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. Author manuscript; available in PMC: 2023 Mar 1.
Published in final edited form as: Ann Phys Rehabil Med. 2021 Nov 16;65(2):101553. doi: 10.1016/j.rehab.2021.101553

Cause of death trends among adults with and without cerebral palsy in the U.S., 2013-2017

J Dalton Stevens 1, Margaret A Turk 2, Scott D Landes 1
PMCID: PMC9018464  NIHMSID: NIHMS1740207  PMID: 34273570

Abstract

Objectives:

To analyze differences in cause of death for adults who did/did not have cerebral palsy (CP) reported on their death certificates, and to assess sex and racial-ethnic difference in cause of death among adult decedents with CP.

Method:

Data are from the 2013-2017 U.S. Multiple Cause-of-Death Mortality files (N=13,332,871; 13,897 with CP). Adjusted odds ratios from multiple logistic regression models were used to compare differences in causes of death between adults with and without CP, and to determine sex and racial-ethnic differences in causes of death among adults with CP.

Results:

Compared to adults without CP, decedents with CP were more likely to die from pneumonitis (AOR: 31.14, 95% CI: 29.42-32.96), influenza/pneumonia (8.78, 8.30-9.29), respiratory failure (17.24, 15.19-18.69), and choking (20.66, 18.86-22.62); and less likely to die from heart disease (0.61, 0.58-0.65), cancer (0.12, 0.11-0.13), chronic lower respiratory diseases (0.50, 0.44-0.56), and cerebrovascular diseases (0.66, 0.59-0.75). Among adults with CP, female decedents were more likely than males to die from respiratory failure (1.21, 1.03-1.42), and Non-Hispanic Black decedents were more likely than Non-Hispanic White decedents to die from heart disease (1.24, 1.07-1.45) and cerebrovascular disease (1.77, 1.29, 2.49).

Conclusions:

In 2013-2017, heart disease was the leading cause of death for adults with and without CP. However, those with CP had higher rates of individual respiratory causes of death than those without CP, some of which may be preventable. Non-Hispanic Black adults were more likely than Non-Hispanic White adults to die from diseases of the heart and cerebrovascular disease. Public health efforts and clinical practice should employ a multifaceted approach to address increased risk of respiratory and high rates of circulatory diseases in the population with CP. A battery of culturally competent screenings for circulatory, respiratory, and swallowing issues should be implemented, along with emphasis on strategies aimed at improving lung and heart function.

Cerebral palsy (CP) is the most prevalent cause of motor impairment among children, and the majority of individuals with CP now live into adulthood [1]. CP is an umbrella label for an array of lifelong disorders resulting from various injuries or conditions of the fetal or developing brain that affect movement and posture and often limit activity [1,2]. U.S. population estimates of CP suggest the condition occurs in 3 per 1,000 children [3], determined through the Autism and Developmental Disabilities Monitoring Network (monitoring Alabama, Georgia, Missouri, Wisconsin) in 2010, the only CP surveillance system in the U.S. While most of these children survive to adulthood, the U.S. does not have reliable estimates of the size of the adult population with CP [3-5]. Currently, adults with CP in the U.S. have an average age at death that is between 37 and 51 years old, varying by sex and comorbid developmental disability [6], and that has increased 3.5 years on average since 2005 [7]. Despite increasing longevity, adults with CP in the U.S. die an average of 24 years earlier than adults without CP, a health inequality potentially shaped by causes of death [6-8].

Mortality research for people with CP suggests that cause of death patterns differ from those of the general population [9-12]. In 2016, underlying cause of death (UCOD) statistics generated from death certificates indicate that the leading causes of death among the U.S. population were heart disease, cancer , and accidents [13]. However, a recent study of adults with CP suggests respiratory UCODs are the leading causes, accounting for 29% of deaths in the U.S. between 2012-2016 [9]. A prior study suggests circulatory causes, specifically heart disease, were the leading causes of death among adults receiving state services with CP between 1986-1995 in California [14]. Similar rates of respiratory and circulatory diseases have been documented among non-U.S. populations with CP [10,11,15-17]. Unlike cause of death literature for the general population [13], mortality research for adults with CP has not adequately assessed differences in causes of death across age, sex, and race-ethnicity. Aside from a single study reporting death patterning among those with CP by sex for breast cancer [14], no published studies were identified that explore sex or racial-ethnic differences in cause of death patterns among those with CP.

