Article Text

Are there sex differences in completeness of death registration and quality of cause of death statistics? Results from a global analysis
  1. Tim Adair1,
  2. U S H Gamage1,
  3. Lene Mikkelsen1,
  4. Rohina Joshi2,3
  1. 1Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Victoria, Australia
  2. 2The George Institute for Global Health, Newtown, New South Wales, Australia
  3. 3The George Institute for Global Health, New Delhi, India
  1. Correspondence to Tim Adair; timothy.adair{at}


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.

  • health systems
  • indices of health and disease and standardisation of rates
  • medical demography
  • public health

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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  • Handling editor Seye Abimbola

  • Contributors TA developed the analytical methods, conducted the data analyses, contributed to the drafts and edited the final draft. USH contributed to the drafts and edited the final draft. LM contributed to interpretation of the data and made substantive edits to the drafts. RJ conceptualised the study, contributed to the drafts and edited the final draft.

  • Funding This study was funded under an award from Bloomberg Philanthropies and the Australian Department of Foreign Affairs and Trade to the University of Melbourne to support the Data for Health Initiative. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. RJ is supported by a National Heart Foundation Fellowship and a Scientia Fellowship from UNSW.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.