Government of India
MORTALITY
STATISTICS
IN INDIA
2006
Status
of Mortality Statistics Reporting in India
A Report
March 2007
CBHI
website : www.cbhidghs.nic.in
CBHI email : dircbhi@nb.nic.in
Government of India
MORTALITY
STATISTICS
IN INDIA
2006
Status of Mortality Statistics Reporting in
India
A Report
March 2007
Compiled and Edited by
Dr.
Ashok Kumar, M.D., Dy.DG & Director
Dr.
D.K. Raut, Joint Director
Ms.
Pratima Gupta, Assistant Director
Sh.
Umed Singh, Assistant Director
CBHI
website : www.cbhidghs.nic.in
CBHI email : dircbhi@nb.nic.in
PREFACE
The purpose of preparation of country (India) report on Mortality Statistics is to have complete knowledge on status of mortality statistics of the country (India), which is a crucial aspect for assessing the current health situation in the country. Both the magnitude and distribution of disease burden are important for formulating the policies and programmes for enabling resource allocation to better address health needs and for monitoring the impact of health interventions. The status of mortality statistics shows overall picture of mortality reporting system (system of death registration of the country both in the health institutions and the community) age-wise, sex-wise, as well rural/urban.
It is important to understand the challenges faced by the health sector there is a need to have a correct/latest picture on mortality statistics of the country. Working group was constituted and a meeting with the experts from Registrar General of India, Social Statistics Division of Ministry of Statistics and Programme Implementation, office of the Chief Registrar (Births and Deaths) Delhi, Bureau of Health Intelligence, MCD and Dy. Commissioner (MH) Ministry of Health & Family Welfare to discuss the issues related to status of mortality reporting in India.
ACKNOWLEDGEMENT
We acknowledge with sincere thanks
the significant inputs received from office of the Registrar General of India,
Statistics Division of Ministry of Statistics and Programme Implementation,
Office of the Chief Registrar (Births & Deaths) Delhi, Bureau of Health
Intelligence, MCD and Dy. Commission (MH) of Ministry of Health & Family
Welfare for their views and valuable advice for preparing the Mortality Report
of India.
We are grateful to WHO/SEARO, New
Delhi for providing financial support for undertaking this activity.
Contributors
Sh. Harbinder Singh, Dy. Registrar General, O/o. of the Registrar
General of India, New Delhi
Sh. Sunil Jain, Dy. Registrar General of India (SRS), O/o. of the Registrar General of
India, R.K. Puram, New Delhi
H. Borah, Director, M/o. of Statistics and Programme
Implementation, West Block-8, R.K. Puram, New Delhi
S. Chakrabortty, Deputy Director, M/o. of Statistics and
Programme Implementation, West Block-8, R.K. Puram, New Delhi
Sh. N.T. Krishna, Dy. Director, O/o. Chief Registrar, (B&D),
Room No.148, Old Sectt. Delhi –84
Dr. I.P. Kaur, DC(MH), MOHFW/GOI, Nirman Bhawan, New Delhi
Dr. J. Duggal, MO (IT), Room No. 58, Bureau of Health Intelligence, M.C.D, Town Hall
Mr. V.K. Harnal, Medical Record Officer, Medical Record Department & Training Centre,
Safdarjung Hospital, New Delhi
Dr. Ashok Kumar, Director, CBHI
Dr. D.K. Raut, Joint Director, CBHI
Sh. P.K. Mukhopadhyay, Joint Director, CBHI
Ms. Pratima Gupta, Asstt. Director, CBHI
Sh. Umed Singh, Asstt. Director, CBHI
Sh. V.K. Khanna, Asstt. Director, CBHI
Sh. A.K. Chopra, Asstt. Director, CBHI
Ms. R.K. Beniwal, Asstt. Director, CBHI
SELECTED DEFINITIONS USED IN THE
CURRENT REPORT
|
Crude death rate |
Number of deaths during the year |
|
Age-specific mortality |
Number of deaths in a particular
age-group |
|
Infant mortality rate |
Number of infant deaths during the year |
|
Neo-natal mortality |
Number of infant deaths of < than 29
days during the year |
|
Early neo-natal |
Number of infant deaths of < than 7
days during the year |
|
Late neo-natal |
Number of infant deaths of 7 days to <
than 29 days during the year |
|
Post neo-natal |
Number of infant deaths of 29 days to
< than one year during the year |
|
Peri-natal mortality |
Number of still births and infant deaths
of < than 7 days during the year |
|
Still birth rate |
Number of still births during the year |
CONTENTS
|
Sl.No. |
Items |
Page
No. |
|
1. |
Executive
Summary |
8 |
|
2. |
Chapter
1: Indroduction |
11 |
|
3. |
Chapter
2 :Methods of Mortality Statistics Reporting in India |
14 |
|
4. |
Chapter
3: Medical Certification of Cause of Deaths |
27 |
|
5. |
Chapter
4: Status of Mortality Reporting in India |
48 |
|
6. |
Chapter
5: Estimates of Mortality Indicators |
60 |
|
7. |
Chapter
6: Maternal and Infant Mortality |
77 |
|
8. |
References |
88 |
|
9. |
Annexure
– I |
89 |
|
10. |
Annexure
– II |
93 |
|
11. |
Annexure
– III |
95 |
|
12. |
Annexure
– IV |
105 |
|
13. |
Annexure
– V |
127 |
|
14. |
Annexure
–VI |
138 |
|
15. |
Annexure
–VII |
141 |
|
16. |
Annexure
-VIII |
148 |
EXECUTIVE
SUMMARY
Vital Statistics
Sample Registration System (SRS) is the reliable source of nation wide vital statistics. The coverage of vital registration of deaths is 50-69 % through CRS. Cause of death information is most of the times (sometimes) recorded on Civil Registration System (CRS) forms.
The country has adequate capacity to implement data collection, process the data and analyze the data from SRS. Frequency of the assessment of completeness of vital registration is done every year through CRS. Tabulation list ICD 10 is currently in use. Proportion of all deaths coded to ill-defined causes is 11- 19 % (14 % in 2000). Published statistics from SRS are disaggregated by sex, age and geographic region. Sample registration system (SRS) developing and generating timely and accurate data, which is nationally representative. Verbal autopsy (VA) tool validated and questionnaire is publicly available. VA tool is consistent with international standards
Lag time between the statistics from VR /SRS/ DSS were last published and the time that the data were collected is Less than 3 years. Mortality rates from SRS are used for national / sub national analysis and cause of death from Medical Certification of Death (MCD) is used for national reports.
Mortality
Under five mortality (all cause)
Method used to collect the most recent major data point is SRS. For the most recently published estimate (upto 2 years ago) the data were collected through SRS. More than three times the data were collected in last 10 years. No major discrepancies in the data points over time and between sources during last decade noted. Coverage of data upon which the most recently reported estimate is based is sample of deaths. Most recent data point is disaggregated by demographic characteristics (e.g. sex and age) socioeconomic status (e.g. wealth or occupation or education of their parent) and by locality (e.g. urban-rural or major administrative region). SRS is used for country estimates, which is, and transparent well-established method.
