Maternal death registration

 

Definition:

The use of standard definitions for maternal and neonatal death and causes of death is critical for case ascertainment. The World Health Organization (WHO) applies the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) to deaths during pregnancy, childbirth and the puerperium – ICD-Maternal Mortality (ICD-MM) (WHO, 2012). The WHO application of the ICD-10 to deaths during the perinatal period (ICD-PM) provides a framework for the consistent collection, analysis, and interpretation of maternal and neonatal deaths (WHO, 2016).

The succinct definition is percentage of maternal deaths registered with cause of death specified based on ICD-MM codes (WHO, 2018).

Data sources:

There are three data sources for this indicator:

1. Civil registration and vital statistics (CRVS) and other routine national surveillance systems
2. Routinely collected administrative data other than CRVS
3. Population-based household surveys.

Civil registration and vital statistics systems

A well-functioning and integrated national or subnational CRVS system will universally register and certify vital events, including live births, stillbirths and deaths that occur in the country or administrative area. Birth and death certificates are a part of the CRVS system, allowing the compilation, analysis and dissemination of information through vital statistics agencies, including population characteristics (e.g., sex, date of birth or death, place of birth or death, place of usual residence) and cause-of-death information. Some CRVS systems will also register and certify other important vital events within the population, such as adoptions, marriages, and divorces (UN, 2014).

Data from CRVS are the preferred data source for this indicator when the system freely and universally records vital events and data are recorded in a systematic manner that ensures high data quality for both the public and private health sectors and regardless of location of birth or death (e.g., health facility or community-based births and deaths).

Key source of data: The main source of data for this indicator involves several steps and varies based on the policies and procedures of the national or subnational CRVS within health facilities and/or within communities. Declaration of deaths are obtained: (a) through forms completed by health personnel at health facilities; or (b) through community-based sources, including death registration forms. Either paper or electronic forms containing this information are then submitted to the relevant civil authorities and vital statistics agencies, which have the responsibility to officially record the death and death characteristics, such as name, sex, date and place of death, age, nationality, place of residence and cause of death. At the national or subnational level, the civil authority and vital statistics agency issues death certificates. National or subnational civil authorities and vital statistics agencies are responsible for reporting of this indicator.

Indicator definition and calculation: The indicator is calculated as the percentage of maternal deaths registered with cause of death specified based on ICD-MM codes, expressed as a percentage amongst total estimated number of maternal deaths.

Numerator: Number of maternal deaths registered with cause of death specified based on ICD-MM codes.

Denominator: Total number of maternal deaths.

Where information on total deaths is not available because of incomplete civil registration, the denominator for total deaths can be estimated by extrapolating data from a recently conducted census or on the basis of information about mortality rates derived from population-based household surveys.

Frequency of measurement: Within CRVS, this indicator is monitored at a national or subnational level on an annual basis. The data can be compiled and aggregated sub-nationally to provide national-level data.

Disaggregation: By sex, age, place of residence (e.g., urban, rural), subnational administrative units (e.g., districts, provinces, regions), socioeconomic status (e.g., education level, occupation), place of death, cause of death, and type of reporting source (health facility, community).

Missing values: Missing values are usually not known or not reported. To ascertain missing data and to perform data quality assurance, estimates of the total number of deaths in a country or administrative area can be compared with the absolute number of registered deaths in the same period.

Routinely collected administrative data

Data from routinely collected and compiled administrative data sources will provide information as recorded in medical charts/ records or registers and are entered into national and/or subnational health management information systems (HMIS).

Data from health information systems may collect information on the number of deaths officially registered, as well as the cause of death. Routinely collected administrative data and health facility statistics are the preferred data source in settings where the CRVS is non-functioning and there is a high utilization of health facility services and data are recorded in a manner that ensures good data quality for both the public and private health sectors. The compiled data in the national HMIS or District Health Information System (DHIS2) should include data from both public and private health sectors, especially when the private sector is a substantial source of service provision to the population. In settings where utilization of health facilities is not high (e.g., settings with a high prevalence of births or deaths occurring at home), data may suffer from incompleteness if information about deaths occurring outside facilities is not captured. In addition, there are often challenges in accurately measuring the numerator and the denominator when routine HMIS data are used to measure this indicator.

