Medical demography
English
Public Health
Demography
Medicine | 3rd year
Dental medicine | 5th year
Demography is a pillar of public health. It studies the population in terms of size, distribution, and structure. Medical demography is an integrated social science that studies demographic processes closely related to the health of populations. This teaching post covers the history of demography, its branches, the demographic transition model, demographic policy, family planning, population dynamics, migration, natural and vital events, and birth and death registration.
Medical demography – history, classification. Demographic transition model
History
Demographical data has been collected for centuries. The first known census was conducted in 3800 BC in Babylon. The first known census in Europe was conducted in 1086 in England. However, as a social science demography was established early in the sixteenth century, when an ordinance required parish priests in London to compile weekly lists of deaths from plague, called the Bills of Mortality. These were intended initially to identify outbreaks and areas for quarantine. Later, other causes of death were included, as well as weddings and christenings and the collection was extended to cover all English parishes. Disastrous plagues struck London in 1603 and again in 1625. In the latter year an estimated one quarter of the population of London died. Interest in population at the time centred on the effects of epidemics on population numbers, together with the new field of ‘political arithmetic’, concerned with estimating national wealth. Yet seventeenth century London produced the founder of demography, John Graunt (1620-74), a ‘prosperous and intelligent’ cloth merchant who became interested in the Bills of Mortality. He had no scientific training, and he ‘knew not by what accident’ he was moved to begin the studies that led to his book. Graunt’s Natural and Political Observations Made upon the Bills of Mortality, quickly brought him scientific recognition.
Graunt’s book ranged across many important questions including causes of death, proportions surviving at different ages, health and the environment, the balance of the sexes, family size, age structure, employment, population estimates, population growth and its components and the need for social statistics in public administration. Cambridge demographer Peter Laslett described Graunt as ‘ranking among the great natural scientists of the early years of the Royal Society’ and his little book as ‘universally recognized as a work of genius’. Graunt demonstrated the potential for systematic study of population and he is the acknowledged founder of demography.
Definitions
- Demography is the study of population processes and characteristics. Demography is generally considered an interdisciplinary subject with strong roots in sociology and weaker, but still important, connections with economics, statistics, geography, human ecology, biology, medicine and human genetics. It is rarely thought of as a completely separate discipline, but rather as an interstitial subject or as a subdivision of one of the major fields
- Medical demography is an integrated social science that studies demographic processes closely related to the health of populations.
Note! The demographic condition is one of the key elements describing public health. In demography, the term population refers to the inhabitants of a given territory at a given time. In statistics, population refers to a general aggregate.
Branches (sub-disciplines) of demography
Demography studies the population in two main dimensions - demographic statics and demographic dynamics.
- Demographic Statics examines the population in terms of size and structure.
- Demographic Dynamics studies changes in the population resulting from natural events and migration.
Demographic Statics
- Definition: Demographic statics represents a snapshot of the population. It studies the size, distribution, and structure of the population.
- Methods: The primary source of data for statics is the census. A census is a process of statistical observation. It involves the collection, processing, compilation, and publication of demographic, sociological, and economic information at a given time, covering all individuals in a country or specific territory. The census is a demographic study that also aims to compare data between different countries. Censuses are conducted every 10 years and must follow the following basic principles:
- State (government) funding: The costs required for the preparation, organization, execution, processing, and publication of census results are covered by the central budget.
- Precisely defined territory: The 2021 census was conducted simultaneously in all European Union countries under a common regulation.
- Exhaustiveness: Every individual is counted, not groups of people or households. Individuals who refuse to provide data to the census taker under Articles 17–19 of the Census Law are fined 160 BGN.
- Simultaneity: A specific moment (critical moment) is fixed, serving as a dividing line for inclusion or exclusion from the census.
- Periodicity: Censuses are conducted at least every 10 years, preferably in years ending with “1.”
- Demographic structure: This refers to the distribution of a country’s population by gender, age, education, marital status, ethnicity, residence, employment, etc. The distribution of the population by one or more characteristics is presented in tabular or graphical form.
- Population size: As of December 31, 2023, Bulgaria’s population is 6,445,481. Of this, 4,738,461 (73.5%) live in urban areas, while 1,707,020 (26.5%) live in rural areas.