Adult mortality (all cause)
Method used to collect the most recent major data point is Sample vital registration. For the most recently published estimate, (upto 2 years ago) the data were collected through this method. Number of data collection rounds in last decade was three or more. Data points in last decade were consistent over time. Coverage of data upon which the most recently reported estimate is based is Sample of deaths. Most recent data point is disaggregated by demographic variables (age and sex), socio-economic status (e.g. by wealth quintiles, level of education, or occupations) and by locality (e.g. urban/rural), major administrative regions). This method of country estimates is transparent well- established.
Maternal Mortality
Data collection method for most recent data point is sample vital registration with verbal autopsy. For the most recently published estimate (upto 2 years ago) the data were collected. More than three data collection rounds were made in last decade. No major discrepancies in data points in last decade over time. Coverage of data upon which the most recently reported estimate is based is sample of deaths. Most recent data point is disaggregated by demographic variables (age), socio-economic status (e.g. by wealth quintiles, level of education, and occupations) and by locality (e.g. urban/rural, major administrative regions). In country estimates transparent well-established method is used.
Mortality Data
Overall mortality regardless of causes
of death
India has a national compulsory death registration system under the Registration of Birth and Death Act, 1969.
At the local/individual level, the deaths are reported in the civil registry and at some places local health authorities and police are also involved. At the national level, ministry of home affairs and ministry of health & family welfare are responsible for the final data. The national estimated completeness of overall registered deaths is 50-59% (as per the year 2004). The source of completeness estimate is SRS crude death rate and mid year population (projected/census) in thousands. The information on data collection does not include any overseas territorial units.
Population officially covered by the
registration system of the country: All deaths occurring with in the territory of India are
included. Military personnel (armed forces) dying with in the country is
included, but those dying abroad are not included and Ministry of foreign
affairs is responsible for recording these deaths.
Other data
Last census was conducted in the year 2001. The mortality modules included in national census are (i) child ever born and still alive and (ii) sibling survival. These modules were always there since the beginning of census in 1941 and 1971 – 2001.
The number of deaths by age and sex in a specified time period can be derived from the module using P/F (Parity/Fertility) method and Brass method.
For the last ten years the other source of information on adult and /or child mortality is sample vital registration system.
Causes of Death
We have a compulsory national death
registration system and the cause of death is part of the information
collected. The current International form of Medical Certificate of Cause of
Death as recommended by WHO in ICD-10 is used. Three lines are present in Part
I of our death certificate (form 4 & 4A). The percentage of registered
deaths that are certified in our country by
Medical doctors is 15 %. The percentage of registered deaths occurring
in a hospital or other medical institution as per CRS report (1995) is 29.4%.
The follow-up enquiries to the certifier in case of doubt or inconsistency
about the cause of death are undertaken. In order to obtain information on
cause of death Verbal autopsy technique is used and 2005 is the last year it
was done. The cause-of-death statistics
provided to WHO are compiled by date of occurrence. The coding procedure is Decentralized, done at the local/regional
level. The underlying cause of death on the medical certificate and assigning
of ICD code is done by the certifier. ICD-10 is being used in the country and
for deaths due to external causes, dual coding of both the external cause and
the nature of injury is done. The death registration form also includes a
question on pregnancy at the time of death or pregnancy in the last 12 months.
***************
Chapter -1
INTRODUCTION
Mortality
statistics is the key health indicator to assess quality of life. However
reporting of deaths in India has been the challenge for Public Health
organizations, Health planners and programmers. Registration of births and
deaths is an important source for demographic data for socio-economic
development and population control in developing countries. The data on
population growth, fertility and mortality serves as the starting point for
population projections. Apart from
these vital indicators, an adequate evaluation of a number of programs in the
health sector, including family planning, maternal and reproductive health,
immunization programs, is dependent upon the availability of accurate,
up-to-date fertility and mortality data.
It is essential to assess the
status of existing Mortality statistics reporting mechanism in India to take
appropriate interventions for its improvement. World Health Organisation(WHO)
has requested to prepare a report on the mortality statistics coverage, current
status of data collection, flow of mortality statistics including cause of
death in the country and utilization of the mortality data.
The
demographic scenario in the country has been undergoing a change since the
inception of SRS; however, the profile and rate of change is not uniform in all
the states. Overall, the crude birth
rate in the country has come down from 36.9 per one thousand population in 1971
to 23.8 in 2005, whereas the crude death rate has declined from 14.9 to a low
of 7.6 in the same period. The infant
mortality rate, which is an important indicator of the health status of the
country, has registered a significant decline from 129 per one thousand live
births in 1971 to 58 in 2005. During
the period, the total fertility rate of the country has declined from 5.2 to
2.9. To fulfill its objective of monitoring the changes in vital indicators,
the SRS sampling units are retained for about ten years, making it a panel
household survey.
The
Survey of Causes of Deaths (Rural) has been merged with Sample Registration
System from 1st January 1999 to give more impetus covering both rural and urban
areas and wider representation of sample villages and urban blocks for Causes
of Death. The primary objective of the survey is to build up statistics on
“Most Probable Causes of Death” for rural and urban areas using “lay diagnosis
reporting (Post Death Verbal Autopsy)” method through post death enquiry based
on symptoms, conditions, duration and anatomical site of the disease as
observed by family members of the deceased at the time of death. As the
collection of causes of death requires knowledge on medical terminologies,
symptoms of disease and interview techniques, the supervisors of SRS have been
trained by medical professionals in the art of collection of data on causes of
deaths. A well-designed VA instrument
has been developed and introduced in SRS. Supervisors of all states have been
trained with the new VA instrument. To enhance the objectivity of the system,
the role of SRS supervisor is restricted to faithfully collect data on sign and
symptoms by interviewing the close relative of the deceased. Apart from
recording the responses for closed questionnaire, he has to fill up the narrative
portion of the VA instrument.
CONSULTATION MEETING FOR
PREPARATION OF COUNTRY (INDIA) REPORT ON MORTALITY STATITICS
A working group was constituted to
discus the current issues related to Mortality statistics in the country.
Representatives from DteGHS, Ministry of Health & Family Welfare GOI,
Registrar General of India, Ministry of Statistics and Programme
Implementation, Delhi State health information Bureau and Officers of CBHI
actively participated in the meeting. The list of the participants is enclosed
along with the Programme schedule (Annexure-1).
The consultation meeting of working
group was conducted on 8th March 2007 at Niramna Bhawan, New Delhi with the
following objective.
To
discus and summarise the mortality statistics coverage, current status of data
collection, flow of mortality statistics including cause of death in the
country and utilization of the mortality data.
The following three sub-groups were
formed to discuss mortality specific key issues during the meeting. The groups
were requested to perform the following task.
Key issues:
Group 1: Overview of mortality
Reporting System in India
Group 2: Reporting Cause of Death
A. Cause of death (COD)
B. Completeness of death
registration
Group 3: Maternal and infant
mortality statistics.
