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The use of the disability-adjusted life year (DALY) as the unit in which to calculate the burden of disease associated with reproductive ill-health has given rise to considerable debate. Criticisms include the failure to address the problem of missing and inadequate epidemiological data, inability to deal adequately with co-morbidities, and lack of transparency in the process of ascribing disability weights to sexual and reproductive health conditions. Many of these criticisms could be addressed within the current DALY framework and a number of suggestions to do so are made. These suggestions include: (1) developing an international research strategy to determine the incidence and prevalence of reproductive ill-health and diseases, including the risk of long-term complications; (2) undertaking a research strategy using case studies, population-based surveillance data and longitudinal studies to identify, evaluate and utilize more of the existing national data sources on sexual and reproductive health; (3) comprehensively mapping the natural history of sexual and reproductive health conditions -- in males and in females t and their sequelae, whether physical or psychological; (4) developing valuation instruments that are adaptable for both chronic and acute health states, that reflect a range of severity for each health state and can be modified to reflect prognosis; (5) undertaking a full review of the DALY methodology to determine what changes may be made to reduce sources of methodological and gender bias. Despite the many criticisms of the DALY as a measurement unit, it represents a major conceptual advance since it permits the combination of life expectancy and levels of dysfunction into a single measure. Measuring reproductive ill-health by counting deaths alone is inadequate for a proper understanding of the dimensions of the problem because of the young age of many of the deaths associated with reproductive ill-health and the large component of years lived with disability from many of the associated conditions. Keywords: reproductive medicine; cost of illness; health status indicators; quality of life; disability evaluation; sexually transmitted diseases; maternal mortality; longitudinal studies., Voir page 664 le resume en francais. En la pagina 665 figura un resumen en espanol Introduction The concept of sexual and reproductive health was first fully articulated at the [...]

The following article provides a commentary on the articles by Lush et al. and Wheeler, which are published in this section of the Bulletin, and gives some background information about the International Conference on Population and Development (ICPD), which was held in Cairo in 1994., In June 1999, the Twenty-first Special Session of the United Nations General Assembly reviewed the implementation of the Programme of Action of the International Conference on Population and Development (ICPD), [...]

Public health decision-making is critically dependent on the timely availability of sound data. The role of health information systems is to generate, analyse and disseminate such data. In practice, health information systems rarely function systematically. The products of historical, social and economic forces, they are complex, fragmented and unresponsive to needs. International donors in health are largely responsible for the problem, having prioritized urgent needs for data over longer-term country capacity-building. The result is painfully apparent in the inability of most countries to generate the data needed to monitor progress towards the Millennium Development Goals. Solutions to the problem must be comprehensive; money alone is likely to be insufficient unless accompanied by sustained support to country systems development coupled with greater donor accountability and allocation of responsibilities. The Health Metrics Network, a global collaboration in the making, is intended to help bring such solutions to the countries most in need. Copyright © 2005 World Health Organization [ABSTRACT FROM AUTHOR]

Maternal mortality is an important measure of women's health and indicative of the performance of health care systems. Several international conferences, most recently the Millennium Summit in 2000, have included the goal of reducing maternal mortality. However, monitoring progress towards the goal has proved to be problematic because maternal mortality is difficult to measure, especially in developing countries with weak health information and vital registration systems. This has led to interest in using alternative indicators for monitoring progress. This article examines recent trends in two indicators associated with maternal mortality: the percentage of births assisted by a skilled health care worker and rates of caesarean delivery. Globally, modest improvements in coverage of skilled care at delivery have occurred, with an average annual increase of 1.7% over the period 1989-99. Progress has been greatest in Asia, the Middle East and North Africa, with annual increases of over 2%. In sub-Saharan Africa, on the other hand, coverage has stagnated. In general, caesarean delivery rates were stable over the 1990s. Countries where rates of caesarean deliveries were the lowest--and where the needs were greatest--showed the least change. This analysis leads us to conclude that whereas there may be grounds for optimism regarding trends in maternal mortality in parts of North Africa, Latin America, Asia, and the Middle East, the situation in sub-Saharan Africa remains disquieting. Copyright © 2001 World Health Organization [ABSTRACT FROM AUTHOR]