Key source of data: Administrative data sources include health facility and health services data abstracted from medical records, including health services registers. Relevant information about the death is recorded by health personnel within health facilities on paper forms completed by health personnel and/or through an electronic medical record. Data from paper or electronic sources are entered or abstracted into a database or registry and are compiled and analyzed within the national and/or subnational HMIS. The Ministry of Health (MoH) and/or National Statistical Offices (NSO) are usually responsible for the reporting of this indicator.

Indicator definition and calculation: The indicator is calculated as the percentage of maternal deaths registered with cause of death specified based on ICD-MM codes, expressed as a percentage amongst total estimated number of maternal deaths.

Numerator: Number of maternal deaths registered with cause of death specified based on ICD-MM codes.

Denominator: Total number of maternal deaths.

Frequency of measurement: This indicator can be calculated on an annual basis, or may be tracked on a more frequent and ongoing basis (e.g., monthly, quarterly), depending on facility, subnational and national processes for data entry, compilation and analysis. As a guide, the recommended frequency of measurement based on reporting level is outlined below:

• Facility level: Monthly, quarterly, or as needed based on the country and/or facility need
• Subnational (first and second administrative) level: Monthly or quarterly
• National level: Annually (data can be aggregated to provide national-level data).

Disaggregation: By age, place of residence (e.g., urban, rural), socioeconomic status (e.g., education level, wealth quintile), timing of death, place of death, cause of death, level of facility and location of facility (e.g., urban, rural).

Missing values: Missing values are usually not known or not reported.

Population-based household surveys and censuses

Population-based household survey data or censuses are the preferred data source where there is a non-functional CRVS or administrative data system, in settings with a low utilization of health facility services or where private health sector data are excluded from routinely collected administrative data. In the absence of complete death registration, information on maternal, neonatal and child mortality can be collected through population-based household surveys collected through nationally or sub-nationally representative and statistically sound questionnaires, such as the:

• Demographic Health Surveys (DHS)
• Multiple Indicator Cluster Surveys (MICS)
• Reproductive Health Surveys (RHS)
• Other household surveys with a similar methodological design.

Key source of data: Depending on survey methodology, a household questionnaire is used to collect information on characteristics of the usual residents and visitors who slept in the household the night before interview, as well as to identify members of the household eligible for an individual interview, such as women and men of reproductive age and children under the age of 5 years old.

Mortality can be estimated using a few different approaches (Boerma and Mathers, 2010). The first approach is by obtaining information on all deaths of any member in the household. The household survey is designed to collect information on household recent deaths within the past 12 months, or other defined reference period, including the name, sex, age at death and reported cause of death.

Another approach is the sibling method, whereby information is obtained on a full sibling history through individual interviews with eligible women (aged 15–49) who are residents of the household. The information collected for each sibling (all siblings born to the woman’s natural mother) includes: name; sex (male, female); whether still alive (yes, no); if still alive, age in years; and if dead, number of years that have elapsed since the sibling died, and age at death. If the sibling who died was the eligible woman’s sister (female) above the age of 12 years old at the time of death, separate questions are asked to identify if the sister died either (a) while pregnant; (b) during childbirth; or (c) within two months after the end of pregnancy or childbirth. If the death was reported to have occurred after pregnancy or childbirth, the woman is asked the number of days after the end of pregnancy or childbirth when the sister died. To ascertain whether the death was directly related to pregnancy or childbirth, further questions are asked to determine if the death was either due to an act of violence or due to an accident.