Methodology: The following methodology adopted during the meeting.
Discussion on the Questionnaire
provided by WHO (Annexure-3)
Group work of the all participants
from health information & vital registration (including other sectors, e.g.
Central Bureau of Statistics, international and national NGOs) so that
subjectivity is avoided to the highest extend.
The expert’s view / answers to the
questions were obtained by individual discussions with each expert.
Group Task:
Identify group leader and rapporteur
Discus the mortality reporting
status in India on following discussion points
Amend (use reference material) and
prepare the report
Present salient features.
All three groups had detail
discussions on the topics allotted to them and made the draft for the
presentation and subsequently the topics were discussed with other colleagues
in the respective organisations. Suggestions and modifications on the various
topics were again included and final report is updated with latest fact and
figures on mortality data especially from SRS, Registrar General of India. The
key findings and outcome of the consultation meeting of the working group is
compiled and presented in the report.
CHAPTER - 2
METHODS OF MORTALITY STATISTICS
REPORTING IN INDIA
INTRODUCTION
In India Registrar General of India collect compile, analyze and
publish Mortality statistics for the country under the provisions of
Registration of Birth and Death Act (1969) through Civil Registration System
(CRS) and Sample Registration System (SRS).
The registration of births and deaths has
been made compulsory under the Registration of Births & Deaths (RBD) Act,
1969. The state governments under the rules framed by them are implementing the
provisions of this Act. Though more than 30 years have passed since the
enactment of the legislation, the level of birth and death registration is not
satisfactory in certain parts of the country.
The National Population Policy 2000 has
recognized the need for registration of births, deaths and marriages and set
the goal of achieving universal registration of these events by 2010.
Considering the fact that the level of registration of events under the RBD Act
is very low, the National Population Commission appointed a Working Group on
Registration of Births, Deaths and Marriages with Registrar General, India as
Chairman to look into various issues relating to registration of vital events.
A. Civil Registration System (CRS)
The Civil Registration System Unit of the
Office of the Registrar General, India coordinates and unifies the activities
of the State Governments on Registration of Births and Deaths in the country.
It also provides general direction and guidance to the States/UTs in this
matter for effective implementation of the provisions of the Registration of
Births and Deaths Act, 1969 and compiles and disseminates the statistical
information on vital events based on the registration of births and deaths
through various publications.
A.1 Current
Status
The Civil Registration System of a country envisages
recording each and every incidence of vital event for legal purposes and in the
process captures a lot of information on various characteristics of these
events, which help in the compilation of a continuous series of vital events.
Complete, timely and accurate registration of births and deaths is very crucial
for the understanding of population dynamics at the local level and planning of
effective health and development programmes. The extent of completeness and
accuracy of birth and death registration is by itself an indicator of the
modernisation of society as vital statistics belong to the Core Statistics of
any National Statistical System.
In India, civil registration was first introduced in
the last century mainly as an aid to public health administration for locating
and identifying diseases of public health importance and to undertake remedial
measures to control mortality. However, registration was kept voluntary and
different provinces had different legislations and there was no standardisation
of concepts, definitions and classifications. Various Commissions and
Committees have reviewed the civil registration based vital statistics system
in the past. The enactment of the ‘Registration of Births and Deaths (RBD) Act,
1969’ replacing all diverse laws that existed on the subject, and the Model
Rules framed under the Act introduced a uniform piece of legislation to
overcome the problems of multiplicity of Acts and Rules that existed in the
country. Thus, the Act aimed to have a uniform system of registration and data
collection on vital statistics. The Act provides for compulsory registration of
births and deaths in the country.
The RBD Act has provided for a hierarchical set-up for
the registration machinery in the country, headed by the Registrar General of
India at the Centre, The Chief Registrar of Births and Deaths is the chief
executive authority in the State for implementing the provisions of the Act.
There are District Registrars in the districts and Registrars and
Sub-registrars for registering births and deaths occurring in the area allotted
to them within a district. The States with the approval of the Central
Government have made Rules in accordance with the Model Rules to implement
various provisions of the Registration of Births and Deaths Act.
A.2
DEFICIENCIES
It is estimated that 26 million births and 9 million
deaths occur in India every year and based upon the reports received, only 53
percent of births and 48 percent of deaths are registered. About 10 million
births, which are about 25 percent of the unregistered births in the world and
about 4 million deaths, are not registered. The poor registration in the rural
areas of the country is the main reason for incomplete registration. On the
basis of births registered in rural and urban areas, assuming that these births
have taken place to the population living in these areas, the estimated birth
rate works out to 12 and 24 per thousand respectively against 28 and 20 per
thousand estimated from Sample Registration System during 1995. Even if it is
taken that a sizable proportion, say 35-40 per cent of the births registered in
the urban areas come from the population living in the rural areas, the birth
rate of the rural areas could be estimated at around 14 to 15 per thousand,
which shows that the level of registration in the rural areas may be around
only 50 per cent. Further, the levels of registration of births and deaths vary
widely across the States. Thus, the Civil Registration System suffers from
incomplete coverage and the problem is more acute in a few States, which
account for a big chunk of this incomplete coverage. Given the complete coverage, the CRS has the potential to
provide estimates of vital rates such as birth
rate, death rate, infant mortality rate and other related fertility and
mortality indicators even at the district and below levels and will be of
immense importance for micro level planning for development. However, due to
incomplete coverage of the system, these estimates are made available at the
State level only through the Sample Registration Scheme (SRS). However, even
the estimates of infant mortality rate for small States and UTs are not
reliable due to the small sample size.
There are more than 200,000 reporting units in the
country and more than 100,000 local registrars doing the actual work of
registration. Monitoring the receipt of statistical returns from each and every
registration unit on a monthly basis
is a challenging task. Other requirements are of training, supervision and
maintenance of a timely supply of forms and registers in the registration
units.
A combination of administrative factors is responsible
for the poor registration levels of vital events. Except for a few States and
UTs, generally multiple agencies are involved in the registration work at the
sub-national level. This poses immense problems of coordination, monitoring and
supervision, which directly affect the quality and timeliness of data. Though
high -level inter-departmental committees exist, they have remained ineffective
in improving the situation in most of the States. Further, the registration
functionaries at all levels do the work of registration in addition to their
other normal duties in an honorary capacity generally, without any incentive.
This is why the work of registration, preparation and submission of statistical
returns do not get due attention and priority. The quality of data becomes a
major casualty. The number of Registration centres has also been a contentious
issue. If this number is too small there are problems of accessibility. On the
other hand, a large number of registration centres pose huge problems of
control, management and supervision. Lack of adequate budget for supplying
material resources such as forms and registers, for meeting training and supervisory
requirements and publicity efforts put a constraint on the system to perform
better. With regard to the registration of marriages, though legislations exist
in some States, however, there is no uniform legislative enactment in the
country. Some of the existing enactments are applicable to specific religious
groups. There is also no provision for registration of divorces.
