tag:theconversation.com,2011:/us/topics/birth-certificate-19904/articlesBirth certificate – The Conversation2023-02-15T13:23:22Ztag:theconversation.com,2011:article/1968712023-02-15T13:23:22Z2023-02-15T13:23:22ZHow records of life’s milestones help solve cold cases, pinpoint health risks and allocate public resources<figure><img src="https://images.theconversation.com/files/510099/original/file-20230214-2190-iexpcg.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2117%2C1412&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Civil registries in the U.S. are spread across different local jurisdictions.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/several-certificate-of-vital-records-for-birth-royalty-free-image/1197564062">eric1513/iStock via Getty Images Plus</a></span></figcaption></figure><p>After 65 years, Philadelphia police announced in December 2022 that they had identified the remains of <a href="https://www.nbcphiladelphia.com/investigators/after-65-years-philadelphia-police-identify-the-boy-in-the-box/3445387/">Joseph Augustus Zarelli</a>, a 4-year-old boy who was murdered in 1957. Because no one had ever come forward to reliably identify Joseph, he became “<a href="https://www.hmdb.org/m.asp?m=194953">America’s Unknown Child</a>,” a moniker that captured the tragic anonymity of his early death.</p>
<p>Recent advances in DNA analysis and forensic genealogy <a href="https://www.cbsnews.com/philadelphia/news/boy-in-box-joseph-zarelli/">provided the needed breakthrough</a> to build a genetic profile that connected the boy to surviving members of his mother’s family. But linking that genetic profile to Joseph’s identity required finding his name, a piece of information stored alongside his mother’s on his nearly <a href="https://www.inquirer.com/news/philadelphia/joseph-zarelli-boy-in-the-box-dna-genealogy-cold-case-20221216.html">70-year-old birth record</a> in the Pennsylvania Department of Health’s vital records system. </p>
<p>While the revolutionary science of genetic genealogy has received <a href="https://www.cbsnews.com/philadelphia/news/boy-in-the-box-philadelphia-murder-mystery-dna-explainer/">well-earned recognition</a> for its contribution to solving this long-standing mystery, the integral role of the more staid vital records system has mostly gone unnoticed. </p>
<p>Vital records are the stalwart administrative backdrop to life’s milestone events: birth, adoption, marriage, divorce and death. When a child is born in the U.S., the parents and hospital staff complete and sign a <a href="https://www.cdc.gov/nchs/data/dvs/birth11-03final-acc.pdf">certificate of live birth</a> that includes nearly 60 questions about the parents, the pregnancy and the newborn. A local registrar issues a formal birth certificate upon receiving the record as proof of a live birth.</p>
<p>Other vital events follow a similar process. Collectively, the U.S. vital records system comprises <a href="https://www.ncbi.nlm.nih.gov/books/NBK219884/">records of hundreds of millions of events</a> dating back to the beginning of the 20th century.</p>
<p>As a <a href="https://scholar.google.com/citations?hl=en&user=J2RmiawAAAAJ">family demographer</a>, I use information from these vital records to understand how childbirth, marriage and divorce are changing in the United States over time. The scope and quality of these records reflect remarkable administrative coordination from the local to the national level, but examples from other countries illustrate how much more the records could yet tell us. </p>
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<figcaption><span class="caption">While DNA evidence was instrumental to identify “America’s Unknown Child,” vital records also played an important role.</span></figcaption>
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<h2>Vital records mark unique events</h2>
<p>Originally, vital records were intended to publicly register events in order to <a href="https://www.ncbi.nlm.nih.gov/books/NBK219870/">legally recognize</a> the status of the people involved. The two people named on a valid marriage certificate, for example, share the legal protections and obligations of marriage until death or divorce. But over time, vital records have also come to serve as proof of identity. For both purposes, the integrity of the vital records system is critical. </p>
<p>Practically speaking, the system requires a perfect symmetry between people and events. Every recorded event needs to be associated with a unique person or pair of people, in the case of marriage and divorce, and every person or pair needs to be associated with a unique recorded event. Because of this singularity, a <a href="https://travel.state.gov/content/travel/en/passports/how-apply/citizenship-evidence.html">valid birth certificate</a> is required as proof of an individual’s unique identity to obtain a Social Security card, driver’s license or passport. </p>
<p>The uniqueness of each event also underlies <a href="https://www.cdc.gov/nchs/nvss/births.htm">how birth, marriage, divorce and death rates are calculated</a>. Double-counted events will artificially inflate these rates, while uncounted events will reduce them. Valid rates are important because governments and businesses rely on accurate measures of population change for <a href="https://ncvhs.hhs.gov/wp-content/uploads/2018/01/NCVHS_Vital_Records_Uses_Costs_Feb_23_2018-1.pdf">planning and investment</a>. </p>
<h2>America’s local approach to vital records</h2>
<p>In the U.S., the vital records system isn’t a single entity. Rather, there is a collection of state and local vital records offices operating independently but in cooperation with the federal government. </p>
<p>Each U.S. state and territory, as well as New York City and Washington, D.C., is its own vital registration jurisdiction, amounting to <a href="https://www.naphsis.org/systems">57 areas in all</a>. And within each jurisdiction, local offices receive and process records and issue certificates. Nationally there are <a href="https://oig.hhs.gov/oei/reports/oei-07-99-00570.pdf">over 6,000 local registrar offices</a> issuing birth certificates in the city or county where a birth occurred. </p>
<p>In nearly all states, marriage licenses and divorce decrees are certified and filed at the courthouse in the county where the event happened. This local registration system explains why Nevada has the highest marriage rate in the nation: of the <a href="https://weddings.vegas/marriage-services/marriage-statistics/">over 77,000 marriage licenses issued</a> in 2021 in Clark County – home to Las Vegas, America’s wedding capital – more than 60,000 couples provided a home mailing address outside of Nevada.</p>
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<a href="https://images.theconversation.com/files/510128/original/file-20230214-18-l8wspj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Marriage license of Elvis and Priscilla Presley, with Elvis' portrait printed in the center" src="https://images.theconversation.com/files/510128/original/file-20230214-18-l8wspj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/510128/original/file-20230214-18-l8wspj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=474&fit=crop&dpr=1 600w, https://images.theconversation.com/files/510128/original/file-20230214-18-l8wspj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=474&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/510128/original/file-20230214-18-l8wspj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=474&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/510128/original/file-20230214-18-l8wspj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=596&fit=crop&dpr=1 754w, https://images.theconversation.com/files/510128/original/file-20230214-18-l8wspj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=596&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/510128/original/file-20230214-18-l8wspj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=596&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Couples who flocked to get married in Las Vegas on 7/7/07 got a copy of Elvis and Priscilla Presley’s marriage license.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/detail-view-of-a-copy-of-elvis-and-priscilla-presleys-las-news-photo/75259026">Ethan Miller/Getty Images</a></span>
