Population Research and Policy Review 17: 261–274, 1998.
1998 Kluwer Academic Publishers. Printed in the Netherlands.
Socio-demographic correlates of multiple causes of death:
Real or artifactual?
NAN E. JOHNSON
& BRUCE A. CHRISTENSON
Department of Sociology, Michigan State University East Lansing, Michigan, USA
American Institutes for Research, Palo Alto, California, USA
Abstract. The socio-demographic and epidemiological correlates of the total number of causes
of death (TC) reported on death certiﬁcates were examined with multiple classiﬁcation analysis
(MCA). The data were all death certiﬁcates on white and black adult residents of Michigan
who died at ages 25 or older in 1989 to 1991 (n = 222,763). TC was the sum of every
morbid condition named as an underlying, intermediate, or immediate cause of death, or other
medical condition contributing to death but not to its underlying cause. Autopsies performed
for non-forensic reasons by physicians who are not Medical Examiners (MEs) likely yield
the most accurate diagnoses of the underlying medical cause and counts of all other attendant
causes, but they are extremely selective of decedents who are most closely integrated into
the health care system. Thus we required a socio-demographic pattern in TCs to appear in a
multivariate analysis not only for this special group of autopsied decedents but also for the
non-autopsied masses before accepting the pattern as ‘real’ (not an artifact of underreporting
of TC or confoundment with another socio-demographic variable).
The MCAs showed that age at death and its underlying medical cause were the most impor-
tant factors related to TC, as suggested by epidemiologic transition theory. Compared with
other underlying causes, diabetes, hypertension, and septicemia yielded the highest average
TCs. While sex differences were generally not signiﬁcant within racial groups, somewhat
higher average TCs were found for blacks than whites and for lesser educated than for more
educated decedents. These patterns in TC by race and education may reﬂect lifetime disad-
vantages faced by blacks and the less educated to health care or information about health
Key words: Autopsy, Education, Multiple causes of death, Race, Underlying causes of death
Introduction and objectives
The proportion of death certiﬁcates listing multiple causes of death rose
steadily in the USA from about one-third in the ﬁrst quarter of the twentieth
century to over one-half in the 1950s and to over three-fourths by the 1980s
(Guralnick 1966; Israel et al. 1986: Nam et al. 1994).
Multiple causes of
death (fatal comorbidity) can be viewed as an outcome of the epidemiologic
transition from acute and contagious to chronic and degenerative diseases
as the main sources of morbidity and mortality in industrialized countries
(Omran 1971). The epidemiologic transition has been associated with a shift