Mortality certification and cause-of-death reporting in developing countries.

Certification of death is the foundation for monitoring mortality patterns and documenting the leading causes of death, with the results being used to inform health policies and improve prevention strategies. It has been vital to our understanding of the demographic transition. Despite efforts made by the United Nations, the International Institute for Vital Registration and Statistics and WHO to facilitate the organization and management of civil registration and to standardize reporting and coding practices of cause of death, death registration remains inadequate in several countries and mortality patterns are based on vague estimates. Factors contributing to deficient registration systems include incomplete coverage, late registration, missing data, and errors in reporting or classifying the cause of death. Studies examining these deficiencies in the developing world are rare. Nevertheless, the limited information available suggests that inaccuracies in data derived from death certificates are influenced by various characteristics of the certifier, the certificate, the deceased, and the cause of death (1). The responsibility for non-reporting is shared between the family of a deceased person failing to call a physician and the physician failing to report the cause of death (2), accentuated in countries where there are no laws to enforce the obligations of the certifying physician. Moreover, the majority of medical schools in these countries do not give instruction about the process of mortality certification, so physicians have little understanding of the importance of completing death certificates. Reporting is less accurate when death is sudden, attributable to stigmatized conditions, or occurs among certain minorities, social classes and older age groups (3, 4). Cause of death may also be distorted when doctors in developing countries who have been trained in diverse local and foreign educational systems use different terminology in the native language for the same diagnosis (5). The lack of reliable mortality statistics has prompted public health workers and researchers to search for alternative methodologies. These include the sample registration system used in India, in which events are recorded routinely from a representative sample of the population; demographic surveillance systems using verbal autopsies to assess cause of death in Africa and South-East Asia, where most people die at home without having had contact with the health care system; and, in some cases, verbal autopsies at the national level to assess mortality in children under five years of age (6). Researchers differ, however, in the format and content of their verbal autopsies, so the validity and reliability of the data remains questionable and findings are only relevant to the particular social, economic and cultural climate. While these approaches can draw some valid inferences, they have their limits, and comprehensive, comparable cause-of-death statistics from vital registration remain a necessity for all countries. …