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<p>This highly decentralized approach has at least two significant implications. First, because different agencies are responsible for recording different events, there is no straightforward way to assemble an administrative profile for an individual over a lifetime. This challenge is further complicated when records are stored in different jurisdictions as people move and experience events in different places. Name changes – for example, through marriage – and inconsistencies in spellings, dates or other details also potentially impede record matching.</p>
<p>Second, in the absence of a single national repository for vital records, it takes substantial coordination to produce national statistics about vital events. Currently, U.S. jurisdictions send individual-level birth and death records to the <a href="https://www.cdc.gov/nchs/nvss/index.htm">National Center for Health Statistics</a> annually, and these records provide the basis for national birth and death statistics overall, including demographic characteristics like age, sex, race and ethnicity. This coordination is costly, time-consuming and often delayed. </p>
<p>In part because of the administrative burden, <a href="https://www.cdc.gov/nchs/nvss/marriage-divorce.htm">states stopped sending</a> detailed individual-level marriage and divorce records to the National Center for Health Statistics in 1995, and now provide only annual counts of these events. As a result, the only accessible way to examine national demographic patterns in marriage or divorce is through surveys, which are subject to nonresponse and reporting errors.</p>
<h2>Centralized approaches to vital recordkeeping</h2>
<p>In contrast to America’s decentralized system, <a href="https://unstats.un.org/unsd/demographic/sources/popreg/popregmethods.htm">many countries in Northern Europe</a> have centralized and integrated the collection and maintenance of administrative records related not only to vital events but also to circumstances like change in residence, employment and health care. This approach ensures that residents are <a href="https://www.ohchr.org/sites/default/files/Documents/Issues/Children/BirthRegistration/SwedenPopulationRegistration.pdf">continuously registered</a> to receive mail, vote, pay taxes, enroll in school and receive benefits such as housing subsidies at the correct address. It also means that public agencies have full information about their population to inform planning and budgeting.</p>
<p>A centralized system also facilitates rapid turnaround of population statistics. At peak periods during the COVID-19 pandemic, for example, the U.S. <a href="https://covidtracking.com/analysis-updates/how-lagging-death-counts-muddied-our-view-of-the-pandemic">lagged behind many other countries</a> in estimating national death rates as the Centers for Disease Control and Prevention awaited reported counts from public health offices in individual states overwhelmed by the pace and volume of deaths. </p>
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<a href="https://images.theconversation.com/files/510118/original/file-20230214-28-1q5c7c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Close-up of infant's footprints on birth certificate" src="https://images.theconversation.com/files/510118/original/file-20230214-28-1q5c7c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/510118/original/file-20230214-28-1q5c7c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/510118/original/file-20230214-28-1q5c7c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/510118/original/file-20230214-28-1q5c7c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/510118/original/file-20230214-28-1q5c7c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/510118/original/file-20230214-28-1q5c7c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/510118/original/file-20230214-28-1q5c7c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Vital records like birth certificates document your singularity as an individual.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/infants-footprints-on-birth-certificate-royalty-free-image/79250940">Tetra images/Getty Images Plus</a></span>
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<p>Vital records integrated with population register data also allow
social scientists, epidemiologists and other researchers to use deidentified linked records to study how <a href="https://ncrr.au.dk/danish-registers">early life conditions shape an individual’s life over time</a>. Using linked records from the Netherlands, for example, researchers have demonstrated that children who were in utero <a href="https://doi.org/10.1080/09603123.2021.1888894">during the 1944 Dutch famine</a> were more likely to have health problems throughout their lives than those born earlier or later.</p>
<p>The U.S. has made some progress toward developing a more centralized and integrated vital records system. A <a href="https://www.cdc.gov/nchs/nvss/linked-birth.htm">national file linking births to infant deaths</a> has helped scientists study how risk factors like preterm birth and low birth weight contribute to infant mortality. And public health and medical research studies can obtain cause of death information for participants in the <a href="https://www.cdc.gov/nchs/ndi/index.htm">National Death Index</a>, a compilation over 100 million death records since 1979. </p>
<p>But further progress is unlikely to happen any time soon. The current system, while cumbersome and incomplete, is well established and reliable. And at a time when the majority of Americans <a href="https://www.pewresearch.org/politics/2022/06/06/americans-views-of-government-decades-of-distrust-enduring-support-for-its-role/">lack trust in government</a>, there is little political will or public enthusiasm for a change. </p>
<p>For Joseph Zarelli, the durability of the local vital records system in Philadelphia was enough to answer a question that went unanswered for 65 years: A certificate of live birth registered in 1953 reconnected America’s Unknown Child to his name.</p><img src="https://counter.theconversation.com/content/196871/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paula Fomby receives funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. </span></em></p>Vital records document the birth, death, marriage and divorce of every individual. A more centralized system in the US could help public health researchers better study pandemics and disease.Paula Fomby, Professor of Sociology and Research Associate in Population Studies, University of PennsylvaniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1722932022-02-04T13:09:35Z2022-02-04T13:09:35ZNot everyone is male or female – the growing controversy over sex designation<figure><img src="https://images.theconversation.com/files/441210/original/file-20220118-13-l32vzy.jpg?ixlib=rb-1.1.0&rect=0%2C26%2C5906%2C3904&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Although the medical establishment is now recognizing that sex is not binary, society as a whole has been slow to embrace the concept.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/small-beautiful-child-lies-on-the-bed-on-his-royalty-free-image/1300384940?adppopup=true">Vera Livchak/Moment via Getty Images</a></span></figcaption></figure><p>Check out your birth certificate and surely you’ll see a designation for sex. When you were born, a doctor or clinician assigned you the “male” or “female” label based on a look at your genitalia. In the U.S., this has been <a href="https://doi.org/10.1056/nejmp2025974">standard practice for more than a century</a>. </p>