For neonatal, infant, or under-5 child mortality, the approach is to obtain information on a full birth history, whereby eligible women (15– 49 years old) are asked to report the names and relevant information for all live births they have had in their lifetime.1 The birth history does not include stillbirths, miscarriages, or abortions. For each of the children the woman has given birth to, they are asked to record in chronological order from first to last birth: the sex (male or female), multiple births (singleton or multiple), the date of birth (day, month, and year) and if the child is currently alive (yes or no) and if no longer alive, the age at death in days, months, or years.

Information on whether the death was registered or if a certificate of death was issued is not currently asked in the current iterations of the MICS or DHS questionnaires. However, information on death registration may be customized and formally added to future iterations of these surveys. The MoH and NSO typically conduct household surveys and compile, analyze and report the results for this indicator in collaboration with the survey program (e.g., DHS, MICS, RHS) and funding agency.

Indicator definition and calculation: The indicator is calculated as the percentage of deaths (by age and sex) among the total number of population during a specified time period.

Numerator: Number of deaths2 (by age and sex) during a specified time period.

Denominator: Total number of population by age and sex during a specified time period.

Frequency of measurement: Household surveys are typically conducted every 3–5 years.

Disaggregation at population level: By sex, age, place of birth, place of residence (e.g., urban, rural), subnational administrative units (e.g. districts, provinces, regions), socioeconomic status (e.g. education level, household wealth quintile), place of death and cause of death.

Missing values: Missing values are not included.

Purpose:

Vital statistics include the collection of data on events in the lifetime of a person, including pertinent characteristics of those events, the person involved in the event, and those concerned. A complete CRVS system, as defined by the UN, includes every vital event concerning life and death that has occurred to members of the population of the defined area within the specified time period (UN, 2016). Universal, accurate and timely death registration and cause-of-death information is important to facilitate health systems planning and provision of health services delivery (UN, 2016). Birth and death certificates should be issued for all births and deaths as part of the CRVS system, including recording of population characteristics (e.g., sex, date of birth or death, place of birth or death, place of usual residence) and cause-of-death information.

Death registration, like birth registration, protects the rights of women of reproductive age and newborns worldwide (UN, 2014). For women and girls who die from preventable complications during pregnancy or childbirth, death registration and death certificates may identify where, when, and why these deaths are occurring in order to prevent similar deaths from occurring in the future. For newborns who may have lost their mother during childbirth or otherwise, death registration and death certificates are legal documents that may allow the transfer of inheritance, land ownership, or other assets to the children, helping to close the gap on the cycle of poverty.

Information collected in the CRVS provides legal and protective advantages to the person as well as information to the country for medical and health program decision-making. Death registration and data on cause of death provide information to help identify how, where, when, and why women, girls and newborns are dying. Compilation and analysis of death registration and cause-of-death information on a timely basis facilitates systems planning and guides decision-making, such as planning and allocation of funding for resources, infrastructure and services aimed at preventing deaths from occurring and improving the health and survival of the population, particularly, for women, girls and newborns (UN, 2016).

The death registration indicator is a measure of a country’s capacity to plan and implement an effective civil registration system and vital statistics agency that are able to accurately and systematically report vital events, such as births and deaths. Statistics based on crude death rate via the death registration indicator form the demographic profile of communities, regions, and countries. The number of deaths registered can be used to derive population-level indicators of health status, such as infant, child and maternal mortality, and population growth. In turn, these indicators inform health system planning and policy and the allocation of funds and resources for programs and interventions aimed at improved maternal, newborn and child health and survival. The Sustainable Development Goals (SDG) agenda highlights the importance of continued momentum towards improving maternal and newborn health by setting, under SDG goal 17, targets for achieving 100% birth registration and 80% death registration by 2030 (UN, 2020). However, less than half of countries in the world have above 80% coverage of death registration or higher, and the quality of reporting of this indicator varies greatly between and within countries, particularly in countries without effective civil registration systems in place (WHO, 2018). Information about death registration and cause of death is also important for monitoring and reporting of SDG 3 – where death registration is the only source that can provide information on cause of death related to maternal, neonatal and child mortality indicators. Comparisons of the prevalence of death registration at the national or subnational level over time can be used to identify areas where improvements in the capture and reporting of vital events are needed.

