Social Science & Medicine 126 (2015) 59e66

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Social Science & Medicine

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A not so happy day after all: Excess death rates on birthdays in the U.S.
~a
Pablo A. Pen
Microanalitica, Chicago, IL, USA

a r t i c l e i n f o a b s t r a c t

Article history: This study estimates average excess death rates on and around birthdays, and explores differences be-
Available online 10 December 2014 tween birthdays falling on weekends and birthdays falling on weekdays. Using records from the U.S.
Social Security Administration for 25 million people who died during the period from 1998 to 2011,
Keywords: average excess death rates are estimated controlling for seasonality of births and deaths. The average
Timing of death excess death rate on birthdays is 6.7% (p < 0.0001). No evidence is found of dips in average excess death
Death on birthdays
rates in a ±10 day neighborhood around birthdays that could offset the spikes on birthdays. Significant
Death on weekends
differences are found between age groups and between weekend and weekday birthdays. Younger
people have greater average excess death rates on birthdays, reaching up to 25.4% (p < 0.0001) for ages
20e29. Younger people also show the largest differences between average excess death rates on
weekend birthdays and weekday birthdays, reaching up to 64.5 percentage points (p ¼ 0.0063) for ages 1
e9. Over the 13-year period analyzed, the estimated excess deaths on birthdays are 4590.
© 2014 Elsevier Ltd. All rights reserved.

1. Introduction
Symbolically important occasions such as holidays and birth-
days might affect the timing of death. People deviate from their
usual behavior on or around those occasions: they travel more, host
or attend parties, consume different foods, drink alcohol, have more
physical activity, gather with more people, etc. Those behaviors
could expose them to greater risks of death. Additionally, there are
psychosomatic mechanisms that could link important occasions
with the timing of death. An approaching holiday or birthday might
give some patients in critical condition an extra incentive to live
long enough to see that dayda phenomenon referred to as “post-
ponement of death” (Phillips and Smith, 1990; Young and Hade,
2004). A holiday might be a reminder of a traumatic experience,
causing anxiety and other negative feelingsdthe so-called “anni-
versary reaction” (Gabriel, 1992; Porcelli et al., 2012). Some people
might suffer depression symptoms on their birthdaydthe
“birthday blues”dthat could lead to suicide (Williams et al., 2011).
Several empirical studies have searched for evidence of de-
viations from expected mortalitydnamely spikes or dipsdon or
around holidays and birthdays, and they have found mixed
evidence (Phillips and Smith, 1990; Young and Hade, 2004;
Williams et al., 2011; Skala and Freedland, 2004; Reulbach et al.,
2007; Abel and Kruger, 2009; Phillips et al., 2010; Ajdacic-Gross
E-mail address: pablo@uchicago.edu.
et al., 2012). Some studies have found mortality dips before holi-
days and birthdays and spikes on and after those days, while others
have found either the opposite or no dips or spikes at all. The
variation in results could be attributed to differences in the subjects
studied and the causes of death considered. Except for one study in
Switzerland (Ajdacic-Gross et al., 2012), those studies focus on a
specific subgroup of the population (e.g., baseball players, psychi-
atric patients, elderly Chinese-American women, Roman Catholic
priests) or on a subset of the causes of death (e.g., natural causes,
suicide, cancer). In addition, some studies estimate daily-level
patterns, while others estimate patterns at a weekly- or monthly-
level, making direct comparisons difficult to interpret.
Studying deaths on birthdays has a practical advantage over the
study of deaths on holidays. There are only a few salient holidays in
a year, and they happen once a year. Estimating the relationship
between mortality and one particular holiday with some level of
statistical confidence requires many years of datadsomething
rarely available. In contrast, there are people born every day of the
year. Thus every day provides useful information on the association
between mortality and birthdays.
This study estimates excess death ratesddefined as the percent
of deaths above what is expecteddon and around birthdays using a
large sample from the U.S. population. The sample includes
everyone with a Social Security Number (SSN) who died of any
cause from December 1998 to November 2011, totaling over 25
million decedents.
The hypothesis tested here is that more people than expected

http://dx.doi.org/10.1016/j.socscimed.2014.12.014
0277-9536/© 2014 Elsevier Ltd. All rights reserved.
60 ~ a / Social Science & Medicine 126 (2015) 59e66
P.A. Pen

