Improving Mortality Data Quality in Hospitals: Advocating for the Adoption of the WHO Standard Medical Certificate of Death in Nepal

Abstract

Background: Accurate mortality data is vital for public health planning and policy. In Nepal, non-standardized death certificates, often missing structured causal sequences and critical details, compromise data quality in the Civil Registration and Vital Statistics (CRVS) systems. Implementing the World Health Organization’s (WHO) Medical Certificate of Cause of Death (MCCoD) could enhance accuracy, strengthen mortality statistics, and facilitate evidence-based public health interventions.
Methods: This retrospective study analyzed inpatient deaths occurring between 13 April 2024 to 15 December 2024. Demographic and clinical data were extracted from medical records. The leading causes of death were identified by analyzing International Classification of Diseases Eleventh Revision (ICD-11) coded data using the Digital Open Rule Integrated cause of death Selection (DORIS) tool. Additionally, the study assessed documentation errors, predominant causes of in-hospital mortality, and evaluated the accuracy of cause-of-death reporting in the Health Management Information System (HMIS).
Results: The study analyzed 564 death certificates and corresponding medical records. Chronic liver disease was the leading underlying cause of death (UCOD) accounting 11.17% of total deaths. No certificate was entirely error-free, with nearly all (99.9%) failing to document the time interval between symptom onset and death. Approximately 59% contained unclear abbreviations, while 99.7% listed multiple causes in a single line without proper sequencing. Only 2% followed a causal sequence as: immediate, antecedent, and UCOD. Additionally, inaccurately reported cardiopulmonary arrest as the UCOD in HMIS.
Conclusions: Hospital death certification remains critically substandard, undermining mortality data quality. Prioritizing WHO’s MCCoD implementation and clinician training would significantly improve accuracy, supporting SDG targets for reliable cause of death reporting.
Keywords: Cause of death; DORIS Tools; ICD-11; MCCOD; mortality.