- The most important characteristics in demography are gender and age. These are called basic demographic characteristics. The distribution of the population by gender and age is called the age-sex structure. This distribution is graphically represented by an age-sex pyramid. There are three types of age-sex pyramid structures:
- Progressive type: The population under 15 years old predominates.
- Stationary type: Uniform distribution across all age groups.
- Regressive type: The population aged 65 and over predominates.
- Population aging:
- Definition: The change in the age structure of the population, where the relative share of elderly people increases, and the share of children and young people decreases. Demographic aging is a complex restructuring process, but it can be expressed through a simple indicator: the average age of the population. In 2022, the average age of Bulgaria’s population was 45.2 years.
- Types:
- Aging from the top of the age pyramid: A process of expanding the upper part of the age pyramid as the percentage of people surviving to higher ages increases, causing the top of the pyramid to widen.
- Aging from the base: Fewer children are being born.
- Indicators of population aging:
- Relative share of the population aged 65 and over compared to the average annual population: At the end of 2023, individuals aged 65 and over numbered 1,530,909, or 23.8% of the country’s population. Compared to 2022, the share of this age group increased by 0.3 percentage points.
- Child dependency ratio: The number of children relative to the working-age population (15–64 years).
- Old-age dependency ratio: The number of people aged 65 and over relative to the working-age population (15–64 years).
- Total dependency ratio: The dependent population (under 15 and over 65) relative to the working-age population. As of December 31, 2023, Bulgaria’s total dependency ratio is 61.0%, meaning there are fewer than two working-age individuals for every dependent individual. This ratio is more favorable in urban areas (57.6%) than in rural areas (71.3%). In all regions of the country, this indicator exceeds 50.0%. The lowest value is in Sofia (51.5%), while the most unfavorable ratios are in Vidin (74.8%), Gabrovo, and Yambol (72.3% each).
- Replacement ratio: The ratio between the number of individuals entering working age (15–19 years) and those leaving working age (60–64 years). As of December 31, 2023, the replacement ratio is 69.
- Territorial distribution:
- Demographic studies often use population distributions by territory (by regions, settlements, municipalities, etc.), as well as by countries and continents.
- This allows for the calculation of population density.
Demographic Dynamics
Demographic dynamics assess the changes in a population resulting from natural events and migration. Natural events include births, deaths, marriages, and divorces. Dynamics are divided into migrational and natural. Data for studying demographic dynamics are derived from population registers - the unified system for civil registration and administrative servicing of the population. Natural events are recorded through standardized documents - medical certificate for birth (certificat for live birth), marriage certificates, divorce certificates, medical certificate of the causes of death, current address, and personal registration cards.
Model of Demographic Transition
- Definition: The demographic transition model is theoretically based on the historical development of birth and death rates. The model is fundamental and describes population dynamics.
- Structure: The model primarily involves two parameters: crude death rates and crude birth rates. Empirical data show that the development of societies (in Europe and other continents) leads to a point where the death rate begins to decline sharply. This stage is associated with industrialization and related processes of improved living standards, hygiene, healthcare, etc. According to the model, the decline in the death rate naturally leads to a decline in the birth rate, so that after a certain period, the two processes balance at a lower level.
- Stages: The model includes five stages (phases), which are theoretically defined, as each country and region has specific manifestations of these phases, and some countries may lack certain phases entirely.
- First stage:
- Essence: High birth and death rates, which are approximately balanced. Natural growth is low.
- Causes: High mortality due to epidemics, wars, and famine. High fluctuating birth rates influenced by religious beliefs.
- Second stage:
- Essence: Declining death rates, especially infant mortality; increasing life expectancy. High natural growth.
- Causes: Improved sanitary and living conditions. Improved quality and access to healthcare. Effective measures against infectious diseases. Pronatalist policies.
- Third stage:
- Essence: Declining birth rates with a steady decline in death rates. Natural growth is positive but at a reduced intensity, reaching a constant level.
- Causes: Sociophilosophical changes in the role of children and individuals in society. Initiation of gender equality processes. Declining birth rates. Nuclearization of the family. Urbanization.
- Fourth stage:
- Essence: Stable model with zero natural growth. Fluctuations due to epidemics and baby booms.
- Causes: Mass participation of women in economic activity. Demographic policies. Family planning.
- Fifth stage:
- Essence: Birth rates fall below the level of natural replacement. Decline in natural growth.
- Causes: Demographic aging.
- First stage:
- Mechanisms: Changes in the population occur in two ways:
- Change by place: Different countries may be at different stages at a given time.