die on their birthdays. The large sample size allows the exploration around birthdays (e.g., if more people were born in January, and at
of daily-level dips and spikes around birthdays, thereby shedding the same time, people were more likely to die in January, regardless
light on whether there is “postponement of death” or the opposi- of their month of birth). One way to control for such seasonal
teddeath occurring earlier than expected. patterns is to analyze excess death rates relative to what would be
Some studies have found that fatalities are not uniformly expected (Phillips et al., 1992).
distributed across the days of the week: the number of suicides, Ignoring February 29, every death occurs on one of 365 days of
alcohol-related deaths, and homicides is higher on weekends, and the year, from January 1 to December 31. The same holds true for
mortality rates are higher for patients admitted to hospitals on births. Thus, every decedent in the sample can be tagged according
weekends than for those admitted on weekdays (Ajdacic-Gross et al., to the day of the year when he or she was born, denoted by b, and
2014; Pridemore, 2004; Bell and Redelmeier, 2001; Ricciardi et al., the day of the year when he or she died, denoted by d. Since b and
2011). This study also explores whether there is a mortality inter- d can each be one of 365 different days, there are
action between birthdays and the day of the week on which they fall. 365  365 ¼ 133,225 unique combinations of b and d.
For that purpose, average excess death rates are estimated sepa- Let pb denote the fraction of individuals in the sample who were
rately for weekend birthdays and weekday birthdays. born on day b. Analogously, let pd denote the fraction of individuals
In principle, people with different characteristics such as age, who died on day d. Let N be the total number of individuals in the
gender or socioeconomic status, could behave differently on and sample, and let nb,d be the number of individuals who were born on
around their birthdays. The diversity in behaviors could lead to day b and died on day d. The excess death rate on day d among
differences in excess death rates on birthdays. The only trait of those born in day b is defined as:
decedents contained in the data used here is age at death. To
analyze differences by age, excess death rates on birthdays are
separately estimated for different age-at-death groups. nb;d  N  pd  pb
eb;d ¼  100% (1)
The main result of this study is that more people than expected N  pd  pb
die on their birthday, and excess death rates are greater for younger
N  pb  pd is the expected number of deaths for the combi-
people and on birthdays that fall on weekends. The results of the
nation of days of the year b and d. Excess death rates as defined
analysis are potentially relevant for the design of public policies to
above are percent deviations above or below the expected number
prevent premature deaths. In principle, those policies could be as
of deaths. They can be positive or negative, but they average zero
simple as campaigns to increase awareness of the risks associated
both across days of birth, and across days of death. Fig. 1 shows the
with changes in behaviors on or around birthdays.
distribution of excess death rates in the sample. There are 133,225
observations, one for each pair of days of birth and death. Each of
2. Methods
the over 25 million deaths in the sample falls into one of the
133,225 pairs.
2.1. Data source
There are 365 pairs of days of birth and death in which the days
coincide. Fig. 1 also shows the distribution of excess death rates for
The source of the sample of analysis is the Death Master File
those 365 observations, which account for 73,266 deaths in the
(DMF) of the U.S. Social Security Administration. The DMF is a
sample. In other words, 73,266 individuals died on their birthdays.
publicly available list of all people with an SSN who are dead. It is
The average excess death rate when the days of birth and death
published and periodically updated to prevent fraud. The version
coincide is 6.7%. That means the number of people who died on
used here was last updated on November 30, 2011. The DMF only
their birthdays exceeds by 6.7% what would be expected based on
reports SSN, name, date of birth, and date of death. Consequently,
the distribution of births and deaths throughout the year over the
the analysis presented here does not distinguish causes of death
13 years covered by the sample.
nor any decedent attribute other than age at death.
The hypothesis that average excess death rates are positive on
For most deaths prior to 1998, the DMF specifies the month of
birthdays is tested with a t-test. Since socioeconomic characteris-
occurrence but not the day. Thus, the analysis focuses on deaths
tics are not independent of the season of birth (Buckles and
that occurred from December 1998 to November 2011. A total of
Hungerman, 2013), the variance of excess death rates might in
25,199,903 deaths are recorded in the DMF over that period. Some
of them were excluded from the analysis. In 39,595 cases (0.16% of
the original sample) the date of birth or death was not fully spec-
ified. Those cases were excluded because it could not be deter-
mined whether the person died on his or her birthday. In 34,499
cases (0.14%) the decedent was born or died on February 29. Those
cases were excluded in order to simplify the analysis and treat all
years in the sample as having 365 days. In 78,581 cases (0.31%) the
decedent did not reach one-and-a-half years of age. Those cases
were excluded to avoid potential biases due to high infant mortality
rates that rapidly decline with age, while simultaneously preser-
ving a symmetric age-window around the second birthday. After
the exclusions, the sample of analysis consists of 25,047,228
decedents.

2.2. Statistical analysis

Births and deaths are not uniformly distributed throughout the

year (Phillips et al., 2010; Healy, 2003; Buckles and Hungerman,
2013). If not properly accounted for, seasonal patterns in births
and deaths could be confounded with mortality spikes or dips on or Fig. 1. Distribution of excess death rates across pairs of days of birth and death.
 ~ a / Social Science & Medicine 126 (2015) 59e66
P.A. Pen
principle differ across days of birth. Thus, statistical significance is
computed with robust standard errors clustered by day of birth. An
Ordinary Least Squares (OLS) regression allows performing the t-
test with robust standard errors.
In the regression setting, each unique combination of days of
birth and death constitutes one observation. Thus, the regression
has 133,225 observations. The dependent variable is the excess
death rate as defined above. The explanatory variables are one in-
dicator of whether the days of birth and death differ, and one in-
dicator of whether the days of birth and death coincide. The
regression to estimate is:



eb;d ¼ a  1 bsd þ b  1 b ¼ d þ εb;d
where 1($) is an indicator function that takes the value of 1 if the
condition inside the parentheses is true and 0 if it is false. The co-
efficient a is the average excess death rate on non-birthdays. The
coefficient b is the average excess death rate on birthdays. By
construction, the weighted average of a and b is zerodweighting a
by the number of observations for which b s d, and weighting b by
the number of observations for which b ¼ d. εb,d is the error term,
which is assumed to be independent across observations but not
identically distributed. Its variance is allowed to differ across days
of birth. The indicator variables in (2) always add up to one,
therefore a constant term is redundantdit is perfectly collinear
with the regressors.
In order to test for above- or below-expected death rates around
birthdays, a different regression is estimated, adding 20 indicator
variables as explanatory variables to the model in (2), one for each
day in a ±10 day neighborhood around the birthday. Since
December 31 precedes January 1, the ±10 day neighborhood is well
defined for all days of birth. In this case the regression to estimate,
also by OLS, is:
X
10

