a.
Department of Health Statistics and Information Systems, World Health
Organization, 20 avenue Appia, 1211 Geneva 27, Switzerland.
b. Department of Ageing and Life Course, World Health Organization, Geneva,
Switzerland.
Correspondence to Gretchen A Stevens
(e-mail: stevensg@who.int).
(Submitted:
18 January 2013 – Revised version received: 03 May 2013 – Accepted: 08 May
2013.)
Bulletin of the World Health
Organization
2013;91:630-639. doi: http://dx.doi.org/10.2471/BLT.12.109710
Introduction
In almost
all parts of the world, women live longer than men.1 The cause of the differential between male
and female life expectancy is uncertain, but it appears to be partly explained
by biological advantages and partly by environmental and behavioural factors.
Differences in these external factors result in substantial geographic
variation. For example, in 2011 the female advantage in life expectancy at
birth was 1 year in Bangladesh, 7 years in Japan and 12 years in the
Russian Federation.1 Changing patterns of environmental and
behavioural factors can also explain the recent narrowing of the gap in some
developed countries. This may be due, at least in part, to increased smoking
among women and to falling rates of cardiovascular disease among men.2,3
Because of
women’s longer life expectancy, older women outnumber older men. Worldwide in
2011, women comprised 53% of adults aged 50 years or older and 59% of
adults aged 70 and above.4 Most of these older women live in less
developed regions (as defined by the United Nations Population Division),4 which in 2011 were home to 555 million
women aged 50 years or older. In contrast, about 280 million women in
this age group – or just over half as many – were living in developed regions
that same year. By 2050, these numbers are projected to increase to 1.5 billion
in less developed regions and to 379 million in developed regions.4 The share of the globe’s population
comprising older women is also projected to increase – from 12% in 2011 to 19%
in 2050.
Despite this
demographic transition, the health system needs of women in less-developed
settings remain largely confined to reproductive matters, particularly maternal
health and access to contraception. Other needs, including the prevention,
detection and management of noncommunicable diseases, have received less
attention. Given the substantial reduction in maternal and child mortality and
the progressive increase in the absolute number of older women that have taken
place over the past 10 years, these broader health system needs have become
more important and their importance will continue to increase in the future.
This special
issue of the Bulletin
explores those health problems affecting women that are not directly
attributable to their reproductive role. A look at the causes of death among
women can provide insight into their health problems. The objective of this
study is to describe recent epidemiologic changes in women’s health and to
identify key health system priorities stemming from these changes. To this end
we examined mortality levels, mortality trends and causes of death in women
aged 50 years and older (henceforth referred to as “older women”). Although the
scope of our analysis is limited by an exclusive focus on mortality – with
special attention to countries with reliable and complete mortality statistics
– our approach reduces the need to use statistical models to describe patterns
and trends in women’s health. Recent analyses of years lived with disability
and of healthy life expectancy have depended heavily on statistical models
because data on morbidity are seldom routinely collected.5,6
Methods
Life
expectancy
We present
women’s life expectancy at age 50 over the period from 1985 to 2012. Life
expectancy at age 50 is defined as the number of remaining years a 50-year-old
could expect to live if she were to pass through life exposed to the mortality
rates currently prevailing in her country in the year for which the statistic
is calculated. Life expectancy is calculated from World Health Organization
(WHO) life tables.1 Briefly, the procedures used to generate
these life tables depend on the data available. For countries with vital
registration data, we begin by assessing the completeness of the recorded
mortality data for adults by applying demographic techniques. If we determine
that the data are complete enough to be meaningful, we adjust the death rates
for individuals older than 5 years for completeness. For countries without
exploitable vital registration data, we use other sources of adult mortality
data, such as surveys and censuses, to estimate mortality among adults. We
present estimates for countries selected to show a variety of epidemiological
patterns representing all WHO regions and country income categories.
