Our findings revealed that from 1984 to 2008 the injury mortality rate decreased substantially among women aged 15 or older. The total injury mortality rate in Macheng City decreased from 149.01/100,000 in 1984 to 32.90/100,000 in 2008, with a reduction of 77.92% during those years.
The decline in injury death rate most likely resulted from improvement in economic and social status. With one of the fastest growing economies in the world, China has experienced tremendous socioeconomic changes since the economic reforms in 1978. Its rapid growth has been accompanied by substantial changes in mode of transport, housing, and other ways of life, all of which affect exposure to risk factors for injury . There is reportedly an inverse association between economic development and unintentional injury mortality among children and adults in low and middle income countries . The decrease in mortality rate can also be attributed to the dramatic decrease in suicide mortality. As found in our study, suicide accounted for 77.2% of all injury deaths and showed a dramatic decrease during the study period. The suicide rate decreased from 131.1/100,000 in 1984 to 21.9/100,000 in 2008. Our findings are consistent with Chinese national data. Wang et al.  reported that rates of injury-related deaths in China decreased steadily from 1987-2006. Although the injury mortality rate for women decreased sharply during our study period, it was still higher than the injury mortality rates of most developed countries and the national rate in China .
Suicide is a major cause of premature death and thus is an important public health issue worldwide, particularly in China . In this study, we found suicide was the leading cause of injury death in all age groups of women older than age 15 during the whole study period. This finding is consistent with data from most studies in China [11, 12]. However, the suicide rate for women in Macheng City was higher than most suicide rates obtained in other studies conducted in China [8, 13, 14]. Phillips et al  reported an average suicide mortality rate for females of 25.9 per 100,000 yearly during the period of 1995-1999 in China. This rate was higher than that in other countries in the world . In most countries, mortality rates due to suicide are higher among men than women. However, this relationship is reversed in China. Suicide fatalities are more common among women than men, and the highest suicide rate is found in rural women [6, 8, 13, 15]. In Macheng City, the suicide rate for females was 1.3 times higher than of male counterparts (64.6/100,000 vs. 49.5/100,000) during 1984-2008. This unique pattern of suicide in China is attracting attention and requires further investigation. It is speculated that the widely available and common use of pesticides and insufficient emergency medical services in rural areas account most for the high mortality rate of suicide in China [16, 17]. One study in Macheng City reported that 80.4% of suicide completers died by ingesting pesticides in 1992-1994 . Another study reported that 77.9% of suicides in women in Macheng City were attributable to pesticide self-poisoning . In addition, interpersonal conflict and disease as well as social and environmental factors such as economic hardship may be contributing factors . Although suicide was the most common cause of injury death for women, our study revealed a significant improvement in the suicide mortality rate over time. We speculate that the decrease in suicides might be due to social changes, such as general improvement in living conditions, better education of women, small family size, more job opportunities for women, divorce made easier, and improvement of emergency medical services in cases of self-poisoning. To formulate effective strategies for suicide prevention, further research is required to delineate the mechanisms underlying the downward trend in suicide rate.
The most dramatic change in injury mortality during 1984-2008 was in RTI rate, which increased in most groups of women. In 1984, the mortality rate for RTI in Macheng City was lower than that in the USA (1.35 vs. 12.12 per 10,000 population). In 2007, it was higher than that in the USA (12.48 vs. 9.98 per 10,000 population) . The alarming rise in RTI deaths is probably the consequence of the rapid increase in motor vehicles. The number of civil vehicles increased from 13,556 in 1985 to 1,368,635 in 2008 in Hubei province [22, 23]. The rise in RTI deaths may also be associated with poor road conditions, less police supervision on the roads, insufficient emergency medical services, and higher rates of driving under the influence of alcohol. As the mortality rates for other causes of injury decreased during the study period, the RTI mortality rate increased sharply. However, we found that the mortality rate for RTI sharply decreased in 2008. The decreased RTI rate might be explained by the Road Safety Campaign initiated in 2008 in Macheng City to curb the trend of increased RTI mortality. The countermeasures included in this campaign were mandatory use of safety belts or helmets, and punishment for drunk driving and high speed driving.
We also observed that drowning was another major cause of injury death. Similar findings have been reported by Liu and Ni [24, 25]. Contributing factors may be a combination of geographical features of Macheng City, including many ponds, lakes, and natural waterways. In addition, swimming is a popular activity in this city.
When we analyzed the ranking of leading causes of injury, we found that for women older than age 65, fire/flames and falls were the major causes besides suicide. Falls are one of the most common causes of injury in older people, especially for older women [26–28]. It has been reported that the fall-related injury rate in women older than age 65 is significantly higher than in men of comparable age . In our study, fire/flames was another common cause of injuries in women older than age 65. The reasons for high mortality due to fire/flames among women are unclear. However, older women spend more time at home. When they are threatened by fire, they may not have enough time to escape because of muscle weakness and loss of lower body strength.
There are several limitations in this study. First, two systems (ICD-9 for 1984-2002, ICD-10 for 2003-2008) were used for disease coding during the study period. A potential problem occurs if a single injury is coded differently under the two systems. Although the disease coding staff were trained and certified before using the ICD-10, aligning the causes of mortality in the ICD-9 to those in the ICD-10 proved to be a complex issue and presented many challenges. Even though there was no unusual change in rate between 2002 and 2003 in this paper, we could not rule out the possibility of miscoding of injuries due to the coding system transition. The second limitation is that our study was based on data from the death registry system, which does not contain relevant information such as socio-economic status and lifestyle risk factors that would allow us to further analyze causes of injury. The third limitation is that the findings do not represent the entire Chinese population, and cannot be generalized to the overall Chinese population. However, considering the incompleteness of the death registry system in China, results of our study may be supplementary to most studies based on data from the Chinese Ministry of Health Vital Registration System or Disease Surveillance Point system.
Based on the findings of our research, targeted prevention strategies need to be adopted for reducing injury mortality. In the present study, suicide rates dramatically increased with age. Based on previous studies conducted in Macheng City [18, 19], suicide risk among elderly women could be a consequence of increased severe illness and high medical cost. Providing medical insurance and financial support for elderly rural women might be an effective way to reduce the high suicide rate. Moreover, the divergent age patterns for different types of injury indicate that injury control programs should be age appropriate. For instance, drowning prevention should target middle-aged women, and fall prevention programs should focus on women older than age 65. Increasing mortality rates for RTI found during the study period suggest the need for more education programs and counseling for drivers on safe driving. Intervention strategies are urgently needed to address the high mortality rate from suicide injuries in women older than 15 years of age.