Legal Frameworks: A Starting Point for Strengthening Medicolegal Death Investigation Systems and Improving Cause and Manner of Death Statistics in Civil Registration and Vital Statistics Systems.

Medicolegal death investigation systems, which generally fall within one of three types-medical examiner, coroner, or law-enforcement-led systems-investigate deaths that are unnatural or suspicious. The current quality of cause of death statistics on deaths investigated within medicolegal death investigation systems globally limits effective public health response. A starting point to strengthening global medicolegal death investigation systems and improving the quality of cause and manner of death reported to civil registration systems is through a strong legal framework. Two resources, the United Nations Statistics Division Guidelines on the Legislative Framework for Civil Registration, Vital Statistics and Identity Management and the Global Health Advocacy Incubator Legal and Regulatory Toolkit for Civil Registration, Vital Statistics and Identity Management, present recommendations and provide guidance to country stakeholders in reviewing and revising their medicolegal death investigation legal frameworks. Physician determination of cause and manner of death, defined criteria for case referral to the medicolegal death investigation system, an amendment process, and investigation collaboration are four core considerations for medicolegal death investigation system legal frameworks. A strong medicolegal death investigation legal framework is a necessary starting point, but it is not sufficient for ensuring the timely, accurate, and complete reporting of cause and manner of death in national vital statistics.

The COVID-19 Pandemic: Effects on Civil Registration of Births and Deaths and on Availability and Utility of Vital Events Data.

The complex and evolving picture of COVID-19-related mortality highlights the need for data to guide the response. Yet many countries are struggling to maintain their data systems, including the civil registration system, which is the foundation for detailed and continuously available mortality statistics. We conducted a search of country and development agency Web sites and partner and media reports describing disruptions to the civil registration of births and deaths associated with COVID-19 related restrictions.We found considerable intercountry variation and grouped countries according to the level of disruption to birth and particularly death registration. Only a minority of the 66 countries were able to maintain service continuity during the COVID-19 restrictions. In the majority, a combination of legal and operational challenges resulted in declines in birth and death registration. Few countries established business continuity plans or developed strategies to deal with the backlog when restrictions are lifted.Civil registration systems and the vital statistics they generate must be strengthened as essential services during health emergencies and as core components of the response to COVID-19.

National health information systems for achieving the Sustainable Development Goals.

OBJECTIVES: Achieving the Sustainable Development Goals will require data-driven public health action. There are limited publications on national health information systems that continuously generate health data. Given the need to develop these systems, we summarised their current status in low-income and middle-income countries. SETTING: The survey team jointly developed a questionnaire covering policy, planning, legislation and organisation of case reporting, patient monitoring and civil registration and vital statistics (CRVS) systems. From January until May 2017, we administered the questionnaire to key informants in 51 Centers for Disease Control country offices. Countries were aggregated for descriptive analyses in Microsoft Excel. RESULTS: Key informants in 15 countries responded to the questionnaire. Several key informants did not answer all questions, leading to different denominators across questions. The Ministry of Health coordinated case reporting, patient monitoring and CRVS systems in 93% (14/15), 93% (13/14) and 53% (8/15) of responding countries, respectively. Domestic financing supported case reporting, patient monitoring and CRVS systems in 86% (12/14), 75% (9/12) and 92% (11/12) of responding countries, respectively. The most common uses for system-generated data were to guide programme response in 100% (15/15) of countries for case reporting, to calculate service coverage in 92% (12/13) of countries for patient monitoring and to estimate the national burden of disease in 83% (10/12) of countries for CRVS. Systems with an electronic component were being used for case reporting, patient monitoring, birth registration and death registration in 87% (13/15), 92% (11/12), 77% (10/13) and 64% (7/11) of responding countries, respectively. CONCLUSIONS: Most responding countries have a solid foundation for policy, planning, legislation and organisation of health information systems. Further evaluation is needed to assess the quality of data generated from systems. Periodic evaluations may be useful in monitoring progress in strengthening and harmonising these systems over time.