OBJECTIVE: To present estimates of maternal mortality in 188 countries, areas, and territories for 1995 using methodologies that attempt to improve comparability. METHODS: For countries having data directly relevant to the measurement of maternal mortality, a variety of adjustment procedures can be applied depending on the nature of the data used. Estimates for countries lacking relevant data may be made using a statistical model fitted to the information from countries that have data judged to be of good quality. Rather than estimate the Maternal Mortality Ratio (MMRatio) directly, this model estimates the proportion of deaths of women of reproductive age that are due to maternal causes. Estimates of the number of maternal deaths are then obtained by applying this proportion to the best available figure of the total number of deaths among women of reproductive age. FINDINGS: On the basis of this exercise, we have obtained a global estimate of 515,000 maternal deaths in 1995, with a worldwide MMRatio of 397 per 100,000 live births. The differences, by region, were very great, with over half (273,000 maternal deaths) occurring in Africa (MMRatio: > 1000 per 100,000), compared with a total of only 2000 maternal deaths in Europe (MMRatio: 28 per 100,000). Lower and upper uncertainty bounds were also estimated, on the basis of which the global MMRatio was unlikely to be less than 234 or more than 635 per 100,000 live births. These uncertainty bounds and those of national estimates are so wide that comparisons between countries must be made with caution, and no valid conclusions can be drawn about trends over a period of time. CONCLUSION: The MMRatio is thus an imperfect indicator of reproductive health because it is hard to measure precisely. It is preferable to use process indicators for comparing reproductive health between countries or across time periods, and for monitoring and evaluation purposes. Copyright © 2001 World Health Organization [ABSTRACT FROM AUTHOR]

Over the past 70 years, significant advances have been made in determining the causes of death in populations not served by official medical certification of cause at the time of death using a technique known as Verbal Autopsy (VA). VA involves an interview of the family or caregivers of the deceased after a suitable bereavement interval about the circumstances, signs and symptoms of the deceased in the period leading to death. The VA interview data are then interpreted by physicians or, more recently, computer algorithms, to assign a probable cause of death. VA was originally developed and applied in field research settings. This paper traces the evolution of VA methods with special emphasis on the World Health Organization's (WHO)'s efforts to standardize VA instruments and methods for expanded use in routine health information and vital statistics systems in low- and middle-income countries (LMICs). These advances in VA methods are culminating this year with the release of the 2022 WHO Standard Verbal Autopsy (VA) Toolkit. This paper highlights the many contributions the late Professor Peter Byass made to the current VA standards and methods, most notably, the development of InterVA, the most commonly used automated computer algorithm for interpreting data collected in the WHO standard instruments, and the capacity building in low- and middle-income countries (LMICs) that he promoted. This paper also provides an overview of the methods used to improve the current WHO VA standards, a catalogue of the changes and improvements in the instruments, and a mapping of current applications of the WHO VA standard approach in LMICs. It also provides access to tools and guidance needed for VA implementation in Civil Registration and Vital Statistics Systems at scale.

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.

Background: In Bangladesh, a poorly functioning national system of registering deaths and determining their causes leaves the country without important information on which to inform health programming, particularly for the 85% of deaths that occur in the community. In 2017, an improved death registration system and automated verbal autopsy (VA) were introduced to 13 upazilas to assess the utility of VA as a routine source of policy-relevant information and to identify leading causes of deaths (COD) in rural Bangladesh., Methods: Data from 22,535 VAs, collected in 12 upazilas between October 2017 and August 2019, were assigned a COD using the SmartVA Analyze 2.0 computer algorithm. The plausibility of the VA results was assessed using a series of demographic and epidemiological checks in the Verbal Autopsy Interpretation, Performance and Evaluation Resource (VIPER) software tool., Results: Completeness of community death reporting was 65%. The vast majority (85%) of adult deaths were due to non-communicable diseases, with ischemic heart disease, stroke and chronic respiratory disease comprising about 60% alone. Leading COD were broadly consistent with Global Burden of Disease study estimates., Conclusions: Routine VA collection using automated methods is feasible, can produce plausible results and provides critical information on community COD in Bangladesh. Routine VA and VIPER have potential application to countries with weak death registration systems.