Even in States that have achieved high levels of
registration, there is a considerable delay in reporting of statistics from the
local registrars, eventually delaying the compilation of vital statistics at
the State and National levels. A lot of paper work required and pending at the
level of Registrar is one of the major reasons for the delay in submission of
returns. Different States have different arrangements for processing the data
on civil registration, depending on the number of registration centres,
availability of manpower in offices where tabulation is done and the level of
computerisation at the State headquarters. Varying lengths of time taken for
intermediate tabulation at the district and town/municipality levels seriously
affect the tabulation work at the State level resulting in the failure of
States to meet the time limit prescribed under the law for publication of statistical
reports.
The other factors that lead to incomplete
registrations are a general lack of awareness in the public about the statutory
requirements and procedures of registration, lack of demand of birth and death
certificates in rural areas, acceptance of alternate documents as proof of
death, and lack of perception of any benefits of registration by the people.
Further, the registration centres are not always easily visible. Around 75
percent of births and 80 percent of deaths are domiciliary in nature and the
statutory reporting of the events lies with the household.
A.3 RECOMMENDATIONS
The National Statistical Commission working group has
given following recommendations for improvement of Civil Registration System in
India.
The Civil Registration System (CRS), which is capable
of providing vital rates not only at the district but also lower level, is
deficient in most of the States and UTs. The justification for improvement in
the system of civil registration and vital statistics would usually be based on
a demonstration of the potential of such a system to create individual records
that are useful for legal and administrative purposes and also to aggregate
them into usable statistics. The CRS in the country has so far not served the
needs for which it was set up and therefore; it attracts low priority and
attention not only by the Government but also by also potential users. The
Commission observes that incomplete registrations and delays in the upward
movement of the registration data have been major problems for timely
processing and publication of the results of the Civil Registration System and
this has undermined the its utility. At present it is a passive system, in
which most people do not realise the importance of reporting births and deaths.
Where ANMs and other village level workers have been given the responsibility
of reporting births and deaths to the Registrar there has been a positive
impact. Inspite of demands for publication of the absolute number of births,
deaths, infant deaths, etc., such figures are not available. There is growing
need for district level vital statistics, which is a major lacuna in the way of
decentralised planning. Recently, released provisional results of the Census
2001 have revealed that the population has grown at a faster rate than
estimated and the sex ratio in the age group 0-6 years has declined
considerably during the last decade form 945 to 927. Had the Civil
Registration System in the country been efficient in covering all births and
deaths and bringing out data in time, it would have been possible to introduce
necessary preventive measures in time. The results of Census 2001, once again
stress the need for an efficient Civil Registration System. The Commission also
recognises the goal of attaining of complete registration of vital events
namely, births, deaths, marriages and pregnancy as one of the 14
socio-demographic goals to be attained by the year 2010 in the recently
announced National Population Policy, 2000, and therefore recommends:
(i)
There should
be a more pro-active Civil Registration System in place of the existing passive
system. In rural areas, panchayats, local bodies and other basic and
primary workers apart from Auxiliary Nurses, Midwives, Village Watchmen should
play an active role in informing the Registrar about the occurrence of vital
events. They should collect birth and death information from households and
deliver the same to the Registrar. All States should implement this as a part
of strategy to improve the registration. This can be achieved by giving the
local level workers the responsibility for informing and collection of reports
of events and getting them registered.
(ii)
Within a
State, as far as possible, only one department of the Government should be
responsible upto the district level for implementing the provisions of the RBD
Act. Where multiple departments are involved, inter-departmental coordination
committees should ensure effective and periodic reviews to propose measures for
improving registration levels and provision of registration services by drawing
up a plan of action. This requires tight monitoring and supervision of the
registration work at the field level.
(iii)
Recognising
the increasing role of local self-governance in the light of the 73rd
and 74th Constitutional Amendments and considering the fact that
quite a few States in the country have already taken initiative in this
direction, the panchayats in the rural areas and Municipalities in the
urban areas should gradually be given the responsibility for registration of
births, deaths and marriages.
(iv)
Sufficient
resources should be provided to the agencies implementing the Registration of
Births and Deaths (RBD) Act. The Planning Commission should provide funding to
the States for this purpose. Further, to improve the availability of required
forms and registers used for registration of vital events, the Central
Government should bear the expenditure on this account.
(v)
Regular
training programmes should be organised by the States for Registration
officials at all levels. The ‘Registrar’s Manual for Registration of Births and
Deaths’ being prepared by RGI should be made available to all concerned, and
training programmes should be conducted to impart training to all Registrars in
the use of the manual.
(vi)
The revamped
system of registration of births and deaths in the country introduced by
Registrar General of India, mainly with a view to strengthen the statistical
functions of the CRS and to reduce paper work at the level of the local
Registrar, by facilitating computerised data entry, easy retrieval of records
and reducing storage requirements of records, should be vigorously implemented
in all the States. There should be special emphasis on the monitoring and
supervision of the system particularly for poorly performing States in order to
enhance their performance.
(vii)
Production of
birth and death certificates should be encouraged for various purposes, as it
will help in improving the overall registration of vital events. For example,
the production of birth certificates should be made mandatory for entering the
name of new-born child in the ration card, school admission, etc., and death
certificates for settling insurance claims and for inheritance of property by
legal heirs, in case it is not so already in any State and UT.
(viii)
Considering
the stated goal in the National Population Policy of 100 per cent registration
of marriages by 2010, sustained efforts should be made to achieve this goal
through the Civil Registration System by suitably amending the RBD Act for
registration of all marriages and divorces.
(ix)
Public
campaigns should be launched to create awareness among the general public about
the need and importance of registration of births and deaths. Also steps should
be taken to improve customer services by making registration centres more
visible, prompt issue of birth and death certificates, simplifying the
procedure, making registration in big hospitals more efficient and proper preservation
and maintenance of records of vital events.
(x)
Acknowledging
the fact that an efficient Civil Registration System is the lasting solution to
produce a regular series of vital rates e.g., fertility, mortality, etc.
specific for age, sex, and educational level upto the district and even lower
levels, the ultimate goal should be to put in place the Civil Registration
System in the next 10 years and to use the Sample Registration System (SRS) as
a source of data for longitudinal study of the social dynamics of the country
and as a means of validating the CRS data.
(xi)
Recourse to
Information Technology (IT) should be taken for establishment of an effective
system of civil registration that would provide prompt service to the public
and help in quick retrieval of information for both administrative requirements
and statistical purposes. As the costs of hardware and network communications
will come down in the coming years, decentralised data entry and data
transmission at the Registration level should be the goal to be achieved
within a few years. Sustained efforts should be made for adoption of IT in
modernising the CRS. The computers provided by the Department of Family
Welfare, Government of India may be utilised for this purpose as well.
