Number 19

POTENTIALS OF RECORDS AND STATISTICS FROM CIVIL

REGISTRATION SYSTEMS

FOR HEALTH ADMINISTRATION AND RESEARCH

International Institute tor Vital Registration and Statistics

9650 Rockville Pike

Bethesda, Maryland 20814

U.S.A.
 International Statistics
Reference Center
National Center For
Health Statistics

FOREWARD

This is a consolidation of two papers presented at two separate meetings organized by the World Health Organization and
the United Nations. The first paper, entitled "Public Health Uses of Mortality Data," was given at a meeting on
Socioeconomic Determinantsand Consequencesof Mortality held in Mexico City, 19-25June 1979, and the second, entitled
"Advantages and Disadvantages of Continuous Registration Systems for National, Subnational and Differential Mortality
Analysis," was prepared for the meeting of the United Nations/World Health Organization Working Group on Data Bases for
Measurement of Levels, Trends and Differentials in Mortality held in Bangkok, 20-23 October 1981.
Over the vears, mortality statistics derived from the civil registration process have been used extensively for the delineation
of public health problems, and for various analytical studies on health and demography. In addition, the individual death
record has been useful in identifying infective foci of disease as well as in the epidemiologic studies of chronic diseases. The
most important feature of registrationstatistics is that they provide detailed all-purpose reference tables annually for various
segments of the population which can .be tapped for specific studies. For public health purposes, a most valuable datum
relates to causes of death.
The continuous registration system offers data possibilities which cannot be obtained in any other way. On the other hand,
death statistics for the developing countries are frequently of limited usefulness because of incompleteness of the registered
events. The improvement of completeness and quality of official death statistics in these countries is a difficult task requiring
time and effort. Some suggestions are made on steps that might be taken to develop and improve national.deathregistration
systems.
The Technical Papers series is issued by IIVRS for the information of its members. The IlVRS does not necessarily-endorse
the views in this document.
 POTENTIALS OF RECORDS AND STATISTICS FROM CIVIL
REGISTRATION SYSTEMS FOR HEALTH ADMINISTRATION AND RESEARCH

lwao M. Moriyama, Ph.D.

Deputy Executive D i r e c t o r
International I n s t i t u t e f o r V i t a l
R e g i s t r a t i o n and S t a t i s t i c s
Bethesda, Mary1 and

For many years, t h e r e was o n l y one recognized way o f producing v i t a l s t a t i s -

t i c s , and t h i s was from b i r t h and death records f i l e d f o r l e g a l purposes. This,
d e s p i t e t h e f a c t t h a t t h e s t a t i s t i c s d e r i v e d f r o m these documents i n t h e devel-
oping c o u n t r i e s were g e n e r a l l y so i n c m p l e t e as t o be o f l i m i t e d usefulness:

S h o r t l y a f t e r World War I I , t h e r e arose i n developing c o u n t r i e s a demand

for b i r t h and death s t a t i s t i c s for planning, a d m i n i s t r a t i o n and e v a l u a t i o n of
h e a l t h programs; measurement o f p o p u l a t i o n growth f o r f a m i l y p l a n n i n g programs;
and f o r n a t i o n a l s o c i a l and economic development p l a n n i n g purposes. Because t h e
then c u r r e n t c i v i l r e g i s t r a t i o n systems were incapable o f p r o v i d i n g t h e needed
s t a t i s t i c s , o t h e r ways and means were sought t o e s t i m a t e b i r t h , death and popu-
l a t i o n growth data. This l e d t o the a p p l i c a t i o n o f r e t r o s p e c t i v e survey rnethod-
ology, and the development o f i n d i r e c t methods o f e s t i m a t i n g f e r t i l i t y and mor-
t a l i t y r a t e s . The a v a i l a b i l i t y o f these methods f o r e s t i m a t i n g b i r t h and death
s t a t i s t i c s n a t u r a l l y r a i s e s questions about t h e v a l u e o f c i v i l r e g i s t r a t i o n d a t a
for s t a t i s t i c a l purposes.

I t i s t h e purpose of t h i s paper t o d i s c u s s t h e advantages and disadvantages

o f the c u r r e n t continuous death r e g i s t r a t i o n system as a source o f data f o r d i f -
f e r e n t i a l m o r t a l i t y a n a l y s i s and o t h e r uses o f m o r t a l i t y data. To p r o v i d e a
proper p e r s p e c t i v e t o t h e problem, a h i s t o r i c a l background r e l a t i n g t o t h e devel-
opment of m o r t a l i t y s t a t i s t i c s w i l l f i r s t be given. T h i s w i l l be followed by
b r i e f d i s c u s s i o n s o f t h e death r e g i s t r a t i o n process and t h e uses of b o t h i n d i -
v i d u a l records and s t a t i s t i c s d e r i v e d from t h e death c e r t i f i c a t e . Then the.ad-
vantage and disadvantages o f t h e continuous r e g i s t r a t i o n system for t h e produc-
t i o n o f n a t i o n a l m o r t a l i t y s t a t i s t i c s w i l l be discussed.

H i s t o r i c a l development

The forerunner t o t h e c i v i 1 r e g i s t e r s were t h e e c c l e s i a s t i c r e g i s t e r s .

These r e g i s t e r s recorded weddings, baptisms, and b u r i a l s o c c u r r i n g i n t h e p a r i s h .
The e a r l i e s t known c o m p i l a t i o n o f b i l l s o f m o r t a l i t y was issued i n 1532 i n Lon-
don. These b i l l s were weekly l i s t s o f b u r i a l s , and i n c l u d e d the name of t h e
deceased, t h e p a r i s h i n which t h e b u r i a l took place, and t h e cause of death w i t h
p a r t i c u l a r reference t o t h e plague. The cause o f death was determined by t h e
searcher a f t e r she had viewed the body. I n t h e more d i f f i c u l t cases, t h e
searcher c o n s u l t e d a doctor. The searchers made t h e i r r e p o r t t o t h e p a r i s h
c l e r k who prepared an account o f a l l t h e b u r i a l s every Tuesday n i g h t . On
Wednesday, t h e general account was made up and p r i n t e d . On Thursday, t h e b i l l s
were d i s t r i b u t e d t o s u b s c r i b e r s who payed 4 s h i l l i n g s a year.

More than a c e n t u r y l a t e r , John Graunt conceived o f t h e idea of u t i l i z i n g ...

t h e B i l l s o f M o r t a l i t y f o r a n a l y t i c a l s t u d i e s w h i c h were.published,.int 1662 % I

under t h e t i t l e o f N a t u r a l and P o l i t i c a l Observations Upon t h e London B i : l l s o f ,

Mortality. D e s p i t e medical progress, t h e d i a g n o s t i c q u a l i t y o f t h e b i l l s d i d
n o t improve. Also, i n t e r e s t , i n t h e old. b i l l s waned. Clerks o f many p a r i s h e s
f a i led t o report, 0r::reported only i r r e g u l a r l y . Even when complete, t h e b i 11s
gave no i n f o r m a t i o n about t h e p o p u l a t i o n o f towns and c o u n t r i e s .

I n 1837, t h e R e g i s t r a t i o n Act was passed i n England w i t h p r o v i s i o n s for an

i n q u i r y i n t o t h e causes o f death. I n 1839, W i l l i a m F a r r was appointed c o m p i l e r
o f a b s t r a c t s i n t h e R e g i s t r a r General’s O f f i c e , and he, probably more then any-
one else, developed and analyzed m o r t a l i t y s t a t i s t i c s t o d e l i n e a t e t h e s a n i t a r y
and h e a l t h problems o f t h e day. F a r r (1) r e p o r t e d on l i f e and death i n England,
on p o s s i b i l i t i e s and d i f f i c u l t i e s o f e x t e n d i n g human l i f e , t h e e f f e c t s o f s a n i -
t a t i o n on m o r t a l i t y , m o r t a l i t y and t h e economic s i t u a t i o n , m o r t a l i t y and t h e
water Supply; urban and r u r a l m o r t a l i t y p o i n t i n g o u t h e a l t h y and unhealthy d i s -
t r i c t s , m o r t a l i t y a t d i f f e r e n t ages by sex, m o r t a l i t y o f i l l e g i t i m a t e infants; \
and o t h e r t o p i c s .