<p>But sex designation is not as simple as a glance and then a check of one box or another. Instead, the overwhelming evidence shows that <a href="https://doi.org/10.1002/ase.2002">sex is not binary</a>. To put it another way, the terms “male” and “female” don’t fully capture the complex biological, anatomical and chromosomal variations that occur in the human body. </p>
<p>That’s why calls are growing to remove sex designation from birth certificates, including <a href="https://thehill.com/changing-america/respect/equality/566767-ama-doctors-experts-recommend-removing-sex-designation-from">a recent recommendation</a> from the American Medical Association. </p>
<p>I am a <a href="https://www.bumc.bu.edu/busm/profile/carl-streed/">professor of medicine</a> who has worked extensively <a href="https://scholar.google.com.au/citations?user=Rv-dZJ4AAAAJ&hl=en">on lesbian, gay, bisexual, transgender, queer, intersex and asexual (LGBTQIA+) issues</a>. My co-author is a <a href="https://www.childrenshospital.org/directory/physicians/g/frances-grimstad">professor of gynecology</a> who is deeply involved in the health of people who are trans and intersex. </p>
<p>Our research and clinical experience show that sex designation is not something to take for granted. For those who don’t fit neatly into one of two categories – <a href="https://doi.org/10.1002/(sici)1520-6300(200003/04)12:2%3C151::aid-ajhb1%3E3.0.co;2-f">and there are millions</a> – an inappropriate classification on a birth certificate can have consequences that last a lifetime.</p>
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<figcaption><span class="caption">What does intersex mean?</span></figcaption>
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<h2>The problems with sex designation</h2>
<p>Variations in genital anatomy happen more frequently than you might think; <a href="https://doi.org/10.1002/(sici)1520-6300(200003/04)12:2%3C151::aid-ajhb1%3E3.0.co;2-f">they occur in 0.1 to 0.2% of births annually</a>. In the U.S., that’s about 4,000 to 8,000 babies each year. </p>
<p>Other sex traits don’t necessarily help either. Doctors examining the reproductive organs <a href="https://doi.org/10.1038/518288a">can find people</a> born with both a vagina and testes, and also those born without any gonads. And when evaluating an individual’s estrogen and testosterone hormone levels, long defined as key determinants of female and male bodies, doctors find some people with vaginas still produce <a href="https://doi.org/10.1016/S0140-6736(12)60071-3">significant amounts of testosterone</a>. Because of this, testosterone is not a great indicator for defining sex; higher amounts of testosterone do not necessarily make someone male. </p>
<p>Even karyotyping – a laboratory procedure used since the 1950s to evaluate an individual’s number and type of chromosomes – doesn’t tell the whole story. While we typically expect people to either have XX or XY pairs of sex chromosomes, <a href="https://doi.org/10.1038/518288a">many people have variations</a> that <a href="https://dx.doi.org/10.1159%2F000499274">do not fit either category</a>. These include <a href="https://www.mayoclinic.org/diseases-conditions/turner-syndrome/symptoms-causes/syc-20360782#">Turner syndrome</a>, in which a person is born with a single X chromosome, and <a href="https://www.mayoclinic.org/diseases-conditions/klinefelter-syndrome/symptoms-causes/syc-20353949#">Kleinfelter syndrome</a>, which occurs when a person is born with a combination of XXY chromosomes. </p>
<p>In short, human diversity has demonstrated that the binary categories of male and female are incomplete and inaccurate. Sex designation, rather than “two sizes fit all,” <a href="https://doi.org/10.1089/lgbt.2021.0018">is on a spectrum</a>. Up to 1.7% of the U.S. population – that’s more than 5 million Americans – have an anatomy and physiology that present intersex traits.</p>
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<figcaption><span class="caption">What it’s like to be intersex.</span></figcaption>
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<h2>Binary designations can be damaging</h2>
<p>Those with intersex traits who <a href="https://doi.org/10.1371/journal.pone.0240088">are assigned at birth</a> to be female or male can <a href="https://www.amnesty.org/en/latest/campaigns/2017/05/intersex-rights/">experience medical care that harms them</a>, both physically and psychologically. </p>
<p>Sometimes physicians perform surgeries to align bodies into binary categories. For example, those born with a larger than typical clitoris <a href="https://doi.org/10.1089/lgbt.2021.0018">may have it reduced in size</a>. But some who have this childhood surgery suffer as adults from pain and difficulty having sex.</p>
<p>[<em><a href="https://memberservices.theconversation.com/newsletters?nl=science&source=inline-science-corona-important">Get The Conversation’s most important coronavirus headlines, weekly in a science newsletter</a></em>]</p>
<p>Additionally, governments sometimes limit those with intersex traits from fully participating in society. For instance, in Australia, <a href="https://ihra.org.au/16808/annulment-marriage-due-intersex-marriage-falsely-called/">marriages have been annulled</a> because governments have previously ruled that an intersex person – someone not seen to be “100% man” or “100% woman” – cannot be legally married.</p>
<p><a href="https://stillmed.olympics.com/media/Documents/News/2021/11/IOC-Framework-Fairness-Inclusion-Non-discrimination-2021.pdf">Private entities</a> often do the same. The International Olympics Committee uses <a href="https://www.wired.com/story/caster-semenya-and-the-twisted-politics-of-testosterone/">cutoffs of hormone levels</a> to determine who plays in women’s sports. As a result, some athletes have been barred from participation. </p>
<p>And for those with a gender identity that differs from the sex designation on a government document, <a href="https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf">discrimination, harassment or violence</a> can result. </p>
<p>State governments have begun to acknowledge sex diversity. Some let gender-diverse people change their designation on birth certificates, <a href="https://www.lgbtmap.org/equality-maps/identity_document_laws/birth_certificate">although there are restrictions</a>. Medicine too <a href="https://doi.org/10.1089/lgbt.2021.0018">is changing</a>. For example, some pediatric centers have stopped performing surgeries on newborns with <a href="https://protect-us.mimecast.com/s/jNAuCVOrlMC8Dq3vuQEnoR?domain=them.us">differences in sex development</a>. Still, society at large <a href="https://www.cnn.com/2017/09/20/health/geas-gender-stereotypes-study/index.html">has been much slower to move beyond</a> the use of strictly binary categories. </p>