Causes
of death in 2008
To portray
the regional distributions of causes of death in people 50 years of age and
older we used WHO’s cause-of-death estimates for 2008.7 We generated country mortality estimates
based on national data on mortality and distribution of causes of death that
were available at the end of 2010. We combined this data with the most recent
information on causes of death of public health importance, as reported by WHO
programmes, the International Agency for Research on Cancer and the Joint
United Nations’ Programme on HIV/AIDS. We categorized countries according to
the World Bank’s 2009 income classification.8
Analysis
of death registration data
We
calculated cause-specific mortality rates and their trends from death
registration data in the WHO mortality database.9 To ensure the reliability of the data used,
we limited our analysis to countries where the proportion of deaths (recorded
and unrecorded) for which cause-of-death information could be obtained exceeded
80% in at least 80% of the years between 1980 and 2008. To determine this we
used the estimated completeness of vital registration and the fraction of
recorded deaths that were assigned an ill-defined cause-of-death code (e.g. for
the 10th revision of the International
classification of diseases and related health problems, codes
R00–R99).1,10 The data for country–years having less than
100% complete registration coverage were adjusted for incomplete registration.
Many
countries were missing data for some years. To create a continuous time series
of data, for each country we interpolated mortality rates, by cause of death,
if three or fewer consecutive years of data were missing. We also extrapolated
up to three years of data at the beginning and end of the data series. To
interpolate, we fit a logistic regression model for each missing data point.
The dependent variable is the death rate for the specific country, age, sex and
cause group. The independent variable is year. The regression was fitted using
death rates for the five years before and the five years after every year for
which the data were missing. To extrapolate, we fit an equivalent regression to
the first or the final six years of data.
Data from 58
countries whose population in 2010 exceeded 500 000 fulfilled our quality
criteria. This comprised 1827 country–years of data from 1970 to 2011, the year
for which the most recent data were available. After interpolation and
extrapolation, we obtained 2005 country–years of data that provided a complete
time series from 1970 to 2010 for 29 countries and from 1980 to 2010 for 39
countries. All 39 of these countries with a high-quality and relatively
complete cause-of-death time series were either high-income countries or
middle-income countries in eastern Europe or Latin America. For simplification,
in the results section we discuss the results from 11 of these countries, which
include two from each of these areas. The countries are Chile, France, Germany,
Greece, Japan, Mexico, New Zealand, Poland, the Russian Federation, the United
Kingdom of Great Britain and Northern Ireland and the United States of America.
Causes
of death
We
reassigned deaths with ill-defined or intermediate causes using previously
published methods.11 We redistributed cancers of unspecified
site pro rata to all sites excluding liver, pancreas, ovary, trachea, bronchus
and lung, which are cancer sites that are less likely to be assigned an
ill-defined cancer code. We redistributed ill-defined cardiovascular causes of
death to ischaemic heart disease and other cardiovascular causes of death, as
described in Mathers et al.11 Finally, we redistributed ill-defined
causes of death pro rata to all non-injury causes of death.
We grouped
deaths into the following six broad cause categories: communicable diseases and
nutritional deficiencies, cancers, cardiovascular diseases and diabetes
mellitus, chronic respiratory diseases, other noncommunicable diseases,
injuries. For some analyses, we disaggregated lung cancer mortality from other
cancer mortality. We present together cardiovascular and diabetes deaths from
death registration data because of inconsistencies across countries and over
time in designating the cause of death when both types of diseases contribute
to the death. We calculate age-standardized mortality rates using the WHO
reference population.12
Life
table methods
Abridged
life tables for people aged 50 years or older were constructed using death
records data. Mortality rates in 5-year age intervals up to the age of 85 years
and beyond were extracted. To clearly identify the contribution of deaths
caused by tobacco use, we calculated the total deaths attributable to tobacco
smoking across all causes of death using the method of Peto et al., who
proposed that current mortality for lung cancer can be used as an indicator of
past exposure to tobacco smoke.15 Briefly, we calculated the smoking impact
ratio by comparing lung cancer mortality rates in each population with the lung
cancer mortality rates among non-smokers and smokers observed in the American
Cancer Society study.16–19 In the life table analyses presented here,
deaths caused by tobacco are grouped in a single cause category and are
excluded from the other six cause categories listed above.
