Mortality in the Islamic Republic of Iran, 1964–2004

607Bulletin of the World Health Organization | August 2007, 85 (8) Objective Reliable information on the pattern, level and trend of mortality is essential for evidence-based policy to improve health. Various sources of mortality data in the Islamic Republic of Iran have not been critically assessed. This paper aims to document and evaluate the completeness of the different data sources on mortality and to estimate the level and trends of mortality over the past 40 years according to various mortality indices such as child mortality, adult mortality and life expectancy. Methods We undertook a systematic review of all available studies on infant mortality from 1964 to 2004 and estimated the most probable trend in child mortality. Death registration data from between 1992 and 2004 were assessed for completeness to estimate the level of adult mortality. Life tables for 2004 were constructed for the Islamic Republic of Iran based on these data, corrected for underregistration of death. Findings Infant mortality decreased from an estimated 154 deaths per 1000 live births in 1964 to 26 in 2004. The risk of adult mortality in 2004 was estimated to be 0.124 and 0.175 for females and males respectively. According to adjusted death registration data, life expectancy at birth in 2004 was 71.2 for females and 68.7 for males. The average completeness of death registration for ages 5 years and older across all systems was 76% for the period 2001–2004. Conclusion There has been a general decline in child mortality in the Islamic Republic of Iran over the past three decades. Adult mortality levels also have declined, but less substantially. Mortality information systems have improved, yet serious concerns remain regarding the completeness and quality of data. Bulletin of the World Health Organization 2007;85:607–614. Une traduction en français de ce résumé figure à la fin de l’article. Al final del artículo se facilita una traducción al español. Mortality in the Islamic Republic of Iran, 1964–2004 Ardeshir Khosravi,a Richard Taylor,a Mohsen Naghavi b & Alan D Lopez a .ةلاقلما هذهل لماكلا صنلا ةياهن في ةصلاخلا هذهل ةيبرعلا ةمجترلا a School of Population Health, University of Queensland, Herston 4006, Brisbane QLD, Australia. Correspondence to Alan D Lopez (e-mail: a.lopez@sph.uq.edu.au). b Ministry of Health and Medical Education, Tehran, Islamic Republic of Iran. doi: 10.2471/BLT.06.038802 (Submitted: 14 November 2006 – Final revised version received: 6 March 2007 – Accepted: 14 March 2007) Introduction Reliable information on a population’s levels and patterns of causes of death is essential for health planning and priority-setting for interventions to control diseases and injuries, and for population-based evaluation of health programmes.1 The ultimate data source is an accurate and complete national vital registration system. Unfortunately, WHO reports that complete mortality data are available routinely for only a minority of countries worldwide. Com- pleteness is highest (> 90%) in developed countries (e.g. in Europe and North America) and lowest in developing coun- tries, particularly in Africa.2,3 Mortality data sources As in many other developing coun- tries, the Islamic Republic of Iran has incomplete mortality information.4–6 Currently, the National Organization for Civil Registration (NOCR) and the Ministry of Health and Medical Education (MOH&ME) operate death registration systems (Fig. 1). The NOCR was established in 1918 and is responsible for the registra- tion of births, marriages, divorces and deaths.7 In 1984 the Iranian Parliament revised and passed civil registration leg- islation requiring a report to be sent to the NOCR within ten days of any Iran resident’s death. In addition, deaths must be confirmed by a physician or two witnesses.7 Of the four vital events registered by the NOCR, mortality data are the least complete and of the poorest quality.6 This may be due in part to unregistered births when the infants die soon after birth. Recent assessments suggest some progress in capturing and registering deaths but problems remain, including delayed registration and inaccurate re- cording of causes of death. As a result, previous studies generally have not used this data source for analysing Iranian mortality.6,8 Until 2002, the MOH&ME Dep- uty of Research and Technology (DRT) operated a system to record the causes of deaths.9–11 Between 1966 and 1995, mortality data based on cemetery records were collected in a sample of 24 cities. In 1995, the system was redesigned to cover the entire country.9,12 This did not allow delayed registration of deaths and thus was more timely than the NOCR data. However, the causes of death were based on cemetery records and therefore were susceptible to bias (e.g. informa- tion bias due to misclassification).8 No study has assessed the validity of this data. The system was discontinued