eb;d ¼ a  1ðjb  dj > 10Þ þ bi  1 b ¼ d þ i þ εb;d
i¼10
where j$j denotes absolute value. a is the average excess death rate
on days that fall outside of neighborhood of ten days around
birthdays. bi is the average excess death rate i days before (if i < 0),
after (if i > 0) or on (if i ¼ 0) the birthday. If above-expected death
rates on birthdays are offset by below-expected deaths before (or
after) birthdays, then a positive estimate for birthdays would be
accompanied by negative estimates for the days before (or after)
the birthday. The indicator variables in (3) always add up to one,
making a constant term redundant.
Over a period of several years, any given day of the year falls
sometimes on weekdays (Monday through Friday) and sometimes
on weekends (Saturday or Sunday). For instance, in the period from
1999 to 2011 March 10 fell three years (2001, 2002, and 2007) on
weekends and ten years (1999, 2000, 2003e2006, 2008e2011) on
weekdays. Over the 13-year period of analysis, of the 365 days in
the year: 157 days fell three times on weekends, 156 days fell four
times on weekends, and 52 days fell five times on weekends. The
fact that over the period covered by the sample every day of the
year fell sometimes on weekdays and sometimes on weekends,
allows the estimation of separate average excess death rates for
weekday birthdays and weekend birthdays.
Since every day of death (e.g., March 10) in the sample can be
one of two types (weekday or weekend), the number of observa-
tions in the analysis of weekdays vs weekends is 266,450, two for
each day of death. Let t stand for the type of day of death: t ¼ 0
denotes weekdays and t ¼ 1 denotes weekends. Let m(d,t) be the
number of times that day d was of type t in the period December
61
1999eNovember 2011. It is worth noting that m(d,0) þ m(d,1) ¼ 13
for every day of death d. Excess death rates are now computed
separately for weekday deaths and weekend deaths. The excess
death rate for the combination of day of birth b, day of death d, and
type of day t is:
nb;d;t N p 
mðd;tÞ
 13 d pb
eb;d;t ¼ N p p
 100% (4)
13 d b
where nb,d,t stands for the number of deaths on day d when it fell on
type t, among those with birthday b. When dividing nb,d,t by m(t,d)
we are expressing the number of deaths on a per-day basis. The
(2) number of total deaths is also expressed on a per-day basis: N is
divided by the number of times the same day appears in the
sample, which is 13. Excess death rates average zero across days of
birth and death when weighted by m(d,t).
The regression has four regressors: (i) an indicator for non-
birthday weekdays, (ii) an indicator for non-birthday weekends,
(iii) an indicator for weekday birthdays, and (iv) an indicator for
weekend birthdays. The regression to estimate by OLS is:


eb;d;t ¼ a  1ðbsd∧t ¼ 0Þ þ bw  1ðbsd∧t ¼ 1Þ þ bb  1 b


¼ d∧t ¼ 0 þ bwb  1 b ¼ d∧t ¼ 1 þ εb;d;t
(5)
The symbol ^ denotes the logical operator “and”. a is the average
excess death rate on non-birthday weekdays. bw is the average
excess death rate on non-birthday weekends. bb is the average
excess death rate on weekday birthdays. bwb is the average excess
death rate on weekend birthdays. εb,d,t is the error term indepen-
dent across observations but not identically distributed across days
of birth. Since the indicator variables in (5) always add up to one, a
constant term would be redundant. The regression is run weighting
each observation by m(d,t)/13 to ensure that every death is given
the same weight regardless of the day of the week on which it
(3) occurred. Standard errors are clustered by day of birth.
The regressions described above are estimated for the full
sample and separately for nine age-at-death categories: 1e9,
10e19, 20e29, 30e39, 40e49, 50e59, 60e69, 70e79, 80e89, and
90þ. Age at death is computed as year of death minus year of birth.
The number of observations is the same for each age category
(133,225 or 266,450). The only difference is in the number of deaths
corresponding to each pair of days of birth and death, which results
in differences in the excess death rates. Since regressions are run
only to provide appropriate t-tests using robust standard errors,
goodness of fit is irrelevant and is not reported.
3. Results
Panel A of Table 1 shows the estimates of average excess death
rates on birthdays. Each column reports the results of a separate
regression. In all regressions the number of observations is the
same. The difference between regressions is in the excess death
rates across those observations. The average excess death rate on
birthdays considering all ages is 6.7% (p < 0.0001). The point esti-
mates for all age-at-death categories are positive, and they are
greater for younger categories. The p-values are below 0.0001 for
ages 20þ, and below 0.01 for ages 10e19. The relatively small
number of deaths for ages under 20 (less than 50,000) might
explain the low significance. The point estimates peak at 25.4% for
ages 20e29, and steadily decline to less than 5% for ages 80þ.
A cause of concern regarding the estimates in Panel A of Table 1
is that births and deaths on the 1st and 15th of the month are
abnormally frequent in the sample. The number of births on the 1st
62 ~ a / Social Science & Medicine 126 (2015) 59e66
P.A. Pen

Table 1
Estimates of average excess death rates (%) on birthdays and non-birthdays.

Age at death

All ages 1e9 10e19 20e29 30e39 40e49 50e59 60e69 70e79 80e89 90þ

A. Full sample
Birthdays 6.72 14.60 16.71 25.39 23.60 14.84 13.16 5.75 5.34 4.60 4.72
p-Value <0.0001 0.1383 0.0040 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001
Non-birthdays 0.02 0.04 0.04 0.07 0.06 0.04 0.04 0.02 0.01 0.01 0.01
p-Value <0.0001 0.4949 0.2128 0.0001 <0.0001 <0.0001 <0.0001 0.0035 0.0015 0.0067 0.1000
Observations 133,225 133,225 133,225 133,225 133,225 133,225 133,225 133,225 133,225 133,225 133,225
Deaths 25,047,228 49,040 121,083 299,259 455,884 1,094,219 2,060,435 3,362,559 5,763,749 7,768,058 4,072,942
B. Estimates excluding births and deaths on the 1st or 15th of the month
Birthdays 6.77 10.94 15.93 26.65 23.84 15.00 13.86 5.66 5.28 4.58 4.75
p-Value <0.0001 0.2835 0.0082 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001
Non-birthdays 0.02 0.03 0.04 0.08 0.07 0.04 0.04 0.02 0.02 0.01 0.01
p-Value <0.0001 0.6570 0.2295 <0.0001 <0.0001 <0.0001 <0.0001 0.0005 <0.0001 0.0016 0.0659
Observations 116,281 116,281 116,281 116,281 116,281 116,281 116,281 116,281 116,281 116,281 116,281
Deaths 21,430,297 42,742 104,868 257,574 388,784 936,505 1,771,385 2,881,921 4,924,216 6,644,098 3,478,204

Age at death defined as year of death minus year of birth. p-Values computed using robust standard errors clustered by day of birth.