<p>As clinicians, we strive to be accurate. The evidence shows that using male and female as the only options on birth certificates is not consistent with scientific reality. Evidence shows that removing this designation will tell new parents that it’s not sex assignment that’s most important at birth but rather the celebration of a healthy and happy baby.</p><img src="https://counter.theconversation.com/content/172293/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Carl Streed receives funding from the National Heart, Lung, and Blood Institute and the American Heart Association. He is affiliated with the US Professional Association for Transgender Health and the American Medical Association. </span></em></p><p class="fine-print"><em><span>Frances Grimstad does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Millions of people do not fit neatly into male or female sex designations at birth, and wrong identification can set them up for a lifetime of physical and mental harm.Carl Streed Jr, Assistant Professor of Medicine, Boston UniversityFrances Grimstad, Assistant Professor of Gynecology, Harvard UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1221252019-08-22T04:03:34Z2019-08-22T04:03:34ZVictorian changes to gender on birth certificate will not increase sexual violence. Here’s why<figure><img src="https://images.theconversation.com/files/288981/original/file-20190821-170922-zkor79.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Under the proposed changes, TGD people in Victoria can change the gender on their birth certificate without having to undergo medical intervention.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The Victorian government is considering changes to the <a href="http://www.legislation.vic.gov.au/domino/Web_Notes/LDMS/PubPDocs.nsf/ee665e366dcb6cb0ca256da400837f6b/f667b734de4f601bca25841d000e43c1!OpenDocument">Births, Deaths and Marriages Registration Act 1996</a>. The changes will mean transgender and gender diverse (TGD) people can change the sex recorded on their birth certificate without having to undergo medical or surgical intervention. </p>
<p>Other Australian and <a href="https://www.icj.org/sogi-legislative-database/">international jurisdictions</a> have recognised the value of this kind of reform. Earlier this year, <a href="https://www.abc.net.au/news/2019-04-10/birth-certificate-gender-laws-pass-in-tasmania/10989170">Tasmania</a> passed laws similar to the ones being considered in <a href="https://www.theguardian.com/australia-news/2019/aug/11/victorian-mps-to-debate-bill-to-let-transgender-people-change-birth-certificate-without-surgery">Victoria</a>. The <a href="https://www.canberratimes.com.au/story/6144323/transgender-people-will-be-able-to-alter-birth-certificates/#ixzz40IQQgjFo">Australian Capital Territory</a>, Northern Territory, South Australia and Western Australia have also removed the requirement for surgical intervention. </p>
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Read more:
<a href="https://theconversation.com/explainer-why-removing-sex-from-birth-certificates-matters-to-gender-diverse-people-105571">Explainer: why removing sex from birth certificates matters to gender diverse people</a>
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<p>There is no evidence that these changes have had negative effects in any of these jurisdictions. Despite this, these legislative amendments have prompted fierce debate. </p>
<h2>Why are these changes necessary?</h2>
<p>A person’s access to legal documentation that accurately reflects their identity should not depend on first having to undergo body modification procedures. In some cases, these may be unwanted and may also cause unwanted effects such as sterilisation, given that “sex affirmation surgery” <a href="https://www.bdm.vic.gov.au/changes-and-corrections/change-your-recorded-sex">requires modifying reproductive organs</a>.</p>
<p>TGD people also have diverse needs: some need or want to use surgery to help affirm their identity, others do not. Moreover, surgery is expensive, tightly regulated by medical practitioners, and often <a href="https://equalopportunity.tas.gov.au/__data/assets/pdf_file/0009/338490/EOT_Options_paper_on_legal_recognition_of_sex_and_gender_diversity_in_Tasmania_%7E_CONSULTATION_DOC.pdf">inaccessible for many TGD people</a>. </p>
<p>It is <a href="https://www.humanrights.gov.au/our-work/lgbti/publications/sex-files-legal-recognition-sex-documents-and-government-records#Heading234">unfair and discriminatory</a> for appropriate legal documentation to be offered only to those who want and/or are able to access these surgeries for financial, social or other reasons.</p>
<p>Should this reform pass, it will represent part of a broader shift towards removing discriminatory recognition barriers for TGD people.</p>
<h2>Do these changes conflate sex and gender?</h2>
<p>Critics have claimed changes like the ones proposed collapse sex with gender. “Sex” is generally a term used to refer to a range of biological markers and is often understood in terms of “male” versus “female”.</p>
<p>However, contrary to popular belief, biological sex is <a href="https://theconversation.com/whats-the-point-of-sex-it-frames-gender-expression-and-identity-or-does-it-67849">much more complex</a> than these two binary categories. Determining “sex” is <a href="https://www.nytimes.com/2016/07/03/magazine/the-humiliating-practice-of-sex-testing-female-athletes.html">highly debated</a> and may be based on a range of factors, including chromosomes, sexual organs, secondary sex characteristics, and hormone levels.</p>
<p>Gender is generally used to refer to the social and cultural interpretations of “sex”, as well as an individual’s identification with such categories. It is <a href="https://www.yourtango.com/2019324626/how-many-genders-are-there-list-of-definitions-lgbtqia-identity-spectrum">also more complex</a> than the often presumed binary of “man” versus “woman”.</p>
<p>The relationship(s) between sex and gender are deeply <a href="https://www.humanrights.gov.au/our-work/lgbti/publications/sex-files-legal-recognition-sex-documents-and-government-records#Heading234">contested</a>. Despite a common assumption that sex and gender are the same thing, historically feminists have articulated the <a href="https://plato.stanford.edu/entries/feminism-gender/#SexDis">need for a distinction</a> between sex as biology and gender as cultural. </p>
<p>Crucially, “sex” as it is recorded on birth certificates operates as a social marker of gender (as identity), not simply as a marker of biology. </p>
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Read more:
<a href="https://theconversation.com/whats-the-point-of-sex-it-frames-gender-expression-and-identity-or-does-it-67849">What’s the point of sex? It frames gender expression and identity – or does it?</a>
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<p>For TGD people, a perceived discrepancy between the “sex” recorded on their official documents and their stated gender identity can “out” someone as transgender or gender diverse. This can lead to <a href="https://www.airport-technology.com/features/travelling-while-trans/">extra scrutiny, surveillance and stigmatisation</a> and can be used to deny <a href="https://www.humanrights.gov.au/our-work/lgbti/publications/sex-files-legal-recognition-sex-documents-and-government-records#Heading234">access to government and other services</a>. </p>
<p>For this reason, “sex” as it is recorded on birth certificates and other legal documents is best thought of as a legal gender marker. As some have argued, it may be better to <a href="https://theconversation.com/explainer-why-removing-sex-from-birth-certificates-matters-to-gender-diverse-people-105571">remove “sex” from birth certificates altogether</a>, to avoid any concerns over conflation of biology with identity.</p>
<p>This is a debate for another time. For now, it is imperative that TGD people are offered an even playing field when it comes to accessing appropriate legal documentation. </p>
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<h2>Will these changes increase the risk of sexual violence?</h2>
