Sample Registration of Vital Events with Verbal Autopsy: A Renewed Commitment to Measuring and Monitoring Vital Statistics

Article excerpt

Making people count

Registration of births, recording deaths by age, sex and cause, and calculating mortality levels and differentials are fundamental to evidence-based health policy, monitoring and evaluation. Yet few of the countries with the greatest need for these data have functioning systems to generate them despite legislation providing for the establishment and maintenance of vital registration systems. Reliable data on age-, sex- and cause-specific mortality are lacking in more than half of all countries (1). Sample vital registration (SVR) systems are a viable solution to this predicament. SVR complements other sources of data, and should be considered a necessary part of comprehensive national health and demographic information systems.

Briefly, SVR is a community-based system implemented in a nationally representative cluster sample (Fig. 1). The three basic functions of SVR are: continuous enumeration of births, deaths and migrations; active follow-up of all perinatal deaths (i.e. stillbirths and infant deaths within 1 week of birth) to determine probable cause of death; and periodic independent re-enumeration of populations and vital events (births and deaths) to verify resident populations and assess completeness of registration (2). While these ideas are not new (3), there has been little adoption and promotion of SVR to date. Although the main outputs of interest from SVR are data on mortality, fertility and other demographic characteristics, optional nested or "rider" surveys using biomarkers or validated measures of poverty status (4, 5), for example, can be implemented in SVR systems and can complement statistics obtained from other sources.


Techniques used in SVR, including the verbal autopsy (VA) methods used to determine probable cause of death, are imperfect. (A VA is a questionnaire administered to the caregivers or family members of deceased persons to elicit signs and symptoms and their durations, and other pertinent information about the decedent in the period before death.) Nevertheless, the demand for and use of VA data by a variety of sources is rapidly gaining importance in the quest for evidence needed to set global health priorities (6-9).

SVR can be seen as leading towards universal vital registration or can serve as a permanent, stand-alone system. Indeed, SVR is already the best source of representative mortality statistics in China and India, and partial coverage has been obtained through a "sentinel" vital registration system in the United Republic of Tanzania (1, 6). National statistics offices and ministries of health in four African and two Asian countries are evaluating the costs and benefits of SVR and have begun to plan for and establish systems.

Status of vital registration and medical certification of deaths

The registration and documentation of vital events by civil authorities is a key public health function of a vital statistics system. This function, commonly termed "civil registration" or "vital registration" (VR), ideally serves a dual purpose: first, it meets legal requirements to establish civil status and protect individual rights; second, it should serve as a source of data for informing policy and planning. Unfortunately, relatively few VR systems produce data suitable for this purpose.

Births are generally not registered with sufficient completeness to provide accurate statistics; in sub-Saharan Africa registered births made up less than 1% of total estimated births in 2000 (10). There are also persistent disparities in death registration and in the quality of medical certification of causes. Of 115 Member States reporting mortality statistics to WHO, only 23 had high coverage, used the International Statistical Classification of Diseases and Related Health Problems (ICD) to assign causes, and reported a minimal proportion deaths as being due to ill-defined causes (1). …