1. 1 Excess female mortality within the reproductive age group in South Africa Presentation To Global Forum on Gender Statistics 11-13 October 2010 Manila, Philippines Statistics South Africa 11 October 2010 ESA/STAT/AC.19/9

2. 2 Presentation outline Overview of the functioning of the civil registration system: deaths Objectives Methods Results Limitations of the study and overall challenges faced Conclusion Way forward

3. 3 Overview of the functioning of the death registration system Statistics South Africa has a mandate to publish vital statistics based on deaths reported at the Department of Home Affairs The registration of deaths is governed by the Births and Deaths Registration Act, 1992 (Act No. 51 of 1992)

4. 4 Overview of the functioning of the death registration system continued The Department of Home Affairs collects information on deaths for administrative purposes: To update the population register To issue death certificates The form used to report a death is the BI-1663 form: Notification / Register of Death / Stillbirth

5. 5 The BI-1663 form  It consists of two pages  The Department of Home Affairs (DHA) is responsible for the first page.  It includes socio-demographic details of the deceased and particulars of the informant and funeral undertaker.  The Department of Health (DoH) is responsible for the second page.  It includes information on the causes of death.  The second page from DoH is submitted to DHA where the two pages are matched.

6. 6 Page one of the death notification form

7. 7 Page two of the death notification form

8. 8 Processing of death notification forms

9. 9 ICD-10 coding  Classification of causes of death  International Classification of Diseases, 10th revision (ICD-10) coding used to classify causes of death  “Code what you see” Rule  Code up to three characters  Coding staff  20 Trained and experienced coders  Regular up-dates and re-fresher courses  Trained in anatomy and physiology, medical terminology  Attend ICD-10 Standards meetings and NHISSA meetings

10. 10 Derivation of the underlying cause  ACME (2000 version) is used to automatically derive the underlying cause of death  ACME usually fails to derive about 1% of the total of deaths in a particular year  Rejected cases derived manually by selected staff

11. 11 Objectives of the study To assess the potential for usability of death registration data for maternal mortality estimation To verify the suspicion that there is excess female mortality at the reproductive age group in the era of HIV/AIDS To establish causes of death associated with excess female mortality To establish patterns and trends of maternal deaths reflected in these data

12. 12 Methods The scope includes registered deaths from 1999-2005 Indirect methods of estimating completeness are used Comparison of sex ratios between the periods 1999-2001 and 2002-2005 Comparison of leading causes between the two study periods Maternal mortality ratios are also provided

13. 13 Completeness was found to be at about 91%: applying GGB and SEG Total numbers of female deaths aged 12-50 in 1999-2005 Pregnancy status Number Pregnant9932 Not pregnant202709 Unknown1249 Unspecified560616 Total774506 Source: South African death registration data Note: Figures may have been updated over time Results

14. 14 Causes of death grouped according to ICD-10 chapters % Deaths Pregnancy, childbirth and puerperium (O00-O99)31 Infectious diseases (A00-B99)26 Respiratory diseases (J00-J99)9 Disorders of the immune mechanism (D80-D89)7 External causes (V01-Y98)7 Other natural causes20 N9932 Source: South African death registration data Percentages of female deaths who died while pregnant, aged 12-50: 1999-2005

15. 15 Comparison of sex ratios – female deaths per 100 male deaths

16. 16 The ten leading natural causes of death for females aged 20-29 1999-20012002-2005 Causes of death based on the Tenth Revision of the ICD RankFrequency%RankFrequency% Tuberculosis (A15-A19)11524922.213410422.9 Influenza and pneumonia (J10-J18)2817711.922077314.0 Certain disorders involving the immune mechanism (D80- D89)355238.05118377.9 Human immunodeficiency virus [HIV] disease (B20-B24)450367.3393176.3 Intestinal infectious diseases (A00-A09)544316.4479375.3 Other viral diseases (B25-B34)619902.9651003.4 Other forms of heart disease (I30-I52)719552.8840622.7 Inflammatory diseases of the central nervous system (G00- G09)813201.9730962.1 Noninfective enteritis and colitis (K50-K52)98881.3…25891.7 Chronic lower respiratory diseases (J40-J47)108811.3923531.6 Protozoal diseases (B50-B64)118631.31018671.3 Ill-defined and unknown causes of mortality (R95-R99)912213.3 1891012.7 Other natural causes1326919.3 2696118.1 Total 68704100.0 148906100.0

17. 17 Adjusted numbers of maternal deaths: 1999-2005 Adjusted for completeness of death registration for each age group, Estimated completeness using Extinct Generation Method Adjusted for unspecified pregnancy status: Proportional allocation of missing information based on specified pregnancy status

18. 18 Comparison of maternal mortality ratios

19. 19 Limitations of the study Incompleteness of death notification forms The proportions of unspecified for pregnancy status at the time of death range from 68% in 1999 to 75% in 2005

20. 20 Challenges faced: recording of information Lack of adherence to the guidelines for completing the death notification form provided on the Department of Health website Inconsistent information among variables on the death notification form High proportions of non-response for some demographic variables Invalid responses recorded on some variables Under reporting of female deaths

21. 21 Methodological and administrative issues among stakeholder departments Lack of a checking point for content quality at the Department of Home Affairs There is no cut-off date for collection of death notification forms for a specific statistical release Some forms that are separated during data capturing at the DHA may not be reconciled during processing

22. 22 Conclusions Vital registration data provides expected age patterns and trends of maternal mortality, therefore, usability is confirmed However, maternal mortality ratios derived from these data are implausibly low compared to those derived from enumerated data Excess female mortality is linked to the age group 20-29 in 2002- 2005 Leading causes of death for females aged 20-29 seem to be HIV/AIDS-related, also, shifting of rankings and proportions of deaths due to selected diseases signify misclassification of causes of death

23. 23 Way forward  Improvements required in civil registration: o Department of Home Affairs – coverage; fully completed and accurate information collected o Department of Health – accurate and detailed certification of causes of death o Statistics South Africa – accurate and timely production of vital statistics  Prioritising civil registration and vital statistics nationally and internationally, e.g. o African Ministers responsible for civil registration took a resolution that African statisticians must prioritise civil registration and vital statistics (recommended as the next theme of African Symposia for Statistical Development)  Statistics South Africa to take the lead through National Statistics System to address problems identified with civil registration by forming partnerships to improve civil registration.

24. 24 Thank you