after the launch of the MOH&ME Deputy of Health (DH) programme. The DH established a comprehen- sive programme for death registration in order to improve district health net- works’ registration and certification of all deaths by age, sex, cause and place of residence. This was piloted in Busher Province in 1997. To improve the level of registration, different sources of mor- tality data in a district (e.g. NOCR, cem- etery and hospital) are cross-checked for omissions and duplication. The annual report of mortality data in ten provinces for 2000 compared these results with those from the NOCR and the DRT and found more reliable completeness 608 Bulletin of the World Health Organization | August 2007, 85 (8) Research Mortality in the Islamic Republic of Iran, 1964–2004 Ardeshir Khosravi et al. and classification of the causes of death.13 For instance, the DH recorded 6 681 more deaths than the NOCR and 15 390 more than the DRT.13 The DH system is being implemented progressively and currently covers 29 provinces. It is expected that all 30 provinces will be covered by the end of 2007. The Iranian Vital Horoscope (VH) is another mortality and population source that operates in rural areas. Rural health workers (behvarz) conduct peri- odic censuses and household visits to record information in family files. A notice pinned to the wall of each Health House (the basic primary health-care unit, covering between one and four vil- lages) displays this up-to-date informa- tion on the number of births, deaths and population and family planning activi- ties within the rural community. The VH is sent to the District Health Centre at year’s end; these data are entered into a customized computer programme and forwarded to Tehran for aggregation at national level.14 Since 1988, the Deputy of Health has analysed and published the results of this innovative system.15 Other mortality data sources in- clude censuses and surveys conducted by the Statistical Centre of Iran (SCI), and MOH&ME surveys. Mortality es- timates obtained from censuses or sur- veys using direct methods (retrospective questions about deaths in households during the previous 12 months) suffer from well-known problems of under- counting and misreporting of age and sex, particularly for adult mortality. For this reason, indirect demographic tech- niques have often been used to estimate the level of mortality and to create life tables. The level of child mortality and information on children ever born and children surviving (CEBCS) have been estimated by collecting and analysing data according to the Brass methodology.4,6 The results of this analysis and data sources are shown in Fig. 2. Methods A systematic review was conducted to obtain all published and unpublished documents in Farsi and/or English con- cerning child mortality in Iran between 1973 and 2004. Unpublished data and government reports were obtained from various organizations that collect mortality data, such as the NOCR, SCI and MOH&ME.4,5,16–18 The SCI carried out the most comprehensive assessment of infant mortality trends from 1956 to Fig. 1. Overview of death registration systems of various organizations in the Islamic Republic of Iran Ministry of Health and Medical Education (MOH&ME) National Organization for Civil Registration (1918-) MOH&ME Deputy of Research and Technology (in 24 cities 1966—1995; whole country 1996—2001) MOH&ME MOH&ME Deputy of Health (1997-) Vital Horoscope (rural areas) (1988-) MOH&ME: Iranian Ministry of Health and Medical Education. 2021, based on data from various stud- ies conducted between 1973 and 2001 using Brass’s indirect CEBCS method (Table 1, available at: http://www.who. int/bulletin).4 Adult mortality was estimated as the risk of death between ages 15 and 60 based on the following available data sources:6,16–27 (1) DRT: death registration system for 2001 (entire country except Tehran Province); (2) DH: VH data for 1992–2004; death registration in 18 provinces in 2000–2001, 23 in 2003, and 29 (of 30) in 2004; and (3) NOCR-registered deaths in 2002 and 2003 for the whole country. To remove natural disaster effects on background mortality rates, 28 745 deaths from the Bam earthquake in 2003 were excluded from the analysis. The most recent population census in the Islamic Republic of Iran was carried out in 1996 and no up-to-date popula- tion estimates by age or sex were avail- able.28 As a result, we used the United Nations (UN) estimated population size by age and sex to calculate national age- specific death rates from 2001 onwards. We applied the observed ratio in the Iranian Demographic and Health Survey (DHS) 2000 to the under-5 population estimated by the UN in order to separate this population into those aged 0–1 and 1–4 years.18 Analytical methods Estimation of child mortality from previous studies With relatively few studies on child mor- tality over the past three decades, trends in infant mortality were