B. SAMLE REGISTRATION SYSTEM
In India, the need for dependable demographic data was felt
soon after independence heralding the era of five year planning. The registration of births and deaths
started on voluntary basis and there was no uniformity in statistical returns
resulting in both under-registration and incomplete coverage. In order to unify the civil registration
activities, the Registration of Births & Deaths Act, 1969 was enacted. Despite having the registration of birth
& death compulsory under the statute, the level of registration of births
and deaths under the Act has continued to be far from satisfactory in several
states/UTs. With a view to generate reliable and continuous data on these
indicators, the Office of the Registrar General, India, initiated the scheme
of sample registration of births and deaths in India popularly known as Sample
Registration System (SRS) in 1964‑65 on a pilot basis and on full scale
from 1969‑70. The SRS since then
has been providing data on regular basis.
B.1
Objectives:
The main objective of SRS is to provide reliable estimates
of birth rate, death rate and infant mortality rate at the natural division
level for the rural areas and at the state level for the urban areas. Natural
divisions are National Sample Survey (NSS) classified group of contiguous
administrative districts with distinct geographical and other natural
characteristics. It also provides data for other measures of fertility and
mortality including total fertility, infant and child mortality rate at higher
geographical levels.
B.2
Methodology:
The SRS in India is based on a dual record system. The
field investigation under Sample Registration System consists of continuous
enumeration of births and deaths in a sample of villages/urban blocks by a
resident part‑time enumerator, and an independent six monthly
retrospective survey by a full‑time supervisor. The data obtained through these two sources are matched. The unmatched and partially matched events
are re-verified in the field to get an unduplicated count of correct
events. The advantage of this
procedure, in addition to elimination of errors of duplication, is that it
leads to a quantitative assessment of the sources of distortion in the two sets
of records making it a self‑evaluating technique.
The revision of SRS sampling frame is undertaken in every
ten years based on the results of latest census. While changing the sample,
modifications in the sampling design; wider representation of population;
overcoming the limitations in the existing scheme; meeting the additional
requirements are taken into account. The first replacement was carried out in
1977-78 and the last being in 2004. Whereas the replacement of samples in
earlier years was undertaken in phases spread over 2-3 years, the replacement
in 2004 was completed within a year. The following table provides the sample
size in different replacement period.
|
Table 2.1 |
|||||
|
Number of sample units at different replacement period |
|||||
|
Residence |
1969-70 |
1977-78 |
1983-85 |
1993-95 |
2004 |
|
Rural |
2432 |
3684 |
4176 |
4436 |
4433 |
|
Urban |
1290 |
1738 |
1846 |
2235 |
3164 |
|
Total |
3722 |
5422 |
6022 |
6671 |
7597 |
The earlier sample was based on the
reliability of birth rate at the state level, whereas the 2004 sample is
estimated using IMR and reliability at natural division level.
B.2.1 Structure of the Sample Registration System
The
main components of SRS are:
(i) Base‑line
survey of the sample units to obtain demographic details of the usual resident
population of the sample areas;
(ii) Continuous
(longitudinal) enumeration of vital events pertaining to usual resident
population by the enumerator;
(iii) Independent
retrospective half‑yearly surveys for recording births and deaths which
occurred during the half‑year under reference and up‑dating the
House list, Household schedule and the list of women in the reproductive age
group along with their pregnancy status by the Supervisor;
(iv) Matching of events recorded during continuous enumeration and those listed in
course of half‑ yearly survey;
(v)
Field
verification of unmatched and partially matched events; and
(vi)
Filling
of Verbal Autopsy Forms for finalized deaths (Annexure-7)
B.2.1.1 Baseline Survey:
The
base‑line survey is carried out prior to the start of continuous
enumeration. This involves preparation
of a notional map of the area to be surveyed, house numbering and house
listing and filling‑in of a household schedule. The supervisor prepares a
notional map with the help of the enumerator showing important landmarks and
location of the houses to be covered in the sample unit. He then prepares a list of houses/households
covered by the sample in the House List (Form-1) and fills‑in the
Household Schedule (Form-2) wherein he records the residential status and other
demographic particulars of each individual residing in the household viz.
identification code, name, sex, date of birth, age, educational/marital status
and relation to head of household, etc. The inmates of public institutions
like hotels, inns, schools and hospitals are excluded, but households living
permanently within the compound of such institutions are covered. A list of all women in the reproductive span
along with their pregnancy status is also prepared in Form 3 at the time of the
base line survey.
B.2.1.2 Continuous
enumeration:
The
enumerator maintains a Birth Record (Form 4) and a Death Record (Form 5) in
respect of his area. The enumerator is
expected to record all births and deaths occurring within the sample unit, as
well as those of the usual residents occurring outside the sample unit. The events in respect of visitors occurring
within the sample unit are also listed, but these are not taken into account
while calculating rates. Thus, the
events to be netted by the enumerator are those pertaining to: (i) usual residents
inside the sample unit; (ii) usual residents outside the sample unit; (iii)
inmigrants present; (iv) inmigrants absent; and (v) visitors inside the sample
unit.
For
ensuring complete netting, the enumerator uses different sources to get
information of the occurrence of vital events in the sample unit. These include the help of the village
priest, barber, village headman, midwife and such other functionaries. The
enumerators maintain contact with these informants at frequent intervals and
collects information about the occurrence of births and deaths. On being informed about the occurrence of an
event, he visits the concerned household and records the prescribed
particulars. He also keeps in touch
with other socially important persons and visits local or nearby hospitals,
nursing homes, cremation or burial grounds, at frequent intervals to keep
himself updated about the occurrence of events. He maintains and updates a list of all women in the reproductive
span along with their pregnancy status, which helps him in netting of all the
births. Despite all these efforts, the
enumerator may miss information about some of the events. Therefore, he is required to visit all the
households once in each quarter in rural areas and once a month in urban areas,
so as to ensure that all the events have been recorded.
B.2.1.3 Half‑yearly
survey:
Half-yearly
survey is carried out independently in each sample unit by a full‑time
supervisor. The supervisor belonging to
the statistical cadre of the State Census Directorates (either a Compiler or a
Sr. Compiler or Statistical Investigator or any suitable official) visits each
household in the sample unit and records the particulars of births and deaths
in Forms 9 & 10 respectively in respect of all the usual residents and
visitors (only those occurring within the sample unit) which had occurred
during the half‑yearly period (January‑June or July‑December)
under reference. Simultaneously, he updates the house-list, the household
schedule and the pregnancy status of women by making entries of changes, if
any. While carrying out this survey he
does not have access to the birth and death records of the enumerator for the
same periods which are withdrawn from the field before the supervisor’s visit
for the half yearly survey.
B. 2.1.4 Matching:
On
completion of the half‑yearly survey, the Forms 9 & 10 filled‑in
by the supervisors are compared with those in the Forms 4 & 5 (filled‑in
by the enumerators). This is done at
the office of Directorate of Census Operations for all states except for rural
areas of Kerala and Maharashtra, where it is done at the office of Directorate
of Economics and Statistics of the respective states. Selected important
entries in the enumerator's and supervisor's record are matched item by item
and events are classified as fully matched, partially matched and
unmatched. The items generally
considered for matching are: Identification code of the head of Household and
mother, Relationship of the mother to head, date of live birth, month in case
of still birth/abortion, sex in case of live birth /still birth (for birth) and
identification code of the head of household and mother in infant death,
relationship of the deceased to head, date of death and sex in case of death.