T r a d i t i o n a l l y , o f f i c i a l m o r t a l i t y s t a t i s t i c s have been d e r i v e d from t h e

death r e c o r d f i l e d i n compliance w i t h t h e requirements o f t h e c i v i l r e g i s t r a t i o n
laws t o prevent t h e i l l e g a l d i s p o s i t i o n and/or t r a n s p o r t a t i o n o f a dead body.
I n o t h e r words, death s t a t i s t i c s are, by and l a r g e , by-products o f a l e g a l pro-
cess. An e x c e p t i o n t o t h i s has been t h e a t t e m p t t o c o l l e c t n a t i o n a l death s t a -
t i s t i c s i n t h e U n i t e d States by t h e enumeration method i n c o n j u n c t i o n w i t h t h e
decennial p o p u l a t i o n censuses o f 1880 t o 1900. I t should be noted t h a t death A

r e g i s t r a t i o n laws were a s l r e a d y ’ i n e f f e c t i n a l l t h e S t a t e s a t t h a t time. How-

ever, i t was f e l t t h a t t h e r e g i s t r a t i o n coverage was n o t s u f f i c i e n t l y complete
f o r t h e c o m p i l a t i o n o f n a t i o n a l m o r t a l i t y s t a t i s t i c s . Therefore, census i n t e r -
viewers were used t o c o l l e c t , on a r e t r o s p e c t i v e b a s i s , i n f o r m a t i o n on deaths
t h a t occurred i n t h e household over a p e r i o d o f a year. U n f o r t u n a t e l y , the cen-
sus approach y i e l d e d fewer deaths than were a b s t r a c t e d through t h e death r e g i s -
t r a t i o n process i n t h e S t a t e s w i t h reasonably good r e g i s t r a t i o n systems. The
census enumeration procedure was t h e r e f o r e abandoned a f t e r t h e 1900 census, and
t h e U.S. Death R e g i s t r a t i o n Area was formed as a b a s i s f o r n a t i o n a l m o r t a l i t y
statistics .
I t was n o t u n t i l a f t e r World War I I t h a t developing c o u n t r i e s f e l t - an acute
need f o r adequate m o r t a l i t y s t a t i s t i c s . Death r e g i s t r a t i o n data were then found
wanting, w i t h l i t t l e p o s s i b i l i t y o f r a p i d development o f t h e r e g i s t r a t i o n system.
Other methods were t h e r e f o r e sought t o produce m o r t a l i t y data. The r e s u l t i n g
research e f f o r t s l e d i n t w o general d i r e c t i o n s , one b e i n g d i r e c t methods o f e s t i -
mation u t i l i z i n g f i e l d surveys o r a combination o f records and surveys, and t h e
o t h e r b e i n g techniques o f e s t i m a t i o n u t i l i z i n g i n d i r e c t i n d i c a t o r s o f m o r t a l i t y .

m1/
-
The l e g a l base f o r death r e g i s t r a t i o n i s some k i n d of c i v i l law on r e g i s -
t r a t i o n which e s t a b l i s h e s the compulsory n a t u r e o f 2nd t h e requirements for
r e g i s t r a t i o n o f deaths. The law designates t h e person r e s p o n s i b l e f o r r e g i s t r a -
t i o n , t h e p l a c e o f r e g i s t r a t i o n , and p r e s c r i b e s t h e time allowed f o r the r e g i s - i
t r a t i o n o f t h e event, fees required, i f any, and t h e p e n a l t y f o r f a i l u r e t o
register.

I / For f u l l d e s c r i p t i o n o f t h e c i v i l r e g i s t r a t i o n procedure, see Handbook of

V i t a l S t a t i s t i c s Methods. Studies i n Methods. Series F, No. 7, U n i t e d
Nak lions, 1955 ;
 I n most c o u n t r i e s , t h e r e s p o n s i b i l i t y f o r t h e r e g i s t r a t i o n of a death r e s t s
w i t h a r e l a t i v e o r t h e head of t h e f a m i l y o r o f t h e household. Data concerning
t h e decedent a r e o b t a i n e d from t h e informant p r i o r t o or a t t h e t i m e of t h e reg-
istration. These d a t a u s u a l l y i n c l u d e t h e t i m e and p l a c e o f death, t h e personal
p a r t i c u l a r s about t h e decedent, and c h a r a c t e r i s t i c s of t h e parents, a t t e n d a n t a t
death, informant, witnesses and the r e g i s t r a r , and t h e method o f interment.
Another important datum i s provided by t h e medical a t t e n d a n t , i f any, o r by t h e
medicolegal a u t h o r i t y , on t h e cause of death.

I n most c o u n t r i e s , t h e l e g a l record, u s u a l l y i n the f o r m o f books o f actas,

i s brief. For s t a t i s t i c a l purposes, a d d i t i o n a l i n f o r m a t i o n i s c o l l e c t e d f r o m
t h e informant a t t h e t i m e of r e g i s t r a t i o n . The l e g a l r e c o r d i s placed i n a
permanent r e p o s i t o r y w h i l e t h e s t a t i s t i c a l t r a n s c r i p t i s t r a n s m i t t e d t o t h e
government agency r e s p o n s i b l e f o r v i t a l s t a t i s t i c s .

I n o t h e r c o u n t r i e s , t h e l e g a l acd t h e s t a t i s t i c a l forms a r e combined i n t o a

s i n g l e death c e r t i f i c a t e . The o r i g i n a l death c e r t i f i c a t e s a r e bound i n t o books
and f i l e d permanently f o r l e g a l purposes. P r o v i s i o n s safeguarding t h e c o n f i -
d e n t i a l i t y o f i n f o r m a t i o n i n these documents vary depending on t h e country. How-
ever, c e r t i f i e d copies o f t h e r e c o r d a r e g e n e r a l l y issued t o i n d i v i d u a l s upon
request . *

Uses of death s t a t i s t i c s

O f f i c i a l m o r t a l i t y s t a t i s t i c s d e r i v e d f r o m death records a r e used exten-

s i v e l y f o r demographic s t u d i e s and i n p u b l i c h e a l t h programs. These s t u d i e s may
deal w i t h m o r t a l i t y d i f f e r e n t i a l s by age, sex, occupation, socioeconomic charac-
t e r i s t i c s , etc., or t h e y may deal w i t h t h e demographic c h a r a c t e r i s t i c s o f t h e
decedent t o e l i m i n a t e t h e e f f e c t s o f ase, sex, and e t h n i c i t y for s t u d i e s of
mortality r i s k factors. For p u b l i c h e a l t h purposes, t h e s t a t i s t i c s on causes of
death f i g u r e p r o m i n e n t l y . Death s t a t i s t i c s have l o n g been used as i n d i c a t o r s
o f h e a l t h , as measures o f t h e magnitude o f h e a l t h problems, and f o r t h e evalua-
t i o n o f h e a l t h programs, d e s p i t e c e r t a i n l i m i t a t i o n s of m o r t a l i t y d a t a f o r t h i s
purpose. The a v a i l a b i l i t y o f m o r t a l i t y s t a t i s t i c s ora a roiit1ne b a s i s f o r t h e
various p o l i t i c a l s u b d i v i s i o n s of a c w n t r y i s of c e n t r a l importance t o t h e
u t i l i z a t i o n o f death s t a t i s t i c s f o r these m a n i f o l d purposes.

An important use of m o r t a l i t y s t a t i s t i c s i s i n t h e study o f determinants of

disease. For example, Pool and Char (2) observed t h e d i f f e r e n t i a l d e c l i n e i n
t h e t u b e r c u l o s i s m o r t a l i t y r a t e f o r t h e Macris and a t t r i b u t e d t h e d e c l i n e t o t h e
disadvantageous p o s i t i o n of t h e Maoris i n New Zealand s o c i e t y u n t i l t h e 1940s.
Poverty, poor d i e t , and f a i l u r e t o seek medical treatment were cdted as causes
of t h e h i g h m o r t a l i t y r a t e for t h e Maoris, and t h e . d e c l i n e was a t t r i b u t e d t o i m -
proved medical technology i n t h e post-war p e r i o d . Mass X-ray campaigns and
a n t i b i o t i c s were s a i d t o * h a v e c o n t r i b u t e d t o t h e a c c e l e r a t e d %rateo f d e c l i n e .
\
Another example may be c i t e d as a r e s u l t o f postwar experlences i n a number
of c o u n t r i e s where n a t i o n w i d e m a l a r i a c o n t r o l programs were c a r r i e d out, and
where s i g n i f i c a n t r e d u c t i o n s i n t h e general m o r t a l it y r a t e occurred. Pampana ( 3 )
presented d a t a for 6 c o u n t r i e s where such programs had been i n o p e r a t i o n f o r a t
l e a s t 5 years and for which adequate d a t a were a v a i l a b l e . I n a l l o f these coun-
t r i e s , a r a p i d d e c l i n e i n t h e crude death r a t e and i n t h e i n f a n t m o r t a l i t y r a t e
i n v a r i a b l y followed the-countrywJde ,appl i c a t i o n of DDT. The d e c l i n e i n m o r t a l i t y
was most s t r i k i n g i n Cey.lon whc:.re..the crude death r a t e dropped from 20.3 t o 14.3
per 1000 p o p u l a t i o n i n a singlevyeair., 1946 t o 1947, a f t e r t h e s t a r t o f t h e

i
1

!
m a l a r i a e r a d i c a t i o n program. Although t h e r e appeared t o be l i t t l e q u e s t i o n about
the dramatic d e c l i n e i n m o r t a l i t y i n Ceylon, t h e r e was n o t general agreement as
t o t h e cause o f t h e r e d u c t i o n . Meegama (4) a t t r i b u t e d p a r t of the. decrease t o
i
m a l a r i a c o n t r o l and t h e r e s t t o t h e establishment and p r o v i s i o n o f h e a l t h and
medical s e r v i c e s . F r e d r i k s e n (5) found s i m i l a r m o r t a l i t y r e d u c t i o n s i n non- I