assessed first as estimates of these were more readily available. The results of all studies carried out between 1973 and 2001, and of MOH&ME death registrations between 1992 and 2004, were collected and locat- ed in time between 1958 and 2004 (Fig. 2). Given the methodological limitations of some estimation techniques and small sample sizes, some estimates were judged to be implausible and needed to be censored. Standard statistical methods were used to censor implausible data points and infant mortality for 2004 was predicted from the fitted trend line (Fig. 2).29 Child mortality by sex was then estimated from overall infant mortality based on observed age-sex patterns from the Iranian DHS. Assessment of 2004 death registration data Brass’s growth balance method was used to adjust for undercounting in mortality data for those aged over 5. This assumes that a population is stable and closed to migration, and that the partial birth rate has a linear relationship with the partial death rate (deaths above age x in population aged x and over) for ages over 5. Standard procedures were applied to estimate the slope of the fitted line describing the relationship between the birth and death rates.30,31 We applied this technique to all data sources for the pe- riod 2001–2004, and used the average completeness estimate (65.0% for fe- males and 89.8% for males) to adjust the DH registration data to estimate adult mortality in 2004. Estimated complete- ness for each data source is summarized in Table 2. 609Bulletin of the World Health Organization | August 2007, 85 (8) Research Mortality in the Islamic Republic of Iran, 1964–2004Ardeshir Khosravi et al. Fig. 2. Estimates of infant mortality per 1000 live births according to different sources, Islamic Republic of Iran, 1958–2004 Socioeconomic Survey 1994 4 Intercensal Population Survey 1991 4 Population Growth Survey 1973 4 Socioeconomic Survey 1992 4 Census 1986 4 Measuring Population Change 1990 4 Intercensal Population Survey 1993 4 Iranian Vital Horoscope 1992—2004 17 Fertility and Mortality Survey 1996 4 Socioeconomic Survey 2001 4 Fertility Survey 1977 4 Socioeconomic Survey 1987 4 Population Growth Survey 1998—99 4 Birth Survey 1991 4 Intercensal Population Survey 1994 4 Socioeconomic Survey 1993 4 Intercensal Population Survey 1992 4 Iranian MOH&ME Surveys 5 16 18 Iranian MOH&ME - Deputy of Health 2001—2004 17 Socioeconomic Survey 1995 4 200 In fa nt m or ta lit y 1950 0 Year 1960 1970 1980 1990 2000 2010 180 160 140 120 100 80 60 40 20 Circled data were censored by Cook’s distance method. Comparison of adjusted and regis- tered child mortality from death registra- tion systems suggests that the complete- ness of data for both sexes was about 59% for the DRT (2001), 50% for NOCR (2002–2003) and 61% for DH (2001–2004) (Table 2). Completeness of death registration data for females in all systems and all age groups was lower. Completeness of death registration for age groups above 5 years was estimated at 74% for DRT, 74% for NOCR (2002–2003) and 79% for DH (average completeness 2001–2004). Since each system had similar estimated complete- ness, we used the average assessment of underreporting to correct reported mortality rates. Estimation of adult mortality We began the assessment of the risk of adult mortality between ages 15 and 60 (45 Q 15), the key summary indicator, by assessing the trends. We did this by exam- ining results of all studies between 1973 and 2000 and of deaths registered be- tween 1992 and 2004 (Table 1, available at: http://www.who.int/bulletin, Fig. 3, Fig. 4). Estimates that were clear outliers were censored based on plausibility or known methodological problems with estimation techniques or data sources. A logistic curve was fitted to the remain- ing points and trends were estimated. Current (2004) levels were estimated based on the predicted value of the fitted line for 2004 (Fig 3, Fig. 4). Constructing 2004 life tables Life tables based on adjusted data from death registration systems were con- structed for both sexes according to data from 2004 DH death registration in 29 provinces. Child mortality was estimated based on the methods described earlier, and all death rates at ages 5 and over were adjusted based on the correction factor from Brass’s growth balance method. An alternative approach predicts the level of adult mortality corresponding to observed (estimated) child mortality. Our prediction model is based on a modification of Brass’s relational model life table. Brass proposed that the logit of the survival values at each age x ( lx) in a given life table has a linear relationship with the logit of the survival values in a standard life table.32 As departures from the standard lead to a systematic bias in predictive ability, particularly among children and older adults, a modified model based on two additional correc- tion factors for child and adult mortality, has been proposed.33 This