Background: Civil registration and vital statistics (CRVS) systems play a key role in upholding human rights and generating data for health and good governance. They also can help monitor progress in achieving the United Nations Sustainable Development Goals. Although many countries have made substantial progress in strengthening their CRVS systems, most low- and middle-income countries still have underdeveloped systems. The objective of this systematic review is to identify national policies that can help countries strengthen their systems., Methods and Findings: The ABI/INFORM, Embase, JSTOR, PubMed, and WHO Index Medicus databases were systematically searched for policies to improve birth and/or death registration on 24 January 2017. Global stakeholders were also contacted for relevant grey literature. For the purposes of this review, policies were categorised as supply, demand, incentive, penalty, or combination (i.e., at least two of the preceding policy approaches). Quantitative results on changes in vital event registration rates were presented for individual comparative articles. Qualitative systematic review methodology, including meta-ethnography, was used for qualitative syntheses on operational considerations encompassing acceptability to recipients and staff, human resource requirements, information technology or infrastructure requirements, costs to the health system, unintended effects, facilitators, and barriers. This study is registered with PROSPERO, number CRD42018085768. Thirty-five articles documenting experience in implementing policies to improve birth and/or death registration were identified. Although 25 countries representing all global regions (Africa, the Americas, Southeast Asia, the Western Pacific, Europe, and the Eastern Mediterranean) were reflected, there were limited countries from the Eastern Mediterranean and Europe regions. Twenty-four articles reported policy effects on birth and/or death registration. Twenty-one of the 24 articles found that the change in registration rate after the policy was positive, with two supply and one penalty articles being the exceptions. The qualitative syntheses identified 15 operational considerations across all policy categories. Human and financial resource requirements were not quantified. The primary limitation of this systematic review was the threat of publication bias wherein many countries may not have documented their experience; this threat is most concerning for policies that had neutral or negative effects., Conclusions: Our systematic review suggests that combination policy approaches, consisting of at least a supply and demand component, were consistently associated with improved registration rates in different geographical contexts. Operational considerations should be interpreted based on health system, governance, and sociocultural context. More evaluations and research are needed from the Eastern Mediterranean and Europe regions. Further research and evaluation are also needed to estimate the human and financial resource requirements required for different policies., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: ABS is a member of the Editorial Board of PLOS Medicine.

Problem: Bangladesh has no national system for registering deaths and determining their causes. As a result, policy-makers lack reliable and complete data to inform public health decisions., Approach: In 2016, the government of Bangladesh introduced a pilot project to strengthen the civil registration and vital statistics system and generate cause of death data in Kaliganj Upazila. Community-based health workers were trained to notify births and deaths to the civil registrar, and to conduct verbal autopsy interviews with family members of a deceased person. International experts in cause-of-death certification and coding trained master trainers on how to complete the international medical certificate of cause of death. These trainers then trained physicians and coders., Local Setting: Kaliganj Upazila has an estimated population of 304 600, and 5600 births and 1550 deaths annually. Health assistants and family welfare assistants make regular visits to households to track certain health outcomes., Relevant Changes: Following the start of the project in 2016, the number of births registered within 45 days rose from 873 to 4630 in 2018. The number of deaths registered within 45 days increased from 458 to 1404. During this period, health assistants conducted 7837 verbal autopsy interviews. Between January 2017 and December 2018, 105 master trainers and more than 7000 physicians were trained to complete the international medical certificate of cause of death and they completed more than 12 000 certificates., Lessons Learnt: Training community-based health workers, physicians and coders were successful approaches to improve death registration completeness and availability of cause-of-death data.

Competing Interests: Competing interests: None declared.