malarious areas n o t p r o t e c t e d by p e s t i c i d e s , and concluded t h a t t h e d e c l i n e i n

m o r t a l i t y was a s s o c i a t e d w i t h economic development and t h e consequent r i s e i n t h e i
I
l e v e l of l i v i n g . Newman(61, on t h e o t h e r hand, took t h e p o s i t i o n t h a t i t was n o t
p o s s i b l e t o d i s e n t a g l e t h e e f f e c t s o f t h e v a r i o u s f a c t o r s t h a t were o p e r a t i n g a t
i
t h a t per iod. I
I
There a r e many o t h e r examples o f e p i d e m i o l o g i c s t u d i e s based on o f f i c i a l
mortality statistics. Hoover and Fraumeni (7) s t u d i e d t h e cancer m o r t a l i t y i n
counties where c e r t a i n i n d u s t r i e s were l o c a t e d and found e x c e s s i v e l y h i g h death
r a t e s f o r bladder, lung, l i v e r and c e r t a i n o t h e r cancer s i t e s i n 139 c o u n t i e s
where t h e chemical i n d u s t r y was centered. B l o t and Fraumeni (8) compared t h e
lung cancer m o r t a l i t y for c o u n t i e s i n t h e U n i t e d States where paper, chemical,
petroleum and t r a n s p o r t a t i o n i n d u s t r i e s were l o c a t e d w i t h t h a t f o r adjacent
counties where t h e r e were no such i n d u s t r i e s . E x c e s s i v e l y h i g h l u n g cancer
death r a t e s among males were observed i n t h e c o u n t i e s where these i n d u s t r i e s were
located, which may account fo'r p a r t of t h e r a p i d increase i n l u n g cancer r e p o r t e d
f o r the southern c o a s t a l c o u n t i e s - i n t h e U n i t e d States. I t was suggested t h a t
these p a r t i c u l a r i n d u s t r i a l o p e r a t i o n s be s t u d i e d t o a s c e r t a i n t h e e t i o l o g y of
lung cancer.

I n t h e s t u d i e s d e s c r i b e d thus far, t h e observed changes and d i f f e r e n t i a l s

r e s u l t e d i n inferences l e a d i n g t o hypotheses a b u t disease causation. There a r e
a l s o s t u d i e s t h a t s t a r t w i t h a hypothesis about a disease and accumulate data t o
t e s t i t . For example, Fears (91, i n an e f f o r t t o a s c e r t a i n i f n a t u r a l l y occur-
r i n g asbestos r e s u l t e d i n increased r i s k of cancer m o r t a l i t y , i d e n t i f i e d t h e
various c o u n t i e s i n t h e U n i t e d States w i t h asbestos d e p o s i t s . Each of these
counties was then matched w i t h t w o nearby c o u n t i e s t h a t d i d n o t have known
asbestos d e p o s i t s . The comparison o f cancer m o r t a l i t y r a t e s for t h e two s e t s of
counties gave no evidence t h a t n a t u r a l l y o c c u r r i n g asbestos i s a hazard t o t h e
genera 1 popu 1a t ion.

A l l o f t h e s t u d i e s t h a t have been c i t e d have one c h a r a c t e r i s t i c i n common,

namely, t h a t t h e i n v e s t i g a t i o n s a r e based on t r a d i t i o n a l o r o f f i c i a l m o r t a l i t y
impinging on t h e general p o p u l a t i o n as w e l l as t h e s p e c i a l r i s k f a c t o r s . There-
fore, i t i s not p o s s i b l e t o determine t h e e f f e c t o f any p a r t i c u l a r f a c t o r . How-
ever, d e s c r i p t i v e epidemiology i s v a l u a b l e i n suggesting hypotheses o r leads for
further investigation.

For t h e t e s t i n g o f e p i d e m i o l o g i c hypotheses, i t is.necessary t o i n c l u d e i n

the study measures o f s p e c i f i c r i s k factors. T h i s i s t h e b a s i s o f t h e case con-
t r o l o r t h e r e t r o s p e c t i v e e p i d e m i o l o g i c study and t h e p r o s p e c t i v e e p i d e m i o l o g i c
study which w i l l be discussed l a t e r i n connection w i t h t h e uses of death records.

Uses o f death records

The death r e c o r d p r o v i d e s a p r o o f o f death for b u r i a l o r o t h e r means o f

d i s p o s i t i o n of t h e remains; f o r t h e s e t t l e m e n t o f l i f e insurance and s o c i a l i n - '
isurance claims; and for t h e a d j u d i c a t i o n o f p r o p e r t y ownership and i n h e r i t a n c e
claims. I t a l s o p r o v i d e s lege1 evidence on t h e r i g h t s of s u r v i v i n g spouse t o i
remarry; The death r e c o r d has a l s o been used f o r c l e a r i n g v a r i o u s k i n d s o f f i l e s
i
I

4c
e-.
I
such as s o c i a l s e c u r i t y f i l e s , disease case r e g i s t e r s , e l e c t o r a l l i s t s , bank ac-
counts, m i s s i n g persons f i l e s , e t c .

The death c e r t i f i c a t e o r t h e death r e p o r t s have been used e x t e n s i v e l y i n

p u b l i c h e a l t h and medical s t u d i e s . , The death r e c b r d has been u s e f u l f o r program
purposes i n p u b l i c h e a l t h , f o r linkages t o o t h e r records, i n f o l l o w back i n v e s t i -
gations, and f o r r e t r o s p e c t i v e and p r o s p e c t i v e e p i d e m i o l o g i c s t u d i e s . A b r i e f
d e s c r i p t i o n w i l l be g i v e n of each o f these uses.

P u b l i c h e a l t h program uses. One o f t h e common uses o f v i t a l records i n

p u b l i c h e a l t h i s t h e r e f e r r a l o f c e r t a i n problems t o s p e c i f i c program u n i t s f o r
f o l l o w - u p or i n v e s t i g a t i v e purposes. For example, i n many l o c a l h e a l t h depart-
ments, death records i n v o l v i n g i n d i v i d u a l s t h a t d i e d from c e r t a i n i n f e c t i v e
diseases a r e r o u t i n e l y r e f e r r e d t o t h e communicable disease u n i t . T h i s makes
p o s s i b l e t h e s p o t t i n g o f epidemics, or i n t h e case o f v i r u l e n t epidemic diseases
an i n v e s t i g a t i o n t o examine c o n t a c t s i n attempts t o c o n t a i n t h e spread o f t h e
disease.

Other program uses may be mentioned. B i r t h records o f immaturely born

c h i l d r e n may be r e f e r r e d t o t h e maternal and c h i I d program f o r f o l l o w - u p purposes
t o a d v i s e on t h e proper neonatal care f o r t h e baby. I n t h e event t h a t the c h i l d
was born w i t h a malformation, t h e c r i p p l e d c h i l d r e n s ' program may p r o v i d e a s s i s -
tance o r make t h e parents aware o f t h e a v a i l a b l e s e r v i c e s f o r such c h i l d r e n .
None o f these community and personal s e r v i c e s can be p r o v i d e d w i t h o u t t h e iden-
t i t y o f i n d i v i d u a l s involved.

For many s e r v i c e programs, i t i s i m p o r t a n t t o update t h e r e g i s t e r s by r e -

moving on a c u r r e n t b a s i s those t h a t dropped o u t of t h e program through death.
T h i s can be done by matching t h e death records w i t h t h e r e g i s t r y f i l e . Then
t h e r e a r e t h e a d m i n i s t r a t i v e and s c i e n t i f i c purposes t o be served by v i t a l r e -
cords. One o f these i s t h e s u r v e i l l a n c e - o f c e r t a i n disease problems. For
example, i n e s t a b l i s h i n g a r e g i s t r y f o r i n c i d e n c e o r prevalence s t u d i e s , t h e
death r e c o r d p l a y s an important r o l e . For one, t h e cancer r e g i s t r y attempts t o
r e c o r d every known case o f cancer. Deaths f r o m cancer, i f r e p o r t e d t o cancer
r e g i s t r i e s , w i l l serve t o supplement t h e known cases. I n t h e poorer r e g i s t r i e s ,
more than h a l f o f t h e r e g i s t r y cases a r e those t h a t were i d e n t i f i e d by the death
certificate. Even i n t h e b e t t e r cancer r e g i s t r i e s , more than 10 percent of t h e
t o t a l cancer cases come t o t h e a t t e n t i o n o f t h e r e g i s t r y f r o m t h e death record.
Other s u r v e i l l a n c e systems w i l l a l s o b e n e f i t f r o m a r o u t i n e f l o w of i n f o r m a t i o n
f r o m t h e v i t a l records. Cates, e t a l , (10) found t h a t s u r v e i l l a n c e techniques
i d e n t i f i e d more deaths as a b o r t i o n - r e l a t e d than t h e death records. However,
when t h e death records were combined w i t h s u r v e i l l a n c e records, t h e r e was a
s i g n i f i c a n t improvement i n t h e i d e n t i f i c a t i o n o f a b o r t i o n - r e l a t e d deaths.