enables us to predict the level of adult mortality based on the estimate of child mortality, and compare this with the observed values in the life tables based on adjusted data (as before). Using the estimated level of child mortality for 2004, the modified logit life table system was also used to estimate a life table for the Islamic Re- public of Iran for 2004.33,34 Results Child mortality estimates from previous studies Infant mortality has decreased sharply over the past three decades: from around 154 per 1000 live births in 1964 to about 26 per 1000 (95% confidence in- terval, CI: 19-36) in 2004. This implies child mortality levels of 30 and 34 per 1000 live births for females and males respectively. Adult mortality After censoring the outlying data, vari- ous mortality data sources suggest that adult mortality has been decreasing over the past four decades, particularly for females. The predicted adult mortality risk for females in 1960 was around 0.382 (95% CI: 0.277-0.52), drop- ping to 0.108 (95% CI: 0.08-0.146) by 2004. The male index was 0.370 (95% CI: 0.274-0.499) in 1960, declining to 0.160 (95% CI: 0.122-0.211) in 2004. In the adjusted life tables for 2004, based on DH data, adult mortality risk was 0.124 for females and 0.175 for males (Table 3). Based on the modified logit life table system (using estimated child 610 Bulletin of the World Health Organization | August 2007, 85 (8) Research Mortality in the Islamic Republic of Iran, 1964–2004 Ardeshir Khosravi et al. Fig. 3. Estimates of female adult mortality according to different sources and surveys, Islamic Republic of Iran, 1960–2004 0.50 A du lt m or ta lit y 1950 0 Year Survey 1985, retrospective method in rural areas 22 Census 1986, retrospective method (estimated by authors) 20 Life tables based on two successive censuses (1956—1966) 24 Life tables based on 1976 census data (stable population and logit life tables) 27 Survey 1973; retrospective method and final tables were based on corrected mortality rates ( logit life table) 16 Multi round survey 1973—76 by Statistical Centre of Iran 27 Life tables based on relationship between population aged 65+ and crude death rate based on the 1996 census (Mazur and Palmor method) 6 Multi-round survey (1998—99) (estimated by authors) 26 Life tables based on child mortality data in 1986 census 4 Survey based on census 1996, retrospective method (estimated by authors) 19 Intercensal survey 1991, retrospective method (estimated by authors) 25 Life tables based on Vital Horoscope 1996 (main villages) 21 Adjusted data from MOH&ME - Deputy of Research and Technology Death Registration Sytem 2001 (estimated by authors) 17 DHS 2000, retrospective method (estimated by authors) 18 Adjusted data from NOCR Death Registration 2002—2003 (estimated by authors) 23 The Iranian Vital Horoscope, rural areas, unadjusted data, 1992—2004 (estimated by authors) 17 Adjusted data from MOH&ME - Deputy of Health Death Registration Sytem 2001—2004 (estimated by authors) 17 1960 1970 1980 1990 2000 2010 0.45 0.40 0.35 0.30 0.25 0.20 0.15 0.10 0.05 Table 2. Estimated completeness (%) of Iranian data on child and adult deaths according to different death registration systems, 2001–2004 Child deaths Deaths above 5 years Females Males Both Females Males Both DRTa (2001) 50 48 49 63 84 74 NOCRb (2002/03) 53 47 50 62 85 74 DHc (2001/04) 59 63 61 67 90 79 a Ministry of Health and Medical Education Deputy of Research and Technology. b National Organization for Civil Registration. c Ministry of Health and Medical Education Deputy of Health. mortality for 2004), the predicted value of adult mortality was 0.128 (mean) for females, and 0.224 (mean) for males. The predicted levels of adult female mortality in the trend analysis and from the registered mortality data, corrected for undercounting, agree quite closely with predictions from applying model life tables based on observed values for child mortality. For males, the estimated level (0.160–0.175) is significantly lower than what is expected from model life tables (0.224) given the observed level of male child mortality (Table 3). Estimation of life expectancy in 2004 We chose the adjusted (higher) levels of adult mortality as the best estimate, given our preference for using local evi- dence over models. This suggests that life expectancy at birth in 2004 was 71.2 years for females and 68.7 years for males (Tables 3 & 4, available at: http://www. who.int/bulletin). By comparison, the values based on the modified logit life table system suggested a larger sex dif- ferential, with implied life expectancies of 72.5 years for females and 66.8 for males (Table 3). Discussion Lack of documentation about methods and data sources is of major concern when studying mortality. This study presents the first comprehensive analy- sis of mortality levels and trends in the Islamic Republic of Iran, using different methods and sources of published and unpublished