B.2.1.5 Field verification of unmatched and partially
matched events:
Every
unmatched or partially matched event is verified by a visit to the concerned
household. This is done either by a
third person or jointly by the supervisor and the enumerator, depending upon
the availability of staff.
B.2.2 Sample design
The
Sample design adopted for SRS is a uni-stage stratified simple random sample
without replacement except in stratum II (larger villages) of rural areas,
where two stages stratification has been applied. In rural areas of bigger states (population with ten million or
more as per Census 2001), natural division is the first geographical stratification
or in rural areas of a smaller states, the stratification has been done on size
of villages with villages having population less than 2,000 forming Stratum I
and villages with population 2,000 or more forming Stratum II. Smaller villages with population less than
200 are excluded from the sampling frame in a manner that the total population
of villages so excluded did not exceed 2 per cent of the total population of
the concerned natural division in the state. The number of sample villages in
each state is allocated to the substrata proportionally to their size
(population). The villages within each size stratum are ordered by the female
literacy rate based on the Census 2001 data, and three equal size substrata are
established. The sample villages within each substratum are selected at random
with equal probability. In the case of
villages of Stratum 2, each sample village with a population of 2,000 or more
is subdivided into two or more segments in a way that none of the segments cut
across the Census Enumeration Blocks (CEBs) and the population of each segment
formed by grouping the contiguous CEBs is approximately equal and do not exceed
2000. A frame of segments are prepared and selection of one segment is done at
random at the second sampling stage for the SRS enumeration.
In
urban areas, the categories of towns/cities have been divided into four strata
based on the size classes in contrast to the six strata in the earlier sampling
frame. Towns with population less than one lakh have been placed under stratum
I, towns/cities with population one lakh or more but less than 5 lakhs under
stratum II, towns/cities with population 5 lakh or more under stratum III and
four metro cities of Delhi, Mumbai, Chennai and Kolkata as separate strata viz.
stratum IV. The sampling unit in urban area is a Census Enumeration Block. The Census Enumeration Block within each
size stratum is ordered by the female literacy rate based on the Census 2001
data, and three equal size substrata are established. The sample Census
Enumeration Block within each substratum is selected at random with equal
probability. A simple random sample of these enumeration blocks are selected
within each sub-strata without replacement from each of the size classes of
towns/cities in each State/Union Territory.
B.2.3 Sample size
The Infant Mortality is the
decisive indicator for estimation of sample size at Natural Division, the
ultimate level for estimation and dissemination of indicators for rural areas.
The permissible level of error is taken as 10 prse (percentage relative
standard error) at Natural Division level for rural areas and 10 prse at state
level for urban areas, in respect of major states having population more than
10 million as per Census 2001. For minor states, 15 prse has been fixed at the
total state level. Usually, the above criteria is followed, however, there have
been a few exceptions, on account of operational constraints. Based on the
above criteria, the number of units has been increased from 6671 to 7597 with
4433 in rural and 3164 in urban areas. Table 2.2 shows the number of sample
units and population covered in 2005, separately for rural and urban areas of
all the states and union territories.
B.3 Estimation procedure
Estimates of population, births, deaths and infant
deaths for natural division in rural areas for bigger states and at state level
for smaller states separately for rural/urban areas for all states/UTs are
obtained using unbiased method of estimation.
The estimates of birth, death and infant death rates are obtained as the
ratios of the ‘estimated births to estimated population’, ‘estimated deaths to
the estimated population’ and ‘estimated infant deaths to estimated births’
respectively expressed in terms of per thousand.
|
Table: 2.2 |
|||||||
|
Number of sample units and population covered India, States and Union territories, 2005 |
|||||||
|
|
|||||||
|
India/States/Union
territories |
Number of sample units |
Population covered (in'000) |
|||||
|
Total |
Rural |
Urban |
|
Total |
Rural |
Urban |
|
|
1 |
2 |
3 |
4 |
|
5 |
6 |
7 |
|
India |
7,597 |
4,433 |
3,164 |
|
6,830 |
3,513 |
3,318 |
|
Bigger States |
|
|
|
|
|
|
|
|
1. Andhra Pradesh |
375 |
235 |
140 |
|
394 |
199 |
195 |
|
2. Assam |
300 |
90 |
210 |
|
195 |
101 |
94 |
|
3. Bihar |
330 |
200 |
130 |
|
334 |
175 |
159 |
|
4. Chhattisgarh |
130 |
40 |
90 |
|
99 |
51 |
48 |
|
5. Delhi |
200 |
10 |
190 |
|
142 |
77 |
65 |
|
6. Gujarat |
365 |
215 |
150 |
|
351 |
181 |
170 |
|
7. Haryana |
210 |
100 |
110 |
|
202 |
108 |
94 |
|
8. Jammu & Kashmir |
260 |
150 |
110 |
|
213 |
111 |
102 |
|
9. Jharkhand |
170 |
60 |
110 |
|
112 |
59 |
53 |
|
10. Karnataka |
480 |
330 |
150 |
|
431 |
216 |
215 |
|
11. Kerala |
250 |
150 |
100 |
|
333 |
161 |
172 |
|
12. Madhya Pradesh |
340 |
220 |
120 |
|
305 |
159 |
146 |
|
13. Maharashtra |
485 |
250 |
235 |
|
398 |
204 |
194 |
|
14. Orissa |
405 |
290 |
115 |
|
324 |
163 |
161 |
|
15. Punjab |
250 |
150 |
100 |
|
235 |
124 |
111 |
|
16. Rajasthan |
350 |
250 |
100 |
|
317 |
166 |
151 |
|
17. Tamil Nadu |
465 |
250 |
215 |
|
448 |
225 |
223 |
|
18. Uttar Pradesh |
500 |
350 |
150 |
|
537 |
284 |
253 |
|
19. West Bengal |
555 |
310 |
245 |
|
555 |
286 |
269 |
|
Smaller
States |
|
|
|
|
|
|
|
|
1.
Arunachal
Pradesh |
60 |
45 |
15 |
|
30 |
16 |
15 |
|
2.
Goa |
85 |
43 |
42 |
|
76 |
38 |
38 |
|
3.
3. Himachal Pradesh |
190 |
140 |
50 |
|
92 |
46 |
46 |
|
4.
Manipur |
150 |
110 |
40 |
|
129 |
65 |
64 |
|
5.
Meghalaya |
120 |
90 |
30 |
|
61 |
30 |
30 |
|
6.
Mizoram |
40 |
20 |
20 |
|
29 |
15 |
15 |
|
7.
Nagaland |
45 |
33 |
12 |
|
36 |
19 |
17 |
|
8.
Sikkim |
60 |
45 |
15 |
|
57 |
29 |
27 |
|
9.
Tripura |
80 |
60 |
20 |
|
102 |
52 |
50 |
|
10.
Uttaranchal |
150 |
100 |
50 |
|
108 |
56 |
52 |
|
Union
Territories |
|
|
|
|
|
|
|
|
1. Andaman & Nicobar Islands |
50 |
34 |
16 |
|
33 |
17 |
16 |
|
2.