<p><a href="https://parliament.nt.gov.au/__data/assets/pdf_file/0011/597557/Submission-3a-Women-Speak-Tasmania-Attachments.pdf">Another critique that has been raised</a> is that this kind of reform leads to increased sexual offending against cisgender women, particularly in public toilets and other “sex”-segregated spaces (again here, “sex” is often deployed in ways that conflate biology with gender identity). </p>
<p>This critique <a href="https://www.theguardian.com/australia-news/2019/aug/15/bill-to-allow-transgender-people-change-birth-certificate-without-surgery-clears-first-hurdle-in-victoria">has several strands</a>: that male offenders will change their legally documented sex to access women’s spaces; and/or that women will be less able to challenge men who access women’s spaces. </p>
<p>Sexual violence is extremely common, with an estimated <a href="https://www.abs.gov.au/ausstats/abs@.nsf/mf/4906.0">one in five women</a> experiencing it in their lifetimes. Any potential risk to women’s safety should, of course, be taken very seriously.</p>
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Read more:
<a href="https://theconversation.com/marriage-equality-was-momentous-but-there-is-still-much-to-do-to-progress-lgbti-rights-in-australia-110786">Marriage equality was momentous, but there is still much to do to progress LGBTI+ rights in Australia</a>
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<p>However, we need to critically interrogate these claims. First, is it possible that sexual offenders could use the reforms in these ways? And, second, how likely is this? </p>
<p>The answer to the first question is “yes” – we can never rule out the remote possibility that someone could take advantage of the reforms in this way. However, possibility alone is not sufficient grounds for good policy. </p>
<p>Rather, we need to focus on the relative likelihood of this occurring. To answer this, we turn to the research on what we know about sexual offending. </p>
<p>Survivors overwhelmingly <a href="https://content.police.vic.gov.au/sites/default/files/2019-01/crimestats2012-13.pdf">experience sexual violence</a> in the context of interpersonal relationships. And the majority of this violence takes place in private locations. Perpetrators are most often someone <a href="https://www.abs.gov.au/ausstats/abs@.nsf/mf/4906.0">known to the survivor</a>, such as a current or former partner, friend, family member or acquaintance.</p>
<p>In contrast, the critiques raised above are based on the misconception that sexual violence is only perpetrated by a stranger in public spaces. This reinforces <a href="https://www.ourwatch.org.au/Understanding-Violence/Myths-about-violence">damaging and narrow understandings</a> of what “real” sexual violence is, and of where women (and other survivors) face the most risk.</p>
<p>This critique also assumes “sex”-segregated spaces are currently safe or protective ones for women. However, sexual violence has been <a href="https://www.heraldsun.com.au/news/victoria/elderly-woman-bashed-sexually-assualted-at-southern-cross-station/news-story/94a0abb3c5a020127b63e5001738e1aa?sv=acc9ee92fbdef11c19cb60c5fed0a214">documented in public toilets</a>. </p>
<p>These (relatively rare) cases suggest that perpetrators <em>already</em> access these spaces to offend. The cases documented in <a href="https://www.palgrave.com/gp/book/9781137587909">research</a> and media reporting also suggest it is the isolated nature of these sites that facilitates perpetration. </p>
<p>Such instances have nothing to do with what “sex” is officially recorded on someone’s legal documents. Ultimately, good policy should be founded on research-based evidence, not on remote or unlikely “what ifs”.</p>
<h2>TGD people are at higher risk of violence</h2>
<p>Also missing in this debate is acknowledgement of the extent to which TGD people experience disproportionate rates of sexual (and other) violence, including within interpersonal relationships and in public spaces. </p>
<p>While we lack a robust evidence base on sexual violence experienced by LGBTQ+ communities in general, the <a href="https://aifs.gov.au/publications/sexual-violence-and-gay-lesbian-bisexual-trans-intersex-and-queer-communiti">best available evidence</a> indicates that these communities experience this violence at rates similar to, if not higher than, cisgender heterosexual women. Transgender women experience <a href="https://transgender.or.ke/wp-content/uploads/2019/01/Violence-Against-Transgende-People.pdf">particularly high rates of sexual violence</a>. </p>
<p>There is no evidence that TGD people pose a greater risk of perpetration than cisgender men or women.</p>
<p>Toilets (and similar sex/gender-segregated spaces) <a href="https://transgenderlawcenter.org/resources/youth/beyond-the-binary">have also been identified as heightened spaces of violence</a>, abuse and harassment for TGD people, particularly transgender women. For example, in <a href="https://www.palgrave.com/gp/book/9781137587909">research by one of the authors</a>, one participant discussed how her trans partner often experienced sexual and physical violence from cisgender men who believed they were using the “wrong” toilet. </p>
<p><a href="https://www.tandfonline.com/doi/abs/10.1080/0966369042000258668">Other research</a> has shown how the strict regulation of space through binary understandings of “sex” results in harassment, abuse and violence against people who do not present their gender in a normative way, regardless of whether they identify as cis, trans, or otherwise. </p>
<p>In other words, “sex”-segregated spaces are themselves often sites of victimisation, particularly but not exclusively for TGD people.</p>
<h2>These reforms are important and should go ahead</h2>
<p>All of this suggests that concerns raised in relation to the proposed reforms are largely based on misplaced understandings of sexual offending, while ignoring the extent to which TGD people already experience violence. This is also concerning given that the strict policing of binary and narrow understandings of both sex and gender <a href="https://www.ourwatch.org.au/getmedia/13fded0c-851b-4935-b402-e00fdb9b6e4b/Summary-report_Preventing-FV-against-people-in-LGBTI-communities-(Accessible-PDF).pdf.aspx">contribute towards sexual violence</a>. </p>
<p>These reforms will not only affirm TGD people’s identities and remove barriers to navigating their daily lives more safely, but also help to make gender categories in general less strictly defined.</p>
<p>They will contribute to the broader feminist project of dismantling the oppressive patriarchal system that reduces gender to a narrow and limiting binary. In disrupting these norms, <a href="https://read.dukeupress.edu/tsq/article-abstract/3/1-2/22/91760/An-Affinity-of-Hammers">we all have the potential to benefit</a>.</p>
<p><em>Anyone needing support can contact 1800 RESPECT or Qlife: https://qlife.org.au/</em></p><img src="https://counter.theconversation.com/content/122125/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bianca Fileborn has been actively involved in political campaigning in relation to the proposed changes to the Victorian Births, Deaths and Marriages Registration Act (1996)</span></em></p><p class="fine-print"><em><span>Hannah McCann has been actively involved in political campaigning in relation to the proposed changes to the Victorian Births, Deaths and Marriages Registration Act (1996)</span></em></p><p class="fine-print"><em><span>Priya Kunjan has been actively involved in political advocacy in relation to the proposed changes to the Victorian Births, Deaths and Marriages Registration Act (1996).</span></em></p><p class="fine-print"><em><span>Matthew Mitchell does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Proposed reforms in Victoria will not only remove barriers for many TGD people to navigate their daily lives more safely, but help to make gender categories in general less strictly defined.Bianca Fileborn, Lecturer in Criminology, The University of MelbourneHannah McCann, Lecturer in Cultural Studies, The University of MelbourneMatthew Mitchell, PhD Candidate in Criminology, The University of MelbournePriya Kunjan, PhD Candidate in Political Science, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/485072015-10-09T04:00:11Z2015-10-09T04:00:11ZWhen communities help authorities tally births and deaths, health care equalises<figure><img src="https://images.theconversation.com/files/97750/original/image-20151008-9685-1q8mr4a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Important information about death can be collected from a person's surviving relatives.</span> <span class="attribution"><span class="source">REUTERS/Mohamed Abd El-Ghany</span></span></figcaption></figure><p>Recent <a href="http://www.thelancet.com/series/counting-births-and-deaths">research</a> suggests that two thirds of deaths across the world are unrecorded. In addition, unrecorded deaths occur more frequently among disadvantaged people.</p>
