Cause-specific mortality in Spain during the pandemic: educational differences and its impact on life expectancy

BACKGROUND: Life expectancy in Spain fell by 1 year between 2018/19 and 2020. Yet, little is known on the impact on cause-of-death (COD) dynamics and educational inequalities therein. METHODS: We use individual-level death counts data by age, sex, education and multiple causes of death (MCOD) and the corresponding population exposures from national registers in Spain. Deaths were examined both as underlying cause of death (UCOD) and as contributory cause. We estimated life expectancies and lifespan inequalities by subpopulation groups and decomposed life expectancy differences between 2018/19 and 2020 by age groups and COD to assess the impact of COVID-19 (as MCOD) and major UCOD. RESULTS: COVID-19 contributed to a decline in male and female life expectancy in Spain between 2018/19 and 2020 (respectively, −1.7 and −1.4 years). Conversely, cancer, respiratory and circulatory system diseases and ill-defined causes as UCOD contributed to life expectancy increases. Life expectancy declines equalled −1.4 years among the low-educated in both sexes (population 30+), −1.0 and −0.7 years among middle-educated and −1.1 and −0.9 years among high-educated men and women. Without COVID-19, educational inequalities in life expectancy would have remained at similar levels, whereas lifespan variation would have been lower (−22% for women and −8% for men). CONCLUSIONS: Life expectancy declines in Spain in 2020 were mainly driven by COVID-19, with possible substitution effects, especially for respiratory system diseases (fewer deaths compared to 2018/19 when coded as UCOD but more as contributing cause). We therefore advocate analysing MCOD when studying changing COD patterns during the pandemic.