Death certificate data is essential in understanding mortality trends; however, many cause of death certifiers inaccurately report CP as the UCOD on death certificates [9-11,14,15,18]. A recent study reports that 59.5% of U.S. death certificates of people with CP in 2012-2016 report CP as the UCOD, the statistic most often used to report cause of death patterning [9]. A growing and diverse group of experts contend that CP is an inaccurate UCOD, asserting that identifying CP as the UCOD is inaccurate reporting; this obscuring effect limits public health utility [9,10,14,15,19-21]. Because CP refers to many conditions that affect movement and posture, stemming from different etiologies [1], the causal role CP plays in death is suspect [10,20]. Consequently, experts have started revising UCODs on death certificates that provide invalid causes of death for this population [9,10,21-23].

This study provides analysis of recent cause of death patterns among adults with CP in the U.S. The prevailing literature has relied on limited samples, has limited focus on demographic differences in cause of death patterning, and does not account for wide-spread inaccuracies in cause of death reporting for people with CP. We addressed these gaps by using 2013-2017 data from the U.S. Multiple Cause of Death Mortality files from the National Vital Statistics System (NVSS), stratifying analyses by age, providing analysis to determine sex and racial-ethnic heterogeneity in cause of death patterning among those with CP, and employing a sequential UCOD revision process. We hypothesized that comparative risk of respiratory causes of death would be higher for adults with CP than those without CP, likely remaining high across the life course. Additionally, we expected similar rates of circulatory causes of death between study groups, rising with age. Given the limited extant research on sex and racial-ethnic differences in cause of death patterns among adults with CP, we hypothesized that patterns may mirror that of the general population [13,24].

Method

We used data from the U.S. 2013-2017 Multiple Cause of Death Mortality files that report underlying and multiple causes of death for all individuals who died in the U.S. We compared the cause of death patterns of decedents who did (N=13,897) or did not (N=13,318,974) have CP reported on their death certificate. We then restricted analysis to only those decedents with CP identified on the death certificate (N=13,897) to determine sex and racial-ethnic differences in cause of death patterning. We limited analyses to adults ages 18-126 at the time of death. We identified CP when death certificates included International Classification of Disease, 10th Edition (ICD-10) code G80.0-G80.9 in the cause of death statement (Part I) or as a co-morbid condition present at the time of death that did not contribute to death (Part II). There were no measures for topographical distribution or functioning available for this study. We measured age in single years; dichotomously coded sex for female and male; and included the categories Non-Hispanic White, Non-Hispanic Black, Hispanic, and Non-Hispanic Other for race-ethnicity. Year at death was coded as a continuous measure.

To address the obscuring effect of cause of death certifiers reporting CP as the UCOD on the death certificate, we employed a sequential UCOD revision process [9]. Unlike studies that retain CP as the UCOD [11,12,15] or have not described how the obscuring effect was addressed [14,16], we revised the UCOD on 8,132 (58.5%) of the death certificates of decedents with CP based on multiple cause of death data included on the death certificate. Our revision method was similar to that of Duruflé-Tapin and colleagues [10], who revised 56% of the death certificates in their study. We used an algorithm to conduct the sequential UCOD revisions. The algorithm first identified death certificates of individuals with CP listed as the UCOD. It then systematically sorts through the ICD-10 codes reported in Part I of the death certificate and identifies the first valid UCOD among the sequentially ordered ICD-10 codes. The process was further elaborated in a prior study [9]. We conducted sensitivity analysis to determine the effect of revision on UCOD distribution and found consistency with findings reported previously [9].

We selected the 10 leading causes of death among adult decedents with CP in the 2013-2017 NVSS data. Our reporting scheme was similar to the Centers for Disease Control and Prevention (CDC), [13] which is based on public health impact and future planning [13]. This strategy allows comparison to trends reported in the U.S. general population. We added specific coding for respiratory failure and choking as they are more common causes of death among adults with developmental disabilities and are not included in the CDC coding scheme1 [13]. We selected the top 10 causes of death for analysis. We included a category forunknown/unspecified causes of death when no valid UCOD appeared on the death certificate. In these cases, CP and/or a an R-Code [19] were the only available codes and were uninformative. Table 1 provides all ICD-10 codes used in this study.

