The COVID-19 Pandemic: Effects on Civil Registration of Births and Deaths and on Availability and Utility of Vital Events Data.

The complex and evolving picture of COVID-19-related mortality highlights the need for data to guide the response. Yet many countries are struggling to maintain their data systems, including the civil registration system, which is the foundation for detailed and continuously available mortality statistics. We conducted a search of country and development agency Web sites and partner and media reports describing disruptions to the civil registration of births and deaths associated with COVID-19 related restrictions.We found considerable intercountry variation and grouped countries according to the level of disruption to birth and particularly death registration. Only a minority of the 66 countries were able to maintain service continuity during the COVID-19 restrictions. In the majority, a combination of legal and operational challenges resulted in declines in birth and death registration. Few countries established business continuity plans or developed strategies to deal with the backlog when restrictions are lifted.Civil registration systems and the vital statistics they generate must be strengthened as essential services during health emergencies and as core components of the response to COVID-19.

Routine mortality surveillance to identify the cause of death pattern for out-of-hospital adult (aged 12+ years) deaths in Bangladesh: introduction of automated verbal autopsy.

BACKGROUND: In Bangladesh, a poorly functioning national system of registering deaths and determining their causes leaves the country without important information on which to inform health programming, particularly for the 85% of deaths that occur in the community. In 2017, an improved death registration system and automated verbal autopsy (VA) were introduced to 13 upazilas to assess the utility of VA as a routine source of policy-relevant information and to identify leading causes of deaths (COD) in rural Bangladesh. METHODS: Data from 22,535 VAs, collected in 12 upazilas between October 2017 and August 2019, were assigned a COD using the SmartVA Analyze 2.0 computer algorithm. The plausibility of the VA results was assessed using a series of demographic and epidemiological checks in the Verbal Autopsy Interpretation, Performance and Evaluation Resource (VIPER) software tool. RESULTS: Completeness of community death reporting was 65%. The vast majority (85%) of adult deaths were due to non-communicable diseases, with ischemic heart disease, stroke and chronic respiratory disease comprising about 60% alone. Leading COD were broadly consistent with Global Burden of Disease study estimates. CONCLUSIONS: Routine VA collection using automated methods is feasible, can produce plausible results and provides critical information on community COD in Bangladesh. Routine VA and VIPER have potential application to countries with weak death registration systems.

Estimating causes of death where there is no medical certification: evolution and state of the art of verbal autopsy.

Over the past 70 years, significant advances have been made in determining the causes of death in populations not served by official medical certification of cause at the time of death using a technique known as Verbal Autopsy (VA). VA involves an interview of the family or caregivers of the deceased after a suitable bereavement interval about the circumstances, signs and symptoms of the deceased in the period leading to death. The VA interview data are then interpreted by physicians or, more recently, computer algorithms, to assign a probable cause of death. VA was originally developed and applied in field research settings. This paper traces the evolution of VA methods with special emphasis on the World Health Organization's (WHO)'s efforts to standardize VA instruments and methods for expanded use in routine health information and vital statistics systems in low- and middle-income countries (LMICs). These advances in VA methods are culminating this year with the release of the 2022 WHO Standard Verbal Autopsy (VA) Toolkit. This paper highlights the many contributions the late Professor Peter Byass made to the current VA standards and methods, most notably, the development of InterVA, the most commonly used automated computer algorithm for interpreting data collected in the WHO standard instruments, and the capacity building in low- and middle-income countries (LMICs) that he promoted. This paper also provides an overview of the methods used to improve the current WHO VA standards, a catalogue of the changes and improvements in the instruments, and a mapping of current applications of the WHO VA standard approach in LMICs. It also provides access to tools and guidance needed for VA implementation in Civil Registration and Vital Statistics Systems at scale.

Evaluation of approaches to strengthen civil registration and vital statistics systems: A systematic review and synthesis of policies in 25 countries.

