Cross-national commonalities and differences in place of death from international comparative death certificate studies: a systematic review

Background Place of death is a key population health indicator routinely recorded in death certificates. Monitoring place of death can help identify health inequalities. Studies using death certificates have examined place of death across countries, yet no synthesis exists. We aimed to identify cross-national commonalities and differences in place of death classifications, distributions and associated factors in multi-country comparative death certificate studies. Methods We searched MEDLINE, PsycINFO, EMBASE, CINAHL, Web of Science and grey literature for death certificate studies comparing place of death across two or more countries. We extracted data on countries, years, causes of death, place of death and associated factors, assessed study quality using the Newcastle-Ottawa Scale and narratively synthesised findings. Results We included 19 studies (68,433 − 100 million deaths; 1957–2021) examining place of death and associated factors across 72 countries (27 low- and middle-income). Despite heterogeneity, hospital/health institution (60 countries, 17 studies) and home (62 countries, 12 studies) were the most frequently analysed place of death categories. Hospital/health institution deaths ranged from 11% (Albania) to 87% (Taiwan) and home deaths ranged from 11% (Malta) to 83% (Uganda). Fewer studies examined deaths at long-term care facility/nursing home and palliative care/hospice facility. Age, sex/gender and cause of death were the most frequently examined factors. Oldest age was generally associated with death at home and long-term care facility/nursing home, while findings on sex/gender were inconsistent. Cancer was consistently associated with lower odds of death in long-term care facility/nursing home and markedly higher odds of death in palliative care/hospice facility (relative risk 2.5–32). Country differences persisted after adjustment for confounding factors, including individual characteristics and healthcare resource availability. Conclusion Our findings show cross-country variation in place of death classifications, distribution, and associated factors. Persistent country differences suggest that broader health and care system and policy contexts may influence where people die, underscoring concerns about global health inequalities. An internationally harmonised place of death classification may help improve health monitoring and support future epidemiological research.