information and registration data. Previous attempts by organizations such as the UN and WHO have used substantially poorer and less complete data sets and have not been explicit about methods. Review of infant mortality trends based on various sources (surveys, cen- suses, registration systems) indicates that over the past three decades this indicator has declined dramatically. A key factor in this decline may have been the expan- sion of the Iranian health network and access to primary health care, particu- larly in rural areas.35 Studies to estimate infant and child mortality using indirect demographic methods, such as the CEBCS tech- nique, generally yield more plausible estimates than other methods. Although these methods are valuable in situations where death registration is incomplete, 611Bulletin of the World Health Organization | August 2007, 85 (8) Research Mortality in the Islamic Republic of Iran, 1964–2004Ardeshir Khosravi et al. Fig. 4. Estimates of male adult mortality according to different sources and surveys, Islamic Republic of Iran, 1960–2004 0.50 A du lt m or ta lit y 1950 0 Year 1960 1970 1980 1990 2000 2010 0.45 0.40 0.35 0.30 0.25 0.20 0.15 0.10 0.05 Survey 1985, retrospective method in rural areas 22 Census 1986, retrospective method (estimated by authors) 20 Life tables based on two successive censuses (1956—1966) 24 Life tables based on 1976 census data (stable population and logit life tables) 27 Survey 1973; retrospective method and final tables were based on corrected mortality rates ( logit life table) 16 Multi round survey 1973—76 by Statistical Centre of Iran 27 Life tables based on relationship between population aged 65+ and crude death rate based on the 1996 census (Mazur and Palmor method) 6 Multi-round survey (1998—99) (estimated by authors) 26 Life tables based on child mortality data in 1986 census 4 Survey based on census 1996, retrospective method (estimated by authors) 19 Intercensal survey 1991, retrospective method (estimated by authors) 25 Life tables based on Vital Horoscope 1996 (main villages) 21 Adjusted data from MOH&ME - Deputy of Research and Technology Death Registration Sytem 2001 (estimated by authors) 17 DHS 2000, retrospective method (estimated by authors) 18 Adjusted data from NOCR Death Registration 2002—2003 (estimated by authors) 23 The Iranian Vital Horoscope, rural areas, unadjusted data, 1992—2004 (estimated by authors) 17 Adjusted data from MOH&ME - Deputy of Health Death Registration Sytem 2001—2004 (estimated by authors) 17 the results depend on the quality of the reported information. In addition, this method assumes stable fertility and child mortality during recent decades. The fertility rate in the Islamic Republic of Iran has increased dramatically over the past three decades,31,36 so caution is nec- essary when interpreting these estimates of child mortality. The few studies carried out to esti- mate adult mortality used the retrospec- tive method and have serious problems with underrecorded deaths. Therefore, this study used demographic methods to estimate mortality levels and construct life tables. While Iranian death registra- tion systems undercount deaths (par- ticularly of females), our study suggests that these data sources may be useable in combination with other sources, such as survey or census data, to estimate adult mortality levels. Our estimates of child mortality are somewhat lower than those of the UN and WHO (36–42 per 1000 live births). Our estimates of adult mortality risk in 2004 (0.124 and 0.175 for females and males respectively) are very nearly identi- cal to WHO’s figure (0.125) for females but somewhat lower than that for males (0.201).37 Recent data showing a decline in child mortality may have been un- available to WHO; this could explain the difference in these estimates. More comprehensive and recent data from the MOH&ME undoubtedly have helped in reducing uncertainly regarding adult mortality levels. Despite the NOCR’s long history of death registration, underreporting of death is common, particularly for females.6 Delayed registration by indi- viduals is this system’s chief limitation: often there is a year or more between the date of death and its registration. The main aim of the DH registration system is to collate cause of death data from different sources. This system shows improving completeness and coverage, and the results of this study suggest sufficient completeness of data for use in mortality analysis, with appropriate corrections. Although we have attempted a comprehensive evaluation of trends and levels of mortality, our study has several limitations. First, up-to-date population data by age and sex were not available for this study. The UN estimate of the Iranian population (2000–2005) was used although its method is not clear.28 Second, since there were few sources of data on child mortality levels, we estimated these indirectly using infant mortality