Chandigarh |
35 |
5 |
30 |
|
30 |
17 |
13 |
|
3.
Dadra &
Nagar Haveli |
30 |
22 |
8 |
|
37 |
20 |
17 |
|
4.
Daman &
Diu |
20 |
13 |
7 |
|
26 |
15 |
12 |
|
5.
Lakshadweep |
12 |
6 |
6 |
|
14 |
7 |
7 |
|
6.
Pondicherry |
50 |
17 |
33 |
|
44 |
22 |
22 |
Note: Rural-Urban population may not add up to total due to rounding
B.4 Organization and Supervision
From
1995, the SRS is being implemented mainly through the Directorates of Census
Operations in both rural and urban areas. However, in the states of Kerala and
Maharashtra the implementation of fieldwork and their monitoring for rural
units has been entrusted to the Directorate of Economics & Statistics and
the urban units to the Directorate of Census Operations.
For
continuous enumeration, there is an enumerator for each sample unit, who is
usually a anganwadi/resident teacher employed on a part‑time basis and is
paid honorarium for this purpose. For supervision and conduct of half‑yearly
surveys, there are full‑time supervisors at the state headquarters. One supervisor is usually assigned a set of
10 to 12 sample units for conducting half‑yearly surveys. Each state headquarters have a complement of
staff necessary for planning and organizing various field operations, training
of the field staff, effecting proper supervision and control, ensuring regular
flow of returns from the field, forwarding of various returns to the Office of
the Registrar General, India and for undertaking certain minimum tabulations.
At
the national level, the Vital Statistics Division of the office of the
Registrar General, India coordinates the implementation work, formulates and
prescribes necessary standards, provides necessary instructions and guidance,
undertakes tabulation, analysis and dissemination of data.
Supervision
of the field work is an important component of SRS. This is undertaken by the
supervisory level officials such as the Investigator, Assistant Director,
Deputy Director, Joint Director and Director.
Officers at the state headquarters undertake visits to sample units and
inspect the work at the field level. Officers of Vital Statistics Division in
the headquarters also undertake surprise checks and visits in SRS units for
control of the quality of work.
B.5 SRS Forms and their flow
For
collecting information on population and vital events various forms/schedules
have been prescribed under the SRS.
Depending upon various operations under the system, the following 17
types of forms are in use:
A. Baseline Survey Forms
Form 1: House
List
Form 2: Household
Schedule
Form 3: Pregnancy
Status of women
B. Continuous Enumeration Forms
Form 4: Outcome of Pregnancy recorded by
Enumerator (January‑June/July‑December)
Form 5: Deaths
recorded by Enumerator (January‑June/July‑December)
Form 6: Monthly
report of Outcome of Pregnancy
Form 7: Monthly
report of Deaths
C. Half yearly Survey Forms
Form 9:
Outcome of Pregnancy recorded by Supervisor (January‑June/July‑December)
Form 10: Deaths recorded by Supervisor
(January‑June/July‑December)
Form 15: Distribution of usual resident
population by age, sex and marital status
(as on 1st July/1st January)
Form 16: Distribution of Female population
by broad age groups and levels of
education (as on 1st July of the year)
Form 17: Number of females who got married
by age at effective marriage (January‑June/July‑December)
D. Compilation/Tabulation Forms
Form 8:
Consolidated monthly report on births and deaths
Form 11: Finalised list of Outcome of
Pregnancy (January‑June/July‑December)
Form 12: Finalised list of Deaths (January‑June/July‑December)
Form 13: Results of the HYS for Outcome of
Pregnancy (January‑June/July‑December)
Form 14: Results of the HYS for Deaths
(January‑June/July‑December)
Every
enumerator records all births and deaths events (Forms 4 and 5) on a continuous
basis and retains with him for six months prior to initiation of the next half
yearly surveys. He is required to send to the state headquarters in the first
week of the following month a monthly report on births and deaths (Forms 6 and
7). He copies down the relevant entries of birth and death records in monthly
report from six monthly records and sends to the state headquarter. On the
basis of the monthly reports received from the sample units, the state
headquarters are required to prepare a consolidated monthly report (Form 8) and
forward the same to the Office of the Registrar General, India by the end of
the following month. The monthly
reports for the individual units remain at the state headquarters. The supervisor records details of each birth
and death event occurring during the six-month reference period in Forms 9 and
10 respectively. After matching of
each birth and death event recorded in Forms 4 and 5 with those in Forms 9 and
10 and verification of partially and unmatched events in the field, finalized
forms 11 and 12 are prepared after necessary corrections and inclusion of
additional events recorded during the survey.
These forms are sent to the Office of the Registrar General, India along
with the half‑yearly survey results in Forms 13, 14, 15, 16 and 17. Efforts are being made to computerize the
entire system of period report including matching report and generation of
specific tables thereon.
cHAPTER - 3
MEDICAL CERTIFICATION of Cause of DEATHs
1. Introduction:
At the national level, the Registrar General of India (RGI)
is responsible for collection, collation and publication of cause of death
statistics. At the state level, the Vital Statistics Division of the
Directorate of Health deals with cause of death statistics. It is of vital
importance to know the leading causes of deaths, as they are essential for
prioritizing Public Health Initiatives and various National Health Programmes.
Medical Certification of cause of Death is an important
tool of obtaining authentic & scientific information regarding causes of
mortality. The Scheme is formulated by Office of the Registrar General, India
is a big step towards the establishment of a system in the country for
obtaining data on causes of death. The Scheme had undergone phase-wise
implementation in the State, starting from medical college hospitals. In second
phase, District hospitals, specialized hospitals were covered. The office of
the Registrar General had given necessary administrative guidelines regarding
coverage of MCCD Scheme in both urban & rural area. Attempts are being made
to cover all private & govt. hospitals since 1998. A brief overview of the cause of death
reporting systems in India is given below.
2. Flow of MCCD Data
Cause of death reports originate from
lay reporters in rural areas and medical attendants in urban areas. The reports
reach the State Vital Statistics office through the primary health centre, in
case of rural areas, and the municipal health office for urban areas.
The data of MCCD flows from
Hospitals/medical institutions of the notified areas to the Registrar (B&D)
who has the functional jurisdiction. Thereafter it gets channelized to the District level and in turn to
the o/o Chief Registrar of the concerned State for the preparation of Annual
Report. The state reports will be consolidated into national level report on
MCCD. A novel system of reporting of vital events is in vogue in NCT of Delhi
(Area under Municipal Corporation of Delhi) wherein all registered health
institutions furnish data “online” as they have been provided with unique
“user-id” and “password”. This modal is likely to be replicated in other states
in the future which will enhance the accuracy and reduce the time lag.
Tabulation is usually done at the
state level but the statistics are published by the RGI. Until December 1998,
cause of death data for the rural areas used to be collected under the Survey
of Cause of Death Rural (SCD-Rural) scheme, from a sample of villages by a lay
diagnosis and reporting system.
