Completeness of death registration in the Civil Registration System, India (2005 to 2015)

Neonatal, Infant, and Child Mortality in India: Progress and Future Directions

In India, considerable progress has been made in reducing child mortality rates. Despite this achievement, wide disparities persist across and socio-economic strata, and persistent challenges, such as malnutrition, poor sanitation, and lack of clean water. This paper provides a comprehensive review of the state of child health in India, examining key risk factors and causes of child mortality, assessing the coverage of child health interventions, and highlighting critical public health programs and policies. The authors also discuss future directions and recommendations for bolstering ongoing efforts to improve child health. These include state- and region-specific interventions, prioritizing social determinants of health, strengthening data systems, leveraging existing programs like the National Health Mission (NHM) and Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY), and the proposed Public Health Management Cadre (PHMC). The authors argue that reducing child mortality requires not only scaled-up interventions but a comprehensive approach that addresses all dimensions of health, from social determinants to system strengthening.

Stillbirth undercount in the sample registration system and national family health survey, India

Objective

To assess the extent of under-reporting of stillbirths in India by comparing stillbirth and neonatal mortality rates from two national data sources and to review possible reasons for undercounting of stillbirths.

Methods

We extracted data on stillbirth and neonatal mortality rates from the annual reports for 2016-2020 of the sample registration system, the Indian government's main source of vital statistics. We compared the data with estimates of stillbirth and neonatal mortality rates from the fifth round of the Indian national family health survey covering events from 2016-2021. We reviewed the questionnaires and manuals from both surveys and compared the sample registration system's verbal autopsy tool with other international tools.

Findings

The stillbirth rate for India from the national family health survey (9.7 stillbirths per 1000 births; 95% confidence interval: 9.2-10.1) was 2.6 times higher than the average rate reported in the sample registration system over 2016-2020 (3.8 stillbirths per 1000 births). However, neonatal mortality rates in the two data sources were similar. We identified issues with the definition of stillbirth, documentation of gestation period, and categorization of miscarriages and abortions that could result in undercounting stillbirths in the sample registration system. In the national family health survey only one adverse pregnancy outcome is documented, irrespective of the number of adverse pregnancy outcomes in the given period.

Conclusion

For India to attain its 2030 target of single-digit stillbirth rate and to monitor actions to end preventable stillbirths, efforts are needed to improve the documentation of stillbirths in its data collection systems.

Non-communicable diseases as a major contributor to deaths in 12 tribal districts in India

Background & objectives

Non-communicable diseases (NCDs) are the leading cause of death in India. Although studies have reported a high prevalence of NCD in tribal populations, there are limited data pertaining mortality due to NCDs. Therefore, in this study we estimated the proportion of deaths due to NCDs among 15 yr and older age group in tribal districts in India.

Methods

We conducted a community-based survey in 12 districts (one per State) with more than 50 per cent tribal population. Data were collected using a verbal autopsy tool from the family member of the deceased. The estimated sample size was 452 deaths per district. We obtained the list of deaths for the reference period of one year and updated it during the survey. The cause of death was assigned using the International Classification of Diseases-10 classification and analyzed the proportions of causes of death. The age-standardized death rate (ASRD) was also estimated.

Results

We surveyed 5292 deaths among those above 15 years of age. Overall, NCDs accounted for 66 per cent of the deaths, followed by infectious diseases (15%) and injuries (11%). Cardiovascular diseases were the leading cause of death in 10 of the 12 sites. In East Garo Hills (18%) and Lunglei (26%), neoplasms were the leading cause of death. ASRD due to NCD ranged from 426 in Kinnaur to 756 per 100,000 in East Garo Hills.

Interpretation & conclusions

The findings of this community-based survey suggested that NCDs were the leading cause of death among the tribal populations in India. It is hence suggested that control of NCDs should be one of the public health priorities for tribal districts in India.

Performance barriers of Civil Registration System in Bihar: An exploratory study

Objectives

Vital statistics generated by the Civil Registration System (CRS) are essential for developing healthcare interventions at all administrative levels. Bihar had one of the lowest levels of mortality registration among India’s states. This study investigates CRS’s performance barriers from the perspective of CRS staff and community members in Bihar.

Methods

We conducted a primary qualitative survey in the two districts of Bihar during February-March 2020 with CRS staff (n = 15) and community members (n = 90). We purposively selected the Patna and Vaishali districts of Bihar for the survey. Thematic analysis was done to identify the pattern across the data using the Atlas-ti software.

Results

Most participants showed a good understanding of registration procedures and birth and death registration benefits. The perceived need for death registration is lower than birth registration. Birth registration was higher among female children than male children. We found that most participants did not report children or adult female death due to lack of financial or property-related benefits. Most participants faced challenges in reporting birth and death due to poor delivery of services at the registration centres, higher indirect opportunity cost, and demand of bribes by the CRS staff for providing certificates. We found a lack of adequate investment, shortage of dedicated staff, and limited computer and internet services at the registration centres.