One o f t h e important uses o f t h e cancer r e g i s t r i e s i s t o make a systematlc

follow-up of cancer p a t i e n t s i n o r d e r t o schedule p e r i o d i c examinations. For
t h i s purpose, i t i s e s s e n t i a l t h a t t h e r e g i s t r y c l e a r a l l cancer p a t i e n t s t h a t
d i e by matching death records t o t h e r e g i s t e r cases. T h i s a l s o makes p o s s l b l e
t h e d e t e r m i n a t i o n of s u r v i v a l r a t e s f o r t h e v a r i o u s groups o f cases. The s u r v i -
Val r a t e i s one means of assessing the e f f e c t i v e n e s s of d i f f e r e n t k i n d s of can-
c e r therapy.

Record linkage. The value o f m o r t a l i t y s t a t l s t l c s per -9se t h a t i s , o f f i -

c i a 1 m o r t a l i t y s t z i s t i c s , i s l i m i t e d f o r e p i d e m i o l o g i c and c v a l u a t i o n purposes.
T h i s i s because m o r t a l i t y data a r e n o t g e n e r a l l y c l a s s i f i e d according t o t h e
factors that need to be studied. One needs to go beyond the usually available

demographic characteristics such as age, sex, ethnicity, etc. To break out of

the limiting bounds of mortality statistics, one could utilize the death record

to link with other pertinent information. A simple example of this may be found

in the study of infant deaths. The conventional infant mortality statistics in-

cludes rates by age, sex, and cause of death. Although immaturity is tabulated

as a cause of death, there is no way of obtaining death rates for low birth

weight infants using the death record alone. However, the birth certificates

for many countries contain information on birth weight. Therefore, if the infant
I
death record were to be matched to the birth record, it would be possible to

utilize the birth weight data recorded on the birth certificates for the numera-
I
tor as well as the denominator of the rate. Similarly, it will be possible to
j
obtain infant death rates by age of mother, parity, and other information con-
I
cerning the mother or child which may not be recorded on the death certificate.

Other examples of linked records are available. The Canadian Atomic fnergy
Commission (11) designed a record-linked population for genetic studies. Birth
certificates were matched to marriage records, thus establishing a roster of Tam-
ily units as well as individuals. The death record was also linked. This record
linkage system was to keep track of groups o f individuals exposed to low levels
of radiation to determine the causes of eventual death.

The Oxford Record Linkage Study dealt with a central file of mortality and
hospital mortality records for a defined population. Although the pilot study
was designed primarily for administrative studies, it also offered resources for
epidemiologic investigation oT diseases which are generally tceated in hospitals.
As a result of the pilot study, Acheson, et al, (12) suggested that a national
record 1 inkage,system be considered for England and Wales by the adoption of a
unique identity number for each patient in the National Health Service.

Follow back studies. To go beyond the limitations of the traditional mor-

tality statistics, it has also been suggested .that supplemental data be collected

by going back to the informants named on,the death record. By obtaining the

same information for a sample of the living population, it would be possible to

present death rates on items not covered in the. death record. Also, by going

back to the medical attendant at death, it should be possible to obtain addi-

tional diagnostic information as well as making the evaluation of the quality of

diagnostic data.
\

Epidemiologic studies. One of the significant developments. in the postwar

period was the burgeoning of public health interest in environmental problems
which gave rise to many studies in chronic disease epidemiology. In these
efforts, mortality statistics proved to be an inadequate source of data. It
remained for the death record to serve this new need by providing a starting
point in retrospective studies and by providing an end point in prospective
epidemiologic studies.

In the retrospective, or the case control, study approach, the death record *
i s employed to identify the casesfor retrospective epidemiologic study, one
group of cases being related to the disease under study and the other to a
matched control or comparison group. A follow back is then made to a data source
for information on the etiologic factor, and a comparison is made between these
two groups to establish whether the factor is associated with one group and not
w i t h ,therother.
4 I .

.,>
-~
 Stewart, e t a l , (13) MacMahon (14) and o t h e r s have made s t u d i e s o f c h i l d -
hood cancer u t i l i z i n g t h e death c e r t i f i c a t e as t h e s t a r t i n g p o i n t . I n the for-
mer study, more mothers o f c h i l d r e n who d i e d o f leukemia and o t h e r malignant
diseases remembered having abdominal or p e l v i c X-ray d u r i n g t h e r e l a t e d pregnancy
than d i d t h e mothers o f a sample o f c h i l d r e n who d i d n o t d i e o f cancer. In
MacMahon's study, t h e c h i l d r e n born i n a s t u d y p o p u l a t i o n who subsequently d i e d
o f cancer were i d e n t i f i e d i n a review o f death and b i r t h c e r t i f i c a t e s . Records
o f pregnancy and d e l i v e r y of these c h i l d r e n were a l s o reviewed. I t was found
t h a t cancer m o r t a l i t y was much h i g h e r ixn t h e X-rayed than i n t h e u n i r r a d i a t e d
c h i l d r e n i n t h e study population.

More r e c e n t l y , B l o t , e t a l , (15) undertook a case c o n t r o l study t o i d e n t i f y

t h e f a c t o r s associated w i t h t h e u n u s u a l l y h i g h lung cancer death r a t e among t h e
male r e s i d e n t s of c o a s t a l Georgia. I t was found t h a t t h e increased r i s k was
a s s o c i a t e d w i t h employment i n t h e shipyards d u r i n g World War I t . I t was a l s o
found t h a t c i g a r e t t e smoking produced a s y n e r g i s t i c e f f e c t . The f i n d i n g s sug-
gested t h a t asbestos and p o s s i b l y o t h e r exposures d u r i n g wartime employment ac-
counted f o r p a r t o f t h e excess m o r t a l i t y from lung cancer i n t h e southeastern
c o a s t a l areas of t h e U n i t e d States.

The p r o s p e c t i v e study s t a r t s w i t h a hypothesis about a disease and data a r e

c o l l e c t e d f o r fwo d e f i n e d populations, t h e "experimental" group and t h e compara-
t i v e o r t h e " c o n t r o l " group. These t w o p o p u l a t i o n cohorts a r e then f o l l o w e d un-
, t i l an event (i.e., death i n t h e case o f m o r t a l i t y s t u d i e s ) occurs. The use of
matched c o n t r o l s , t h a t i s , two p o p u l a t i o n s s i m i l a r i n a l l respects except for
t h e f a c t o r b e i n g tested, p r o v i d e s a s t r o n g e r b a s i s f o r showing a s s o c i a t i o n be-
tween v a r i a b l e s than t h e mentioned r e t r o s p e c t i v e approach.

I n a p r o s p e c t i v e study o f m o r t a l i t y f r o m lung cancer among asbestos workers,

D o l l (16) and Knox, e t a l , (17) found lung cancer t o be a s p e c i f i c environmental
hazard o f c e r t a i n asbestos workers. The average r i s k among men employed f o r 2 0 ,
years o r more was i n t h e o r d e r of 10 times t h a t of t h e general p o p u l a t i o n . The
r i s k lessened as d u r a t i o n o f employment under o l d dusty c o n d i t i o n s decreased.

One o f t h e more s i g n i f i c a n t e p i d e m i o l o g i c a l f i n d i n g s of recent years a r e

those demonstrating t h e a s s o c i a t i o n between smoking and l u n g cancer. Doll and
H i l l (18) sent q u e s t i o n n a i r e s t o about 60,000 men and women on t h e Medical Regis-
t e r and e l i c i t e d i n f o r m a t i o n on i n d i v i d u a l smoking h a b i t s . Some 40,000 who r e -
sponded were f o l l o w e d f o r a p e r i o d o f time and deaths o c c u r r i n g i n t h i s popula-
t i o n were i d e n t i f i e d from t h e f i l e s o f t h e General Medica? Council and t h e
B r i t i s h Medical Association. W i t h t h e i d e n t i f i c a t i o n o f these deaths, t h e Regis-
t r a r - G e n e r a l s i n t h e U n i t e d Kingdom provided t h e p a r t i c u l a r s on t h e cause o f
death. This study showed a s i g n i f i c a n t a s s o c i a t i o n between smoking and lung
cancer.