<p>This raises important questions about the links between material and data poverty. And it has left researchers trying to understand how health authorities can interact with communities to improve these statistics. </p>
<p>Civil registration is the recording of births, deaths, marriages and divorces. The process of combining, analysing and reporting this data is known as vital statistics. </p>
<p>In many developing and transitional countries functioning civil registration and vital statistics systems are incomplete or absent. This has been described as the single most critical <a href="http://www.thelancet.com/series/who-counts">development failure</a> of the past 30 years. </p>
<p>The World Health Organisation says that only four of 54 African countries record more than <a href="http://www.aho.afro.who.int/profiles_information/index.php/AFRO:Civil_registration_and_vital_statistics_systems">75%</a> of births and deaths. This seriously limits the capacity of the health system to respond to population health needs. </p>
<h2>Finding a solution</h2>
<p>Our research wants to address the unrecorded deaths worldwide. We want to develop a method which connects communities, health authorities and researchers to assess local situations, identify health priorities and plan for the future. </p>
<p>The project is a collaboration between the Medical Research Council and the Wits Rural Public Health and Health Transitions Research Unit (<a href="http://www.agincourt.co.za">Agincourt</a>), the <a href="http://www.abdn.ac.uk/iahs">University of Aberdeen</a> in Scotland and <a href="http://www.globalhealthresearch.net">Umeå University</a> in Sweden. </p>
<p>Our project consists of three phases over 18 months. We have just completed phase one and phase two is about to begin. It will be done in three poor and rural communities in the Agincourt research area in Mpumalanga, South Africa’s province with the <a href="http://mg.co.za/article/2014-06-12-a-district-in-despair">second highest</a> HIV rate. This will allow us to develop a method that can be adapted for use in poor communities in different locations.</p>
<h2>The value of verbal autopsy</h2>
<p>The first phase of the project will redefine how deaths are recorded. Currently deaths are recorded using medical information. Less attention is paid to the critical limiting factors that arise from the health systems and social contexts.</p>
<p>This phase is helping us understand incomplete health data, particularly among disadvantaged groups. It is also helping us understand the social and health system contexts that influence how deaths occur. Official health data, used to plan services, often fails to account for this.</p>
<p>The phase used <a href="http://www.who.int/healthinfo/statistics/verbalautopsystandards/en/">verbal autopsy</a>, interviewing relatives of people who died. They were questioned about the medical signs and symptoms of the person before they died. The data is used to conclude probable medical causes.</p>
<p>Verbal autopsy is applied in over 45 low and middle-income countries and has become an established research method. It provides crucial burden-of-disease information in otherwise uncounted populations.</p>
<p>Verbal autopsy has gained considerable momentum since it was introduced in the <a href="http://epirev.oxfordjournals.org/content/32/1/38.long">1950s and 1960s</a>. Today it is a scalable solution to strengthen civil registrations and vital systems. In 2012 the World Health Organisation released a <a href="http://www.who.int/healthinfo/statistics/verbalautopsystandards/en">short form</a> for it to be implemented more widely. In 2014 and 2015 ministerial conferences were held in <a href="http://www.getinthepicture.org/">Asia</a> and <a href="http://ea.au.int/en/content/%203rd-African-Ministers-responsible-for-Civil-Registration">Africa</a> to promote verbal autopsies in civil registrations and vital systems.</p>
<p>The researchers used the standard verbal autopsy method to collect additional information about access to health care and social circumstances at the time of death. From this, extended systems which classify deaths will be developed to account for social and health systems contexts. The team will also explore how the information can be integrated into health planning.</p>
<h2>Building a knowledge base</h2>
<p>In the second phase, the researchers will use the new data to work with local communities so that the authorities can act on the newly acquired health information. These discussions will also help them pinpoint the priorities for local services and what the potential co-benefits will be to empower these communities and socially include everyone.</p>
<p>It will help authorities to deepen their understanding of the mechanisms that shape the social and health systems used by the poor. It will also encourage a more democratic knowledge production on health which can then be acted on.</p>
<p>Through this community-based analysis, which capitalises on the long-standing relationships between communities and researchers in <a href="http://www.agincourt.co.za/index.php/activities/linc">Agincourt</a>, complementary accounts of cause of death will be developed.</p>
<p>In the final phase, using the robust evidence, researchers and health authorities will develop a practical way to strengthen the health system in the long term.</p>
<p>This will result in a method to generate health data more rigorously at population level, which uses an inclusive process so that there can be sustainable health gains through better data and improved capacity for evaluation.</p>
<h2>Working together is key</h2>
<p>This work is <a href="http://www.equinetafrica.org/bibl/docs/PAR%20Methods%20Reader2014%20for%20web.pdf">action oriented</a>. It aims to connect communities, researchers and health authorities and is a response to the lack of meaningful connections between research and policy observed in <a href="http://www.nature.com/nature/journal/v463/n7282/full/463733a.html">South Africa</a> and <a href="http://www.who.int/alliance-hpsr/resources/publications/9789241504409/en">elsewhere</a>.</p>
<p>For researchers the significance of registering all individuals in a population is that the researcher will be able to move towards a more people-centred methodology for their health systems research. For health authorities, it will result in better health planning, which ultimately will help the citizens get better health services.</p><img src="https://counter.theconversation.com/content/48507/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lucia D'Ambruoso receives funding from the Medical Research Council, the Economic and Social Research Council, the Wellcome Trust and the UK Department for International Development.