Table 1.

All study variables by cerebral palsy status, 2013-2017 U.S. Multiple Cause of Death Mortality Files (N=13,332,871).

Cerebral palsy
(N=13,897)		 No Cerebral palsy
(N=13,318,974)
Age - M(SD) 50.30 (0.17) 74.11 (0.00)
Female 45.87% 49.33%
Race-ethnicity
 Non-Hispanic White 74.32% 78.92%
 Non-Hispanic Black 14.18% 11.56%
 Hispanic 8.89% 6.45%
 Non-Hispanic Other 2.61% 3.07%
Year at death
 2013 18.49% 19.23%
 2014 18.44% 19.46%
 2015 19.95% 20.10%
 2016 20.82% 20.34%
 2017 22.29% 20.87%
Cause of death (Top 10 UCODs * )
 Heart disease (I00-I09, I11, I13, I20-I51)1 11.38% 23.61%
 Pneumonitis (J69.0, J69.1, J69.8)2 10.32% 0.73%
 Influenza and Pneumonia (J09-J18)3 10.04% 2.07%
 Respiratory failure (J96.0, J96.1, J96.9)4 4.68% 0.35%
 Malignant Neoplasms (C00-C97)5 4.53% 22.26%
 Choking - Aspiration, ingestion, or inhalation of gastric contents, food, or other objects (W78-W80)6 3.69% 0.19%
 Septicemia (A40.0-A41.9)7 2.76% 1.49%
 Genitourinary diseases - Nephritis, nephrotic syndrome, and nephrosis; urinary tract infection (N00-N07, N17-N19, N25-N27, N39)8 2.58% 2.29%
 Chronic lower respiratory diseases (J40.0-J47.0)9 2.28% 5.75%
 Cerebrovascular diseases (I60.0-I69.8)10 2.07% 5.19%
 Unknown/unspecified (No UCOD, R-codes) 16.64% 1.15%
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*:

We use the NVSS coding scheme for reporting specific cause of death which groups some ICD-10 together for more informative reporting. Cause of death by ICD-10 chapter is available upon request.

1-10:

Superscript number indicates ranking of specific cause of death for people with cerebral palsy.

We first provide summary statistics for all study variables by CP diagnosis. Subsequent analysis uses adjusted odds ratios (AORs) from multiple logistic regression models to compare the risk associated with the ten leading causes of death between decedents with and without CP. AORs compare the death ratio for a specific cause of death to all other causes of death between study populations. AORs standardize comparisons across two populations when accurate population estimates are unavailable [25-27], as is the case for adults with CP in the U.S. [1]. We express AORs in the language of comparative risk to facilitate interpretation. We also plot and compare the predicted probabilities of dying from the selected causes of death for adults with and without CP across age, using an age (centered at the mean) and age-squared term due to non-linearity of cause of death patterns. We provide additional multiple logistic regression analysis to compare the risk associated with each cause of death by sex and race-ethnicity among decedents with CP. We adjust each model for age at and year of death. We use STATA 16.0 (College Station, TX) for analyses.

Results

CP prevalence was 1.04 per 1,000 decedents in this study. Results in Table 1 demonstrate that the mean age at death for decedents with CP (50.30 years) was 23.81 years younger than those without CP (74.11 years). Compared to adults without CP, a lower percentage of decedents with CP were female, Non-Hispanic White, and Non-Hispanic Other. A greater percentage of decedents with CP were Non-Hispanic Black and Hispanic. Unadjusted differences in cause of death patterns between decedents with and without CP were stark.

As noted in Table 1, the most prevalent causes of death among decedents with CP in the 2013-2017 NVSS data were: (1) heart disease; (2) pneumonitis; (3) influenza/pneumonia; (4) respiratory failure; (5) malignant neoplasms (cancer herein); (6) choking – aspiration, ingestion, or inhalation of gastric contents, food, or other objects; (7) septicemia; (8) genitourinary diseases – nephritis, nephrotic syndrome, nephrosis, and urinary tract infection (genitourinary diseases herein); (9) chronic lower respiratory diseases (CLRD); and (10) cerebrovascular disease. Decedents with CP were more likely than decedents without CP to die from pneumonitis, influenza/pneumonia, respiratory failure, choking, septicemia, and genitourinary diseases. In contrast, decedents with CP were less likely than decedents without CP to die from heart disease, cancer, CLRD, and cerebrovascular disease. Among decedents with CP, 16.64% had no valid or an unspecified UCOD on the death certificate despite using a sequential UCOD revision process.