Dorn (19) s t a r t e d w i t h about 200,000 p o l i c y h o l d e r s o f U.S. government l i f e

insurance. A q u e s t i o n n a i r e was s e n t t o each member of t h i s c o h o r t o b t a i n l n g In-
formation on smoking h a b i t s . M o r t a l i t y o f t h i s group of war veterans was ascer-
t a i n e d when t h e death claims were made. The m o r t a i l i t y o f those who smoked.clgar-
e t t e s o n l y was found t o be the3highest o f a l l . g r o u p s of'smokers, and 58 percent
g r e a t e r than nonsmokers. The g r e a t e s t increase l n r i s k of developing a d l s s a s s
was f o r cancer o f t h e lung. The m o f i t d i t y r a t i o , f o r r e g u l a r smokers was about
10 times t h a t fortnonsmokers. JTheideath r a t e of men smoking more than one pack-
age p e r day was 16 times t h a t of nonsmokers.

 The atomic bomb explosions o v e r Hiroshima and Nagasaki made t h e w o r l d

a c u t e l y aware o f t h e dangers o f i o n i z i n g r a d i a t i o n n o t o n l y t o those who were
esposed b u t t o t h e i r progeny. S h o r t l y a f t e r t h e end o f World War I I , t h e A t o m i c
Bomb Casualty Commission was e s t a b l i s h e d t o study t h e delayed e f f e c t s o f i o n i z i n g
r a d i a t i o n from the A-bombs. A major p a r t of t h e program i s t h e l i f e span study
(20) o f A-bomb s u r v i v o r s . I n t h i s study, a sample o f about-110,000 s u r v i v o r s
and c o n t r o l s who were a l i v e on October 1, 1950 was s e l e c t e d t o be followed. Dose
e s t i m a t i o n was made f o r each s u r v i v o r f r o m i n f o r m a t i o n r e g a r d i n g t h e i r p h y s i c a l
l o c a t i o n and t h e s h i e l d i n g c o n f i g u r a t i o n a t t h e time o f the bomb. Deaths occur-
r i n g t o t h e members o f t h i s c o h o r t a r e a s c e r t a i n e d p e r i o d i c a l l y from checks of
t h e f a m i l y r e g i s t e r , and copies o f death c e r t i f i c a t e s secured. T h i s unique
Japanese system o f f a m i l y r e g i s t r a t i o n makes p o s s i b l e t h e ascertainment o f v i r -
t u a l l y a l l deaths i n t h e sample r e g a r d l e s s o f t h e p l a c e of death i n Japan.

Comparison o f t h e m o r t a l i t y experience o f t h e exposed p o p u l a t i o n by dose

w i t h t h a t o f t h e nonexposed group g i v e s a measure o f t h e r e l a t i v e m o r t a l i t y r i s k
due t o v a r y i n g degrees of exposure t o i o n i z i n g r a d i a t i o n . To date, i t appears
t h a t t h e major problem (21) o f A-bomb r a d i a t i o n exposure r e l a t e t o neoplasia,
e s p e c i a l l y leukemia among t h e exposed poptrlation. O f t h e s o l i d tumors, l u n g
cancer, b r e a s t cancer, cancer o f t h e esophagus, cancer o f t h e u r i n a r y t r a c t and
lympnomas have been found t o be associated w i t h A-bomb exposure. I n addition,
a r e s i d u a l group o f cancers o f t h e d i g e s t i v e t r a c t o t h e r than esophagus, stomach,
l a r g e bowel, rectum, and pancreas was found t o be r e l a t e d t o r a d i a t i o n dose,
suggesting t h a t one o r more a d d i t i o n a l d i g e s t i v e organs may a l s o be involved.

Advantages o f a continuous r e g i s t r a t i o n system

,r

A major advantage o f a continuous r e g i s t r a t i o n system i s t h e f a c t t h a t ,

once t h e system has been e s t a b l i s h e d on an adequate b a s i s , t h e r e w i l l be a con-
t i n u o u s f l o w o f death records from t h e l o c a l r e g i s t r a t i o n u n i t s t o a, permanent
r e p o s i t o r y t o serve l e g a l purposes. T h i s makes p o s s i b l e t h e t r a n s c r i p t i o n and/or
t r a n s m i s s i o n o f copies of death records t o a c e n t r a l agency f o r data p r o c e s s i n g
and s t a t i s t i c a l compilations.

R e g i s t r a t i o n data deal w i t h t h e whole u n i v e r s e o f events. Therefore, n o t

a l l of t h e d a t a may have been t a b u l a t e d r o u t i n e l y , b u t much of t h e needed s t a -
t i s t i c s are usually r e a d i l y available annually. T h i s i s an i n v a l u a b l e f e a t u r e
o f r e g i s t r a t i o n s t a t i s t i c s i n p r o v i d i n g , d e t a i l e d a l l - p u r p o s e reference t a b l e s
f o r v a r i o u s segments o f t h e p o p u l a t i o n t h a t can be tapped f o r , s p e c i f i c s t u d i e s .
I
I t makes p o s s i b l e t h e conduct of a n a l y t i c a l s t u d i e s on numerous ,topics e i t h e r on I
a c r o s s - s e c t i o n a l b a s i s or over a p e r i o d o f time. The a v a i l a b i l i t y o f t r e n d data
i s a v e r y important advantage o f a continuous r e g i s t r a t i o n system.

The general a v a i l a b i l i t y o f m o r t a l i t y d a t a by v a r i o u s personal c h a r a c t e r i s -

t i c s o f t h e decedent such as age, sex and e t h n i c i t y f o r t h e c o u n t r y as a whole
and for t h e d i f f e r e n t geographic d i v i s i o n s down t o t h e s m a l l e s t p o l i t i c a l sub-
d i v i s i o n makes p o s s i b l e t h e u t i l i z a t i o n o f m o r t a l i t y data f o r many purposes, as
i l l u s t r a t e d previously. Shapiro (22) p o i n t s o u t t h a t for l o c a l h e a l t h p l a n n i n g
purposes t h e a v a i l a b i l i t y o f data f o r t h e p a s t and present, and l i k e l y a v a i l -
a b i l i t y f o r t h e foreseeable f u t u r e , f o r g e o g r a p h i c a l l y disaggregated l e v e l s down
t o subd'ivisions of a c i t y makes up f o r many o f t h e d e f e c t s t h a t may be p r e s e n t
i n mortality statistics. The q u e s t i o n pcsed t o t h e user o f m o r t a l i t y d a t a - f o r
p l a n n i n g purposes i s how t o maximize t h e u t i l i t y o f t h i s resource a l t h o u g h con-
ceptual and t e c h n i c a l issues s t i l l remain.
 The compi l e d data w i 11, a t l e a s t f o r c o u n t r i e s w i t h we1 1-establ ished systems,
g e n e r a l l y be comparable from p l a c e to p l a c e w i t h i n a country, and from one time
p e r i o d t o another. Such i n t e r n a l c o n s i s t e n c y i s one o f t h e remarkable c h a r a c t e r -
i s t i c s o f r e g i s t r a t i o n data. Also, because t h e d e f i n i t i o n s and c l a s s i f i c a t i o n s
used i n v i t a l s t a t i s t i c s a r e u s u a l l y i n t e r n a t i o n a l i n nature, t h e r e i s a consid-
e r a b l e amount o f c o m p a r a b i l i t y i n t h e data f o r t h e v a r i o u s c o u n t r i e s .

The a v a i l a b i l i t y o f s t a t i s t i c s on causes o f death, and t h e p o s s i b i l i t y o f

o b t a i n i n g o t h e r medical i n f o r m a t i o n through t h e follow-back procedure, makes
r e g i s t r a t i o n s t a t i s t i c s v i r t u a l l y i n d i s p e n s a b l e f o r p u b l i c h e a l t h and medical
programs. Even developing c o u n t r i e s may be a b l e t o generate u s e f u l cause-of-
death data through a system o f l a y r e p o r t i n g . This i s n o t as f a r f e t c h e d as i t
may sound because i n developing c o u n t r i e s a l a r g e p r o p o r t i o n o f - a l l deaths occur
i n t h e c h i l d h o o d years. The common diseases o f c h i l d h o o d may f r e q u e n t l y b e
recognized by t h e mother. These cases, p l u s t h e a c c i d e n t a l causes, do n o t
r e q u i r e medical t r a i n i n g f o r an adequate d e s c r i p t i o n of t h e cause o f death.

I t i s d i f f i c u l t t o a s c e r t a i n t h e c o s t o f r e g i s t r a t i o n s t a t i s t i c s because a
l a r g e p a r t o f t h e c o l l e c t i o n c o s t s i s borne by t h e l e g a l r e g i s t r a t i o n process.
However, i t i s probably f a i r t o say t h a t t h e u n l t c o s t o f r e g i s t r a t i o n d a t a i s
c o n s i d e r a b l y l e s s than t h a t o f data o b t a i n e d from i n t e r v i e w surveys.