Gains in
life expectancy between two time points were decomposed into cause
contributions using the methods set out by Beltrán-Sánchez et al.20 The death registration data from the WHO
Mortality Database provides cause-specific deaths, by sex, for the single age
group of people aged 85 years or older. We assumed that this cause distribution
applied within each five-year age interval, starting with the group of people
aged 85 to 89 years. For this age group and all five-year age groups above it,
we assumed that the force of decrement function from each specific cause is
proportional to the force of decrement function for all causes combined in each
age interval. For the open-ended interval beginning at age 100, we follow
Beltrán-Sánchez et al. in assuming mortality rates to be constant and that no
person–years are lived above the age of 110.20
Mortality
projections
We have
projected mortality using methods applied in previous studies,21,22 with updated inputs for baseline deaths and
covariates. Briefly, a set of regression models was used to project future
health trends for baseline, optimistic and pessimistic scenarios, based on
projections of economic and social development and on the historically observed
relationships between such development and cause-specific mortality rates. The
projections presented in this study have been revised to take into account the
updated base estimates of deaths by cause for 2008,7 updated projections of real change in income
per capita that reflect the impacts of the global financial crisis23,24 and updated projections of tobacco-related
deaths that modify the previous smoking impact projections to reflect the
recent, flatter trends in tobacco consumption for 1990–2008.25 The projected chronic disease mortality
rates for older women are not highly sensitive to a reasonably broad range of
assumptions about future economic growth and trends in the tobacco epidemic.
However, the projections do not take into account trends in major risk factors
unrelated to tobacco or to the pace of economic growth. These risk factors may
not follow the same historical patterns observed in countries with death
registration data.
Results
Mortality
over the life course
The
distribution of deaths by age group varies substantially between countries as a
function of the level of socioeconomic development, population age structure
and mortality rates (Fig. 1).7 In low- and middle-income countries, where
child mortality rates are high and younger people comprise a greater fraction
of the population than in high-income countries, more female deaths occur in
the first 5 years of life than in any other five-year age group; in
high-income countries, on the other hand, children’s risk of death is very low.
In low-income countries, deaths in women over the age of 5 years are
spread evenly across the life course, but in medium- and high-income countries,
such deaths are more concentrated among older women.
The leading
causes of death also vary depending on the level of socioeconomic development,
and this variation is observed most markedly in younger ages (Fig. 1).7 In low-income countries, the deaths spike in
childhood as a result of communicable, perinatal and nutritional diseases and
injuries. In these settings, most women in early adulthood are killed by
communicable diseases (primarily acquired immunodeficiency syndrome [AIDS]),
maternal causes, injuries and cancers. The pattern is similar in middle-income
countries, although the proportion of deaths occurring during early adulthood
is much smaller. In high-income countries, deaths in early life are rare and
most are caused by injuries, although cancers are also a common cause.
In women
over the age of 50 years, noncommunicable diseases, particularly cancers and
cardiovascular diseases, are the most common causes of death, regardless of the
level of economic development of the country in which they live. Cardiovascular
diseases account for 45% of older women’s deaths globally and another 15% of
deaths are caused by cancers – mainly of the lung, breast, colon and stomach.7 Chronic respiratory conditions, primarily
chronic obstructive pulmonary disease, cause another 10% of the deaths seen in
these older women.
Recent
trends
Worldwide
and in most countries, female life expectancy at age 50 has increased in recent
decades (Fig. 2).1 Some countries have shown rapid gains in
older women’s life expectancy over the 23 years from 1990 to 2012. They include
Brazil and Japan – a country that already had the world’s second highest life
expectancy in 1990 – both with gains of four or more years. Older women in
China and the United States experienced measured gains of 2.2 and
1.8 years, respectively – slightly less than the global average of
2.3 years and India’s gain of 2.6 years. Some countries faced
setbacks during this period. Among them are the Russian Federation and other
eastern European countries, where the economic transition affected female life
expectancy, and South Africa, which was affected by the epidemic of human
immunodeficiency virus (HIV) infection, like other countries in sub-Saharan
Africa. South Africa has recently experienced gains in female life expectancy
at age 50, perhaps as a result of the increased use of antiretroviral
treatment.