data and patterns observed in the Iranian DHS of 2000. Third, as the DH death registration system is not yet operational in Tehran province (popula- tion 12 million) we have assumed that its pattern of mortality is the average of all other provinces. Fourth, it is uncer- tain whether the Brass growth balance method is appropriate for estimating underregistration of deaths, given its assumption that populations should be stable and closed to migration. While there is little international migration to and from the Islamic Republic of Iran, the assumption of a stable population is unlikely to hold. In conclusion, the Islamic Republic of Iran might be considered to be at the end of the second stage of health and de- mographic transition. Decreasing child and infant mortality indicate declines in infectious and nutritional diseases. It is probable that the leading causes of death will shift to chronic diseases in adults. Female mortality is now lower than that 612 Bulletin of the World Health Organization | August 2007, 85 (8) Research Mortality in the Islamic Republic of Iran, 1964–2004 Ardeshir Khosravi et al. Table 3. Estimated Iranian adult mortality and life expectancy at birth by sex according to adjusted data (life tables 2004) and modified logit life table system (predicted, based on child mortality), 2004 Adult mortality Life expectancy at birth Females Males Females Males Estimated life tables 2004 0.124 0.182 71.2 68.7 Predicted life table based on estimated child mortality in 2004 +3 standard deviationsa 0.141 0.252 71.8 65.6 meana 0.128 0.224 72.5 66.8 -3 standard deviationsa 0.116 0.200 73.1 67.8 a Of adult mortality risk. Résumé Mortalité en République Islamique d’Iran, 1964 – 2004 Objectif Des informations fiables sur les caractéristiques, le niveau et les tendances de la mortalité sont essentielles à une politique d’amélioration de la santé reposant sur des bases factuelles. On n’a pas évalué d’une manière critique les diverses sources de données sur la mortalité en République Islamique d’Iran. Nous souhaitons dans cet article documenter et évaluer l’exhaustivité des différentes sources de données sur la mortalité et estimer le niveau et les tendances de cette dernière au cours des 40 dernières années, grâce à plusieurs indices tels que la mortalité de l’enfant, la mortalité de l’adulte et l’espérance de vie. Méthodes Nous avons procédé à une revue systématique des études disponibles sur la mortalité infantile de 1964 à 2004 et estimé la tendance la plus probable de la mortalité de l’enfant. Nous avons évalué le degré d’exhaustivité des données provenant de l’enregistrement des décès entre 1992 et 2004 pour estimer le niveau de la mortalité adulte. Nous avons établi les tables de survie pour la République islamique d’Iran pour 2004 sur la base de ces données, en les corrigeant pour tenir compte du sous-enregistrement des décès. Résultats La mortalité infantile a diminué, passant de 154 décès pour 1000 naissances vivantes en 1964 à 26 en 2004 selon les estimations. Le risque de mortalité adulte en 2004 a été estimé à 0,124 pour les femmes et 0,175 pour les hommes. Selon les données ajustées provenant de l’enregistrement des décès, l’espérance de vie à la naissance en 2004 était de 71,2 ans pour les femmes et de 68,7 ans pour les hommes. Le degré d’exhaustivité de l’enregistrement des décès pour les personnes âgées de 5 ans et plus a été de 76% pour la période 2001 - 2004 pour l’ensemble des systèmes d’enregistrement. Conclusion Il y a eu au cours des trois dernières décennies une baisse générale de la mortalité de l’enfant en République islamique d’Iran. La mortalité adulte a elle aussi diminué, mais moins fortement. Les systèmes d’information sur la mortalité se sont améliorés, mais il subsiste de sérieux problèmes quant à l’exhaustivité et à la qualité des données. Resumen La mortalidad en la República Islámica del Irán durante el periodo 1964-2004 Objetivo La disponibilidad de información fidedigna sobre las pautas, niveles y tendencias de la mortalidad es fundamental para poder formular políticas de mejora de la salud basadas en la evidencia. Algunas de las fuentes de datos sobre la mortalidad en la República Islámica del Irán no han sido objeto de una evaluación crítica. Este artículo tiene por objeto documentar y evaluar la completud de las diferentes fuentes de datos sobre la mortalidad y estimar el nivel y las tendencias de la mortalidad durante los últimos 40 años a partir de diversos índices, como la mortalidad en la niñez, la mortalidad de adultos y la esperanza de vida. Métodos Emprendimos una revisión sistemática de todos los estudios disponibles sobre la mortalidad infantil entre 1964 y 2004 y estimamos la tendencia más probable de la mortalidad en la niñez. Los datos de los registros de defunción correspondientes al periodo 1992-2004 fueron evaluados para determinar su completud a fin de estimar la mortalidad de adultos. A partir de of males at