Lucia D'Ambruoso is affiliated with the Umeå Centre for Global Health Research in Sweden.</span></em></p>Health authorities need to bridge the gap and connect with communities to successfully identify health priorities and plan for the future.Lucia D'Ambruoso, Lecturer in Global Health, University of AberdeenLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/482672015-10-02T04:39:40Z2015-10-02T04:39:40ZCounting every birth and death could make a difference to health inequities in Africa<figure><img src="https://images.theconversation.com/files/96798/original/image-20150930-5798-j553su.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Most African countries record less than 75% of their births and deaths. </span> <span class="attribution"><span class="source">Reuters/Andreea Campeanu </span></span></figcaption></figure><p>For many African countries and especially among poorer communities, when people die there is no trace in any official legal record or statistic. It is common for a person who lives in the city and falls terminally ill to return to their rural village to <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2825805/pdf/ukmss-28804.pdf">await their death</a>. When they die they are buried without any legal or official documentation of the death specifying the cause. </p>
<p>At the same time millions of births in Africa are not <a href="http://www.unicef.org/esaro/Technical_paper_low_res_.pdf">legally documented</a>. In developed countries this would be unheard of.</p>
<p>In Australia and Denmark, <a href="http://www.who.int/healthinfo/civil_registration/crvs_report_2013.pdf">99%</a> of all deaths are captured. But only four out of 54 countries in Africa – Algeria, Mauritius, Seychelles and South Africa – capture <a href="http://www.aho.afro.who.int/profiles_information/index.php/AFRO:Civil_registration_and_vital_statistics_systems">75%</a> or more of their births and deaths. </p>
<p>Africa’s situation is mainly due to problems with what is known as civil registration and vital statistics systems.</p>
<p>And this is detrimental for planning purposes on the continent. If we do not know how many people are dying and why they are dying we cannot do much to prevent deaths that could have been avoided. </p>
<p>Many African governments were unable to monitor the <a href="http://www.un.org/millenniumgoals">millennium development goals</a> because they lacked the vital statistics, especially in the area of infant and maternal health.</p>
<p>A well-functioning civil registration and vital system that makes every death and birth in Africa count will be crucial to monitor the progress in achieving the newly set <a href="https://sustainabledevelopment.un.org/topics">sustainable development goals</a>.</p>
<h2>The marks of a well functioning system</h2>
<p>According to the <a href="http://www.who.int/healthinfo/civil_registration/en/">World Health Organisation</a>, a country has a well-functioning civil registration and vital statistics system if it registers all births and deaths, issues birth and death certificates and compiles and disseminates birth and death statistics, including cause-of-death information.</p>
<p>Other “vital” events that could be captured by the system are marriages, divorce and migration. These statistics are needed to inform local authorities that have to allocate public resources and monitor health progress. </p>
<p>A well-functioning civil registration and vital statistics system needs to be:</p>
<ul>
<li><p>universal to include all areas and the country’s entire population;</p></li>
<li><p>continuous to record vital events as they happen and on a permanent basis;</p></li>
<li><p>compulsory and be backed by a legal framework for its administration, operation and maintenance; and</p></li>
<li><p>confidential to retain public confidence by protecting citizens from misuse of records for legal matters.</p></li>
</ul>
<p>Despite the well-documented benefits of civil registration and vital statistics systems, many countries in Africa have not managed to get it right. </p>
<p>In Kenya for example, only about 46% of deaths and 60% of births are registered by the civil registration and vital statistics system. And even so, there are disparities within the country. In Kenya’s far-flung rural Mandera County, which borders Somalia, only 3% of deaths and 17% of births are said to be registered. </p>
<p>In general, poorer and more remote communities tend to be excluded from these systems. This fosters health inequities. It renders deaths and births in such communities invisible to local authorities. And if local authorities can’t determine how many people are dying, why they are dying, or how many children are born, they can’t plan for or respond to the health needs of the communities.</p>
<h2>Africa’s challenges</h2>
<p>There are several reasons why these systems remain ineffective. First, many policymakers are largely unaware of the value and importance of these systems. As a result, civil registration and vital statistics systems are not backed by strong governance frameworks or policies. Nor are they adequately funded and resourced. </p>
<p>The laws and procedures guiding civil registration and vital statistics systems in some African countries date back to the colonial era. This means they are not relevant or implementable today. </p>
<p>But there are also infrastructural and technological challenges. Many countries still rely on paper-based records for their systems. This is in contrast to Denmark, where, for example an electronic system was established as far back as 1968. </p>
<p>In the past decade various global and regional initiatives have been aimed at improving these systems in the developing world. In one such initiative, the World Health Organisation partnered with the Health Metrics Networks to create the Monitoring of Vital Events through the use of information technology, also known as the <a href="http://www.who.int/healthmetrics/move_it/en/">MOVE-IT</a> project. </p>
<p>The project successfully piloted electronic death registration systems in Kenya and Mozambique. But its greatest limitation was being project-based. It focused solely on collecting statistics rather than creating a coordinated and comprehensive approach to strengthen civil registration and vital statistics systems.</p>
<p>There are renewed and more co-ordinated efforts to improve systems in Africa. </p>
<p>The Economic Commission for Africa, with the African Union Commission, the African Development Bank and other key regional and international organisations developed a regional policy and advocacy <a href="http://www.uneca.org/sites/default/files/images/apai_crvs_23-august-final-formatted.pdf">framework</a> to speed up civil registrations and vital systems. </p>
<p>Ministers across the continent responsible for civil registrations are supporting its implementation. They pledged their political commitment at a civil registrations conference in Ethiopia in 2010. </p>
<p>Earlier this year they met in Yamoussoukro, Côte d’Ivoire where they agreed to launch a ten-year <a href="http://www.uneca.org/stories/ministers-propose-2015-2024-decade-civil-registration">programme</a> supporting civil registrations and vital statistics until 2024. Their goal is to leave no child or country behind.</p>
<h2>Developing a comprehensive approach</h2>
<p>The meetings in 2010 and this year have brought much-needed political commitment to improve civil registrations and vital systems in Africa.</p>
<p>The initiative provides the policy and programmatic framework to strengthen these systems across the continent, backed by the necessary political goodwill. </p>
<p>This sets the stage for all countries to comprehensively assess their systems and prepare costed national action plans to improve them, irrespective of their state of development.</p><img src="https://counter.theconversation.com/content/48267/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Samuel Oti receives funding from Bill & Melinda Gates Foundation, and International Development Research Center. </span></em></p>In Africa, only four countries record more than 75% of their births and deaths. This creates an unequal system and impacts on how governments plan for these citizens.Samuel Oti, Senior Research Officer, African Population and Health Research Center, and Millennium Promise Fellow, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/466442015-09-02T05:35:37Z2015-09-02T05:35:37ZWorldwide, 65% of deaths go uncounted – here’s how to change that<figure><img src="https://images.theconversation.com/files/93336/original/image-20150828-19943-lt4yds.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Burial in Madagascar, 2013</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&search_tracking_id=liBoMtFRrjPB-eTXPn9qcw&searchterm=africa%20funeral&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=220233388">Dennis van de Water</a></span></figcaption></figure><p>It has <a href="http://www.sciencedirect.com/science/article/pii/S0140673607614184">been described</a> as the most critical development failure of the past 30 years, and shows no sign of improving: many countries’ systems for registering major life events like births and deaths are incomplete or absent. </p>