Conclusions

Poor data on birth and death registration could lead decision-makers to target health services inappropriately. Strengthening health institutions’ linkage with the registration centres, mobile registration in far-flung areas and regular CRS staff training could increase death registration levels. An adequate awareness campaign on the benefits of birth and death registration is required to increase the reporting of vital events.

Suicide deaths among medical students, residents and physicians in India spanning a decade (2010-2019): An exploratory study using on line news portals and Google database

BACKGROUND

Despite having one of the world's largest medical education consortium, India lacks a comprehensive and nationally representative data on suicide deaths among medical students and physicians unlike the one found in most of the developed nations of the world.

AIM

We aimed to explore the different characteristics of suicide deaths among medical students, residents and physicians in India over a decade (2010-2019).

METHODS

Content analysis of all suicide death reports among medical students, residents and physicians available from online news portals and other publicly available sites was done. Search was done retrospectively using pertinent search words individually or in combination with language restricted to Hindi and English and timed from January 2010 to December 2019. Reports on completed suicide by allopathic medical students, residents and physicians from India were included. Socio-demographic and suicidological variables were analysed using R software.

RESULTS

A total of 358 suicide deaths among medical students (125), residents (105) and physicians (128) were reported between 2010 and 2019. Around 7 out of 10 suicides happened before the age of 30 and had mean age 29.9 (±12.2) years. Female residents and physicians were younger than their male counterparts at the time of suicide. Overall maximum suicide deaths were concentrated in South India except the state of Kerala. The specialty of anesthesiology (22.4%) followed by obstetrics-gynaecology (16.0%) had the highest suicide deaths. Violent suicide methods were more commonly used by all, with hanging being the most common mean of suicide. Academic stress among medical students (45.2%) and residents (23.1%), and marital discord among physicians (26.7%) were the most noticeable reasons for suicide. Mental health problems were the next most common reason in medical students (24%) and physicians (20%) while harassment (20.5%) was in residents. Twenty six percent had exhibited suicide warning signs and only 13% had ever sought psychiatric help before ending their lives. A total of nine reports of suicide pact were found with the average deaths per pact being 2.4 and predominantly driven by financial reasons.

CONCLUSION

Academic stress among medical students and residents, and marital discord in physicians emerged as the key reasons for suicide. However, this preventable domain should be further explored through focused research. This is the first of its kind study from India which attempted to explore this vital yet neglected public health issue using the most feasible and practical method of online news content-based analysis.

An alternative estimation of the death toll of the Covid-19 pandemic in India

The absence of reliable registration of Covid-19 deaths in India has prevented proper assessment and monitoring of the coronavirus pandemic. In addition, India's relatively young age structure tends to conceal the severity of Covid-19 mortality, which is concentrated in older age groups. In this paper, we present four different demographic samples of Indian populations for which we have information on both their demographic structures and death outcomes. We show that we can model the age distribution of Covid-19 mortality in India and use this modeling to estimate Covid-19 mortality in the country. Our findings point to a death toll of approximately 3.2-3.7 million persons by early November 2021. Once India's age structure is factored in, these figures correspond to one of the most severe cases of Covid-19 mortality in the world. India has recorded after February 2021 the second outbreak of coronavirus that has affected the entire country. The accuracy of official statistics of Covid-19 mortality has been questioned, and the real number of Covid-19 deaths is thought to be several times higher than reported. In this paper, we assembled four independent population samples to model and estimate the level of Covid-19 mortality in India. We first used a population sample with the age and sex of Covid-19 victims to develop a Gompertz model of Covid-19 mortality in India. We applied and adjusted this mortality model on two other national population samples after factoring in the demographic characteristics of these samples. We finally derive from these samples the most reasonable estimate of Covid-19 mortality level in India and confirm this result using a fourth population sample. Our findings point to a death toll of about 3.2-3.7 million persons by late May 2021. This is by far the largest number of Covid-19 deaths in the world. Once standardized for age and sex structure, India's Covid-19 mortality rate is above Brazil and the USA. Our analysis shows that existing population samples allow an alternative estimation of deaths due to Covid-19 in India. The results imply that only one out of 7-8 deaths appear to have been recorded as a Covid-19 death in India. The estimates also point to a very high Covid-19 mortality rate, which is even higher after age and sex standardization. The magnitude of the pandemic in India requires immediate attention. In the absence of effective remedies, this calls for a strong response based on a combination of non-pharmaceutical interventions and the scale-up of vaccination to make them accessible to all, with an improved surveillance system to monitor the progression of the pandemic and its spread across India's regions and social groups.

