DEMOGRAPHIC & HEALTH STATUS OF THE MALTESE POPULATION

Demography
The Maltese population in the 1985 census stood at 345,418 with a male to female ratio of 0.97. Only 1.4 percent of the population were non-Maltese. A century previously (1881) the Maltese population stood at about 149,000 made up of 73,000 males and 76,000 females. Since 1842, when the first population census in a series of regular censuses was taken, there has been a more or less continuous growth of the population during each intercensal period except in 1911-1921 and 1957-1967, when the population decreased because of long-term migration to other countries. The sex-ratio of the population has always been characterised by an excess of females over males.

Table 1: Population Growth Census Years

The age structure of the population has changed significantly since the Second World War (1939-1945). The immediate post-war period was characterised by a baby-boom which continued until 1957 when a drop in birth rate was documented. This fall in birth rate has persisted. The age structure now has a roughly pyramidal pattern of an increasing population where the crude birth rate [15.9 per 1000 population] is in excess of the crude death rate [8.3 per 1000 population]. There is little effect on the population from emigration-imigration patterns, making the Maltese population a relatively closed community with limited changes in the genetic pool.

Assuming the maintanance of average death and natality rates, and a zero migration, estimates of the population structure in the Maltese Islands can be worked out using standard methods of projections. Based on the 1985 census, the Maltese population is projected to grow by 6.4 per cent by the year 2000, and by a further 5.1 per cent during the following decade. These population changes will also alter the age structure of the population. The young segment (0-14 years) is expected to decline by one percentage point every five years until the turn of the century, and will continue to ease at a much slower rate in the subsequent decade. The working age group (15-64 years) is expected to increase slightly until the year 2000 and will thereafter level off. The 65+ age group is expected to increase continuously by about 0.23 per cent per annum, so that by the year 2010 21.2 per cent of the population will be over 60 years of age.

Life expecancy

In the Maltese Islands, information regarding life expectancy at different ages has been available since. Life expectancy at birth describes the total mortality experience of a population, and is little affected by any pattern of the age and sex pyramid or by the pattern of the birth rate. It is also little affected by migration patterns. The life expectancy at birth for the Maltese population, estimated for 1993, stood at 74.67 years for males and 78.55 years for females. In the six decades between 1870 and 1930, life expectancy for the newborn remained quite constant and relatively low averaging 44.5 years. There was no appreciable difference between the life expectancy for males and females. Life-expectancy rose sharply during the 1930s reaching in 1948, 55.7 years for males and 57.7 for females. The gap in longevity between males and females has gradually increased from nil in 1900, to 2 years in 1948 and to 5.3 years in 1985. Since 1985, the progressive increase in life-expectancy at birth is showing signs of levelling off reaching a difference of 3.9 years in 1993.

Examination of life-expectancy at age-groups other than at newborn serves to underline the differences in longevity between the genders and is mainly due to differences in mortality during adulthood. These values thus exclude the losses resulting from infant and childhood mortality. Between 1900 and 1993, life-expectancy at age 25 increased by 10.7 years in males and 14.3 years in females. At age 45, life expectancy had increased by 7.5 years in males and 10.4 years in females. Figure 1 presents a summary life-table for the twentieth century at selected ages.

Figure 1 : Total Life-Expectancy

Death rate and trends

For the last decade 1984-1993, the crude death rate averaged 8.0 per 1000 population. This rate is slightly less than that obtained for the 1950s when the decade averaged 9.5 per 1000 population. Indeed the rate reached a plateau in the mid-1950s being maintained through the 1970s, thereafter declining in the last decade. The crude mortality rate in the 1930s was markedly higher, averaging 21.2 per 1000 population, mainly because of a high infant mortality rate (Figure 1).

Figure 2: Crude Death Rates Trends

The crude death rate is however a very general and vague indicator, and comparisons or rates at different times may be misleading in view of the marked changes in population structure over the years. When population changes are accounted for and deaths from all causes are standardised accordingly, a downward trend in mortality is discerned even by comparing the triennia 1982-1984 with the subsequent ones (Table 1). At all ages and in both sexes the standardised mortality is lower in the latter triennia. With regard to differences between the sexes, in most age groups the downward trend is even faster in females, and this is of course reflected in the trend of life expectancy.

Table 2: Deaths by age groups

Birth rate and trends

The crude birth rate prior to the Second World War varied little fluctuating around a mean of 33.26 per 1000 population. The rate fell during the years of hostility, but the aftermath of the war saw a 'baby-boom' which raised the birth rate to the 40.54 level in 1944. This rise persisted until 1950, after which the birth rate reached pre-war levels and subsequently fell progressively further. The rate of fall levelled in the 1970s to reach present levels. The crude birth rate in the last decade averaged 15.4 live births per 1000 population. The birth rate is expected to decline further and by the year 2000 it is estimated to reach 13.7 per 1000 population (Figure 3).

Figure 3: Birth Rate Trends

A better index of fertility in the community is the fertility rate, which is the number of live births per 100 women in the 15-44 years age group. This index corrects for the influence of the male and children proportions of the population and the proportion of women beyond the reproductive age. The fertility rate reflects the attitudes towards family size and contraceptive practices. The traditionally Catholic matrix of the Maltese population has allowed the Roman Catholic Church to maintain its strong influence in spite of the increasing secularization of the population. There has been however a significant fall in fertility rates which occurred in the 1960s (Figure 4).