- Change over time: Theoretically, every country progresses through the stages.
Demographic policy. Family planning
Demographic Policy
- Definition: Demographic policy represents the purposeful management of demographic processes in the country.
- Types: There are three main types of demographic policy:
- Pronatalist demographic policy: Aims to increase the population. It focuses on increasing birth rates.
- Antinatalist demographic policy: Aims to decrease birth rates.
- Liberal policy: Does not set a specific goal regarding birth rates. It serves as a means and combines methods from both pronatalist and antinatalist policies to improve overall demographic indicators.
- Governing Bodies: The Council of Ministers leads, while the Ministry of Labor and Social Policy (MLSP) coordinates and oversees the implementation of state demographic policy, as well as activities related to analyzing, evaluating, and forecasting demographic processes.
- Legal Framework: The National Strategy for Demographic Development.
- Demographic Policy in Bulgaria - Moderate Pronatalist Policy:
- Measures to protect families and children:
- Financial compensations (paid maternity leave, one-time childbirth allowance, child benefits).
- Network of childcare facilities for raising and educating children.
- Programs for maternal and child healthcare.
- Legal norms for protecting women’s reproductive abilities (occupational safety, prohibition of certain work activities, employment).
- Harmonizing women’s employment and motherhood.
- Measures for education, social, and health protection for adolescents:
- Preferences in using public services for families with children.
- Provision of free, quality, and universally accessible education and healthcare.
- Promotion of family planning. Support for new reproductive technologies.
- Integration with migration policy measures targeting women of reproductive age.
- Measures to protect families and children:
- Levels of Implementation of Demographic Policy:
- National level: Through measures valid for all Bulgarian citizens in the country.
- Regional level: Measures aimed at specific regions with deteriorating demographic indicators (Northwest region).
- Local level: Measures in specific municipalities (e.g., financial support for infertility treatment for families, couples, and women without partners experiencing reproductive problems, residents of the Plovdiv Municipality).
- Business environment: Demographic policy is supported by the private economic sector through corporate social responsibility methods. For example:
- Additional leave for childcare.
- Additional financial incentives from the employer upon childbirth in the family.
- Flexibility in work schedule combined with childcare.
- Construction of daycare centers and kindergartens at enterprises.
Family Planning
- Definition: Family planning (FP) signifies the right of individuals and couples to plan and have the desired number of children, as well as to determine the most suitable timing for their births.
- Terms:
- Protogenetic interval: The interval between the beginning of marriage (conjugal union) and the birth of the first child.
- Intergenetic interval: The interval between the birth of the previous and the next child.
- Infertility:
- Primary infertility: The couple has not achieved conception despite attempts for at least 2 years (new definition - 1 year).
- Secondary infertility: The couple has had conception but cannot achieve it again despite attempts for at least 2 (new definition - 1) year(s). If the woman has been breastfeeding, the time for attempts at conception is calculated from the end of lactational amenorrhea.
- Number of children:
- Ideal number of children: The number of children considered ideal for an individual’s perception of a “perfect family.” The ideal number of children depends on cultural, social, personal, and economic factors.
- Desired number of children: The number of children an individual or couple would like to have in the future, taking into account their fertility, partner preferences, access to family planning services, etc.
- Planned number of children: The number of children a couple plans to have in the near future, considering housing conditions, socio-economic status, age, work conditions, etc. Example: According to one partner, the ideal family consists of 4 children (ideal number of children). However, due to reproductive problems, the partner desires 2 children (desired number), with the couple planning for one child (planned number) in the next two years.
- Methods:
- Contraception, defined as any method to prevent pregnancy.
- Treatment for unwanted infertility.
- Contraceptive Methods:
- Types:
- Temporary methods include:
- Barrier methods: Placing a barrier to prevent sperm from entering the upper part of the female genital tract (e.g., condoms, diaphragms, spermicides).
- Hormonal methods: Using reproductive hormones (e.g., oral pills, injections, long-acting implants).
- Traditional methods: Withdrawal; Utilizing natural periods of infertility (e.g., during breastfeeding and postpartum amenorrhea).
- Permanent methods: Permanent contraception methods include sterilization of men and women. NB! In Bulgaria, this contraception by choice is prohibited by law.
- Temporary methods include:
- Principles:
- Adequate information and counseling for family planning.