The continuous f l o w o f data on a permanent b a s i s o b v i a t e s t h e n e c e s s i t y o f

mounting p e r i o d i c surveys w i t h a t t e n d a n t h i g h costs, and p o s s i b l e changes i n
survey personnel, o b j e c t i v e s , procedures and d e f i n i t i o n s . I n addition to the
s t a t i s t i c s , t h e death r e g i s t r a t i o n system p r o v i d e s death records which make
p o s s i b l e t h e i d e n t i f i c a t i o n o f deaths o f i n d i v i d u a l s f o r use In communicable
disease c o n t r o l and i n o t h e r p u b l i c h e a l t h programs such as those on maternal
and c h i l d h e a l t h . I t a l s o makes a v a i l a b l e death records for r e t r o s p e c c t l v e and
p r o s p e c t i v e e p i d e m i o l o g i c s t u d i e s . The General R e g i s t e r O f f l c e of England and
Wales g i v e s i n v a l u a b l e assistance i n n o t i f y i n g e p i d e m i o l o g i s t s of deaths occur-
r i n g t o members o f a stud) cohort. The U.S. N a t i o n a l Center for H e a l t h S t a t l s -
t i c s i s now e s t a b l i s h i n g a n a t i o n a l death index t o p r o v i d e a l m l l r r s e r v l c e s t o
those engaged i n s c i e n t i f i c i n v e s t i g a t i o n s . These servlceo rnrrda p o s s l b l e t h e
conduct o f e p i d e m i o l o g i c s t u d i e s which would o t h e r w i s e be l m p o r s l b l e t o c a r r y
out, except a t e x o r b i t a n t cost.

-
b i

Disadvantages of a continuous r e g i s t r a t i o n system I . I

-The m o n o l i t h i c n a t u r e o f t h e r e g i s t r a t i o n system d e a l i n g w i t h the t o t e l , ,

p o p u l a t i o n o f a c o u n t r y i s a d e f i n i t e disadvantage i n any e f f o r t t o make chqnges,
o r o t h e r w i s e improve t h e system. Changes come s l o w l y . The Unltsd S t a t e s , an
i n d u s t r i a l i z e d c o u n t r y w i t h a l i t e r a t e p o p u l a t i o n , took over 30 years t o qualify
a l l t h e S t a t e s for t h e n a t i o n a l death r e g l s t r a t l o n area.

Another disadvantage o f a continuous r e g l s t r a t l o n system l e the lack of, 1

f l e x i b i l i t y i n making changes i n t h e c o n t e n t of s t a t l s t l c e l r e p o r t s . In
view surveys, i t i s possib1.e t o make changes I n the q u e e t l o n n a l r e forms, and to1
i n c l u d e p r o b i n g questions If needed, I n a r e g l s t r a t l o n form, e s p e c l a l l y I f I t IS
p a r t o f a l e g a l documen& hereloare d e f l n l t e c o n s t r a i n t s on t h e k l n d of t o p l c s
t h a t can be incIuded..an&how d e t a i l e d the q u e s t i o n s are. There may be a l i t t l e . ,
more freedom1 w i t h ? A h eis&a$lstlcaJ. r e p o r t form Independent of t h e l e g a l r e g l s t r a -
t i o n document, , b u t it%lrarrregtstratlon o f f l c l a l s are g e n e r a l l y c o n s e r v a t l v e about
making substanIt!fala changes ,In t h e c o n t e n t o f , t h e s t a t l s t l c a l r e p o r t forms.
, :!

\
,
a
. ‘I, ! r;+! “*C!

 I
I
The disadvantages o f a continuous r e g i s t r a t i o n system a r e r e l a t i v e l y few, b u t
there a r e a number o f improvements t h a t need t o be made b e f o r e t h e c i v i l r e g i s -
t r a t i o n and v i t a l s t a t i s t i c s systems a r e capable o f producing useful s t a t i s t i c s i,

on a continuous b a s i s . The most s e r i o u s problem i n developing c o u n t r i e s i s i n - 1

completeness o f coverage. I n most developing c o u n t r i e s , access t o t h e l o c a l
r e g i s t r a t i o n o f f i c e s i s d i f f i c u l t i n t h e r u r a l areas. I n mafiy c o u n t r i e s , t h e r e
a r e s p e c i a l problems posed by nomadic and indigenous p o p u l a t i o n s . 70 c o m p l i c a t e
matters s t i l l f u r t h e r , t h e r e i s very l i t t l e i n c e n t i v e t o r e g i s t e r v i t a l events
even i f t h e r e i s awareness o f the need t o r e g i s t e r deaths. The absence o f need
f o r death c e r t i f i c a t e s and t h e l a c k o f awareness on t h e p a r t o f t h e p u b l i c of
the n e c e s s i t y t o r e g i s t e r deaths have been c i t e d b y c i v i l r e g i s t r a t i o n a u t h o r -
i t i e s ( 2 3 ) as t h e b i g g e s t o b s t a c l e s t o r e g i s t r a t i o n improvement. Incomplete
death r e g i s t r a t i o n , p a r t i c u l a r l y o u t s i d e t h e major c i t i e s , i s a major impediment
t o t h e use o f d a t a f o r m o r t a l i t y a n a l y s i s . Another major f a c t o r i s t h e q u a l i t y
o f t h e l o c a l r e g i s t r a t i o n personnel i n developing c o u n t r i e s . Sometimes they a r e
s c a r c e l y l i t e r a t e ; almost always they a r e inadequately compensated and u n t r a i n e d .
As a r e s u l t , t h e completeness a r d q u a l i t y of t h e c o l l e c t e d data a r e a d v e r s e l y
affected. I n a d d i t i o n , d e a l i n g w i t h an i l l i t e r a t e p o p u l a t i o n presents s p e c i a l
problems i n e l i c i t i n g seemingly simple i n f o r m a t i o n such as t h e age o f t h e dece-
dent, and t h e poor q u a l i t y o f i n f o r m a t i o n concerning t h e c h a r a c t e r i s t i c s of t h e
decedent r e p r e s e n t s a f u r t h e r c o m p l i c a t i o n i n t h e use of data f o r F r t a l i t y
studies.

I n view of these problems, v i r t u a l l y a l l d e v e l o p i n g c o u n t r i e s f i n d them-

selves w i t h o u t adequate death s t a t i s t i c s i n t h e i r p e r i o d o f g r e a t e s t need for
data f o r s o c i a l and economic planning, and f o r h e a l t h p l a n n i n g and adrninistra-
t i o n o f s h e a l t h programs. Some c o u n t r i e s a r e a d o p t i n g o t h e r means o f c o l l e c t i n g
data t o f i l l . t h e gap. On t h e o t h e r hand, a l a r g e m a j o r i t y o f t h e c o u n t r i e s a r e
s t i l l s t r u g g l i n g a l o n g w i t h r e g i s t r a t i o n o f v i t a l events.

Discuss i o n

The continuous r e g i s t r a t i o n system o f f e r s d a t a p o s s i b i 1 i t i e s t h a t cannot

be achieved i n any o t h e r way. S i n g l e round and even m u l t i - r o u n d surveys have
n o t a b l y n o t been s u c c e s s f u l i n o b t a i n i n g adequate counts of deaths (24) (25).
Lunde, (26) i n h i s d i s c u s s i o n o f t h e l i m i t a t i o n s o f s i n g l e round surveys,
p o i n t s o u t t h a t m o r t a l i t y data f o r Uganda, N i g e r , A l g e r i a , and t h e U n i t e d
Republic o f Tanzania were never pub1isthed:because of t h e obvious d e f e c t s i n t h e
i n f o r m a t i o n on deaths o b t a i n e d from s i n g l e v i s i t r e t r o s p e c t i v e surveys. Basi-
c a l l y , i t i s e x t r e m e l y d i f f i c u l t t o i d e n t i f y r e t r o s p e c t i v e - l y persons who a r e no
longer present, For example, deaths o c c u r r i n g i n s i n g l e - p e r s o n households are
n o t i d e n t i f i a b l e i n r e t r o s p e c t i v e surveys. . D i s s o l u t i o n o f t h e farn3ly o r house-
h o l d may a l s o occur on t h e death of the head o f t h e f a m i l y or hocqsehold, o r of
one o f t h e spouses. I n a d d i t i o n , t h e r e may be taboos and/or general r e l u c t a n c e
about r e v e a l i n g t h e f a c t s o f death, e s p e c i a l l y t o strangers. I n a l l countries,
i t i s d i f f i c u l t t o o b t a i n i n f o r m a t i o n on deaths o f i n f a n t s who d i e scion a f t e r
birth. There a r e a l s o o t h e r non-sampling problems encocintered i n s o c i a l surveys
such as r e c a l l problems, erroneous d a t i n g o f events and m i s r e p o r t i n g of age.

The i n d i r e c t e s t i m a t i o n methods a r e basec! on c h a r a c t e r i s t i c s of t h e l i v i n g

p o p u l a t i o n o b t a i n e d i n a censcs o r a survey. These data such as s u r v i v i n g
c h i l d r e n o f mothers a t various ages o r o f persons a t v a r i o u s ages who were
orphaned a r e transformed i n t o m o r t a l i t y e s t i m a t e s o f c h i dren and a d u l t s . The
r e s u l t s o f i n d i r e c t e s t i m a t i o n techniques a r e s u b j e c t t o e r r o r s from t h e a l r e a d y
mentioned nonsampling problems a r i s i n g i n census and SOC a1 survey i n t e r v i e w s .