Figure 1 and Supplemental Table 1 (all supplemental tables are online only) report the adjusted comparative likelihood that decedents with and without CP died from the leading causes of death. The causes of death in Figure 1 appear in rank order for decedents with CP and comprised the top ten specific leading causes of death for decedents with CP in the U.S. from 2013-2017. Although heart disease was the leading cause of death among decedents with CP, those with CP were 39% (AOR=0.61, CI 0.58-0.65) less likely than decedents without CP to die from heart disease. Respiratory causes of death – pneumonitis, influenza/pneumonia, respiratory failure, and CLRD – were the second, third, fourth, sixth, and ninth leading causes of death among decedents with CP, respectively. Decedents with CP were 31.1 times (CI 29.42-32.96) more likely than decedents without CP to die from pneumonitis, 8.8 times (CI 8.30-9.29) more likely to die from influenza/pneumonia, 17.2 times (CI 15.91-18.69) more likely to die from respiratory failure, 20.7 times (CI 18.86-22.62) more likely to die from choking, and 19.0 times (CI 18.11-19.84) more likely to have an unknown/unspecified UCOD. Decedents with CP were 88% (CI 0.11-0.13) less likely to die from cancer, 50% (CI 0.44-0.56) less like to die from CLRD, and 34% (CI 0.59-0.75) less likely to die from cerebrovascular disease.

Figure 1.

Figure 1.

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Adjusted odds ratios of specific causes of for adults with compared to adults without cerebral palsy, 2013-2017 U.S. Multiple Cause of Death Mortality Files (N=13,332,871).

Figure 2 provides a visual representation of the cause of death patterns between adults with and without CP across age. Corresponding Supplemental Table 2 details the adjusted odds ratios used to plot these figures. People with CP died at slightly higher rates of heart diseases than those without CP prior to age 25. Despite a general rise in heart disease deaths among those with CP across the life course, beyond age 25 decedents with CP died at comparatively lower rates of heart disease than those without CP. Throughout adulthood, to varying degrees, people with CP were more likely to die from most respiratory related causes of death inclusive of pneumonitis, influenza/pneumonia, respiratory failure, and choking than any other causes. Additionally, people with CP were slightly more likely to die from septicemia and genitourinary diseases. Conversely, people with CP were less likely to die from cancer across the life course, increasingly so through age 65. Unknown/unspecified causes were more common among decedents with CP than those without CP; however, unknown/unspecified causes of death among both study populations decreased with age.

Figure 2.

Figure 2.

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Predicted probabilities of leading causes of death by age for adults with and without cerebral palsy, 2013-2017 U.S. Multiple Cause of Death Mortality Files (N=13,332,871).

Cause of death by sex and race-ethnicity among decedents with CP

Figures 3 and 4 present salient distinctions in comparative risk of causes of death among decedents with CP by sex and race-ethnicity, respectively (data used to plot figures is provided in Supplemental Table 3). The results show some heterogeneity in cause of death patterns among adults with CP. Females with CP were 1.2 times more likely than males with CP to die from respiratory failure (CI 1.03-1.42) and unknown/unspecified causes of death (CI 1.06-1.27). Females and males had comparable risk across all other causes. Non-Hispanic White adult decedents with CP were no more or less likely than Non-Hispanic Other adult decedents with CP to die from any of the causes of death analyzed. However, compared to Non-Hispanic White adult decedents with CP, Non-Hispanic Black adult decedents with CP were 1.2 times (CI 1.07-1.45) more likely to die from heart disease; 1.8 times (CI 1.29-2.49) more likely to die from cerebrovascular disease; and 1.3 times (CI 1.12-1.42) more likely to die from unknown/unspecified causes of death. Conversely, Non-Hispanic Black adult decedents were 39% (AOR=0.61, CI 0.51-0.74) less likely to die from pneumonitis than Non-Hispanic White adult decedents, and 35% less likely to die from influenza/pneumonia (AOR=0.65, CI 0.54-0.78). Both Non-Hispanic Black and Hispanic adult decedents with CP were less likely than Non-Hispanic White adult decedents with CP to die from choking, 30% (AOR=0.70, CI 0.53-0.92) and 39% (AOR=0.61, CI 0.42-0.87) respectively.