Figure 4: Fertility rates per 100 population: Maltese Islands

Perinatal and Infant mortality

Infant mortality rates remain one of the main indicators of health care in the community. The infant mortality rate in the Maltese Islands during the first part of the twentieth century maintained a high level of about 253 per 1000 live births prior to the Second World War. The pre-Second World War years had seen the initiation of a gradual fall in infant mortality rates attributed to various factors including the organization of infant health services at the time. During this period, the main cause of death in the infant aged less than one year appears to have been diarrhoeal disease, where social circumstances played an important role in prevention and management. The cessation of hostilities saw a marked change in infant death rates with a sharp drop in mortality, mainly from deaths caused by diarrhoea. The post-war decline was attributed to a lower incidence of infectious disease, the use of sulphonamides, and the intensive work of the health visitors. The main factors however were the increasing prosperity of some classes of the population, better nutrition, and the greater care bestowed in general on the requirements of health. In addition, the post-war marriage boom resulted in a greater proportion of births being first-born infants allowing better infant care from the mothers. The infant mortality rates continued to fall progressively to reach in the last decade an average figure of about 10 per 1000 live births, the majority of which are early (first week) neonatal deaths.

Figure 5: Infant Mortality Rate Trends

Published information about first month neonatal deaths is only available since 1935, while first week neonatal deaths were considered separately only after 1951 (Figure 6). The latter are better indicators of obstetric care. The neonatal death rates show a gradual fall which started in the post-war period coinciding with the fall in infant deaths, though the fall was more gradual since diarrhoeal disease accounted for a smaller proportion of neonatal deaths. The neonatal death rate in the last decade averaged 7.5 per 1000 live births. The early neonatal death rate exhibited a sharp drop in 1953, thereafter assuming a more gradual decline to an average of 10 per 1000 live births. The last decade registered an average rate of 5.6 per 1000 live births. The two major causes of early neonatal death which had taken a progressive downward trend were conditions associated with delivery giving rise to hypoxia and deaths associated with low birth weight infants. The specific mortality rate from delivery complications decreased from 14.3 per 1000 live births in 1950-54 to 5.6 in 1965-69, 1.8 in 1985-89 and 0.8 in 1990-1993. Deaths caused by low birth weight decreased similarly from 11.2 per 1000 live births in 1950-54, to 8.0 in 1965-69, 1.4 in 1985-89 and 1.4 in 1990-1993. This decrease in deaths is attributable to better antenatal, intrapartum and neonatal care of the infants, compounded with a betterment in the social circumstances of the population.

The stillbirth rates for the Maltese Islands are available throughout the twentieth century (Figure 6). The first part of the century showed a rise in stillbirth rates from 28.9 per 1000 total births in 1903 to 41.5 in 1931. This rise may be partly attributed to registration practices. There was subsequently a gradual fall in stillbirth rates. The first marked drop in stillbirth rates occurred just after the Second World War when the rate decreased from 37.4 in 1937 to 23.2 in 1948. This decline has been attributed to the greater antenatal supervision that was initiated by war conditions and the increase in the proportion of supervised hospital confinements. Another sharp fall in stillbirth rate occurred after 1963. This drop has been correlated to the decrease in birth rate which occurred during this period. The relative decrease in births decreased the load on antenatal services provided allowing for better supervised pregnancies. The stillbirth rate in the last decade averaged 6.8 per 1000 total births.

Figure 6: Stillbirth & Neonatal Mortality Rate Trends
(SB rates per 1000 total births; ND rates per 1000 live births

Maternal Mortality

Maternal mortality has been traditionally considered a useful yardstick of obstetric practice, though the annual rates for the Maltese Islands show wide fluctuations resulting from the relatively small numbers of births which occur annually on the Islands. These fluctuations make analysis difficult, more so in the last decades when the mortality rates have decreased significantly. The quinquina averages of maternal mortality rates during the twentieth century suggest that the mortality rate in the Maltese Islands showed an initial rise from the 283.7 per 100,000 total births level in 1900-04 to a rate of 423.2 in 1930-34. This rise which occurred in the 1920's has been noted from a number of other European countries. One of the factors responsible for this rise in these European countries has been reported to be an increase in deaths from septic abortion. In the Maltese Islands, the rise appears to have been a result of a greater incidence in puerperal sepsis, which accounted for the greater majority of the deaths. The incidence of puerperal sepsis rose from the 428.2 per 100,000 total births in 1900-04 to 600.0 in 1930-34. The specific maternal mortality from sepsis similarly rose from 157.9 per 100,000 total births in 1900-04 to 164.3 in 1930-34. Deaths from haemorrhage related to pregnancy also exhibited a rise. The maternal mortality rate started to fall in the late 1930's reaching 170.6 in 1945-49 and 80.0 in 1955-59. This pattern of decline has been identified from other countries. The international improvement in maternal mortality rates which occurred after 1935 has been attributed to a number of factors which were also operative on the Maltese Islands. These factors included the improvement in the general health of the population in the post-war period, the improvement in maternal care, and the introduction of antimicrobials and blood transfusion. The decrease correlated with a decrease in deaths from puerperal sepsis and haemorrhage initially, followed by a decrease in deaths from eclampsia. The maternal mortality rate in the last decade averaged 3.7 per 100,000 total births.

Figure 7: Maternal Mortality Rate Trends

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Citation: C. Savona-Ventura: The Health of the Maltese Population. Internet Home Page [http://www.oocities.org/savona.geo/index.html], 1996