Are there sex differences in completeness of death registration and quality of cause of death statistics? Results from a global analysis

Abstract

Introduction: Recent studies suggest that more male than female deaths are registered and a higher proportion of female deaths are certified as 'garbage' causes (ie, vague or ill-defined causes of limited policy value). This can reduce the utility of sex-specific mortality statistics for governments to address health problems. To assess whether there are sex differences in completeness and quality of data from civil registration and vital statistics systems, we analysed available global death registration and cause of death data.

Methods: Completeness of death registration for females and males was compared in 112 countries, and in subsets of countries with incomplete death registration. For 64 countries with medical certificate of cause of death data, the level, severity and type of garbage causes was compared between females and males, standardised for the older age distribution and different cause composition of female compared with male deaths.

Results: For 42 countries with completeness of less than 95% (both sexes), average female completeness was 1.2 percentage points (p.p.) lower (95% uncertainty interval (UI) -2.5 to -0.2 p.p.) than for males. Aggregate female completeness for these countries was 7.1 p.p. lower (95% UI -12.2 to -2.0 p.p.; female 72.9%, male 80.1%), due to much higher male completeness in nine countries including India. Garbage causes were higher for females than males in 58 of 64 countries (statistically significant in 48 countries), but only by an average 1.4 p.p. (1.3-1.6 p.p.); results were consistent by severity and type of garbage.

Conclusion: Although in most countries analysed there was no clear bias against females in death registration, there was clear evidence in a few countries of systematic undercounting of female deaths which substantially reduces the utility of mortality data. In countries with cause of death data, it was only of marginally poorer quality for females than males.

Keywords: health systems; indices of health and disease and standardisation of rates; medical demography; public health.

Figure 1

Summary of available data to measure completeness of registration and cause of death quality. MCCOD, Medical Certificate of Cause of Death.

Figure 2

Female vs male completeness by country, countries with completeness for both sexes of less than 95%. Dashed line indicates equality of male and female completeness. Marker size indicates estimated deaths in country in 2019.

Figure 3

Female vs male garbage (age-cause standardised) by country. Dashed line indicates equality of male and female garbage.