Issues:

Civil registration and vital statistics systems

Death registration is part of a national and/or subnational CRVS system. However, CRVS systems are either non-existent and/or the complete coverage, accuracy and timeliness of civil registration systems is a major issue in many countries worldwide. To assess the completeness of the CRVS system, evaluations should be conducted to ascertain the quality of the system, as recommended by the United Nation’s revised Principles and Recommendations for a Vital Statistics System (UN, 2014). As a result, it is common for deaths not to be registered due to lack of a legal framework within civil authorities and vital statistics agencies or a functioning CRVS system, especially when it comes to deaths that occur at home or in the community as opposed to a health facility. Even in countries with functional CRVS systems and legal frameworks in place, missing or unregistered deaths still occur due to health professionals and/or family members not knowing the requirement to register deaths.

Data collected from administrative and other routine data systems

Administrative data may suffer from poor quality such as irregularities in report generation, data duplication and inconsistencies (Abouzahr and Boerma, 2005). Reporting challenges exist at the facility level given data quality issues, including incomplete, inaccurate and lack of timely data due to insufficient capacity in the health system or inadequate system design, such as no integration with the private sector.

Many HMIS databases or registries are event-based and only include information on deaths within a health facility. In settings where routine HMIS data lack information on deaths that occur outside the public sector – for example, in homes or in private sector facilities – the total number of deaths recorded in the HMIS should not serve to estimate the denominator for this indicator.

Data collected through household surveys

The systematic recording of deaths in many countries remains a serious challenge. In the absence of reliable CRVS systems/ administrative data, household surveys have become the key source of data to monitor levels and trends of death registration. In most low-and middle-income countries, such surveys represent the sole source of this information.

Information on whether the death was registered or if a certificate of death was issued is not currently asked in the current iterations of the MICS or DHS questionnaires, which compromises the ability to measure the “death registration” indicator and instead allows for measurement of mortality indicators. For surveys that do collect information on death certificates or that plan to collect this information in the future, it is anticipated that there will be similar challenges, as experienced with collection of information on birth registration in household surveys. For example, respondents to the survey may not always be clear on who the civil authorities in charge of the death registrations are and may misinterpret notifying a church or village chief of a death as formal registration. Household surveys should customize questionnaires by naming the specific national authority responsible for registration. However, even then, confusion about the death registration process may occur. Similarly, questions regarding the possession of a death certificate may also be the source of erroneous data since respondents may confuse a death certificate with another document.

Respondents to the survey may not always understand that the surveyors are interested in collecting information on household members who are no longer alive or those who do not live in the dwelling during interviews regarding full sibling or birth history. Additionally, many respondents will not report on deaths and cause of deaths of household and family members due to cultural sensitivities.

References:

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2. Principles and recommendations for a vital statistics system. Revision 3. New York: United Nations; 2014 (https://unstats.un.org/unsd/demographic/standmeth/principles/M19Rev3en. pdf)
3. The WHO application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD-MM. Geneva: World Health Organization; 2012 (https://apps.who.int/iris/bitstream/ handle/10665/70929/9789241548458_eng.pdf)
4. The WHO application of ICD-10 to deaths during the perinatal period: ICD-PM. Geneva: World Health Organization; 2016 (https://apps.who.int/iris/bitstream/hand le/10665/249515/9789241549752-eng.pdf)
5. Global reference list of 100 core health indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/handle/10665/259951/WHO-HIS-IER-GPM-2018.1-eng.pdf)
6. The DHS Program [website]. Rockville: ICF International; 2020 (http://www.dhsprogram. com/, accessed 21 October 2020)
7. Multiple Indicator Cluster Surveys (MICS) [website]. New York: UNICEF; 2020 (http://mics. unicef.org)
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9. Sustainable Development Goals [website]. New York: United Nations; 2020 (http://www. un.org/sustainabledevelopment/sustainable-development-goals/)
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Health System Strengthening