and 15th of the month exceeds by 6.5% the number of births on the
2nd and 16th. Similarly, the number of deaths on the 1st and 15th
exceeds by 22.7% the number on the 2nd and 16th. Those differ-
ences could be due to the use of approximate dates in birth and
death certificates when the exact date is not available. However, the
estimates in Panel A of Table 1 are not the result of those apparent
anomalies. Panel B shows estimates that exclude from the sample
of analysis all individuals who were born or died on the 1st or 15th
of the month. There are fewer observations in every regression
because fewer combinations of days of birth and death are possible
(341  341 ¼ 116,281). The results are similar to those using the full
sample. Since no meaningful differences were found with the
exclusion, the remainder of the analysis uses the full sample.
Table 2 presents the estimates of excess death rates in a ±10 day
neighborhood around birthdays. The spike on birthdays is neither
preceded nor followed by negative estimates significant at 99%,
except for the estimate for six days after the birthday for ages
20e29 (7.5%, p ¼ 0.0064). Two estimates for one day after the
birthday are positive and significant: for ages 20e29 (21.4%,
p < 0.0001) and 30e39 (9.2%, p ¼ 0.0015). The positive average
excess death rates one day after the birthday together with a
smaller magnitude of those estimates relative to the estimates for
the birthday suggest that for ages 20e39 the phenomenon causing
the spike on the birthday carries on to the next day with some
decay.
Table 3 shows the results of the weekend vs weekday analysis.
Excess death rates are 6.6% (p < 0.0001) on weekday birthdays, and
7.0% (p < 0.0001) on weekend birthdays. The estimates by age-at-
death category display some noteworthy patterns.
First, average excess death rates for non-birthday weekends
have a non-monotone relation with age: they increase for the three
youngest groups, then decline for the following four age groups,
then increase again for the last three age groups. They are positive
(p < 0.0001) for ages 1e49, negative (p < 0.001) for ages 50e89, and
statistically not different from zero for the age group 90þ. The
largest point estimate is 16.8% (p < 0.0001) for ages 20e29, sug-
gesting this age group is the most sensitive to non-birthday
weekends.
Second, excess death rates for children and teenagers on
weekday birthdays are not statistically different from zero. For all
other age groups they are positive and significant (p ¼ 0.0006 for
20e29 and p < 0.0001 for 30þ). The largest point estimate is 16.4%
(p < 0.0001) for ages 30e39.
Third, excess death rates on weekend birthdays are positive for
all age-at-death categories (p ¼ 0.0057 for 1e9, p ¼ 0.0104 for
10e19, p < 0.0001 for 20e59, and p < 0.01 for 70þ). The largest
point estimates are 60.7% for ages 1e9 and 48.3% for ages 20e29.
All point estimates for ages 1e39 exceed 30%.
Fourth, the average excess death rate on weekend birthdays
exceeds that of weekday birthdays for age-at-death categories
under 40 (p ¼ 0.0063 for 1e9 and p < 0.001 for 20e39). The dif-
ference reaches up to 64.5 percentage points for ages 1e9.
Finally, for age-at-death categories 1e39 the average excess
death rate when birthdays and weekends combine exceeds the sum
of the average excess death rates on non-birthday weekends and
weekday birthdays. The differences are presented in the bottom
panel of Table 3. The only difference significant at 99% is observed
for ages 30e39 (19.5 percentage points, p ¼ 0.0061). This is inter-
preted as evidence of a positive interaction: in that case the
“whole” (weekend birthdays) exceeds the sum of the “parts” (non-
birthday weekends and weekday birthdays).
Table 4 shows similar results to Table 3 using an alternative
definition of weekends: Friday through Sunday. The most salient
difference with respect to Table 3 is in the gap between excess
death rates on weekend birthdays and weekday birthdays. They
are smaller for age-at-death categories under 40, and larger (or
less negative) for age-at-death categories over 40. The inclusion
of Friday as part of the weekend dilutes the weekend-birthday
effect for younger people, and it strengthens it for older people.
Additionally, the difference between the average excess death
rate on weekend birthdays and the sum of the average excess
death rates on non-birthday weekends and weekday birthdays
become significant for ages 1e9, at 54.6 percentage points
(p ¼ 0.0091).
Table 5 presents differences in average excess death rates across
age-at-death categories. Panel A shows differences in average
excess death rates on birthdays regardless of day of the week
(based on the main estimates in Table 1). The most significant
differences (p < 0.0001) are observed between ages-at-death
20e59 and 60e90þ. Average excess death rates for the non-
elderly (20e59) exceed those for the elderly (60e90þ) by a range
of 7.4e20.8 percentage points. Panels B, C and D show differences in
average excess death rates for non-birthday weekends, weekday
birthdays, and weekend birthdays, respectively (based on the es-
timates in Table 3). Of the 45 pairwise comparisons of non-birthday
weekends in panel B, 41 show significant differences (p < 0.0001)
that range between 0.5 and 18.3 percentage points (in absolute
value). In 31 of those 41 cases, the younger group has a higher
average excess death rate. In other words, excess death rates on
weekends tend to decline with age. In terms of weekday birthdays
 ~ a / Social Science & Medicine 126 (2015) 59e66
P.A. Pen 63

Table 2
Estimates of excess death rates (%) in a ±10 day neighborhood of the birthday.