Verbal autopsy (VA) methods are designed to collect cause-of-death information from populations where many deaths occur outside of health facilities and where death certification is weak or absent. A VA consists of an interview with a relative or carer of a recently deceased individual in order to gather information on the signs and symptoms the decedent presented with prior to death. These details are then used to determine and assign a likely cause-of-death. At a population level this information can be invaluable to help guide prioritisation and direct health policy and services. To date VAs have largely been restricted to research contexts but many countries are now venturing to incorporate VA methods into routine civil registration and vital statistics (CRVS) systems. Given the sensitive nature of death, however, there are a number of ethical, legal and social issues that should be considered when scaling-up VAs, particularly in the cross-cultural and socio-economically disadvantaged environments in which they are typically applied. Considering each step of the VA process this paper provides a narrative review of the social context of VA methods. Harnessing the experiences of applying and rolling out VAs as part of routine CRVS systems in a number of low and middle income countries, we identify potential issues that countries and implementing institutions need to consider when incorporating VAs into CRVS systems and point to areas that could benefit from further research and deliberation., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Reliable and representative cause of death (COD) statistics are essential to inform public health policy, respond to emerging health needs, and document progress towards Sustainable Development Goals. However, less than one-third of deaths worldwide are assigned a cause. Civil registration and vital statistics (CRVS) systems in low- and lower-middle-income countries are failing to provide timely, complete and accurate vital statistics, and it will still be some time before they can provide physician-certified COD for every death. Proposals: Verbal autopsy (VA) is a method to ascertain the probable COD and, although imperfect, it is the best alternative in the absence of medical certification. There is extensive experience with VA in research settings but only a few examples of its use on a large scale. Data collection using electronic questionnaires on mobile devices and computer algorithms to analyse responses and estimate probable COD have increased the potential for VA to be routinely applied in CRVS systems. However, a number of CRVS and health system integration issues should be considered in planning, piloting and implementing a system-wide intervention such as VA. These include addressing the multiplicity of stakeholders and sub-systems involved, integration with existing CRVS work processes and information flows, linking VA results to civil registration records, information technology requirements and data quality assurance., Conclusions: Integrating VA within CRVS systems is not simply a technical undertaking. It will have profound system-wide effects that should be carefully considered when planning for an effective implementation. This paper identifies and discusses the major system-level issues and emerging practices, provides a planning checklist of system-level considerations and proposes an overview for how VA can be integrated into routine CRVS systems.

Background: The MDG era relied on global health estimates to fill data gaps and ensure temporal and cross-country comparability in reporting progress. Monitoring the Sustainable Development Goals will present new challenges, requiring enhanced capacities to generate, analyse, interpret and use country produced data., Objective: To summarize the development of global health estimates and discuss their utility and limitations from global and country perspectives., Design: Descriptive paper based on findings of intercountry workshops, reviews of literatureon and synthesis of experiences., Results: Producers of global health estimates focus on the technical soundness of estimation methods and comparability of the results across countries and over time. By contrast, country users are more concerned about the extent of their involvement in the estimation process and hesitate to buy into estimates derived using methods their technical staff cannot explain and that differ from national data sources. Quantitative summaries of uncertainty may be of limited practical use in policy discussions where decisions need to be made about what to do next., Conclusions: Greater transparency and involvement of country partners in the development of global estimates will help improve ownership, strengthen country capacities for data production and use, and reduce reliance on externally produced estimates.