Which causes
of death are contributing to these gains in life expectancy can be determined
by looking at estimated death rates. Globally, age-standardized death rates for
both sexes declined by an estimated 21.5% from 1990 to 2010.26 Progress by disease has not been uniform.
Death rates from some diseases have declined rapidly: chronic respiratory
disease death rates declined by 41.9% and cardiovascular death rates declined
by 21.2% between 1990 and 2010. In contrast, the overall cancer death rate
dropped by 13.8%, the lung cancer death rate decreased by 8.3% and the diabetes
death rate increased by 19.7% since 1990.26
Annual data
on deaths by age, sex and cause are available for countries with complete or
nearly complete death registration, namely most high-income countries and some
middle-income countries (Fig. 3, Fig. 4 and Fig. 5). Older
women’s rates of death from cardiovascular diseases and diabetes combined have
declined in all the countries shown in Fig. 3. Of the 11 countries shown
in Fig. 3, New Zealand experienced the median decline (66% from 1970 to
2010). Japanese women recorded the greatest relative decline (79%). Declines
were moderate in Mexico, where increases in the rate of death from diabetes
offset declines in deaths from cardiovascular disease. The Russian Federation
also experienced a moderate decline (11%) from 1980 to 2010. Increasing alcohol
use may have reduced the rate of decline of cardiovascular deaths recorded in
the Russian death records.27
Lung cancer
mortality rates are determined by past and current exposures to tobacco
smoking. They are affected by both the prevalence and the intensity of smoking
(i.e. the average number of cigarettes smoked per day). Fig. 4 shows the
heterogeneity in lung cancer mortality levels and their trends arising from
diverse patterns of tobacco smoking among women across time in different national
contexts. In the United States, lung cancer mortality rates peaked in 1998 at
130 per 100 000 and then declined 10% – to 117 per 100 000 – by 2010
(Fig. 4). Rates of death from lung cancer more than doubled from 1970 to
2010 in France, Germany and Poland and are still rising in all three countries.
Mortality
from cancers in sites other than the lung has declined moderately but
consistently during the past 40 years (Fig. 5). In six of the 11 countries
shown in Fig. 5, rates of death from cancers other than lung cancer
declined between 20 and 30% from 1970 to 2010. Declines in mortality from
cancers of the stomach, colon, breast and cervix contributed most to these
overall declines in cancer mortality.
Decomposing
gains in life expectancy into their constituent causes provides insight into
the epidemiological changes that have driven these improvements (Fig. 6).
In the high-income countries shown in Fig. 6, reductions in
non-tobacco-related mortality from cardiovascular diseases and diabetes
contributed the most to gains in women’s life expectancy at age 50 between 1980
and 2011 (gains ranged from 2.5 years in France and the United Kingdom to
3.5 years in Germany and Japan). Although reductions in tobacco-related
mortality played an important role in gains in life expectancy among men in
high-income countries (data not shown), among women the rates of
tobacco-related death increased in France, Germany, Greece and the United
States, and this resulted in a reduction in life expectancy at age 50 that
ranged from 0.02 years (in the United States) to 0.6 years (in France).
Among women, overall declines in cancer mortality led to moderate gains in life
expectancy – from 0.3 to 0.7 years – in the high-income countries
shown.