Age at death

All ages 1e9 10e19 20e29 30e39 40e49 50e59 60e69 70e79 80e89 90þ

Estimates (%) by number of days before or after the closest birthday

Ten days before 0.13 2.26 0.24 0.56 6.06 2.27 0.43 1.03 0.17 0.25 0.18
p-Value 0.7241 0.7922 0.9639 0.8750 0.0326 0.2412 0.7442 0.2955 0.8345 0.7133 0.8367
Nine days before 0.19 6.19 1.24 2.71 2.92 3.18 0.99 0.59 0.28 0.32 1.09
p-Value 0.6186 0.4891 0.8206 0.4271 0.3185 0.0766 0.4365 0.5585 0.7231 0.6306 0.2374
Eight days before 0.03 5.34 9.60 1.72 5.44 0.55 1.21 0.85 0.20 0.33 0.18
p-Value 0.9313 0.5192 0.0949 0.6240 0.0422 0.7602 0.3662 0.4010 0.8050 0.6131 0.8441
Seven days before 0.82 9.92 1.79 2.75 4.21 0.32 2.02 1.13 0.41 1.40 1.73
p-Value 0.0270 0.2700 0.7310 0.4254 0.1495 0.8608 0.1160 0.2850 0.6182 0.0361 0.0568
Six days before 0.32 5.48 3.00 0.03 0.55 1.65 0.83 0.69 0.23 0.74 1.73
p-Value 0.3992 0.5211 0.5838 0.9929 0.8448 0.3539 0.5374 0.4997 0.7725 0.2892 0.0670
Five days before 0.51 15.34 6.21 5.70 1.57 2.54 0.64 1.17 0.11 0.52 0.41
p-Value 0.1858 0.1013 0.2470 0.0665 0.5872 0.1741 0.6264 0.2829 0.8838 0.4445 0.6782
Four days before 0.29 13.46 0.75 1.71 4.52 1.59 0.22 0.78 0.46 0.13 1.10
p-Value 0.4423 0.1067 0.8922 0.6329 0.1357 0.3780 0.8639 0.4406 0.5600 0.8523 0.2790
Three days before 0.18 3.27 1.63 1.49 4.75 1.83 1.59 0.94 0.22 0.07 0.05
p-Value 0.6606 0.6995 0.7638 0.6811 0.1025 0.3384 0.2183 0.3730 0.7897 0.9195 0.9603
Two days before 0.49 4.64 2.01 2.52 6.45 2.01 0.84 0.54 0.09 0.79 0.25
p-Value 0.1965 0.5892 0.7135 0.4647 0.0256 0.2398 0.5235 0.5941 0.9185 0.2542 0.7952
One day before 0.67 4.54 3.14 1.19 3.78 2.40 0.22 0.41 1.90 0.08 0.79
p-Value 0.0951 0.5753 0.5649 0.7119 0.2038 0.1907 0.8593 0.6884 0.0150 0.9136 0.4194
Birthday 6.72 14.60 16.71 25.39 23.60 14.84 13.16 5.75 5.34 4.60 4.72
p-Value <0.0001 0.1383 0.0040 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001
One day after 0.67 9.92 1.61 21.36 9.18 3.84 2.25 0.04 0.59 0.34 0.70
p-Value 0.0719 0.2857 0.7719 <0.0001 0.0015 0.0344 0.0938 0.9666 0.4549 0.6233 0.4514
Two days after 0.84 8.32 4.11 0.15 0.64 0.79 0.70 0.56 0.34 0.69 2.58
p-Value 0.0319 0.3088 0.5048 0.9654 0.8173 0.6373 0.5951 0.5993 0.6706 0.3538 0.0123
Three days after 0.81 9.56 3.27 1.43 2.19 0.77 1.91 2.13 1.38 0.54 0.24
p-Value 0.0372 0.2813 0.5674 0.6850 0.4292 0.6539 0.1727 0.0437 0.0943 0.4406 0.8045
Four days after 0.45 4.43 0.54 1.68 1.31 0.88 0.03 0.53 0.80 0.04 1.72
p-Value 0.2618 0.5962 0.9195 0.6368 0.6561 0.6296 0.9819 0.5917 0.3574 0.9498 0.0828
Five days after 0.76 6.71 1.76 0.41 2.55 2.66 1.02 0.64 1.14 0.43 1.72
p-Value 0.0635 0.4020 0.7661 0.9115 0.3937 0.1454 0.4314 0.5655 0.1443 0.5486 0.0774
Six days after 0.30 10.22 5.78 2.89 7.38 1.54 0.44 1.29 0.38 1.39 0.70
p-Value 0.4471 0.2685 0.2934 0.3797 0.0077 0.4022 0.7497 0.1963 0.6233 0.0599 0.4817
Seven days after 0.65 10.00 1.77 8.46 1.57 0.74 0.55 0.44 1.64 0.04 1.25
p-Value 0.0881 0.2809 0.7327 0.0240 0.5942 0.6849 0.6877 0.6539 0.0522 0.9560 0.1753
Eight days after 0.10 6.85 0.52 1.84 0.11 0.13 0.68 0.12 0.89 0.44 0.87
p-Value 0.7902 0.3738 0.9268 0.6282 0.9711 0.9425 0.6123 0.9083 0.2701 0.5144 0.3625
Nine days after 0.59 0.63 9.61 6.12 2.60 2.03 2.39 0.15 0.52 0.69 0.18
p-Value 0.1559 0.9418 0.0758 0.0675 0.3659 0.2508 0.0701 0.8819 0.5049 0.3253 0.8500
Ten days after 0.38 8.26 2.36 7.41 0.81 1.95 0.71 1.16 0.05 0.92 0.82
p-Value 0.3127 0.3430 0.6891 0.0443 0.7833 0.2610 0.6206 0.2722 0.9468 0.1897 0.3366
Other days 0.034 0.069 0.009 0.139 0.151 0.065 0.052 0.008 0.032 0.031 0.040
p-Value <0.0001 0.5878 0.9046 0.0045 0.0001 0.0066 0.0051 0.5912 0.0048 0.0013 0.0044
Observations 133,225 133,225 133,225 133,225 133,225 133,225 133,225 133,225 133,225 133,225 133,225
Deaths 25,047,228 49,040 121,083 299,259 455,884 1,094,219 2,060,435 3,362,559 5,763,749 7,768,058 4,072,942

Age at death defined as year of death minus year of birth. p-Values computed using robust standard errors clustered by day of birth.

