title: Undertaking cause-specific mortality measurement in an unregistered population: an example from Tigray Region, Ethiopia.
abstract: BACKGROUND
  The lack of adequate documentation of deaths, and particularly their cause, is often noted in African and Asian settings, but practical solutions for addressing the problem are not always clear. Verbal autopsy methods (interviewing witnesses after a death) have developed rapidly, but there remains a lack of clarity as to how these methods can be effectively applied to large unregistered populations. This paper sets out practical details for undertaking a representative survey of cause-specific mortality in a population of several million, taking Tigray Region in Ethiopia as a prototype.
  
  
  METHODS
  Sampling was designed around an expected level of maternal mortality ratio of 400 per 100,000 live births, which needed measuring within a 95% confidence interval of approximately ±100. Taking a stratified cluster sample within the region at the district level for logistic reasons, and allowing for a design effect of 2, this required a population of around 900,000 people, equating to six typical districts. Since the region is administered in six geographic zones, one district per zone was randomly selected.
  
  
  METHODS
  The survey was implemented as a two-stage process: first, to trace deaths that occurred in the sampled districts within the preceding year, and second to follow them up with verbal autopsy interviews. The field work for both stages was undertaken by health extension workers, working in their normally assigned areas. Most of the work was associated with tracing the deaths, rather than undertaking the verbal autopsy interviews.
  
  
  CONCLUSIONS
  This approach to measuring cause-specific mortality in an unregistered Ethiopian population proved to be feasible and effective. Although it falls short of the ideal situation of continuous civil registration and vital statistics, a survey-based strategy of this kind may prove to be a useful intermediate step on the road towards full civil registration and vital statistics implementation.
authors.affiliation: Tigray Regional Health Bureau, Mekelle, Ethiopia.
authors.forename: Hagos
authors.initials: H
authors.lastname: Godefay
authors.affiliation: Tigray Regional Health Bureau, Mekelle, Ethiopia.
authors.forename: Atakelti
authors.initials: A
authors.lastname: Abrha
authors.affiliation: WHO Collaborating Centre for Verbal Autopsy, Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
authors.forename: John
authors.initials: J
authors.lastname: Kinsman
authors.affiliation: WHO Collaborating Centre for Verbal Autopsy, Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
authors.forename: Anna
authors.initials: A
authors.lastname: Myléus
authors.affiliation: WHO Collaborating Centre for Verbal Autopsy, Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden; Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Institute of Applied Health Sciences, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, United Kingdom; peter.byass@epiph.umu.se.
authors.forename: Peter
authors.initials: P
authors.lastname: Byass
mesh_terms: D000293:Adolescent; D000328:Adult; D002423:Cause of Death; D003625:Data Collection / Q000379:methods* / Q000592:standards; D004282:Documentation / Q000379:methods* / Q000592:standards; D005002:Ethiopia / Q000453:epidemiology; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008428:Maternal Mortality; D008875:Middle Aged; D009026:Mortality; D055815:Young Adult
keywords: Ethiopia; civil registration and vital statistics; evidence-based decision making; mortality; population survey; verbal autopsy