Middle-income
countries showed context-specific patterns in cause-specific mortality
reductions. Of the three middle-income countries shown in Fig. 6, Chile
and Poland resembled high-income countries in terms of the magnitude and
patterns of mortality reduction. In Mexico, decreases in communicable disease
mortality contributed the most to gains in female life expectancy – a gain of
1.3 years at age 50. The overall gain in life expectancy in Mexico was
smaller than in Chile or Poland. Female life expectancy increased even less in
the Russian Federation, where life expectancy at age 50 improved by only
1.2 years from 1980 to 2011. The Russian Federation, unlike most
high-income countries, experienced little decline in deaths from cardiovascular
diseases and diabetes. Such a decline contributed only 0.44 years to its modest
gain in life expectancy.
Mortality
projections for 2010 to 2050
The global
average female life expectancy at age 50 is projected to increase from 29 years
in 2010 to 33 years in 2050. The largest gains over this period are expected to
take place in WHO’s South-East Asia and Western Pacific regions (5.7 years
on average for the two regions combined) and in the middle-income countries of
the European Region (5.1 years). Because high-income countries have
already achieved reductions in female mortality at younger ages, in such
countries any further decreases in female mortality, mainly at older ages, will
have a lesser impact on gains in life expectancy. Thus, women in high-income
countries stand to gain less than women in other countries in terms of life
expectancy at age 50 – projected to increase 2.7 years (from 33.4 to
36.1 years) over the period from 2010 to 2050.
Despite
favourable trends in life expectancy at age 50 the world over, globally the
absolute number of deaths in women over the age of 50 years is projected to
increase from 18.5 million in 2010 to 39.3 million in 2050 (Fig. 7). Most
of this increase will be attributable to the leading causes of death seen at
present: cardiovascular deaths are projected to increase by 8 million (38%
of the total increase in deaths) and cancer deaths by 3.6 million (17% of the
total increase). Mortality from some causes will increase at a faster rate than
cardiovascular and cancer deaths. Deaths from falls and diabetes among older
women are projected to nearly triple between 2010 and 2050: their increase will
be from 200 000 to 550 000 and from 700 000 to 2 million,
respectively. In 2050, cardiovascular diseases and cancers will continue to be
the leading causes of death and be responsible for 46% and 14% of total deaths
in women over 50, respectively.
The absolute
number of deaths is projected to increase due to the growth in the total
population of older women and to an increase in the average age of these women.
The projected decline in age-specific death rates will offset these increases
to some extent. As a result of these demographic and epidemiological trends, an
increasing proportion of older women’s deaths will occur in low- and
middle-income countries. The increase will be from 76% of deaths in 2010 to 84%
in 2050. At every income level, more than 80% of these deaths will be
attributable to noncommunicable diseases, predominantly cardiovascular diseases
and cancers.
Discussion
Female
mortality and its causes vary considerably depending on a country’s level of
socioeconomic development. These variations are particularly obvious at younger
ages, when communicable diseases and maternal causes of death take many women’s
lives in low- and middle-income countries but relatively few in high-income countries.
However, in later adulthood, differences in female death rates across settings
becomes less marked. In women over the age of 50 years, cardiovascular
diseases, cancers and chronic respiratory diseases become the overwhelming
causes of death everywhere in the world and communicable diseases continue to
play a significant role in mortality only in low-income countries.
These
patterns are not static. Child and maternal mortality rates have declined
rapidly in low- and middle-income countries,28,29 along with death rates in adult women in
countries of all income levels.1 We project that these declines will
continue. At the same time, older women are growing both in number and as a
proportion of the total population. As a result, mortality patterns in all
countries will increasingly resemble those currently seen in high-income
countries. In other words, deaths will be increasingly delayed to older ages
and cancers will cause a larger proportion of deaths in people between the ages
of 20 and 75 years.
This
transition is already under way and may be more complex than initially
anticipated. Low- and middle-income countries face a “double burden” of
communicable and noncommunicable diseases, but according to our analysis,
although the causes of death in women over the age of 50 years are similar in
middle- and high-income countries, in middle-income countries women die of
these causes at younger ages than they do in high-income countries. This may be
because in middle-income countries women are more exposed to various risk
factors over life – e.g. psychological stress, raised blood pressure or certain
infections – and have less access to appropriate cardiac or cancer care and
other health services. Or they may be less resilient to disease in later life
because they faced more detrimental early life experiences than women in
high-income countries.30 Whatever the reasons may be, the fact that
noncommunicable diseases strike women at an earlier age in less developed
countries has important implications for individuals, families and societies.
