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Less than one out of five deaths in India is medically certified to denote cause of death. Deaths with medical certification of the cause were a mere 2.5% of estimated deaths in Jharkhand, 3.1% in Uttar Pradesh and 4.7% in Bihar. This emerges from an analysis of data from two reports recently released by the census commissioner’s office.
This assumes greater significance at a time when a debate is raging on whether Covid-19 deaths are being accurately counted.

The problem in states such as Bihar, UP and Jharkhand is two-fold – a low level of registration of deaths and a low proportion of even registered deaths being certified for cause. In Bihar, for instance, data from the Civil Registration System (CRS) for 2018 shows that only 35% of all deaths were registered, the lowest proportion among major states. And, of those registered, only one in seven was certified for cause of death, according to the report on Medical Certification of Cause of Death (MCCD).
More than 50 years after passing legislation to make registration of births and deaths compulsory, while the registration of deaths has reached 86% of estimated total deaths, medical certification remains low. Among larger states, there is just one, Tamil Nadu, where about 45% of the registered deaths are medically certified.
In some states, a high proportion of registered deaths are medically certified but the proportion of deaths registered is quite low. Thus, the proportion of total deaths for which the cause is certified is quite low. For instance, Telangana with 37.4% of registered deaths being medically certified seems to perform better than Maharashtra with 35%. However, only 58% of deaths were registered in Telangana compared to over 98% in Maharashtra.
According to the report, the MCCD scheme captures mostly deaths in medical institutions in urban areas. Thus, it largely misses out on rural India, where two-thirds of the population lives. Its coverage in urban areas too is patchy with wide variations between states. From covering just 15 states in 1991, the MCCD now covers 35 states and union territories.
The CRS report shows that just over one-third of deaths happened in institutions. Thus, two thirds of deaths would be outside the MCCD scheme.
There are provisions for a separate form for non-institutional deaths attended by medical practitioners. The form is in a prescribed format with the immediate cause of death recorded first and the underlying cause the last. The underlying cause is the morbid condition that initiated the chain of events leading to death. The form also has provision for recording the interval between onset of disease and other details.
“With most deaths happening outside the MCCD system, for better coverage of medical certification, more doctors need to be trained in giving the right code. Though the process of MCCD is part of the MBBS curriculum, doctors should be mentored and assisted in real life scenarios. Ideally, all doctors should understand the importance of assigning the right cause of death as it has policy implications,” said Dr P Giridara Gopal, researcher in community medicine, in AIIMS, Delhi
“Even without a medically ascertained cause of death you can get a death registered and get the death certificate. So no one is bothered. The focus was always on ensuring 100% death registration, not on medical certification of cause. Mumbai municipal corporation is one of the few authorities with a good programme for training doctors in MCCD. Most governments are dependent on verbal autopsies done in a sample population to get the disease profile of a population. This is an accepted and cheaper way of determining the disease profile in resource-poor settings,” explained Dr Jeemon Panniyammakal, assistant professor of epidemiology in the Sree Chithra Institute in Thiruvananthapuram.

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