Over Half of Registered Deaths in 2022 Got No Medical Attention; Unregistered Deaths Not Even Counted
New Delhi: Of all those whose deaths were registered in India, about half did not receive any medical attention at the time they died. According to the civil registration system (CRS)'s latest data for 2022, as many as 50.7% of the registered deceased received no medical care.
This does not include deaths that were not registered. Strangely enough, there is no data available on what percentage of total deaths were registered – and neither can this be calculated in the absence of a dataset. So the conclusion that more than half of the deceased did not receive medical attention may be an understatement.
The percentage of people who were being attended to medically at the time they died in 2022 slid down by five percentage points when compared to 2020.
A comparison between 2022 and 2021 is avoided here as the latter was when the Delta wave of COVID-19 struck and the number of people receiving medical attention was expected to go up, which is indeed what happened.
The fact that such a low percentage of people obtained medical treatment points, by and large, to the poor health infrastructure of state governments and partially to that of the Union government.
In 2022, out of all those who received medical attention, 25% did so from a medical institution. Another 17.1% got medical care in some form or the other, though outside the ambit of institutional care.
Death registration
The number of registered deaths decreased from 102.2 lakh in 2021 to 86.5 lakh in 2022. This is a decrease of 15.4%.
Some of India's major states – Gujarat, Maharashtra, Madhya Pradesh, Andhra Pradesh, Tamil Nadu, Uttar Pradesh, Karnataka, West Bengal, Bihar and Haryana – contributed significantly to the decreased number of registered deaths.
This drop in death registration numbers in 2022 can be viewed from this perspective: The number of deaths that occurred in 2021 – the year of the COVID 19 pandemic's Delta wave – were much higher than what occurred in 2022. Therefore, the number of deaths that were registered in 2021 were higher than in 2022.
The government claimed for a long time that no undercounting of deaths happened in 2021. But the fact that number of deaths registered in 2021 were significantly higher than what happened in 2022 - is also another dataset that questions the assertions of the government
Also read | Undercounting of COVID Deaths: Two Million More People Died in 2021 Compared to 2020, Shows Govt Data
While the total number of deaths registered becomes clear from the CRS's 2022 data, there is no data to suggest what percentage of deaths were unregistered, a crucial indicator to understand the robustness of the system that records deaths.
The percentage of deaths can be calculated by combining two data sources:
- The sample registration system (SRS) estimates the death rate per 1,000 population and, therefore, can give an estimated number of the total deaths that occurred in a given year, say 2022.
- The CRS, which gives the exact total number of deaths registered in a given year, say 2022.
Therefore, the percentage of deaths registered = (the total number of registered deaths (CRS) / estimated number of deaths (SRS)) * 100.
Though the government has released CRS data for 2022, it has not released SRS data for 2022. Therefore, it is impossible to calculate the percentage of deaths registered in 2022.
India's death registration has been at around 80%, but it is crucial to look at state-wise differences. Since the percentage of deaths registered in 2022 remains unknown, for reasons mentioned above, it is not possible to look at the states’ individual performance.
The implementation of death registration law is the responsibility of state governments. According to the Registration of Births and Deaths Act of 1969, it is mandatory to have every death registered.
The CRS, which contains the actual number of deaths and births registered, has to be conducted by state governments. On the other hand, the SRS, which gives the estimated number of deaths and births, is the responsibility of the Union government.
The SRS is important because if the number of actual deaths are missed, it is through this survey that the number of deaths per 1,000 population can be estimated.
The CRS 2022 has been released by the Union government, while the SRS 2022 has been withheld.
The urban-rural divide in terms of death registration is also clearly visible. Of whatever number of deaths are registered, rural areas perform better than urban ones in recording deaths.
Death registration is important not just as a simple statistic.
While it does serve the purpose of record-keeping, it also helps in finding out the cause of deaths – referred to as the medically certified cause of deaths (MCCD) in demographic jargon.
There are 19 categories under which deaths are classified, including broad diseases and other causes of death.
The causes of only 22.3% of deaths were medically certified in 2022. In other words, for more than three-fourths of deaths that year, the causes remain unclassified.
The state-wise disparities are telling. For example, the MCCD rate was 5.4% in Bihar, 43% in Tamil Nadu and 48.6% in Sikkim, in 2022.
One of the fallouts of less than half of registered deaths receiving medical attention is a low MCCD rate. If such a high proportion of deaths are not attended to medically (as high as 50.7% in 2022), there is no way their cause can be identified.
Even so, the fact that the remainder of registered deaths received medical attention does not automatically mean that their cause has been correctly ascertained. There are several reasons why, but the primary reason is incorrect procedures used by healthcare providers.
Stillbirths
Stillbirths are a matter of concern. The WHO defines a stillbirth as a baby born with no signs of life at or after 28 weeks' gestation. The stillbirth rate is the number of stillbirths per 1,000 live births.
India attained a stillbirth rate of 7.54 stillbirths per 1,000 live births in 2022, meeting the target of reducing the figure to the single digits as per India's Newborn Action Plan.
However, states like Meghalaya, which registered the highest stillbirth rate at 14.46, continue to be a matter of concern. It is followed by Rajasthan (12.91 per 1,000 live births) and Gujarat (10.47 per 1,000 live births).
Some studies indicate that stillbirths may be undercounted in India.
This paper authored by the Public Health Foundation of India's Rakhi Dandona and her colleagues analysed the stillbirth rate between 2016 and 2020. It said that the stillbirth rate for India from the National Family Health Survey (NFHS) (9.7 stillbirths per 1,000 births) was 2.6 times higher than the average rate reported in the sample registration system over 2016-2020.
A high stillbirth rate is an indicator of not-so-adequate maternal care. “The major causes of stillbirth include pregnancy and childbirth-related complications [due to poor health infrastructure]; prolonged pregnancy; maternal infections such as malaria, syphilis and HIV’ maternal conditions, especially hypertension and diabetes; and foetal growth restriction [when an unborn baby is unable to achieve its growth potential and is therefore smaller than it should be],” per the WHO.
Sex ratio
One of the most critical indicators in the CRS is the sex ratio at birth, i.e. the number of females per 1,000 males. Bihar registered the lowest sex ratio of 891. Its sex ratio declined from 908 in 2021 to 891 in 2022.
Bihar chief minister Nitish Kumar in his over-two-decade-long career has launched several schemes to empower women, such as the ‘Mukhyamantri Kanya Suraksha Yojana’ (to financially assist the first-born in below poverty line families), the 'Mukhyamantri Balika Cycle Yojana’ (to improve the enrolment of girls in school), the ‘Mukhyamantri Mahila Udyami Yojana’ (provides Rs 10 lakh to women for starting business ventures) and the ‘Nischay Aarakshit Rozgaar Mahilaao Ka Adhikar’ (reservation for women in government jobs), among others.
These schemes are also aimed at preventing female foeticide and improving the quality of life for women. However, the fact that the state registered the worst sex ratio in the country in 2022 makes one question the wider reach of these schemes and, more so, the impact they are making in society and the psyche of the people at large.
Besides Bihar, a few other states too registered a decline in their respective sex ratios. These are: Karnataka, Madhya Pradesh, Maharashtra, Manipur, Meghalaya, Telangana, Uttarakhand, Uttar Pradesh and West Bengal.
Though the sex ratio of certain states is a matter of concern, India's overall average sex ratio has consistently improved over the years, data from the NFHSs suggests.
The sex ratio registered under the fourth round of the NFHS conducted between 2015-16 was 991, while it rose to 1,020 in the fifth round of the survey conducted from 2020-21.
Thus, for the first time in recent years, the number of girl child births was higher than male births.
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