- Trained personnel for contraception requiring surgical intervention.
- Appropriate equipment, storage, and distribution of contraceptive methods.
- Types:
- Treatment for Unwanted Infertility:
- Methods:
- With own genetic material:
- Medication-based: Gonadotropin-based.
- Intrauterine insemination.
- In vitro fertilization.
- Surrogate motherhood with material from the couple.
- With donor genetic material:
- Donor egg/sperm.
- Adoption.
- With own genetic material:
- Principles:
- Diagnosis of the cause of infertility.
- High-quality and safe medical interventions combined with psychological care.
- Social support (including state funding).
- Methods:
- Public Health Benefits of Family Planning:
- Reduction in maternal and child mortality.
- Reduction in sexually transmitted infections (STIs): Some family planning methods, such as condoms, can provide protection against sexually transmitted diseases.
- Improvement in maternal and child health: Family planning can also help improve maternal and child health by allowing women to plan and prepare for pregnancy, ensuring access to prenatal care, and reducing the risk of complications during pregnancy and childbirth.
- Economic benefits: Family planning can have economic benefits by reducing the financial burden of caring for a large family, allowing women to participate in the workforce, and increasing access to education and resources for families.
- Environmental benefits: Family planning can also have positive environmental benefits by reducing population growth and decreasing the strain on natural resources in certain regions.
- Improved quality of life: Family planning allows people to make informed choices about their reproductive health, which can improve their overall quality of life and well-being.
Medical demography. Population dynamics. Migration: types and health aspects
Definition
Migration represents the spatial population dynamics. Different types of migration exert specific health effects on the population.
Migration is harder to define than the other demographic growth processes, mortality and fertility. Not all moves across geographic boundaries are migrations, since not all of them involve changing residence (that is, reaffiliation with a new population).
The voluntary migration, both individual and mass, that has been so prominent in modern Western history is unusual in the overall picture. Patterns of migration have shifted rapidly in the modern period and probably will continue to do so. Temporary labor migrations have grown to significantly outnumber permanent migrations. Former migration streams from more-developed countries to less-developed countries have reversed. Conflicts, increasingly within less-developed regions, have increased the numbers of people forced to migrate as refugees.
People migrate for a variety of reasons, of course, but there are regularities. Differential rates relate to stage in the life cycle (age), employment status, ethnic identity, gender, and so on. Young adults entering the labor force and their offspring are the most likely to move. The most general model for interpreting migratory motivation is one that features a place of origin and a place of destination, each with attractive pull and unattractive push qualities, separated by a series of intervening obstacles. These empirical generalizations about migration have given rise to several modern migration theories which increasingly reflect the complexity of migration.
Types and Health Aspects
- External Migration - the movement of people from one country to another. It can be forced (war, disaster) and voluntary. It also includes:
- Emigration - the process of leaving the country. The effects are:
- Change in age structure.
- Aging of the population.
- Social isolation of the elderly.
- Increased socioeconomic burden of chronic diseases.
- Decrease in the reproductive cohort - decreased fertility.
- Immigration - the process of settling in the country. Effects are
- Risk of epidemic spread of infectious diseases.
- Change in the epidemiology of genetically related endemic diseases.
- Potential for changes in ethnic and social structure.
- Increase in the reproductive contingent with possible increased fertility.
- Emigration - the process of leaving the country. The effects are:
- Internal Migration - the movement of people within the country.
- Permanent
- Urbanization: The process of moving people from less populated areas (villages) to big cities:
- (-) Increased urbanization stress.
- (-) Environmental pollution.
- (+) Access to medical care.
- (-) Decreased physical activity.
- (-) Increased risk of road traffic injuries.
- Urban depopulation: The process of moving people from cities to smaller settlements:
- (+) Reduced urbanization stress.
- (-) Difficult access to medical care.
- (+) Reduced risk of road traffic injuries.
- Regional migration - relocation of people from one region to another within the country.
- Urbanization: The process of moving people from less populated areas (villages) to big cities:
- Temporary
- Seasonal:
- During summer - increased incidence of gastrointestinal infections; food poisoning; sunburns; cardiovascular incidents.
- During winter - Increased trauma; respiratory infections.
- Daily (communal):
- Increased road traffic injuries; adverse ecological effects on atmospheric air; risk of infectious diseases.