Figure 3.

Figure 3.

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Adjusted odds ratios of specific causes of death for female decedents with cerebral palsy compared to male decedents with cerebral palsy, 2013-2017 U.S. Multiple Cause of Death Mortality Files (N=13,897).

Figure 4.

Figure 4.

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Adjusted odds ratios of specific causes of death for Non-Hispanic Black, Hispanic, and Non-Hispanic Other compared to Non-Hispanic White adult decedents with cerebral palsy, 2013-2017 U.S. Multiple Cause of Death Mortality Files (N=13,897).

Discussion

Our results highlight significant distinctions in the cause of death patterns for adults who did/did not have CP reported on the death certificate. Using the CDC reporting scheme for causes of death, we find that the cause of death patterns between study groups diverged in circulatory and respiratory causes of death, consistent with much of the literature [9,14]. Despite heart disease being the leading cause of death for adults with and without CP, decedents with CP were comparatively less likely than those without CP to die from heart disease, especially beyond age 25. In contrast, those with CP were much more likely to die from various respiratory UCODs – pneumonitis, influenza/pneumonia, respiratory failure, and CLRD – than those without CP, with increased risk extending across the life course. Therefore, clinicians, rehabilitation professionals, service providers, and people with CP should remain cognizant of general mortality risks, such as heart disease, but must consider unique CP-related risk of respiratory causes of death over the life course for the diverse population with CP.

Due to the prevalence of heart disease deaths among adults with CP, results from this study indicate that professionals must consider related risk factors. Research on cardiovascular health and CP suggests hypertension, overweight/obesity, sedentariness, and smoking may influence rates of heart disease for this population [22,28,29]. Accordingly, public health and clinical and rehabilitative practice may improve the health of this population through early screenings and prevention programs aimed at addressing sedentariness, poor nutrition, insufficient knowledge of modifiable cardiovascular risk factors, and inaccessible services [1,22,28]. Rehabilitation professionals aiming to improve health and function for adults with CP should consider implementing routine physical activity assessments and recommend physical activity and exercise that account for physiological differences and environmental barriers, and that can be integrated into daily life [1,30]. Because of the dearth of empirical evidence [22,28], these suggestions are speculative. Further study is pressing [1,22,30].

The excessive risk of respiratory causes of death, especially those considered preventable – influenza/pneumonia, pneumonitis (aspiration), and choking – is concerning and calls attention to respiratory health promotion. Standard hygiene practices such as hand washing, immunizations, daily post-prandial oral hygiene (both tube and oral nutrition), and routine professional dental care can help prevent or mitigate influenza/pneumonia and pneumonitis [1,31-34]. Moreover, professional dental care can also address oral pain limiting food choices that may contribute to obesity and heart disease [32,33]. However, the prevention of choking and aspiration is complicated and depends on anticipatory responses to clinical signs of gastroesophageal reflux, dysphagia, and aspiration [33-35]. Therefore, conducting regular assessments for these conditions and implementing strategies to address oral-motor skills, appropriate dietary supports, and needed meal-time adaptations is necessary [34]. Raising respiratory health awareness with the community with CP may empower individuals to address these concerns [1].

Age comparisons between different causes of death among decedents with and without CP were informative. Studies that consider age in cause of death patterning report that respiratory causes of death are more prevalent in early adulthood, tapering over the life course, and are replaced by circulatory causes of death as the leading cause in mid to late life, prior to rises in circulatory causes of death among the general population [10,14]. We confirm the risk of influenza/pneumonia deaths remain elevated throughout the life course [14]. However, our findings suggest, like that of the general population, risk for heart disease increases with age for those with CP. Additionally, the results suggest risk of pneumonitis, influenza/pneumonia, choking, and respiratory failure was pronounced among those with CP compared to those without CP throughout adulthood. Like the general population, cancer death rates rose during mid-life, ages 40-60, for those with CP. However, decreased risk of cancer death may reflect earlier age at death for adults with CP [6].