New momentum for civil registration and vital statistics (CRVS) is building, driven by the confluence of growing demands for accountability and results in health, improved equity, and rights-based approaches to development challenges, and by the immense potential of innovation and new technologies to accelerate CRVS improvement. Examples of country successes in strengthening of hitherto weak systems are emerging. The key to success has been to build collaborative partnerships involving local ownership by several sectors that span registration, justice, health, statistics, and civil society. Regional partners can be important to raise awareness, set regional goals and targets, foster country-to-country exchange and mutual learning, and build high-level political commitment. These regional partners continue to provide a platform through which country stakeholders, development partners, and technical experts can share experiences, develop and document good practices, and propose innovative approaches to tackle CRVS challenges. This country and regional momentum would benefit from global leadership, commitment, and support., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Increasing demand for better quality data and more investment to strengthen civil registration and vital statistics (CRVS) systems will require increased emphasis on objective, comparable, cost-effective monitoring and assessment methods to measure progress. We apply a composite index (the vital statistics performance index [VSPI]) to assess the performance of CRVS systems in 148 countries or territories during 1980-2012 and classify them into five distinct performance categories, ranging from rudimentary (with scores close to zero) to satisfactory (with scores close to one), with a mean VSPI score since 2005 of 0·61 (SD 0·31). As expected, the best performing systems were mostly in the European region, the Americas, and Australasia, with only two countries from east Asia and Latin America. Most low-scoring countries were in the African or Asian regions. Globally, only modest progress has been made since 2000, with the percentage of deaths registered increasing from 36% to 38%, and the percentage of children aged under 5 years whose birth has been registered increasing from 58% to 65%. However, several individual countries have made substantial improvements to their CRVS systems in the past 30 years by capturing more deaths and improving accuracy of cause-of-death information. Future monitoring of the effects of CRVS strengthening will greatly benefit from application of a metric like the VSPI, which is objective, costless to compute, and able to identify components of the system that make the largest contributions to good or poor performance., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

In this Series paper, we examine whether well functioning civil registration and vital statistics (CRVS) systems are associated with improved population health outcomes. We present a conceptual model connecting CRVS to wellbeing, and describe an ecological association between CRVS and health outcomes. The conceptual model posits that the legal identity that civil registration provides to individuals is key to access entitlements and services. Vital statistics produced by CRVS systems provide essential information for public health policy and prevention. These outcomes benefit individuals and societies, including improved health. We use marginal linear models and lag-lead analysis to measure ecological associations between a composite metric of CRVS performance and three health outcomes. Results are consistent with the conceptual model: improved CRVS performance coincides with improved health outcomes worldwide in a temporally consistent manner. Investment to strengthen CRVS systems is not only an important goal for individuals and societies, but also a development imperative that is good for health., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

The health and development challenges of the coming decades cannot be tackled effectively without reliable data for births, deaths, and causes of death, which only a comprehensive civil registration and vital statistics (CRVS) system can deliver. Alternative methods such as surveys, censuses, or surveillance are not adequate substitutes from a statistical perspective, and do not provide individuals with the legal documentation they need to benefit from services and participate fully in a modern society. Research is needed to generate and disseminate evidence about which CRVS strategies work best in which contexts and to ensure that the potential benefits of innovation are successfully scaled up, and that possible pitfalls are avoided. Research findings need to be compiled and made readily accessible to users for policy making, programming, and practice. Modernisation of CRVS systems necessitates new, broad-based national and international coalitions. The global architecture for CRVS, so far dominated by UN agencies, should extend to include bilateral donors, funds, foundations, non-governmental organisations, the private sector, academic institutions, and civil society. This change is essential to ensure that further development of CRVS systems is inclusive, participatory, multisectoral, and has a strong evidence base., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objective: The objective was to provide a summary description of the current status of women's health globally and trends since the 1990s., Study Design: A compilation and analytic review of available information was performed., Results: Globally, a woman born in 2010 could expect to live some 3½ years longer than her sister born just a decade earlier in 2000 and over 8 years longer than her mother or aunt born in 1980. These huge gains in health have, however, been unevenly spread, and in many parts of the world, women's lives continue to be diminished by preventable illness and premature death due to social and gender inequalities and health system inadequacies. These are most acute in poor countries and among the poorest women everywhere. Health problems that are not adequately addressed in childhood, adolescence and the reproductive years have serious adverse repercussions for the children women bear and cast a long shadow on their own health as they age., Conclusion: Improvements in health, demographic, economic, social and environmental conditions have brought significant benefits to women in terms of their health and development but are also associated with new challenges, especially for the poorest women. As the causes of death and disability change from those associated with acute conditions--infectious diseases and pregnancy-related complications--to chronic, long-term conditions--cancer, cardiovascular diseases, diabetes and mental ill-health--women will be faced with accessing and paying for medical care and medicines. Many of these chronic conditions can, however, be prevented by a combination of behavioral change and early detection. Paying due attention to the health of girls and women today is an investment not just for the present but also for the future and for coming generations., Implications: The findings of this review have important implications for health systems as well as for broader policy dialogue on the underlying determinants of women's health including gender-based inequalities and discrimination. Health systems need to be structured and managed in ways that are responsive to the needs of girls and women, both for information and for care. Impediments to access--including distance, costs, lack of acceptability and discrimination--must be removed. Women themselves should be involved in designing and delivering health services that meet their needs as patients. They need support also in carrying out their roles as carers, both in the formal health care sector and within families and communities. Strategies to improve women's health must take full account of the underlying determinants of health--particularly gender inequality--and address the specific socioeconomic and cultural barriers that hamper women in protecting and improving their health., (Copyright © 2014. Published by Elsevier Inc.)