The trends
described in this paper highlight the urgency of adapting health systems to
better meet the changing health-care needs of women in low- and middle- income
countries, primarily by improving the capacity to prevent and manage
noncommunicable diseases. Some of the strategies adopted in high-income
countries to deal with the trends we have reported can perhaps be incorporated
into this system adaptation process in low- and middle-income countries.
In richer
countries, falls in mortality from cardiovascular diseases constitute the most
dramatic of the changes witnessed in noncommunicable disease mortality among
older women. This reduction can probably be attributed in approximately equal
measure to better prevention and management of the metabolic risk factors for
cardiovascular disease, such as high blood pressure and high serum cholesterol,
and to improved treatment of cardiovascular conditions.31–33 However, low- and middle-income countries have
not experienced the decreases in women’s systolic blood pressure and serum
cholesterol levels that high-income countries have attained, despite the
increase in the prevalences of overweight, obesity and diabetes in these
wealthier countries.34–37 This suggests that stepping up efforts to
stem the rise in these metabolic disorders in low- and middle-income countries
could further accelerate improvements in cardiovascular mortality rates.
In
high-income countries, reductions in cancers of the stomach, colon, breast and
cervix have made small but important contributions to overall improvements in
older women’s life expectancy. These reductions were achieved through a mixture
of prevention and treatment. Breast cancer mortality has declined despite an
increase in disease incidence, which suggests that improved treatment was the driving
factor behind the decline. On the other hand, the drop seen in recent decades
in the incidence of cervical cancer38 suggests improvements in prevention. These
improvements are likely to have resulted from screening with the Papanicolaou
(Pap) test.39 Given the high incidence of cervical cancer
in low-income countries and the likelihood that breast cancer incidence will
increase in these countries owing to socioeconomic development and improved
female longevity, health systems need to take prompt measures against these
conditions too. In the case of cervical cancer, it makes sense to focus on
strengthening the effective screening and preventive interventions; in the case
of breast cancer, it may be more appropriate to focus on early detection and
treatment.
Analyses of
the causes of chronic obstructive pulmonary disease have identified smoking as
a major contributor (responsible for around 40% of deaths from this condition),
together with indoor air pollution from solid fuel cooking stoves (responsible
for around 30% of deaths). Occupational exposures and outdoor air pollution have
been found to contribute in smaller measure.19
In
high-income countries, declining tobacco use among men has been a major driver
of the increase in male life expectancy. Because women in high-income countries
are at a later stage in the tobacco epidemic,40 they have not experienced the same
reduction in tobacco smoking, and the associated lowering of mortality, as men
have in recent decades. In most developing countries, rates of tobacco smoking
among women remains low.41,42 If more women in those countries take up
tobacco smoking, mortality among women over 50 years of age will increase.21 Effective policies designed to discourage
women from taking up tobacco smoking in low- and middle-income countries do
exist, but they have not been sufficiently implemented.41
Finally,
regardless of how avidly health systems promote prevention and early
intervention, many older women will still develop noncommunicable diseases.
These can lead to a loss of function and independence. In lower-income
settings, innovative approaches to rehabilitation for stroke victims and others
who experience functional decline are needed, together with measures to ensure
that the family members who care for them do not become overwhelmed. Access to
palliative care also needs to be improved so that people everywhere can die
with dignity and without unnecessary pain.
Acknowledgements
Many WHO
staff members and external collaborators have helped to compile the WHO
Mortality Database and to prepare estimates and projections of deaths by cause.
We particularly acknowledge the assistance of Jessica Ho, Veronique Joseph and
Doris Ma Fat in this regard.
Competing
interests:
None
declared.
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