<p>In 2007, the Lancet <a href="http://www.thelancet.com/series/who-counts">described the situation</a> as follows: “most people in Africa and Asia, and in many other regions, are born and die without leaving a trace in any legal record or official statistic”. A follow-up series in 2015 <a href="http://www.thelancet.com/series/counting-births-and-deaths">identified</a> a continued lack of political will to improve the situation. Registration of major life events is fundamental to human security and development, but 65% of deaths and 35% of births remain unrecorded across the world. </p>
<p>Civil registration refers to the continuous recording all vital life events in a population (also including marriages and divorces). It brings benefits for everyone. It provides citizens with the legal documents that allow them to protect rights like identity, citizenship and property; enabling them to make claims for public goods such as housing, employment, health care and justice. It helps to protect people, especially the vulnerable, from harm and exploitation in times of disaster or conflict, as well as from human trafficking and child labour. And it ensures that countries’ vital statistics are available for those that need to see them. </p>
<h2>A health essential</h2>
<p>Registering medical causes of deaths has also <a href="http://www.encyclopedia.com/topic/vital_statistics.aspx">long been considered</a> essential for the health of a population. The fact that more than half of all deaths worldwide go unregistered seriously limits the capacity of national health systems to deliver services that respond to the needs of their population. And poor countries are by far the worst affected: governments struggle to establish proper systems and donors often prefer to invest in interventions targeting specific health problems, such as vaccines, bed nets, clean birth kits and so forth. </p>
<p>Civil registration also plays an important role in helping development agencies monitor policies and programmes. Last month, <a href="http://uk.reuters.com/article/2015/08/03/uk-un-development-goals-idUKKCN0Q70Y520150803">the world agreed</a> 17 goals for sustainable development to continue the <a href="http://www.un.org/millenniumgoals/">Millennium Development Goals</a> beyond the 2015 deadline. An aspirational vision of global health and development this may be, but it will fail those it seeks to service if its success is judged on indicators that countries don’t measure. </p>
<p>We therefore urgently need alternatives that can record vital health data. The most obvious option is <a href="http://www.cghr.org/projects/million-death-study-project/what-is-verbal-autopsy/">verbal autopsy</a>, which has already been used in more than 45 low and middle-income countries for more than two decades to determine the causes of death for people who die outside hospitals and health facilities and/or in places where registration practice is poor. It has been used in countries as diverse as <a href="http://www.who.int/bulletin/volumes/90/3/11-092452/en/">Pakistan, Guatemala</a>, <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4490796/">Malaysia</a> and <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4022330/">Kenya</a>, often to gather information about a specific condition, such as <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4022330/">sickle cell anaemia</a>, <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3040016/">stillbirth</a> or <a href="http://www.who.int/bulletin/volumes/90/3/11-092452/en/">child mortality</a>. </p>
<p>It involves trained fieldworkers interviewing final caregivers on the deceased’s medical signs and symptoms prior to death. This information is then interpreted to deduce the probable medical causes. Admittedly it cannot help with the problem of vital documentation, which is one of the reasons it should be seen as an interim measure, but it still has an important role to play. </p>
<p>Not only can it address the critical gaps in our knowledge on world health – Ebola incidence is a good example – it can also shed light on specific issues like exclusion from access to health systems. And contrary to what you might imagine, it <a href="http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(14)70340-7/fulltext?rss=yes">doesn’t have to be</a> very expensive to implement. </p>
<h2>The international push</h2>
<p>We’ve now reached the point where there is considerable momentum around scaling up verbal autopsies. The World Health Organization regularly publishes standard verbal-autopsy interviews to harmonise practice and allow cross-national comparisons. In 2012 it <a href="http://www.who.int/healthinfo/statistics/WHO_VA_2012_RC1_Instrument.pdf">published</a> a formal short verbal-autopsy template to encourage them to be used more widely, as well as using them to contribute to the likes of <a href="http://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2013/en/">maternal mortality data</a>. </p>
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<a href="https://images.theconversation.com/files/93340/original/image-20150828-19916-1llnpvy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/93340/original/image-20150828-19916-1llnpvy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/93340/original/image-20150828-19916-1llnpvy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=812&fit=crop&dpr=1 600w, https://images.theconversation.com/files/93340/original/image-20150828-19916-1llnpvy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=812&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/93340/original/image-20150828-19916-1llnpvy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=812&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/93340/original/image-20150828-19916-1llnpvy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1020&fit=crop&dpr=1 754w, https://images.theconversation.com/files/93340/original/image-20150828-19916-1llnpvy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1020&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/93340/original/image-20150828-19916-1llnpvy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1020&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Signs of change?</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&search_tracking_id=liBoMtFRrjPB-eTXPn9qcw&searchterm=africa%20funeral&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=291072362">Myimages - Micha</a></span>
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<p>The use of verbal autopsy as part of civil registration was also promoted at a <a href="http://www.unescap.org/events/ministerial-conference-civil-registration-and-vital-statistics-asia-and-pacific">ministerial conference</a> on civil registration in Asia in 2014, and at a <a href="http://ea.au.int/en/content/%203rd-African-Ministers-responsible-for-Civil-Registration">similar event</a> for Africa earlier this year. Meanwhile the <a href="http://www.interva.net">latest development</a> is automated interpretation of verbal autopsy data, which makes interpretations between different regions and countries fully consistent. </p>
<p>The University of Aberdeen is involved in these efforts by co-ordinating a <a href="http://www.abdn.ac.uk/news/7999/">new research initiative</a> that aims to help exploit another opportunity presented by verbal autopsies: reconciling health data with information about the broader social circumstances that contribute to avoidable deaths. </p>
<p>Focused on South Africa, the work will develop new ways to classify deaths according to the local social circumstances that contribute to them; work with local communities to make the interpretations as accurate as possible; and embed these data and interpretations into national health systems. Like the rest of the efforts to improve recording of deaths through verbal autopsies, the hope is that by increasing the stock of knowledge about world health, we go some way to helping the people who suffer most from the lack of it.</p><img src="https://counter.theconversation.com/content/46644/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lucia receives funding from the Medical Research Council, the Economic and Social Research Council, the Wellcome Trust and DFID. She is affiliated with the Umea Centre for Global Health Research at Umea University in Sweden.
</span></em></p>One of the biggest problems in international development is that health statistics are badly kept in many of the countries with the most to gain. Finally something is being done about it.Lucia D'Ambruoso, Lecturer in Global Health, University of AberdeenLicensed as Creative Commons – attribution, no derivatives.