The results detailing the sex and racial-ethnic comparisons in cause of death patterns of people with CP suggest some heterogeneity among those with CP. Specifically, females with CP were more likely than males with CP to die from respiratory failure, indicating a potential need for closer monitoring of lung functioning and symptoms of respiratory failure for this group [34]. The results showed some racial-ethnic distinctions in cause of death patterns among adults with CP. Research on the general population suggests that Non-Hispanic Black individuals experience higher rates of cardiovascular disease and related deaths earlier in the life course than their Non-Hispanic White peers [24,36,37]. We found decreased risk of choking, pneumonitis, and influenza/pneumonia deaths among Non-Hispanic Black adult decedents with CP, but increased risk of heart disease and cerebrovascular disease deaths among Non-Hispanic Black adult decedents with CP. This reporting suggests racial-ethnic disparities in heart and cerebrovascular disease deaths observed in the general population [24,36,37] persist among those with CP. Racial-ethnic heterogeneity among those with CP may reflect differences in functioning [14,38], care arrangements [34], and other factors (e.g., nutrition, physical activity, obesity, and smoking) [24,28,38,39]. Culturally-competent treatment and prevention of respiratory failure, heart disease, and cerebrovascular disease in patients with CP through earlier screening, testing, and treatment for populations with heightened risk may prove beneficial to adults with CP [24,40].

Limitations

There are clear limitations to the data used for this study. First, we cannot be sure that all decedents with CP have this disability reported on their death certificate [21]. As accurate population estimates for adults with CP in the US are not available [1], we cannot confirm that decedents with CP in this study represent the population of decedents with CP in the US. Additionally, CP is often reported as the UCOD on the death certificate. After revising death certificates that inaccurately report CP as the UCOD, we determined an appropriate UCOD for 83.36% of decedents with CP. The remaining uninformative death certificates further emphasizes the need to systemically address this problem [21]. Conversely, CP may not be reported on the death certificate for all individuals with CP [21]. Inclusion of decedents with CP in the general population would lead to more conservative estimates than reported here, biasing the analysis toward the null. Finally, U.S. death certificates lack specificity of CP diagnosis, topographical distribution, or functional classification. Some research indicates that these factors influence mortality patterns [14]; however, we are unable to stratify our analysis in these ways.

Conclusion

This study updates and clarifies the U.S. literature on the cause of death patterns of adults with CP by employing national data, utilizing a sequential UCOD revision process, comparing the cause of death patterns of adults with and without CP across age, and determining sex and racial-ethnic differences in cause of death patterning among those with CP. Heart disease persists as the leading specific cause of death among adult decedents with CP, although adults with CP were less likely to die from heart disease than the general population over age 25 years. Public health efforts and clinical practice must account for the significant risk of death of respiratory causes through mitigation strategies that limit respiratory infections and choking. Clinical and rehabilitation practice should account for demographic heterogeneity in cause of death patterning by employing early diagnostic testing and treatment for at risk populations.

Supplementary Material

1

Highlights:

  • Adults with/without CP had similar increases in risk for heart disease death with age.

  • Risk for heart disease death was comparatively lower for adults with CP beyond age 25.

  • Throughout adulthood, those with CP were at higher risk for most respiratory causes.

  • Non-Hispanic Black decedents with CP had higher risk of death from circulatory causes.

  • Among adults with CP, females had higher risk of respiratory failure than males.

Funding Statement:

Research reported in this publication was supported by the National Institute On Aging of the National Institutes of Health under Award Number R03AG065638. This research also benefited from NIA Center (grant P30AG066583), Center for Aging and Policy Studies, Syracuse University. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Abbreviations

CP

Cerebral Palsy

CLRD

Chronic lower respiratory diseases

UCOD

Underlying cause of death

ICD-10

International Classification of Diseases, 10th edition

NVSS

National Vital Statistics System

AOR

Adjusted odds ratio

CI

Confidence Interval

Footnotes

1

Because CDC coding groups heart disease deaths, alternative heart disease analysis is available upon request (cardiac arrest, myocardial infarction, atherosclerotic heart disease, essential hypertension, left ventricular failure, cardiac arrhythmia, and ischemic heart disease).

Ethics Statement: Ethical approval was not needed for this research as it relies on complete data sets already in existence that are publicly available, and therefore, the research is categorically exempt.

Consent Statement: Patient consent was not required as all data is from death certificates from publicly available sources (National Bureau of Economic Research: https://www.nber.org/research/data/vital-statistics-mortality-data-nber).

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