10
The v a l i d i t y o f t h e estimates a l s o depends on t h e assumptions u n d e r l y i n g t h e
a n a l y t i c a l development o f the methods. I n some cases, i t is c l e a r t h a t t h e con-
d i t i o n s were n o t met w h i l e i n others i t i s d i f f i c u l t t o judge the v a l i d i t y o f t h e
assumpt ions .
For c o u n t r i e s w i t h no data a t a l l o r v e r y i n a d e q u a t e ' m o r t a l i t y s t a t i s t i c s ,
even t h e l i m i t e d m o r t a l i t y measures p r o v i d e d by t h e combination o f surveys and
i n d i r e c t e s t i m a t i o n techniques a r e v a l u a b l e f o r c e r t a i n purposes. Also, e s t i -
mates o f death r e p o r t i n g completeness p r o v i d e d by i n d i r e c t methods developed by,
among o t h e r s , Preston, e t a l , (27) a r e u s e f u l approximations f o r assessment pur-
poses. On t h e o t h e r hand, i t seems apparent t h a t t h e s l i m i t a t i o n s o f the survey
and i n d i r e c t methods o f e s t i m a t i o n a r e such t h a t they cannot ever p r o v i d e t h e
k i n d and amount o f s t a t i s t i c a l data which a r e o b t a i n a b l e from death r e g i s t r a t i o n
data. The advantages o f a continuous r e g i s t r a t i o n process as a source of records
and s t a t i s t i c s a r e ' s 0 s u b s t a n t i a l t h a t o t h e r methods cannot be regarded as ade-
quate long-term s u b s t i t u t e s f o r death r e g i s t r a t i o n data, though i n t h e s h o r t run,
such o t h e r methods may represent t h e o n l y f e a s i b l e source of m o r t a l i t y data f o r
some count r ies .
I f t h e r e a r e no s a t i s f a c t o r y a l t e r n a t i v e s t o t h e continuous r e g i s t r a t i o n
process, what a r e t h e p o s s i b i l i t i e s of d e v e l o p i n g r e g i s t r a t i o n data w i t h i n a
reasonable t i m e frame? This i s n o t an easy q u e s t i o n t o answer because t h e r e have
n o t been o u t s t a n d i n g developments i n c i v i l r e g i s t r a t i o n p a r a l l e l t o those i n sur-
vey methodology and i n d i r e c t e s t i m a t i o n methods o v e r t h e p a s t 15 t o 20 years.
Perhaps t h i s i s because changes and improvements cannot be obtained q u i c k l y i n
a continuous r e g i s t r a t i o n system. To t r y t o e s t a b l i s h and improve a nationwide
r e g i s t r a t i o n system i s simply t o o l a r g e a t a s k f o r t h e usual s t a f f and budget.
Also, t h e r e a r e problems amenable and n o t amenable t o s o l u t i o n depending on t h e
s t a t e o f s o c i a l and economic development o f t h e country. L i n d e r (28) has c l a s s l -
f i e d problems of c i v i l r e g i s t r a t i o n under t h e f o l l o w i n g heads:
I

1. ' R e l a t i v e l y i n t r a c t a b l e problems.

Problems which can be solved w i t h i n t h e framework o f long-range-

s o c i a l and economic development, b u t can h a r d l y be solved by s h o r t -
range a c t i o n s taken w i t h i n t h e c i v i l r e g i s t r a t i o n system i t s e l f .

2. Problems s o l u b l e b u t r e q u i r i n g n a t i o n a o r outside technical

a s s i s t a n c e funds.

3. S o l u b l e problems.

Problems t h a t can be solved w i t h i n t h e n a t i o n a l domain w i t h

r e l a t i v e l y small f i n a n c i a l requirements. 1

I n s t e a d o f t a c k l i n g a l l the problems a t once, L i n d e r 'suggests t h a t c e r t a i n ' *

tasks should be deferred. One approach t o i m p r o v i n g ' t h e data along th4s l i n e
i s t h e a d o p t i o n o f t h e r e g i s t r a t i o n area concept. For example, the d e a t h ' r e g l s -
t r a t i o n area was e s t a b l i s h e d i'n the"United S t a t e s ilni 1900 : s t a r t i n g w i t h 10 *
States ( o u t o f 48) and t h e D i s t r i c t of Columbda. ' A 3 fHb'St&es q u a l i f i e d by the
adoption o f a standard death certri.,f'Ra4~1bo'rmend~Jby~idsmorrst'rat I n g t h a t 90 p'er-
cent o r more o f deaths were re'giistd6e'dj +&ey w e ~ e ~ ~ I n c ~ l u d d' tdh .e~ ~ r ei n
gistration
area. By 1933,1.-theliregI?sxraE"iont'c$r%a&v&ribd ailllil th"elipopuI:at loh I n the c o u n t r y .
t ,'%
f a , \ \$, ,

For d e v e l o p i n g countries, a s t a r t might be made w i t h the c a p i t a l c i t y and

11

major e f f o r t s devoted t o t h e establishment of a s a t i s f a c t o r y death r e g i s t r a t i o n

system. A f t e r t h e r e g i s t r a t i o n system i n t h e c a p i t a l c i t y i s deemed o p e r a t i o n a l ,
e f f o r t s should then be t r a n s f e r r e d , one by one, t o t h e o t h e r major c i t i e s , l e a v -
i n g the d i f f i c u l t and t h e sparsely s e t t l e d r u r a l areas t o t h e l a s t . A problem
w i t h t h i s approach i s t h a t u n t i l coverage has been f a i r l y extensive, t h e d a t a
w i l l be l i m i t e d t o urban experience.

Another p o s s i b l e approach i s t h a t suggested by Hauser (29). He proposed

t h a t a n a t i o n a l sample v i t a l s t a t i s t i c s system be e s t a b l i s h e d comprising a sam-
p l e o f complete primary r e g i s t r a t i o n u n i t s o r combinations t h e r e o f . T h i s makes ,
p o s s i b l e t h e f o c u s i n g o f energy and funds on a l i m i t e d number o f primary r e g i s -
t r a t i o n u n i t s i n s t e a d o f d e a l i n g w i t h a l l t h e u n i t s i n t h e c o u n t r y a t once.
Data from a r e p r e s e n t a t i v e sample i s c e r t a i n l y more d e s i r a b l e than data l i m i t e d
t o urban areas, b u t i t would be more complicated a d m i n i s t r a t i v e l y t o work on a ~

number o f non-contiguous primary r e g i s t r a t i o n u n i t s simultaneously. I n addition,

L i n d e r (30) i n r e v i e w i n g t h e experiences o f a number o f c o u n t r i e s u n d e r t a k i n g
sample r e g i s t r a t i o n p r o j e c t s , observed t h a t most o f t h e recent sample r e g i s t r a -
t i o n schemes have departed from the o r i g i n a l concept and have e s t a b l i s h e d a sam-
p l e system independent o f t h e e x i s t i n g l e g a l system. T h i s i s an u n f o r t u n a t e
departure i n t h a t i t defeats t h e o r i g i n a l purpose o f o b t a i n i n g continuous i m -
provement i n t h e r e g i s t r a t i o n system.

As a s t r a t e g y t o improve c i v i l r e g i s t r a t i o n i n a country, i t would seem

s e n s i b l e t o c o n c e n t r a t e a c t i v i t i e s on problems most amenable to s o l u t i o n i n
geographical areas w i t h t h e g r e a t e s t p o p u l a t i o n where government s e r v i c e s a r e
more l i k e l y t<j be a v a i l a b l e t o t h e p u b l i c . However, because o f the n a t u r e of
r e g i s t r a t i o n problems, a f u l l y o p e r a t i o n a l system cannot be expected o v e r n i g h t .
A good deal o f p a t i e n c e and p e r s i s t e n c e a r e needed.