- Semi-permanent (for university). These migrations have profound effects on public health, necessitating targeted policies and interventions to mitigate potential negative impacts and harness potential benefits.
- Seasonal:
- Permanent
- Indicators:
- Rate of inward migration - the number of arrivals divided by the mid-annual population.
- Rate of outward migration - the number of departures divided by the mid-annual population.
- Net migration rate - the difference between the number of arrivals and departures divided by the mid-annual population.
- Gross migration rate - the sum of the absolute values of arrivals and departures divided by the mid-annual population.
- Migration effectiveness ratio - net migration rate divided by the gross migration rate.
Medical demography. Population dynamics. Natural and vital events. Indicators
Natality
- Terms
- Since 2021, according to Order No. 9 of April 27, 2021, approving the medical standard “Obstetrics and Gynecology”, the following definitions for the status of newborns apply:
- “Birth” is the complete expulsion or extraction of a fetus, whether alive or dead, which meets the following criteria:
- A fetus from a pregnancy that has reached 25 gestational weeks and/or weighs 700 grams or more.
- A fetus from a pregnancy with a gestational age of less than 25 weeks is considered as livebirth after it has survived for 72 hours (3 days).
- “Live fetus” is a fetus that demonstrates signs of blood circulation. In the absence of such signs, the fetus is designated as “dead” (foetus mortus, stillbirth).
- “Abortion” is the loss or termination of a pregnancy before the fetus(es) meet the specified criteria for birth.
- Voluntary abortion - the voluntary termination of a pregnancy.
- Spontaneous abortion - the termination of pregnancy by the expulsion of the embryo/fetus before 25 gestational weeks or less than 700 grams.
- The therapeutic termination of pregnancy (TToP) is an induced abortion following a diagnosis of medical necessity. TToP is carried out to avoid the risk of substantial harm to the mother or in cases of fetal unviability
- Criminal abortion is a procedure for terminating an unwanted pregnancy by a person without the necessary skills or in an environment without minimal medical standards, or both. Criminal abortion is a crime regardless of the pregnant woman’s desire.
- Premature birth - Before 37 gestational weeks (less than 259 days).
- Neonatal period - The neonatal period begins from the moment of birth and ends after 28 full days after birth.
- Perinatal period - The perinatal period begins from the 25th full week of intrauterine life of the fetus and ends after 6 full days after birth.
- Postnatal period - From the 29th day until the end of the first year.
- “Birth” is the complete expulsion or extraction of a fetus, whether alive or dead, which meets the following criteria:
- Since 2021, according to Order No. 9 of April 27, 2021, approving the medical standard “Obstetrics and Gynecology”, the following definitions for the status of newborns apply:
- Indicators
- Crude Birth Rate: The birth rate is the ratio of the number of live births to the average population during the same year. It is calculated per thousand and shows the number of live births per 1,000 people in the population.
- Birth rate is positively correlated with public health. High birth rates create a “potential” for an active population, reducing the burden of age-related diseases. In Bulgaria for 2023, the birth rate coefficient is 8.9 per 1000 people.
- Assessment of birth rates is done on a 3-degree scale:
- Low up to 15‰
- Average 15-25‰
- High above 25‰
- Fertility
- Total Fertility Rate: It shows the average number of children (boys and girls) that a woman would give birth to during her entire reproductive period (from 15 to 49 years).
- Net Reproduction Rate: It is the ratio of the number of women giving birth in a year to the number of girls born to them in the same year, taking into account mortality. The NRR estimates the number of daughters who will live to replace their mothers in the future, thereby measuring the replacement of one generation by another. It allows for mortality between birth and the age of the mother at the time of bearing the child. Thus it defines replacement in terms of the numbers of daughters living to their mothers’ ages at confinement:
- NRR = 1, signifies exact replacement, or one daughter per woman: women are bearing just sufficient daughters to replace themselves in the future. The replacement level is always an NRR of 1, irrespective of whether the population has high or low mortality.
- NRR < 1, denotes below-replacement fertility, where there are fewer daughters to succeed their mothers’ generation. Any value less than one means that the population is not replacing itself.
- NRR > 1, indicates above-replacement fertility - the future generation of potential mothers will be larger than the one that produced them.
- Crude Birth Rate: The birth rate is the ratio of the number of live births to the average population during the same year. It is calculated per thousand and shows the number of live births per 1,000 people in the population.
Mortality
- Definition: Death is the cessation of life functions in the body without the possibility of their restoration.