in panel C, no difference is significant at p < 0.0001, and only six 4. Discussion

differences are significant at p < 0.001: age-at-death categories
40e59 have greater average excess death rates than age-at-death
categories 70þ. For weekend birthdays in panel D, the most sig-
nificant differences are between age-at-death categories 20e39
and 40e90þ (nine have p < 0.0001). In those cases average excess
death rates on weekend birthdays are greater for younger people,
and the differences range between 26.2 and 44.6 percentage points.
In sum, there are significant differences in average excess death
rates across age-at-death categories: younger individuals have
greater average excess death rates on birthdays, particularly on
birthdays that fall on weekends.
The estimates of excess death rates can be translated into death
figures. The estimated number of excess deaths on birthdays over
the period from December 1998 to November 2011 is 4590.
Although average excess death rates are greater among younger
people, the estimated number of excess deaths is greater among
older people. People age 50 or older account for 78.6% of the esti-
mated excess deaths on birthdays.
The aim of this study was to test whether more people than ex-
pected die on their birthdays. Using OLS regressions and controlling
for seasonality of births and deaths, the result is that 6.7%
(p < 0.0001) more people than expected die on their birthdays. The
above-expected death rates on birthdays are not offset by below-
expected death rates in the ten days before the birthday or in the
ten days following. Excess death rates on birthdays are larger among
people under 40 years old, reaching 25.4% (p < 0.0001) for in-
dividuals with an age-at-death of 20e29. The day of the week the
birthday falls on makes a difference. The average excess death rate
on weekend birthdays exceeds that of weekday birthdays for age-at-
death categories under 40 (p ¼ 0.0063 for 1e9 and p < 0.001 for
20e39). Additionally, for those same categories there is evidence of a
positive interaction between birthdays and weekends: the average
excess death rate on weekend birthdays exceeds the sum of the
average excess death rates on non-birthday weekends and on
weekday birthdays (p ¼ 0.0114 for 1e9 and p ¼ 0.0061 for 30e39).
64 ~ a / Social Science & Medicine 126 (2015) 59e66
P.A. Pen

Table 3
Estimates of average excess death rates (%) on birthdays, non-birthdays, weekdays and weekends. Weekend defined as Saturday and Sunday.

Age at death

All ages 1e9 10e19 20e29 30e39 40e49 50e59 60e69 70e79 80e89 90þ

(1) Non-birthday weekdays 0.08 2.01 5.71 6.82 2.44 0.60 0.36 0.58 0.46 0.17 0.02
p-Value <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 0.5494
(2) Non-birthday weekends 0.26 4.90 14.15 16.83 5.88 1.37 1.04 1.51 1.19 0.48 0.00
p-Value <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 0.9910
(3) Weekday birthdays 6.61 3.82 11.16 16.23 16.35 14.58 12.55 6.44 5.63 4.96 4.46
p-Value <0.0001 0.7061 0.0989 0.0006 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 0.0001
(4) Weekend birthdays 7.02 60.68 30.60 48.30 41.73 15.50 14.69 4.01 4.61 3.70 5.36
p-Value <0.0001 0.0057 0.0104 <0.0001 <0.0001 <0.0001 <0.0001 0.0646 0.0057 0.0080 0.0028
Observations 266,450 266,450 266,450 266,450 266,450 266,450 266,450 266,450 266,450 266,450 266,450
Deaths 25,047,228 49,040 121,083 299,259 455,884 1,094,219 2,060,435 3,362,559 5,763,749 7,768,058 4,072,942

Tests for differences in average excess death rates (%)

Weekend birthdays vs non-birthday weekends
(4)  (2) 7.27 55.78 16.45 31.47 35.85 14.14 15.73 5.52 5.80 4.17 5.36
p-Value <0.0001 0.0107 0.1675 0.0002 <0.0001 <0.0001 <0.0001 0.0114 0.0005 0.0029 0.0028
Weekend birthdays vs weekday birthdays
(4)  (3) 0.41 64.50 19.45 32.07 25.38 0.93 2.14 2.43 1.03 1.26 0.90
p-Value 0.6963 0.0063 0.1627 0.0005 0.0004 0.8292 0.5009 0.3442 0.6298 0.4502 0.6757
Weekend birthdays vs non-birthday weekends and weekday birthdays
(4)  (2)  (3) 0.67 59.60 5.30 15.24 19.51 0.44 3.18 0.92 0.17 0.78 0.89
p-Value 0.5250 0.0114 0.7035 0.0982 0.0061 0.9180 0.3168 0.7223 0.9368 0.6383 0.6754

Age at death defined as year of death minus year of birth. p-Values computed using robust standard errors clustered by day of birth.

Table 4
Estimates of average excess death rates (%) on birthdays, non-birthdays, weekdays and weekends. Weekend defined as Friday through Sunday.

Age at death

All ages 1e9 10e19 20e29 30e39 40e49 50e59 60e69 70e79 80e89 90þ

(1) Non-birthday weekdays 0.25 3.39 7.52 8.40 3.43 1.10 0.00 0.27 0.11 0.07 0.20
p-Value <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 0.9654 <0.0001 0.0060 0.0226 <0.0001
(2) Non-birthday weekends 0.29 4.44 9.94 11.06 4.43 1.37 0.08 0.39 0.17 0.07 0.23
p-Value <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 0.3007 <0.0001 0.0008 0.1081 <0.0001
(3) Weekday birthdays 5.89 10.67 9.16 13.24 14.08 10.63 11.21 6.39 5.62 4.26 3.84
p-Value <0.0001 0.3426 0.2255 0.0069 0.0006 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 0.0042
(4) Weekend birthdays 7.83 48.35 26.79 41.60 36.30 20.46 15.76 4.88 4.98 5.05 5.89
p-Value <0.0001 0.0059 0.0037 <0.0001 <0.0001 <0.0001 <0.0001 0.0083 0.0003 <0.0001 <0.0001
Observations 266,450 266,450 266,450 266,450 266,450 266,450 266,450 266,450 266,450 266,450 266,450
Deaths 25,047,228 49,040 121,083 299,259 455,884 1,094,219 2,060,435 3,362,559 5,763,749 7,768,058 4,072,942

Tests for differences in average excess death rates (%)