all ages, confirming the pat- tern observed in countries undergoing epidemiological transition. However, increases in male mortality from traffic accidents are a particular public health concern. Undoubtedly, high-quality and complete national vital registration is the best data source to measure mortality. The Islamic Republic of Iran has made considerable progress towards this, but a focus on better registration of adult mor- tality, particularly of females, is an urgent priority for public health policy. Direct measurement of undercounting in the vital registration system would increase confidence in the data. A specific inves- tigation to measure the completeness of data from death registration systems by conducting surveys (e.g. capture-recap- ture method) and subsequent improve- ments in infrastructure, capacity-build- ing and resources for death registration are priorities. O Acknowledgements An Iranian government scholarship sup- ported Mr Khosravi’s studies in Australia. We are grateful to MOH&ME, SCI and NOCR for providing an anonymous copy of the national mortality data. Competing interests: None declared. 613Bulletin of the World Health Organization | August 2007, 85 (8) Research Mortality in the Islamic Republic of Iran, 1964–2004Ardeshir Khosravi et al. esos datos se confeccionaron las tablas de vida de 2004 para la República Islámica del Irán, corrigiendo los valores en función del subregistro de las defunciones. Resultados La mortalidad infantil disminuyó de las 154 defunciones por 1000 nacidos vivos estimadas en 1964 a 26 en 2004. El riesgo de mortalidad de adultos en 2004 fue de 0,124 para las mujeres y 0,175 para los hombres. Según los datos ajustados de los registros de defunción, la esperanza de vida al nacer en 2004 fue de 71,2 años para las mujeres y 68,7 para los hombres. El grado medio de completud de los registros de defunción para las personas de 5 y más años en todos los sistemas fue del 76% durante el periodo 2001-2004. Conclusión Durante los tres últimos decenios se ha registrado una disminución general de la mortalidad en la niñez en la República Islámica del Irán. La mortalidad de adultos también ha descendido, pero de forma menos marcada. Los sistemas de información sobre la mortalidad han mejorado, pero el tema de la completud y calidad de los datos sigue suscitando gran preocupación. صخلم 2004 - 1964 ةترفلا في ةيملاسلإا ناريإ ةيروهمج في تايفولا لدعم لدعم هاجتاو ىوتسمو طنم لوح اهيلع لوعُي يتلا تامولعلما برتعت :ضرغلا ينسحت لىإ ةيمارلاو تانايبلاب ةدنسلما تاسايسلا في ًايساسأ ًاصرنع تايفولا تايطعملل ةفلتخلما رداصلما نم ددع مييقت قبسي لمو .يحصلا عضولا فدهتستو .ًايدقن ًماييقت ةيملاسلإا ناريإ ةيروهمج في تايفولا لدعبم ةقلعتلما ةقلعتلما تايطعلما رداصم فلتخم لماتكا ىدم مييقتو قيثوت ةقرولا هذه ينعبرلأا للاخ تايفولا لدعم تاهاجتاو ىوتسم ريدقتو ،تايفولا لدعبم تايفو لدعم لثم ،تايفولا تاشرؤم نم ةفلتخم ةعومجلم ًاقفو ةيضالما ةنس .ةايحلا لومأمو ،ينغلابلا تايفو لدعمو ،لافطلأا ةحاتلما تاساردلا عيمجل ةيجهنم ةعجاربم ةساردلا هذه في انمق :ةقيرطلا ثركلأا هاجتلاا ريدقتب انمقو ،2004 ماع لىإ 1964 ماع نم ع َّضرلا تايفو لوح ليجست تايطعم لماتكا ىدم مييقت متو .لافطلأا تايفو لدعلم ًلاماتحا .ينغلابلا تايفو ىوتسم ريدقت لجأ نم ،2004 ماع لىإ 1992 ماع نم تايفولا ًءانب ةيملاسلإا ناريإ ةيروهمجل 2004 ماعل ةايحلا تايرجم لوادج دادعإ متو .ليجستلا في صقنلا كرادتل اهحيحصت عم تايطعلما هذه لىع 1000 لكل ةافو 154 نم عضرلا تايفو لدعم ضافخنا ظحول :تادوجولما ضرعتل ةر َّدقلما رطاخلما امأ .2004 ماع في 26 لىإ 1964 ماع في يح دولوم ًاقفوو .روكذلل 0.175 و ثانلإل 0.124 تغلبف 2004 ماع في ةافولل ينغلابلا ثانلإل 71.2 ةدلاولا دنع ةايحلا لومأم غلب ،ةححصلما تايفولا ليجست تايطعلم في مه نلم تايفولا ليجست لماتكا طسوتم غلبو .2004 ماع في روكذلل 68.7 و .2004 – 2001 ةترفلل 76% ،ليجستلا مظن عيمج في ،ثركأف ماوعأ 5 نس ناريإ ةيروهمج في لافطلأا تايفو لدعم في ماع ضافخنا ثدح :جاتنتسلاا تايفو تايوتسم تضفخنا ماك .ةيرخلأا ةثلاثلا دوقعلا للاخ ةيملاسلإا ،تايفولا لدعبم ةصاخلا تامولعلما مظن تنسحتو .لقأ ةبسنب نكلو ،ينغلابلا .تايطعلما ةدوج لماتكا نأشب ديدش قلق كانه لازيلا نكلو References 1. 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Studies on Iranian mortality, 1973–2001 Year Researcher/survey Organization Indexes Study method 1973–1976 Baseline population growth survey Statistical Centre of Iran a, b c, d, e 1973 Iran’s vital indexes survey Tehran University a, b f, d, e 1977 Fertility survey Statistical Centre of Iran a, b c, d, e 1978 Farhani, EM, (abridged life table of Iran, 1956-1966) – b g 1982 Iran’s life tables based on 1976 census Statistical Centre of Iran b g 1984 Mortality and fertility survey MOH&ME a, b f, e 1986 Census Statistical Centre of Iran a, b f, d, e 1987 Socioeconomic characteristics of Iranian households Statistical Centre of Iran a, b c, d, e 1990 Measuring population change Statistical Centre of Iran a c, d 1991 Birth survey NOCR a f, d 1991–1994 Intercensal population survey Statistical Centre of Iran a, b c, d, e 1994 Mortality and fertility survey MOH&ME a h 1992–1995 Socioeconomic