Monitoring universal health coverage (UHC) focuses on information on health intervention coverage and financial protection. This paper addresses monitoring intervention coverage, related to the full spectrum of UHC, including health promotion and disease prevention, treatment, rehabilitation, and palliation. A comprehensive core set of indicators most relevant to the country situation should be monitored on a regular basis as part of health progress and systems performance assessment for all countries. UHC monitoring should be embedded in a broad results framework for the country health system, but focus on indicators related to the coverage of interventions that most directly reflect the results of UHC investments and strategies in each country. A set of tracer coverage indicators can be selected, divided into two groups-promotion/prevention, and treatment/care-as illustrated in this paper. Disaggregation of the indicators by the main equity stratifiers is critical to monitor progress in all population groups. Targets need to be set in accordance with baselines, historical rate of progress, and measurement considerations. Critical measurement gaps also exist, especially for treatment indicators, covering issues such as mental health, injuries, chronic conditions, surgical interventions, rehabilitation, and palliation. Consequently, further research and proxy indicators need to be used in the interim. Ideally, indicators should include a quality of intervention dimension. For some interventions, use of a single indicator is feasible, such as management of hypertension; but in many areas additional indicators are needed to capture quality of service provision. The monitoring of UHC has significant implications for health information systems. Major data gaps will need to be filled. At a minimum, countries will need to administer regular household health surveys with biological and clinical data collection. Countries will also need to improve the production of reliable, comprehensive, and timely health facility data. Please see later in the article for the Editors' Summary.

Objective: Verbal autopsy (VA) is a systematic approach for determining causes of death (CoD) in populations without routine medical certification. It has mainly been used in research contexts and involved relatively lengthy interviews. Our objective here is to describe the process used to shorten, simplify, and standardise the VA process to make it feasible for application on a larger scale such as in routine civil registration and vital statistics (CRVS) systems., Methods: A literature review of existing VA instruments was undertaken. The World Health Organization (WHO) then facilitated an international consultation process to review experiences with existing VA instruments, including those from WHO, the Demographic Evaluation of Populations and their Health in Developing Countries (INDEPTH) Network, InterVA, and the Population Health Metrics Research Consortium (PHMRC). In an expert meeting, consideration was given to formulating a workable VA CoD list [with mapping to the International Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) CoD] and to the viability and utility of existing VA interview questions, with a view to undertaking systematic simplification., Findings: A revised VA CoD list was compiled enabling mapping of all ICD-10 CoD onto 62 VA cause categories, chosen on the grounds of public health significance as well as potential for ascertainment from VA. A set of 221 indicators for inclusion in the revised VA instrument was developed on the basis of accumulated experience, with appropriate skip patterns for various population sub-groups. The duration of a VA interview was reduced by about 40% with this new approach., Conclusions: The revised VA instrument resulting from this consultation process is presented here as a means of making it available for widespread use and evaluation. It is envisaged that this will be used in conjunction with automated models for assigning CoD from VA data, rather than involving physicians.