A paramedical person from the PHC is
designated as the field agent who undertakes the primary survey. (S)he
identifies key informants and maintains liaison with them. A household register
is drawn up and updated on a half yearly basis. For each death occurring in the
village, the field agent identifies one or more persons having knowledge of the
circumstances of death, interviews them and records the symptoms and
circumstances of death in Form-7.
A structured questionnaire is used to
investigate cause of death using the symptoms and circumstances of death. The
structured questionnaire is supplemented by a check list. The field agent
arrives at a probable cause of death by applying the structured questionnaire
to symptoms and circumstances recorded in Form-7. The check list entry against
the probable cause of death is tallied with the symptoms and circumstances of
death. The cause of death thus arrived is reported in Form-3. The PHC
statistician is designated as the recorder of events reported by the field
agent. Half-yearly verification of the household list is done by the recorder.
Medical officer of the PHC is expected to check and certify the correctness of
cause of death assignment by the field agent. Assignment of cause of death is
done by the field agent based on a structured interview with a member of
concerned household. The structured questionnaire currently in use was adopted
after taking into account five years of field experience with a provisional
questionnaire. The non medical list (NML) of causes of death was last revised
in 1983 to correspond to ICD ninth revision (RGI, 1991). SCD-Rural used verbal
autopsy (VA) to arrive at cause of deaths using paramedical personnel.
Since January 1999 a cause of death component has been added to the SRS (RGI, 1999).
Two more columns have been added to SRS Form-5 (Columns 16-17) and Form-10 (columns 12-13). The SRS part-time enumerator (PTE) records cause of death in column 16 and the code in column 17 of the revised Form-5. The SRS supervisor records similar information in columns 12 and 13 of the revised Form-10. A major departure from the SCD-Rural design is doing away with the symptom record (SCD-Rural Form-7). Another departure from the SCD-Rural is the elimination of the structured questionnaire. Instead the instructions contain a list of causes, related symptoms for some, and the corresponding ICD-10 code.In case of the urban areas, a medical certification of cause of death (MCCD) scheme is operational. This scheme has been acceded legal sanction under the Registration of Births and Deaths (RBD) Act. All medically attended deaths are expected to be registered (Form-2) along with cause of death reports in a format (Form-4) which is similar to what is prescribed by the WHO for International Classification of Cause of Death (ICD). The responsibility for reporting cause of death rests with the doctor / health care provider who last attended on the deceased. Reports are sent to the municipal health authorities, who forward them to the concerned state vital statistics office. The medical attendant is required to follow guidelines contained in the Physician's manual on medical certification of cause of death (RGI, 1992). This manual prescribed the WHO form for reporting cause of death according to the current version of ICD. Coding and tabulation is done according to the National List which is an adaptation of the ICD basic tabulation list. Since the MCCD essentially implements ICD coding and guidelines, the design of the system is considered satisfactory.
3. Characteristics of a usable cause of death reporting
system:
Ruzicka and Lopez (1990) have listed
five criteria used by the World Health Organisation to assess fitness of
country-level cause of death data for inclusion in its compilations. Firstly,
the proportion of all deaths attributed to residual categories such as
"Symptoms, signs and ill defined conditions" is within limits, say
less than 10%. Secondly, the proportionate distribution of deaths by cause is
consistent with the estimated mortality level for that country. Thirdly, no
cause of death with a clear age-sex dependency has been incorrectly assigned.
Fourthly, the age-sex distribution for major causes is consistent with what one
may expect for each cause. Finally, data generated by the system are consistent
with previous years. Note that these are basically plausibility checks. A data
set failing these criteria is more likely to be biased. A data set satisfying
these criteria may still not be usable, on account of poor statistical power of
the generated estimates, and biases that are not readily noticeable.
4. Statutory
Frame-work
The scheme on Medical Certification of Cause of Death (MCCD) being implemented by the office of the Registrar General, India aims to provide a reliable database for generating mortality statistics, which forms an integral part of the vital statistics system. Statistics on causes of death is obtained through the Civil Registration System under the Registration of Births and Deaths Act, 1969. Section 10(2) empowers the states to implement this scheme in any given area while taking into account the level of health infrastructure where as Section 10(3) of the Registration of Births & Death Act, 1969 fixes the onus for the issuance of a certificate as to the cause of death on the medical practitioners who attended the deceased at the time of death. However, the Act provides for maintaining the confidentiality of individual information by forbidding its disclosure under section 17(1).
The scheme of Medical Certification of Cause of Death is being implemented in most of States/UTs in a phased manner to provide reliable data on cause of death. The Offices of the Chief Registrar of Births and Deaths are tabulating data on MCCD in conformity with the International Classification of Diseases (ICD)-Tenth Revision. The statistical report generated by analysis of the data collected is published in the annual publication ‘Medication Certification of Cause of Death’.
5. Level of Registration of COD
The quality of
mortality data and the reliability of cause analysis in respect of medically
certified deaths, to a great extent, depend on the level of registration of
deaths. The current level of
registration of births and deaths in the country is far from complete.
Continuous efforts are being made by the Office of the Registrar General, India
to bring about improvements in the system.
The proportion of medically certified
Deaths in the total deaths is highly un-even among states of India. During the
year 2000 it varied from as high as 94%in the state of Goa to a very low of
less than 1% in case of the state of Utter Pradesh. Scheme implementation as
per the Sample Registration Scheme (SRS) estimates, implemented by Registrar
General of India, the level of death registration in the country is about
50%. Further, the proportion of
medically certified deaths is abysmally low of 14.5% during the year 2000. The time series data for the years 1998-2000
is presented in the table 3.1. The diagrammatic presentation also gives the
status of level of registration in the country in a vivid manner.
Table 3.1: Profile of Death
Registration in India
|
Year |
Number of Registered Deaths |
Crude Death Rate (per1000 population) |
Level of Death Registration |
Medically Certified Deaths |
% of Medically Certified Deaths
to Total |
|
1998 |
3,353,703 |
9.0 |
49.7 |
498586 |
14.9 |
|
1999 |
3,603,741 |
8.7 |
51.8 |
488619 |
13.6 |
|
2000 |
3,528,338 |
8.5 |
49.8 |
510580 |
14.5 |
6.
Medical Certification of Cause of Death
During the year 2000, the total number of 510580 medically certified deaths were registered in India under the civil registration system. The cause analysis revealed that about 73.33% of the total medically certified deaths that has taken place in the year 2000 were under five major causes viz. Diseases of the circulatory system (I00-I99)(24.34%), Infectious and Parasitic Diseases (A00-B99)(15.72%), Symptoms, Signs and abnormal clinical & Laboratory finding not elsewhere classified (R00-R99)(14.21%), Injury, poisoning and certain other consequences of external causes (S00-T98)(11.28%), Certain conditions originating in the prenatal period (P00-P96)(7.79%) and the remaining 26.66% certified deaths were classified under the other causes. The MCCD data in terms of 19 major categories for the years 1998-2000 is presented in table 3.2 gender-wise.
