Erin K. Nichols, PhD, MPH

1. In research and in treatment no denominators can be found...without civil registration &vital statistics Erin K. Nichols, PhD, MPH 20 June 2012 USPHS Scientific and Training Symposium National Center for Health Statistics International Statistics Program

2. Developing the National Prevention and Health Promotion Strategy • Prioritize evidence-based policy and program interventions to address both the leading causes of death and disability in the United States and the preventable behaviors that contribute to those causes.

3. Overview • Overview of civil registration and vital statistics (CR/VS) systems • Vital statistics • Uses • Quality • CR/VS systems around the world • Status of systems • Efforts to improve

5. Civil Registration System A system government uses to record vital events as required by laws or regulations of the country • Main purpose – To establish the legal documents required by law • Goal – To record all vital events occurring in the country as they occur Community volunteer gathering information in the Northern Region of Ghana.

6. Characteristics of Civil Registration • Legal framework • Full coverage of population • Continuous & permanent • Confidentiality of personal information

7. Vital Statistics System The process of collecting, compiling & analyzing information from vital events filed through the civil registration system • Main purpose – Presentation of vital event data in statistical form • Goal – To have accurate data from all vital events occurring in the country Health Metrics Network

8. The Civil Registration System creates a data source for Vital Statistics Civil Registry Database Civil Registration System Vital Statistics

9. Sources of Vital Records

10. Uses of Vital Statistics • Planning human development, monitoring, population dynamics & projections, small area data • Only nationally representative source for: • Mortality by cause of death • Risks of premature death by sex & age • Relative risks of death among subgroups • Cause-specific risk of dying trends CDC, NVSS, 2007

11. Quality of Vital Statistics Data • Relevance • Routine tabulations • Small area statistics Mahapatra et al. (2007) Assessment Framework • Accuracy • Completeness & coverage • Missing data* • Use of ill-defined categories • Improbable classifications • Comparability • Over time • Across space • Timeliness • Production time • Regularity • Accessibility • Media • Metadata • User service * other models also include erroneous data

12. Accuracy of Vital Statistics Content Error • Missing & erroneous data • Use of ill-defined categories • Improbable classifications Coverage Error • Completeness & coverage • Evaluated by: analysis of trends & frequency distributions • Anomalies caused by reporting practices, i.e. digit preference

13. Content Error: Problems with Birth & Death Data

14. Problems with Mortality Data Numerators: • Diagnosis errors • Changes in coding rules-ICD • Classification/coding errors • No contributory causes • Age/race/ethnicity errors Denominators: • Erroneous population estimates far from census • Change in age structure can affect age-adjusted rates • Population estimation challenging for small areas/groups

15. Characteristics to Assess for Comparability of Vital Statistics • Data Quality • Consistency • Methodology • Coverage • Time period • Presentation & Interpretation • Presentation • Explanation • Underlying differentials • Context • Choice of Countries • Comparability Australian Institute of Health and Welfare 2012. A working guide to international comparisons of health.

16. US FetalDeaths: 350+ grams or 20+ completed weeks gestation if weight is unknown US Live Births

18. CR/VS Systems around the World: The Challenge • 48 million infants are not registered each year (~ 40%) • 38 million deaths are not registered (2/3 of all deaths globally) • 85 countries have zero or unreliable cause of death information • an additional 52 have low-quality data

19. WHO, 2007

20. Previous International Effortsto Strengthen CR/VS Systems • Setting standards to improve VS comparability • International collection & publication of data • Strengthening national statistical systems • Not a government priority • Lack of recognition as key component of development

21. What Has Changed? • Most countries are now more developed • Mobile technology is eliminating previous communication problems • National ID systems require birth, death info. • Focus on unique advantages of CR/VS: • Identification – via birth registration • Continuous data flow • Small area data • Cause of death information • Inexpensive data source

22. Creating Demand for Vital Statistics • Millennium Development Goals • # 4 (child mortality) & • # 5 (maternal mortality) • Best measured via vital statistics

23. CR/VS Improvement • Create demand by requiring certificates for government services • IT & mobile technology applications • Collaborations to leverage efforts & budgets • Establishing regional training sites: to promote South – South technical assistance • Employing community health workers to record events at household level

24. NCHS International Statistics ProgramCR/VS Improvement Project • Providing training & technical assistance to countries • Facilitating South to South technical assistance / regional training centers • Conducting demonstration projects • Developing curriculum for CDC’s Field Epidemiology Training Program

25. Hans Rosling’s Gapminder • www.gapminder.org • www.bit.ly/L8eQy4

26. Thank you! Erin K. Nichols E-mail: igd1@cdc.gov Web: http://www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. National Center for Health Statistics International Statistics Program