Weekend birthdays vs non-birthday weekends
(4)  (2) 7.54 43.91 16.84 30.54 31.87 19.09 15.84 5.27 5.15 4.98 5.66
p-Value <0.0001 0.0123 0.0672 <0.0001 <0.0001 <0.0001 <0.0001 0.0045 0.0002 <0.0001 <0.0001
Weekend birthdays vs weekday birthdays
(4)  (3) 1.94 59.02 17.62 28.36 22.22 9.84 4.55 1.51 0.64 0.78 2.06
p-Value 0.0586 0.0049 0.1418 0.0002 0.0008 0.0155 0.1159 0.5449 0.7422 0.6193 0.3123
Weekend birthdays vs non-birthday weekends and weekday birthdays
(4)  (2)  (3) 1.64 54.58 7.68 17.30 17.79 8.46 4.63 1.12 0.47 0.71 1.82
p-Value 0.1076 0.0091 0.5217 0.0239 0.0073 0.0369 0.1093 0.6539 0.8108 0.6505 0.3708

Age at death defined as year of death minus year of birth. p-Values computed using robust standard errors clustered by day of birth.

The contributions of the study can be summarized as follows.
First, it provides estimates of excess death rates on birthdays using
the largest sample to datedroughly ten times the size of the largest
samples among previous studies (Ajdacic-Gross et al., 2012; Phillips
et al., 1992). Second, it presents estimates of daily-level dips and
spikes around birthdays for the entire populationdas opposed to
estimates of weekly- or monthly-level patterns or estimates for a
specific subgroup of the population found in other studies (Skala
and Freedland, 2004). Third, it is the only study that estimates
average excess death rates separately for weekend birthdays and
weekday birthdays.
4.1. Strengths and limitations
The main strength of this study is the size of the sample, which
includes over 25 million individuals in the U.S.dpractically
everyone with an SSN who died in the period from December 1998
to November 2011.
The findings do not seem to be an artifact attributable to date-
entry mistakes or inaccuracies. Differences in estimates across
age-at-death categories and across weekdays and weekends are
hard to explain by such errors. Moreover, the results do not change
when suspiciously frequent dates are removed.
The exclusion of 39,595 deaths from the sample due to the lack
of full dates cannot explain the findings. Adding those deaths back
assuming none of them occurred on birthdaysdthe “worst case”
scenariodwould reduce the average excess death rate on birthdays
only 0.2 percent points, from 6.7% to 6.5%.
The main limitation of the study is that it is silent regarding the
causes of excess deaths and the characteristics of decedents. The
DMF does not include that type of information.
 ~ a / Social Science & Medicine 126 (2015) 59e66
P.A. Pen 65

Table 5
Differences in average excess death rates (percentage points) across age-at-death categories.

Age at death Age at death

1e9 10e19 20e29 30e39 40e49 50e59 60e69 70e79 80e89

A. Differences in average excess death rates on birthdays

10e19 2.11
20e29 10.78 8.68
30e39 8.99 6.89 1.79
40e49 0.24 1.87 10.54* 8.76*
50e59 1.44 3.55 12.22# 10.44# 1.68
60e69 8.86 10.96 19.64z 17.85z 9.10z 7.42y
70e79 9.26 11.37 20.04z 18.26z 9.50z 7.82z 0.40
80e89 10.00 12.11* 20.79z 19.00z 10.24z 8.56z 1.15 0.74
90þ 9.88 11.99* 20.67z 18.88z 10.12z 8.44z 1.03 0.62 0.12
B. Differences in average excess death rates on non-birthday weekends
10e19 9.25z
20e29 11.93z 2.68z
30e39 0.98 8.27z 10.95z
40e49 3.53z 12.78z 15.46z 4.51z
50e59 5.93z 15.18z 17.86z 6.91z 2.40z
60e69 6.41z 15.66z 18.34z 7.39z 2.88z 0.48y
70e79 6.09z 15.34z 18.02z 7.07z 2.56z 0.16 0.32#
80e89 5.37z 14.62z 17.30z 6.35z 1.84z 0.56z 1.04z 0.72z
90þ 4.90z 14.15z 16.83z 5.88z 1.37z 1.04z 1.52z 1.19z 0.48z
C. Differences in average excess death rates on weekday birthdays
10e19 14.97
20e29 20.04 5.07
30e39 20.16 5.19 0.12
40e49 18.39 3.42 1.65 1.77
50e59 16.37 1.39 3.68 3.80 2.03
60e69 10.25 4.72 9.79* 9.91# 8.14# 6.11#
70e79 9.45 5.52 10.59* 10.71# 8.94y 6.92y 0.80
80e89 8.77 6.20 11.27* 11.39# 9.62y 7.59y 1.48 0.68
90þ 8.28 6.69 11.76* 11.89# 10.11y 8.09y 1.98 1.17 0.49
D. Differences in average excess death rates on weekend birthdays
10e19 30.08
20e29 12.38 17.70
30e39 18.95 11.13 6.57
40e49 45.18* 15.10 32.80y 26.23y
50e59 45.99* 15.91 33.61y 27.04z 0.81
60e69 56.67# 26.59* 44.29z 37.72z 11.49# 10.68#
70e79 56.07* 25.99* 43.69z 37.12z 10.89# 10.08# 0.60
80e89 56.98# 26.90* 44.60z 38.03z 11.80# 10.99y 0.31 0.91
90þ 55.32* 25.24* 42.94z 36.37z 10.14* 9.33# 1.35 0.75 1.66

*p < 0.05; #p < 0.01; yp < 0.001; zp < 0.0001. Weekend defined as Saturday and Sunday. Age at death defined as year of death minus year of birth. p-Values computed using
robust standard errors clustered by day of birth and age-at-death category. Differences calculated as the average excess death rate for the age-at-death category of the column,
minus the average excess death rate for the age-at-death category of the row.