- Indicators:
- Crude Death Rate: It shows the number of deaths per 1,000 people. It is calculated in per mille as the ratio of the number of deaths in the year to the average population during the same year. For 2023, it’s 15.7 per mille.
- It is assessed as:
- Low up to 10‰;
- Average 10-15‰;
- High above 15‰.
- It is assessed as:
- Life Expectancy: Life expectancy at a given age represents the average number of years of life remaining if a group of persons at that age were to experience the mortality rates for a particular year over the course of their remaining life. Life expectancy at birth is a summary measure of the age specific all cause mortality rates in an area in a given period. The indicator is integrative and highly informative for assessing public health, providing an assessment of living conditions, the activity of the health service, and the socio-economic status of the population.
- Premature mortality: The number of deaths under the age of 65 from the total number of deaths. For this indicator, there is a significant difference between males (27.4) and females (13.1%). It represents, on the one hand, the distribution and strength of action of social risk factors, and on the other hand, the effectiveness of health prevention programs and the healthcare system.
- Mortality Rate by Causes: Number of deaths from a specific disease over the average annual population.
- Case Fatality Rate: Number of deaths from a given disease over the number of cases of that disease for a specific period.
- Proportion of Mortality from Specific Diseases: Number of deaths from a specific disease over the number of deaths from all diseases for a specific period.
- Crude Death Rate: It shows the number of deaths per 1,000 people. It is calculated in per mille as the ratio of the number of deaths in the year to the average population during the same year. For 2023, it’s 15.7 per mille.
Natural Increase
- Natural increase is the difference between the number of births and the number of deaths during a certain period (usually a year). In 2022, due to the negative natural growth, the population of the country decreased by 62,218 people.
- The natural increase rate is the ratio of natural increase (absolute values) to the average population. The decrease in the population measured by the natural increase rate is minus -9.6‰.
- Total growth (population growth) is the sum of natural growth and migration growth.
Factors for birth and mortality. Causes of death. Birth and death registration. Indicators
Factors for Birth Rate
The level of birth rate and the nature of population reproduction are determined by the size of the reproductive cohorts and their fertility. In the period before the so-called demographic transition, when natural fertility dominates, the birth rate level is almost entirely determined by the size of the reproductive cohorts. Later, with the onset of demographic transition, as fertility levels move away from natural fertility due to the beginning of family planning, the influence of reproductive cohorts weakens, and the birth rate is primarily determined by fertility levels.
- Biological Determinants:
- Onset of menarche and menopause – Earlier onset of menarche is associated with acceleration. However, this phenomenon leads to an earlier onset of menopause, and due to educational needs and career development of women during the early periods of their fertile life, this results in fewer opportunities to have more children in the shorter active fertile period.
- Frequency of ovulation – The more frequent ovulation is observed, the higher the likelihood of conception. However, due to limited ovarian reserve, more frequent ovulation can lead to premature depletion of a woman’s fertility and an earlier onset of menopause.
- Age during the reproductive period – The older the woman at the time of the first child’s birth, the lower the chance she will have more children.
- Spontaneous abortions or intrauterine death – A higher frequency of spontaneous abortions or intrauterine death leads to fewer live births and negatively affects fertility.
- Unwanted infertility – Unwanted infertility (due to disease) – Despite a couple’s desire to have children, if one or both partners are infertile, this becomes impossible or very difficult to achieve (with assisted reproduction methods). At a population level, the more widespread diseases that lead to infertility, the lower the fertility rate.
- Behavioral Determinants:
- Marriage rate and frequency of sexual contacts – A higher frequency of marriage and sexual contacts leads to a higher likelihood of conception.
- Use of contraception – The use of contraception results in fewer children.
- Voluntary sterilization – Cultural and individual preferences for sterilization, combined with the legal possibility for such without medical indications, reduces fertility. In Bulgaria, voluntary sterilization without medical indications is NOT allowed.
- Social and religious beliefs and attitudes toward voluntary abortion.
- Duration of breastfeeding – Breastfeeding leads to a lower likelihood of conceiving the next child due to hormonal stimulation (it is not an absolute contraceptive!). The longer the breastfeeding period, the lower the probability of conception for the next child.
- Women’s labor engagement.
- Women’s education – With higher educational levels, the average number of live births decreases.
