. Variability in the accuracy of the data across countries is measured by comparing the percentages of unregistered deaths (under-registration), the percentage of deaths attributed to ill-defined causes of death (from Chapter XVIII of the ICD-10), and the percentage of garbage codes (proportion of deaths assigned to causes that are not considered useful for public health purposes). For countries that do not have good-quality mortality data (data ≥10.0% of under-registration or ≥10% of ill-defined causes of death), a corrected mortality rate is calculated by applying a correction algorithm for under-registration and ill-defined causes of death that distributes both types of deaths into the registered mortality data. For countries with high-quality data (and those with low-quality data that lack inputs for correction), the original death registration data were used for the analyses.

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Reference/Note:

1. Theory of Abdel Omran (1971) connecting displacement of infectious diseases (CDs) by degenerative diseases (NCDs) as main causes of morbidity and mortality to economic development and demographic changes over time as countries’ level of development increases ().

2. Subregions as defined according to PAHO’s Regional Core Health Data Initiative (RCHDI), which lists Brazil and Mexico as subregions due to their population size.

3. Obstetric transition describes the gradual shift from high to low maternal mortality and an aging maternal population, from direct obstetric deaths to indirect obstetric deaths, and from pregnancy and childbirth to institutionalized maternity care.

4. Causes listed in Chapter XVIII of the ICD-10.

5. Deaths assigned to causes that are not considered useful for public health purposes.

6. https://www.paho.org/plisa.

7. From the mortality database of PAHO’s Health Information Platform for the Americas (https://www.paho.org/plisa).

Regional Office for the Americas of the World Health Organization
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