Open Access Research article

Performance criteria for verbal autopsy-based systems to estimate national causes of death: development and application to the Indian Million Death Study

Lukasz Aleksandrowicz1, Varun Malhotra1, Rajesh Dikshit2, Prakash C Gupta3, Rajesh Kumar4, Jay Sheth5, Suresh Kumar Rathi1, Wilson Suraweera1, Pierre Miasnikof1, Raju Jotkar6, Dhirendra Sinha7, Shally Awasthi8, Prakash Bhatia9 and Prabhat Jha1*

Author Affiliations

1 Centre for Global Heath Research, St. Michael’s Hospital, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada

2 Tata Memorial Hospital, Mumbai, India

3 Healis-Sekhsaria Institute for Public Health, Navi Mumbai, India

4 School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India

5 Department of Preventative and Social Medicine, NHL Municipal Medical College, Ahmedabad, India

6 Rajiv Gandhi Jeevanayee Aarogya Yojana Society, Government of Maharashtra, Mumbai, India

7 World Health Organization, South-East Asia Regional Office, New Delhi, India

8 Department of Paediatrics, King George’s Medical University, Lucknow, India

9 Apollo Institute of Medical Sciences and Research, Hyderabad, India

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BMC Medicine 2014, 12:21  doi:10.1186/1741-7015-12-21

Published: 4 February 2014



Verbal autopsy (VA) has been proposed to determine the cause of death (COD) distributions in settings where most deaths occur without medical attention or certification. We develop performance criteria for VA-based COD systems and apply these to the Registrar General of India’s ongoing, nationally-representative Indian Million Death Study (MDS).


Performance criteria include a low ill-defined proportion of deaths before old age; reproducibility, including consistency of COD distributions with independent resampling; differences in COD distribution of hospital, home, urban or rural deaths; age-, sex- and time-specific plausibility of specific diseases; stability and repeatability of dual physician coding; and the ability of the mortality classification system to capture a wide range of conditions.


The introduction of the MDS in India reduced the proportion of ill-defined deaths before age 70 years from 13% to 4%. The cause-specific mortality fractions (CSMFs) at ages 5 to 69 years for independently resampled deaths and the MDS were very similar across 19 disease categories. By contrast, CSMFs at these ages differed between hospital and home deaths and between urban and rural deaths. Thus, reliance mostly on urban or hospital data can distort national estimates of CODs. Age-, sex- and time-specific patterns for various diseases were plausible. Initial physician agreement on COD occurred about two-thirds of the time. The MDS COD classification system was able to capture more eligible records than alternative classification systems. By these metrics, the Indian MDS performs well for deaths prior to age 70 years. The key implication for low- and middle-income countries where medical certification of death remains uncommon is to implement COD surveys that randomly sample all deaths, use simple but high-quality field work with built-in resampling, and use electronic rather than paper systems to expedite field work and coding.


Simple criteria can evaluate the performance of VA-based COD systems. Despite the misclassification of VA, the MDS demonstrates that national surveys of CODs using VA are an order of magnitude better than the limited COD data previously available.

Verbal autopsy; Physician-certified verbal autopsy; Cause of death statistics; Vital statistics; India