- Social, Cultural, Economic, and Political Determinants:
- Tradition, values, the number of siblings in the family;
- State policy (pro-natalist or anti-natalist);
- Availability and accessibility of family planning;
- Economic prosperity (economic paradox - fertility decreases with increasing economic prosperity);
- Poverty;
- Child mortality rate;
- Urbanization.
Factors for Mortality
- Biological (age, sex, race, ethnicity)
- Age – A higher relative proportion of older people leads to higher mortality.
- Sex – Women have a higher life expectancy.
- Behavioral (nutrition, smoking, alcohol abuse, etc.)
- Income – Higher income leads to higher living standards, better access to healthcare, and a longer life expectancy.
- Socio-economic (economic and social status, public health status, medical and health technology development)
- Quality of healthcare.
Causes of Death
- The leading cause of death remains diseases of the circulatory system, with an intensity of 957.1 per 100,000 people, and their relative share is 61.1%. Among these, the highest death rates are due to cerebrovascular diseases and ischemic heart disease.
- The second cause is deaths from neoplasms. In 2023, the mortality rate from this cause was 258.8 per 100,000 of the population, with mortality among men significantly higher than among women.
- The third cause is deaths from diseases of the respiratory system.
Birth and Death Registration
- Birth:
- The birth certificate is an official written document in which the event of birth is registered by the civil status officer according to the Civil Registration Act. The birth certificate is a copy used for administrative purposes.
- The birth certificate is issued at the municipality or town hall of the place where the person was born, based on a birth notification issued by a competent medical professional.
- When a child is born, it is recorded in the hospital register. The birth notification is sent by the hospital to the civil status office in the municipality within seven days.
- A written notification of the birth of a stillborn child must be provided no later than 24 hours after the birth. The birth certificate for a stillborn child is issued no later than 48 hours after birth. If a child is born alive but dies before a birth certificate is issued, both a birth and a death certificate are prepared simultaneously.
- For each live-born child, the first electronic health record in the National Health Information System is the birth information. This information is entered, with an electronic signature from the doctor who performed the delivery, within 24 hours after birth.
- Death:
- The death certificate is issued based on the death notification no later than 48 hours after death occurs.
- Death occurring outside a healthcare facility is established by a doctor, or if a doctor is unavailable, by a paramedic.
- The death is certified and entered in the citizen’s electronic health record in the National Health Information System. After this event, the record becomes “inactive,” and the electronic health record is kept for fifty years from that date. The doctor who established the death enters this event in the National Health Information System within 24 hours with an electronic signature.
- The doctor (or paramedic) who confirms the death fills out the death notification in three copies:
- The first copy is sent to the civil status officer in the municipality or town where the event occurred.
- The second copy is sent to the relevant regional health inspection within two months of its issuance.
- The third copy remains with the doctor/health facility. If death was confirmed in a healthcare facility, the copy is stored in a designated register within the healthcare facility.
- Death from permanent and irreversible cessation of circulation and respiration is determined by a physical examination that checks for the permanent absence of any of the following signs:
- Palpable absence of pulse in both carotid and femoral arteries;
- Auscultatory absence of heart activity;
- Absence of respiratory movements of the diaphragm and chest, observed visually;
- Absence of breathing upon auscultation of the chest bilaterally.
- To confirm the absence of electrical heart activity, an electrocardiogram (ECG) may be used. An ECG alone is not sufficient to establish death.
- The general practitioner (GP) issues the death notification when:
- The death occurred less than 48 hours ago;
- The cause of death is a disease (non-violent);
- If the deceased is identified and has identity documents;
- If the doctor knows the cause of death;
- If the doctor personally visits the place where the person died and ensures through a careful external examination of the head, body, and limbs that there are no signs of violence (mechanical, chemical, thermal, etc.);
- If there are no signs that death occurred following recent trauma, such as an accident, workplace injury, beating, household accident, etc.
- According to the ICD, the causes of death to be entered are all diseases, pathological conditions, or injuries that led to or contributed to death, as well as the circumstances of the accident or violence that caused the fatal injury (see table Table 1).
| Cause of Death | Duration of Illness |
|---|---|
| Disease or pathological condition directly leading to death | Ia |
| Pre-existing complications and conditions leading to the above cause | Ib |
| Underlying cause of death (disease) | Ic |
| Other significant accompanying conditions | II |
Indicators
See the indicators of natality and mortality in the previous sections.