characteristic of Iranian households Statistical Centre of Iran a, b c, d, e 1996 Mortality and fertility survey MOH&ME a, b f, d, e 1998–1999 Measuring population growth survey Statistical Centre of Iran a, b c, d, e 2000 Zanjani and Nourollahi – b g 2000 Iranian DHS MOH&ME and Statistical Centre of Iran a,b f, h, d, e 2001–2003 Socioeconomic characteristics of Iranian households Statistical Centre of Iran a, b c, d a Infant mortality. b Adult mortality. c Multiple-round surveys (retrospective method, questioned member of household on number of deaths at different stages of the study). d Children ever born/children surviving. e Retrospective study for adult mortality (deaths in household during last 12 months). f Single-round survey (retrospective method, questioned on number of deaths in household in past 12 months). g Life tables based on census data. h Direct information.  Bulletin of the World Health Organization | August 2007, 85 (8) Research Mortality in Iran, 1964–2004 Ardeshir Khosravi et al. Table 4(a). Estimated life table (males) for the Islamic Republic of Iran, 2004 Age group Years in interval Mid-year population Adjusted deaths Mortality rate Probability of dying Probability of surviving Individuals surviving Deaths in interval x, x+n Years lived in interval x, x+n Cumulative years lived Life expectancy at age x n nNx nDx nMx nqx npx l x ndx nL x Tx ex 0 1 * * * 0.028 0.972 100 000 2 843 98 010 6 872 228 68.72 1–4 4 * * * 0.006 0.994 97 157 622 387 134 6 774 218 69.72 5–9 5 2 539 219 1 455 0.0006 0.003 0.997 96 535 276 481 984 6 387 084 66.16 10–14 5 3 472 990 2 098 0.0006 0.003 0.997 96 259 290 480 568 5 905 100 61.35 15–19 5 3 693 569 5 731 0.0016 0.008 0.992 95 968 742 477 988 5 424 531 56.52 20–24 5 3 468 229 8 016 0.0023 0.011 0.989 95 227 1 094 473 399 4 946 543 51.94 25–29 5 2 568 691 6 224 0.0024 0.012 0.988 94 133 1 134 467 829 4 473 144 47.52 30–34 5 1 919 087 5 136 0.0027 0.013 0.987 92 999 1 236 461 905 4 005 315 43.07 35–39 5 1 689 984 4 836 0.0029 0.014 0.986 91 763 1 304 455 555 3 543 410 38.61 40–44 5 1 521 943 5 577 0.0037 0.018 0.982 90 459 1 642 448 190 3 087 855 34.14 45–49 5 1 294 589 6 499 0.0050 0.025 0.975 88 817 2 202 438 580 2 639 666 29.72 50–54 5 973 129 7 322 0.0075 0.037 0.963 86 615 3 198 425 080 2 201 086 25.41 55–59 5 647 310 6 822 0.0105 0.051 0.949 83 417 4 283 406 377 1 776 007 21.29 60–64 5 497 030 8 781 0.0177 0.085 0.915 79 134 6 695 378 934 1 369 630 17.31 65–69 5 447 735 13 043 0.0291 0.136 0.864 72 439 9 835 337 610 990 696 13.68 70–74 5 391 693 18 491 0.0472 0.211 0.789 62 605 13 217 279 980 653 086 10.43 75–79 5 268 477 21 249 0.0791 0.330 0.670 49 388 16 316 206 149 373 105 7.55 80–84 5 119 946 18 127 0.1511 0.548 0.452 33 072 18 138 120 015 166 957 5.05 85+ 5 35 661 11 346 0.3181 1 0.000 14 934 14 934 46 942 46 942 3.14 * Deaths and population not required since o Q 5 estimated from censuses and surveys (see fig. 2). CBulletin of the World Health Organization | August 2007, 85 (8) Research Mortality in Iran, 1964–2004Ardeshir Khosravi et al. Table 4(b). Estimated life table (females) for the Islamic Republic of Iran, 2004 Age group Years in interval Mid-year population Adjusted deaths Mortality rate Probability of dying Probability of surviving Individuals surviving Deaths in interval x, x+n Years lived in interval x, x+n Cumulative years lived Life expectancy at age x n nNx nDx nMx nqx npx l x ndx nL x Tx ex 0 1 * * * 0.023 0.977 100 000 2 334 98 367 7 118 931 71.19 1–4 4 * * 0.007 0.993 97 666 639 389 132 7 020 564 71.88 5–9 5 2 383 989 1 428 0.0006 0.003 0.997 97 027 290 484 411 6 631 432 68.35 10–14 5 3 258 197 1 607 0.0005 0.002 0.998 96 737 238 483 090 6 147 022 63.54 15–19 5 3 475 099 3 082 0.0009 0.004 0.996 96 499 427 481 427 5 663 932 58.69 20–24 5 3 282 897 3 266 0.0010 0.005 0.995 96 072 477 479 168 5 182 505 53.94 25–29 5 2 439 540 2 608 0.0011 0.005 0.995 95 595 510 476 702 4 703 337 49.20 30–34 5 1 864 658 2 406 0.0013 0.006 0.994 95 086 611 473 900 4 226 635 44.45 35–39 5 1 641 123 2 448 0.0015 0.007 0.993 94 474 702 470 617 3 752 735 39.72 40–44 5 1 434 407 2 961 0.0021 0.010 0.990 93 772 963 466 455 3 282 118 35.00 45–49 5 1 236 910 3 931 0.0032 0.016 0.984 92 810 1 463 460 390 2 815 663 30.34 50–54 5 1 038 742 5 279 0.0051 0.025 0.975 91 347 2 292 451 003 2 355 273 25.78 55–59 5 768 680 6 114 0.0080 0.039 0.961 89 054 3 472 436 591 1 904 271 21.38 60–64 5 531 669 8 044 0.0151 0.073 0.927 85 582 6 238 412 315 1 467 679 17.15 65–69 5 448 069 12 201 0.0272 0.127 0.873 79 344 10 114 371 434 1 055 364 13.30 70–74 5 370 373 18 426 0.0497 0.221 0.779 69 230 15 316 307 860 683 930 9.88 75–79 5 244 716 21 667 0.0885 0.362 0.638 53 914 19 542 220 715 376 070 6.98 80–84 5 114 808 20 060 0.1747 0.608 0.392 34 372 20 900 119 611 155 355 4.52 85+ 5 39 497 14 887 0.3769 1 0.000 13 472 13 472 35 744 35 744 2.65 * Deaths and population not required since o Q 5 estimated from censuses and surveys (see fig. 2).