Understanding Misclassification between Neonatal Deaths and Stillbirths: Empirical Evidence from Malawi.

Improving the counting of stillbirths and neonatal deaths is important to tracking Sustainable Development Goal 3.2 and improving vital statistics in low- and middle-income countries (LMICs). However, the validity of self-reported stillbirths and neonatal deaths in surveys is often threatened by misclassification errors between the two birth outcomes. We assessed the extent and correlates of stillbirths being misclassified as neonatal deaths by comparing two recent and linked population surveys conducted in Malawi, one being a full birth history (FBH) survey, and the other a follow-up verbal/social autopsy (VASA) survey. We found that one-fifth of 365 neonatal deaths identified in the FBH survey were classified as stillbirths in the VASA survey. Neonatal deaths with signs of movements in the last few days before delivery reported were less likely to be misclassified stillbirths (OR = 0.08, p<0.05). Having signs of birth injury was found to be associated with higher odds of misclassification (OR = 6.17, p<0.05). We recommend replicating our study with larger sample size in other settings. Additionally, we recommend conducting validation studies to confirm accuracy and completeness of live births and neonatal deaths reported in household surveys with events reported in a full birth history and the extent of underestimation of neonatal mortality resulting from misclassifications. Questions on fetal movement, signs of life at delivery and improved probing among older mother may be useful to improve accuracy of reported events.

Evaluation of a mHealth Data Quality Intervention to Improve Documentation of Pregnancy Outcomes by Health Surveillance Assistants in Malawi: A Cluster Randomized Trial.

BACKGROUND: While community health workers are being recognized as an integral work force with growing responsibilities, increased demands can potentially affect motivation and performance. The ubiquity of mobile phones, even in hard-to-reach communities, has facilitated the pursuit of novel approaches to support community health workers beyond traditional modes of supervision, job aids, in-service training, and material compensation. We tested whether supportive short message services (SMS) could improve reporting of pregnancies and pregnancy outcomes among community health workers (Health Surveillance Assistants, or HSAs) in Malawi. METHODS AND FINDINGS: We designed a set of one-way SMS that were sent to HSAs on a regular basis during a 12-month period. We tested the effectiveness of the cluster-randomized intervention in improving the complete documentation of a pregnancy. We defined complete documentation as a pregnancy for which a specific outcome was recorded. HSAs in the treatment group received motivational and data quality SMS. HSAs in the control group received only motivational SMS. During baseline and intervention periods, we matched reported pregnancies to reported outcomes to determine if reporting of matched pregnancies differed between groups and by period. The trial is registered as ISCTRN24785657. CONCLUSIONS: Study results show that the mHealth intervention improved the documentation of matched pregnancies in both the treatment (OR 1.31, 95% CI: 1.10-1.55, p<0.01) and control (OR 1.46, 95% CI: 1.11-1.91, p = 0.01) groups relative to the baseline period, despite differences in SMS content between groups. The results should be interpreted with caution given that the study was underpowered. We did not find a statistically significant difference in matched pregnancy documentation between groups during the intervention period (OR 0.94, 95% CI: 0.63-1.38, p = 0.74). mHealth applications have the potential to improve the tracking and data quality of pregnancies and pregnancy outcomes, particularly in low-resource settings.

Strengthening Community-Based Vital Events Reporting for Real-Time Monitoring of Under-Five Mortality: Lessons Learned from the Balaka and Salima Districts in Malawi.