BACKGROUND: Civil registration and vital statistics (CRVS) systems play a key role in upholding human rights and generating data for health and good governance. They also can help monitor progress in achieving the United Nations Sustainable Development Goals. Although many countries have made substantial progress in strengthening their CRVS systems, most low- and middle-income countries still have underdeveloped systems. The objective of this systematic review is to identify national policies that can help countries strengthen their systems. METHODS AND FINDINGS: The ABI/INFORM, Embase, JSTOR, PubMed, and WHO Index Medicus databases were systematically searched for policies to improve birth and/or death registration on 24 January 2017. Global stakeholders were also contacted for relevant grey literature. For the purposes of this review, policies were categorised as supply, demand, incentive, penalty, or combination (i.e., at least two of the preceding policy approaches). Quantitative results on changes in vital event registration rates were presented for individual comparative articles. Qualitative systematic review methodology, including meta-ethnography, was used for qualitative syntheses on operational considerations encompassing acceptability to recipients and staff, human resource requirements, information technology or infrastructure requirements, costs to the health system, unintended effects, facilitators, and barriers. This study is registered with PROSPERO, number CRD42018085768. Thirty-five articles documenting experience in implementing policies to improve birth and/or death registration were identified. Although 25 countries representing all global regions (Africa, the Americas, Southeast Asia, the Western Pacific, Europe, and the Eastern Mediterranean) were reflected, there were limited countries from the Eastern Mediterranean and Europe regions. Twenty-four articles reported policy effects on birth and/or death registration. Twenty-one of the 24 articles found that the change in registration rate after the policy was positive, with two supply and one penalty articles being the exceptions. The qualitative syntheses identified 15 operational considerations across all policy categories. Human and financial resource requirements were not quantified. The primary limitation of this systematic review was the threat of publication bias wherein many countries may not have documented their experience; this threat is most concerning for policies that had neutral or negative effects. CONCLUSIONS: Our systematic review suggests that combination policy approaches, consisting of at least a supply and demand component, were consistently associated with improved registration rates in different geographical contexts. Operational considerations should be interpreted based on health system, governance, and sociocultural context. More evaluations and research are needed from the Eastern Mediterranean and Europe regions. Further research and evaluation are also needed to estimate the human and financial resource requirements required for different policies.

Improving coverage of civil registration and vital statistics, Bangladesh.

PROBLEM: Bangladesh has no national system for registering deaths and determining their causes. As a result, policy-makers lack reliable and complete data to inform public health decisions. APPROACH: In 2016, the government of Bangladesh introduced a pilot project to strengthen the civil registration and vital statistics system and generate cause of death data in Kaliganj Upazila. Community-based health workers were trained to notify births and deaths to the civil registrar, and to conduct verbal autopsy interviews with family members of a deceased person. International experts in cause-of-death certification and coding trained master trainers on how to complete the international medical certificate of cause of death. These trainers then trained physicians and coders. LOCAL SETTING: Kaliganj Upazila has an estimated population of 304 600, and 5600 births and 1550 deaths annually. Health assistants and family welfare assistants make regular visits to households to track certain health outcomes. RELEVANT CHANGES: Following the start of the project in 2016, the number of births registered within 45 days rose from 873 to 4630 in 2018. The number of deaths registered within 45 days increased from 458 to 1404. During this period, health assistants conducted 7837 verbal autopsy interviews. Between January 2017 and December 2018, 105 master trainers and more than 7000 physicians were trained to complete the international medical certificate of cause of death and they completed more than 12 000 certificates. LESSONS LEARNT: Training community-based health workers, physicians and coders were successful approaches to improve death registration completeness and availability of cause-of-death data.

New challenges for verbal autopsy: Considering the ethical and social implications of verbal autopsy methods in routine health information systems.

Verbal autopsy (VA) methods are designed to collect cause-of-death information from populations where many deaths occur outside of health facilities and where death certification is weak or absent. A VA consists of an interview with a relative or carer of a recently deceased individual in order to gather information on the signs and symptoms the decedent presented with prior to death. These details are then used to determine and assign a likely cause-of-death. At a population level this information can be invaluable to help guide prioritisation and direct health policy and services. To date VAs have largely been restricted to research contexts but many countries are now venturing to incorporate VA methods into routine civil registration and vital statistics (CRVS) systems. Given the sensitive nature of death, however, there are a number of ethical, legal and social issues that should be considered when scaling-up VAs, particularly in the cross-cultural and socio-economically disadvantaged environments in which they are typically applied. Considering each step of the VA process this paper provides a narrative review of the social context of VA methods. Harnessing the experiences of applying and rolling out VAs as part of routine CRVS systems in a number of low and middle income countries, we identify potential issues that countries and implementing institutions need to consider when incorporating VAs into CRVS systems and point to areas that could benefit from further research and deliberation.

Global estimates of country health indicators: useful, unnecessary, inevitable?

BACKGROUND: The MDG era relied on global health estimates to fill data gaps and ensure temporal and cross-country comparability in reporting progress. Monitoring the Sustainable Development Goals will present new challenges, requiring enhanced capacities to generate, analyse, interpret and use country produced data. OBJECTIVE: To summarize the development of global health estimates and discuss their utility and limitations from global and country perspectives. DESIGN: Descriptive paper based on findings of intercountry workshops, reviews of literatureon and synthesis of experiences. RESULTS: Producers of global health estimates focus on the technical soundness of estimation methods and comparability of the results across countries and over time. By contrast, country users are more concerned about the extent of their involvement in the estimation process and hesitate to buy into estimates derived using methods their technical staff cannot explain and that differ from national data sources. Quantitative summaries of uncertainty may be of limited practical use in policy discussions where decisions need to be made about what to do next. CONCLUSIONS: Greater transparency and involvement of country partners in the development of global estimates will help improve ownership, strengthen country capacities for data production and use, and reduce reliance on externally produced estimates.