Mapping Healthcare Data Sources in India

Healthcare data sources collect and report various kinds of health data related to routine service delivery, patient-based care, resources related to infrastructure, human resources and finance. Typically, in developing countries, multiple sources are used for the provision of healthcare data, and these include national health surveys, census and civil registration systems, and routine reporting systems. In addition, rapid infusion of information technology has increased adoption of management information systems in public health programs. During the last decade, India has witnessed a sharp rise in the number of healthcare data sources as identified in this review. These sources have increased data availability in multiple data deficient areas. However, the careful appraisal indicates data gaps in numerous important areas. These sources also suffer from inherent quality, coverage and standardisation issues. To overcome these challenges, remedial measures include the development of a national healthcare data plan, a survey calendar, designation of a nodal survey agency, adoption of indicator dictionary, adequate capacity building, and increased coordination among stakeholders.

Assessing mortality registration in Kerala: the MARANAM study

Complete or improving civil registration systems in sub-national areas in low- and middle-income countries provide several opportunities to better understand population health and its determinants. In this article, we provide an assessment of vital statistics in Kerala, India. Kerala is home to more than 33 million people and is a comparatively low-mortality context. We use individual-level vital registration data on more than 2.8 million deaths between 2006 and 2017 from the Kerala MARANAM (Mortality and Registration Assessment and Monitoring) Study. Comparing age-specific mortality rates from the Civil Registration System (CRS) to those from the Sample Registration System (SRS), we do not find evidence that the CRS underestimates mortality. Instead, CRS rates are smoother across ages and less variable across periods. In particular, the CRS records higher death rates than the SRS for ages, where mortality is usually low and for women. Using these data, we provide the first set of annual sex-specific life tables for any state in India. We find that life expectancy at birth was 77.9 years for women in 2017 and 71.4 years for men. Although Kerala is unique in many ways, our findings strengthen the case for more careful attention to mortality records within low- and middle-income countries, and for their better dissemination by government agencies.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1186/s41118-021-00149-z.

Have inequalities in completeness of death registration between states in India narrowed during two decades of civil registration system strengthening?

Background

In India the number of registered deaths increased substantially in recent years, improving the potential of the civil registration and vital statistics (CRVS) system to be the primary source of mortality data and providing more families of decedents with the benefits of possessing a death certificate. This study aims to identify whether inequalities in the completeness of death registration between states in India, including by sex, have narrowed during this period of CRVS system strengthening.

Methods

Data used in this study are registered deaths by state and year from 2000 to 2018 (and by sex from 2009 to 2018) reported in the Civil Registration Reports published by the Office of Registrar General of India. Completeness of death registration is calculated using the empirical completeness method. Levels and trends inequalities in completeness are measured in each state a socio-economic indicator – the Socio-Demographic Index (SDI).

Results

Estimated completeness of death registration in India increased from 58% in 2000 to 81% in 2018. Male completeness rose from 60% in 2009 to 85% in 2018 and was much higher than female completeness, which increased from 54 to 74% in the same period. Completeness remained very low in some states, particularly from the eastern (e.g. Bihar) and north-eastern regions. However, in states from the northern region (e.g. Uttar Pradesh) completeness increased significantly from a low level. There was a narrowing of inequalities in completeness according to the SDI during the period, however large inequalities between states remain.

Conclusions

The increase in completeness of death registration in India is a substantial achievement and increases the potential of the death registration system as a routine source of mortality data. Although narrowing of inequalities in completeness demonstrates that the benefits of higher levels of death registration have spread to relatively poorer states of India in recent years, the continued low completeness in some states and for females are concerning. The Indian CRVS system also needs to increase the number of registered deaths with age at death reported to improve their usability for mortality statistics.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01534-y.

Birth registration in India: Are wealth inequities decreasing?

Background

This study examines the geographic variation and the magnitude of wealth inequities in birth registration in India between 2005 and 2015.

Methods

Data came from India's 2005 (n = 51,940) and 2015 (n = 250,194) Demographic Health Surveys. We estimated absolute wealth inequities at the national and state-level and specified three-level logistic regression models (children, communities, and states) to calculate the variance partitioning coefficient attributable to each level to examine the variation in birth registration at each time point.

Results

National birth registration coverage was 41.2% in 2005 and improved to 79.6% in 2015. Between 2005 and 2015, coverage among children in the poorest quintile (Q1) improved from 23.9% to 63.8% while coverage among the wealthiest children (Q5) improved from 72.4% to 92.8%. Although the absolute wealth inequity decreased from 48.6%-points to 29.1%-points, children in Q1 still had levels of coverage in 2015 that were lower than children in Q5 in 2005. Between 2005 and 2015, birth registration improved in every state and coverage was higher than 90% in 13 states. Wealth inequities decreased in 21 states and increased in 8 states. In adjusted multi-level models the proportion of total variation in birth registration attributable to states (35.7% 2005 and 29% in 2015) was larger than the variation attributable to communities (15% in 2005 and 13.7% in 2015).

Conclusion

Birth registration is essential for ensuring inclusive population counts of birth and mortality rates. Efforts to reach universal birth registration in India will require a commitment to reducing wealth inequities within states.