The development o f a death r e g i s t r a t i o n system r e q u i r e s a s a t i s f a c t o r v l e g a l

base and an a d m i n i s t r a t i v e o r g a n i z a t i o n o f l o c a l o f f i c e s . It also requires the
understanding and cooperation o f the p u b l i c , o f medical a t t e n d a n t s and o t h e r s i n
t h e h e a l i n g a r t s , h o s p i t a l s and c l i n i c s , o f undertakers, and o f those i n charge
o f b u r i a l p l a c e s and crematoria. An a c t i v e and i n n o v a t i v e program i s needed--
n o t a passive w a i t i n g f o r death c e r t i f i c a t e s t o be f i l e d . I t i s a long road t o
success b u t t h e reward a t t h e end i s w o r t h w h i l e i n t e r m s - o f an i n v a l u a b l e d a t a
source t o serve t h e h e a l t h and demographic needs o f t h e country.
- + ,
RE FERENC ES

1. V i t a l S t a t i s t i c s : Memorial Volume o f S e l e c t i o n s from Reports and W r i t i n g s

o f W i l l i a m Farr. E d i t e d by Noel A. Humphreys. O f f i c e o f Sanitary
l n s t i t u t e , 1885.
2. P o l l , D. 1 . and Chan, #. K. D i f f e r e n t i a l D e c l i n e s i n Tuberculosis
Mortality. Vol. I I , 1006-1-12. I n t . Pop. Conf., IUSSP, London, 1969.
3. Pampana, E. J. E f f e c t o f M a l a r i a C o n t r o l on B i r t h and Death Rates. UN
Proceedings o f t h e World Pc.pulation Conference, Vol. 1, 497-509.
Rome, 1954.
4. Meegama, S. A. M a l a r i a E r a d i c a t i o n and Its E f f e c t on M o r t a l i t y Levels.
Pop. Studies, 21 ( 1 ) :207-237, 1967.
‘5. Fredriksen, H. Determinants and Consequences o f M o r t a l i t y . T r e n d s i n
Ceylon. P u b l i c H e a l t h Reports, 72:543-553, 1961.
6. Newman, P. M a l a r i a E r a d i c a t i o n and I t s E f f e c t on M o r t a l i t y Levels.
Pop. Studies, 23(2) :285-288, 1969.
 7. Hoover, R. and Fraumeni, J. F. Geographic P a t t e r n s o f Lung Cancer:
I n d u s t r i a l C o r r e l a t i o n s . Amer. Jour. Epidemiol. 103(6):539-550, 1976.
8. B l o t , W. J. and Fraumeni, J. F. Cancer M o r t a l i t y i n t h e U . S . Counties
w i t h Chemical I n d u s t r i e s . Environ. Res. 9:196-207, 1975.
9. Fears, T. R. Cancer M o r t a l i t y and Asbestos Deposits. Amer. Jour.
Epidemiol. 104(5) :523-526, November 1976.
10. Cates, W., Smith, J. C., Rochat, R. W., Patterson, J. E. and Dolman, A.
Assessment o f S u r v e i l l a n c e a n d ' v i t a l S t a t i s t i c s Data f o r M o n i t o r i n g
A b o r t i o n M o r t a l i t y , Amer. Jour. Epidemiol. 108(3):200-206, 1978.
11. Newcombe, H. B., Kennedy, J. M., Asford, J. J. and James, A. P.
Automatic Linkage o f V i t a l Records, Science 130:154, 1959.
12. Acheson, E. D., Truelove, S. C. and W i t t s , L. J., N a t i o n a l Epidemiology
B r i t . Med. Jour. 1:668, 1961.
13. Stewart, A., Webb, J. and Hewitt, J. A Survey o f Childhood Malignancies
B r i t . Med. Jour. 1:1495, 1978.
14. MacMahon, B. P r e n a t a l X-ray Exposure and Childhood Cancer Jour. Nat.
Cancer I n s t . 28: 1173, 1962.
15. B l o t , W., H a r r i n g t o n , J. M., Toledo, A., Hoover, R., Heath, C. W. and
frauememi, J. F. Lung Cancer a f t e r Employment i n Shipyards d u r i n g
World War I I . New Eng. Jour. Med. 299 (12) :620-624, 1978.
16. D o l l , R. M o r t a L i t y f r o m Lung Cancer i n Asbestos Workers B r i t . Jour.
Indust. Med. 12:81, 1955.
17. Knox, J. F., Holmes, S., D o l l , R., and H i l l , I . D. M o r t a l i t y from
Lung Cancer and Other Causes among Workers i n an Asbestos T e x t i l e
F a c t o r y B r i t . Jour. Indust. Med. 25:293, 1968,.
18. D o l l , R. and H i l l , B. A. Lung Cancer and Other Causes of Death i n
R e l a t i o n t o Smoking B r i t . Med. Jour. 2:1071, 1956.
19. Dorn, H. F. Tobacco Consumption and M o r t a l i t y from Cancer and Other
Diseases Pub. H e a l t h Rept. 74:581-593, 1959.
20. Beebe, G. W., Kato, H., and Land, C. E. Studies of M o r t a l i t y o f A-bomb
S u r v i v o r s M o r t a l i t y and R a d i a t i o n Dose, 1950-1974, Rad. Res. 75: 138-201 ,
1978.
21. Moriyama, I . M. Capsule Summary o f R e s u l t s o f R a d i a t i o n Studies on
Hiroshima and Nagasaki Atomic Bomb S u r v i v o r s , 1945-1975. Tech. Rept.
RERF TR-5-77, R a d i a t i o n Effects Research Foundation, Hiroshima, Japan,
1977.
22. Shapiro, S. A Tool f o r H e a l t h Planners. Amer. Jour. Pub. Health.
67(9) :816-817, 1977.
23. I n t e r n a t i o n a l I n s t i t u t e f o r V i t a l R e g i s t r a t i o n and S t a t i s t i c s . Major
Obstacles t o Achieving S a t i s f a c t o r y R e g i s t r a t i o n o f V i t a l Events and
t h e Compilation o f R e l i a b l e V i t a l S t a t i s t i c s . Tech. Papers, No. 15,
May 1981.
24. Mauldin, W. P. E s t i m a t i n g Rates of P o p u l a t i o n Growth. Family Planning
and P o p u l a t i o n Programs, pp. 635-654, ed. Bernard Berelson, e t a l .
Univ. o f Chicago Press, 1966.
25. Brass, W. A C r i t i q u e o f Methods f o r E s t i m a t i n g P o p u l a t i o n Growth i n
Countries w i t h L i m i t e d Data. Proc. 38th Session, B u l l . I n t . S t a t .
I n s t . , Vol. 44, 397-412, 1971.
26. Lunde, A. S. The S i n g l e Round R e t r o s p e c t i v e I n t e r v i e w Surveys. SClentlflC
I" Rept. Series No. 24. Labs. f o r Pop. S t a t . , Jan. 1976.
27. Preston, S., Coale, A. J., T r u s s e l l , J., and Weinstein, M. Estlmatlng
the Completeness o f Reporting o f A d u l t Deaths I n Populatlons t h a t a r e ,

Approximately Stable. Population Index, 46(2) :179-202, Summer 1978.

28. Linder, F. E. Problems o f Improving V i t a l R e g i s t r a t i o n Systems i n
Developing Countries. I n t e r n a t i o n a l P o p u l a t i o n Conference, Manila 1981,
Vol. 3, Liege, 1981.
29. Hauser, P. M. The Use o f Sampling f o r V i t a l R e g i s t r a t i o n and V i t a l
Statistics. B u l l . WHO 2:5-23, 1954.
30. Linder, F. E. Measurement o f P o p c l a t i o n C o n t r o l Programs: Design
Problems o f Sample R e g i s t r a t i o n Systems. C o n t r i b u t e d Papers, 3 7 t h
Sess., I n t . S t a t . I n s t . , pp. 50-52, London, 1969.

. . <
. .. .

.. L

. . . . . I

. .

. , . .

. . , ., , : . . .
. .
. ,
. .
 PUBLICATIONS OF THE IIVRS TECHNICAL PAPERS

1. A Programme for Measurement of Life and Death in Ghana,

D.C. Mehta and J.B. Assie, June 1979

2. Vital Statistics System of Japan, Kozo Ueda and Masasuke

Omori, August 1979

3. System of Identity Numbers in the Swedish Population

Register, Karl-Johan Nilsson, September 1979

4. Vital Registration and Marriage in England and Wales, Office

of Population Censuses and Surveys, London, October 1979

5. Civil Registration in the Republic of Argentina, Jorge P.

Seara and Marcel0 E. Martin, November 1979

6. Coordinating Role of National Committees on Vital and

Health Statistics, World Health Organization, Geneva,
January 1980

7. Human Rights and Registration of Vital Events, Nora P.

Powell, March 1980

8. The Organization of the Civil Registration System of the

United States, Anders S. Lunde, May 1980

9. Organization of Civil Registration and Vital Statistics System

in India, P. Padmanabha, July 1980 I

10. Registration of VitalEvents in Iraq, Adnan S. AI-Rabie,

September 1980

11. Generation of Vital statistics in Mexico, General Bureau of

Statistics, Mexico, November 1980

12. Age Estimation Committeein Qatar, Sayed A. Taj El Din,

December 1980

13. The Development of the Vital Statistics System in Egypt,

Gama1 Askar, January 1981

14. Vital Statistics Data Collection and Compilation System:

Hong Kong, Donna Shum, March 1981

15. Major Obstacles to Achieving Satisfactory 'Registration of

\ Vital Events and the Compilation of Reliable Vital Statistics,
IIVRS, May 1981

16. Methods and Problems of Civil RegistretionPrectim end Vital

Statistics Collection in Afrim, Toma J . Mekanneh, July 1881

17. Status of Civil Registretionand VitaJ Stat&'@ In El Ssh@dtv,

Enrique Olmado Sow, July 1982 * , . ' '
4
I

18. Recommendations from Reglorn1 &t&& 4nd S M M ~

on Civil Reglstmtlon & Segtomkr
1982

le. Potent&& of RWM&