4.2. Further research
Further research could focus on three topics. The first topic is the
cause of death, which could be informative of the mechanisms
behind excess death rates on birthdays. For instance, alcohol
intoxication could be related to celebrations, whereas traffic acci-
dents without alcohol involved might be related to more driving on
those days. The second topic is the variation of average excess death
rates on birthdays across demographic and socioeconomic charac-
teristics of decedentsde.g., gender, ethnicity, schooling, and
geographic location. The detection of population subgroups with
the highest average excess death rates could help design public
policies with better targeting. The third topic is the institutional
framework. Some rules might contribute to the different weekends-
vs-weekdays patterns across age groups. For instance, hospital
staffing could be short on weekends, and younger patients might be
more likely to be admitted on those days relative to older patients.
expected death rates in the ten days before the birthday or in the
ten days following. Excess death rates on birthdays are higher
among younger people, especially on weekends.
Greater access to the information contained in birth and death
certificates could help understand the causes of excess deaths on
birthdays, and whether those kinds of deaths can be prevented.
Meanwhile, the patterns found in this study are consistent with
average excess death rates on birthdays being at least in part the
involuntary consequence of celebratory behavior: they are higher
among younger people and on weekends. Public policy could help
prevent some of those deaths with campaigns to create more
awareness of the risks associated with birthday celebrations.
Acknowledgments
The Death Master File used in the research was obtained from
the website SSDMF.INFO.

5. Conclusions References

Abel, E.L., Kruger, M.L., 2009 Feb. Mortality salience of birthdays on day of death in
More people than expected die on their birthday. The above- the Major Leagues. Death Stud. 33 (2), 175e184. http://dx.doi.org/10.1080/
expected death rates on birthdays are not offset by below- 07481180802138936.
66 ~ a / Social Science & Medicine 126 (2015) 59e66
P.A. Pen
Ajdacic-Gross, V., Kno €pfli, D., Landolt, K., Gostynski, M., Engelter, S.T., Lyrer, P.A.,
Gutzwiller, F., Ro€ssler, W., 2012 Aug. Death has a preference for birthdays e an
analysis of death time series. Ann. Epidemiol. 22 (8), 603e606. http://
dx.doi.org/10.1016/j.annepidem.2012.04.016.
Ajdacic-Gross, V., Tran, U.S., Bopp, M., Sonneck, G., Niederkrotenthaler, T.,
Kapusta, N.D., Ro € ssler, W., Seifritz, E., Voracek, M., 2014. Understanding weekly
cycles in suicide: an analysis of Austrian and Swiss data over 40 years. Epi-
demiol. Psychiatr. Sci. http://dx.doi.org/10.1017/S2045796014000195.
Bell, Chaim M., Redelmeier, Donald A., 2001. Mortality among patients admitted to
hospitals on weekends as compared with weekdays. N. Engl. J. Med. 345 (9),
663e668. http://dx.doi.org/10.1056/NEJMsa003376.
Buckles, K.S., Hungerman, D.M., 2013 July 1. Season of birth and later outcomes: old
questions, new answers. Rev. Econ. Stat. 95 (3), 711e724. http://dx.doi.org/
10.1162/REST_a_00314.
Gabriel, M.A., 1992. Anniversary reactions: trauma revisited. Clin. Soc. Work J. 20
(2), 179e192. http://dx.doi.org/10.1007/BF00756507.
Healy, J.D., 2003 Oct. Excess winter mortality in Europe: a cross country analysis
identifying key risk factors. J. Epidemiol. Community Health 57 (10), 784e789.
http://dx.doi.org/10.1136/jech.57.10.784.
Phillips, D.P., Smith, D.G., 1990 Apr 11. Postponement of death until symbolically
meaningful occasions. J. Am. Med. Assoc. 263 (14), 1947e1951. http://dx.doi.org/
10.1001/jama.1990.03440140073034.
Phillips, D.P., Van Voorhees, C.A., Ruth, T.E., 1992 SepeOct. The birthday: lifeline or
deadline? Psychosom. Med. 54 (5), 532e542.
Phillips, D., Barker, G.E., Brewer, K.M., 2010 Oct. Christmas and New Year as risk
factors for death. Soc. Sci. Med. 71 (8), 1463e1471. http://dx.doi.org/10.1016/
j.socscimed.2010.07.024.
Porcelli, P., Fava, G.A., Rafanelli, C., Bellomo, A., Grandi, S., Grassi, L., Pasquini, P.,
Picardi, A., Quartesan, R., Rigatelli, M., Sonino, N., July 2012. Anniversary re-
actions in medical patients. J. Nerv. Ment. Dis. 200 (7), 603e606. http://
dx.doi.org/10.1097/NMD.0b013e31825bfb2e.
Pridemore, W.A., 2004. Weekend effects on binge drinking and homicide: the social
connection between alcohol and violence in Russia. Addiction 99 (8),
1034e1041. http://dx.doi.org/10.1111/j.1360-0443.2004.00762.x.
Reulbach, U., Biermann, T., Markovic, K., Kornhuber, J., Bleich, S., 2007 NoveDec. The
myth of the birthday blues: a population-based study about the association
between birthday and suicide. Compr. Psychiatry 48 (6), 554e557. http://
dx.doi.org/10.1016/j.comppsych.2007.06.006.
Ricciardi, R., Roberts, P.L., Read, T.E., Baxter, N.N., Marcello, P.W., Schoetz, D.J., 2011.
Mortality rate after nonelective hospital admission. Arch. Surg. 146 (5),
545e551. http://dx.doi.org/10.1001/archsurg.2011.106.
Skala, J.A., Freedland, K.E., 2004 MayeJun. Death takes a raincheck. Psychosom.
Med. 66 (3), 382e386.
Williams, A., While, D., Windfuhr, K., Bickley, H., Hunt, I.M., Shaw, J., Appleby, L.,
Kapur, N., 2011. Birthday blues: examining the association between birthday
and suicide in a national sample. Crisis 32 (3), 134e142. http://dx.doi.org/
10.1027/0227-5910/a000067.
Young, D.C., Hade, E.M., 2004 Dec 22. Holidays, birthdays, and postponement of
cancer death. J. Am. Med. Assoc. 292 (24), 3012e3016. http://dx.doi.org/
10.1001/jama.292.24.3012.