BACKGROUND: Malawi ratified a compulsory birth and death registration system in 2009. Until it captures complete coverage of vital events, Malawi relies on other data sources to calculate mortality estimates. We tested a community-based method to estimate annual under-five mortality rates (U5MR) through the Real-Time Monitoring of Under-Five Mortality (RMM) project in Malawi. We implemented RMM in two phases, and conducted an independent evaluation of phase one after 21 months of implementation. We present results of the phase two validation that covers the full project time span, and compare the results to those of the phase one validation. METHODS AND FINDINGS: We assessed the completeness of the counts of births and deaths and the accuracy of disaggregated U5MR from the community-based method against a retrospective full pregnancy history for rolling twelve-month periods after the independent evaluation. We used full pregnancy histories collected through household interviews carried out between November 2013 and January 2014 as the validation data source. Health Surveillance Agents (HSAs) across the 160 catchment areas submitted routine reports on pregnancies, births, and deaths consistently. However, for the 15-month implementation period post-evaluation, average completeness of birth event reporting was 76%, whereas average completeness of death event reporting was 67% relative to that expected from a comparable pregnancy history. HSAs underestimated the U5MR by an average of 21% relative to that estimated from a comparable pregnancy history. CONCLUSIONS: On a medium scale, the community-based RMM method in Malawi produced substantial underestimates of annualized U5MR relative to those obtained from a full pregnancy history, despite the additional incentives and quality-control activities. We were not able to achieve an optimum level of incentive and support to make the system work while ensuring sustainability. Lessons learned from the implementation of RMM can inform programs supporting community-based interventions through HSAs in Malawi.

[Formative research on community-based vital events registration in Mali]. / Recherche formative sur l’enregistrement d’évènements vitaux en milieu communautaire au Mali.

OBJECTIVES: The under-five mortality rate in Mali is high, with most deaths occurring in the community where there is no reliable vital events registration. The objective of this study was to collect data on community-based vital events registration in the Niono and Baroueli districts of the Segou region, in order to improve the community-based vital events registration system. METHODS: Data collection for this cross-sectional, descriptive, and qualitative study was conducted in May 2010. Participants included health and administrative workers, community members, women's associations, and non-governmental organizations. Data collection methods included individual interviews and focus groups, as well as document review. Data were entered and codified with Modalisa version 5.1. RESULTS: Pregnancy registration was performed exclusively by health workers in health facilities and was not performed before the third month of pregnancy due to concerns about losing the pregnancy (due to sorcery or spells). Birth registration was performed in administrative and health structures and at the community level, but after an interval of about 7 days. Childhood deaths were rarely registered because the community did not understand the importance of this registration, and because of problems accessing the structures in which deaths are registered. Community opinions were favourable to the implementation of an improved system involving relays (community-based volunteers). CONCLUSION: Improvements to vital events registration in this setting should make use of relays by increasing the awareness and involvement of the population.

Monitoring child mortality through community health worker reporting of births and deaths in Malawi: validation against a household mortality survey.

BACKGROUND: The rate of decline in child mortality is too slow in most African countries to achieve the Millennium Development Goal of reducing under-five mortality by two-thirds between 1990 and 2015. Effective strategies to monitor child mortality are needed where accurate vital registration data are lacking to help governments assess and report on progress in child survival. We present results from a test of a mortality monitoring approach based on recording of births and deaths by specially trained community health workers (CHWs) in Malawi. METHODS AND FINDINGS: Government-employed community health workers in Malawi are responsible for maintaining a Village Health Register, in which they record births and deaths that occur in their catchment area. We expanded on this system to provide additional training, supervision and incentives. We tested the equivalence between child mortality rates obtained from data on births and deaths collected by 160 randomly-selected and trained CHWs over twenty months in two districts to those computed through a standard household mortality survey. CHW reports produced an under-five mortality rate that was 84% (95%CI: [0.71,1.00]) of the household survey mortality rate and statistically equivalent to it. However, CHW data consistently underestimated under-five mortality, with levels of under-estimation increasing over time. Under-five deaths were more likely to be missed than births. Neonatal and infant deaths were more likely to be missed than older deaths. CONCLUSION: This first test of the accuracy and completeness of vital events data reported by CHWs in Malawi as a strategy for monitoring child mortality shows promising results but underestimated child mortality and was not stable over the four periods assessed. Given the Malawi government's commitment to strengthen its vital registration system, we are working with the Ministry of Health to implement a revised version of the approach that provides increased support to CHWs.