EDITORIAL

 

The importance of including manner of (injury) death on the death notification form

 

 

The COVID-19 pandemic has highlighted the importance of accurate and timely mortality data, particularly cause-of-death information, for monitoring not only natural deaths but also non-natural deaths due to injuries. The South African Medical Research Council (SAMRC)'s Rapid Mortality Surveillance system^[1] provided near realtime measures of weekly excess mortality,^[2] which for natural deaths coincided with COVID waves and, for injuries, with government-imposed lockdowns and alcohol sales bans.^[3,4] The significant impact of alcohol bans on injury deaths provided a rare impetus for stakeholders to consider better alcohol policy to safeguard the post-COVID future of all South Africans.^[5]

Yet, despite the value of the weekly death data, they only provide a composite measure of all injury deaths. Injuries and violence remain an enduring pandemic in South Africa (SA), and there is a need for reliable injury mortality statistics that describe the profiles and trends for major causes of intentional (homicide and suicide) and unintentional injuries (road traffic, falls, poisoning, drowning, etc.). Their importance as a prevention priority is highlighted with their inclusion across multiple Sustainable Development Goals (SDGs).^[6] For example, SDG target 3.6 seeks to reduce road traffic injury and mortality, and SDG 5 seeks to achieve gender equality and empower all women and girls. Target 16.1 seeks the significant reduction of 'all forms of violence and related death rates everywhere'. This implicitly recognises men and boys as vulnerable and at risk, both as perpetrators and as victims, but also as worthy recipients of prevention efforts,^[7] which is an important consideration in SA, where males contribute substantially to the fatal injury burden.

However, SA's vital statistics are currently not suitable for monitoring progress towards these targets.^[8] For this reason, the SAMRC has undertaken intermittent nationally representative surveys of injury mortality in 2009,^[9] 2017^[10] and 2020/21 (forthcoming) to inform its National Burden of Disease estimates. The current study^[11] (in this issue of SAMJ) suggests that this is a data source that could be harnessed to complement vital statistics to provide more regular, reliable information on the injury mortality profile. However, mortuary surveys are time consuming and costly in comparison with routine collection of these data at the time of certification of medical cause of death.

Routine collection of manner-of-death data through vital statistics in SA is currently not possible as, contrary to the World Health Organization (WHO)'s internationally recommended medical certificate of cause of death,^[12] the death notification form (DNF) does not allow for the reporting of the manner of death. We consider that such a field would elicit relevant information and permit accurate coding of injury-related external causes of death. The Births and Deaths Registration Act 51 of 1992^[13] requires a medical practitioner to issue a certificate (DNF) stating the cause of death, but not the manner of death. The Inquests Act 58 of 1959^[14] assigns the responsibility of determining whether an act or omission amounting to an offence led to a death to the judicial officer presiding over an inquest into a death due to 'other than natural causes', which informs the manner of death. While neither Act prevents the inclusion of a presumptive manner of death on the DNF, some interpretative issues have led to a lack of clear guidance and prevented the reporting of the manner of death on the DNF (homicide, suicide, unintentional, disease). However, the perceived prohibition does not align with the systems in place. Forensic pathologists provide the courts with autopsy reports that state the anatomical cause of death, to assist the courts in their determination of the manner of death and possible accountability, whereas the DNF provides mortality data for public health planning and monitoring. Information on the presumptive manner of death along with the external cause is essential for coding to a specific cause.^[11] This issue has repeatedly been brought to government's attention over the past 15 years, to no avail.^[8,15,16]

As previously recommended, this situation needs urgent consideration, and provision needs to be made for reporting the manner of death on the death notification form as recommended by the WHO, for public health surveillance purposes. Most legislation in SA makes provision for exclusions in the interests of public health. Where there is evidence of a legislative barrier to obtaining information required for the public good, review of this legislation, according to the principles of co-operative governance as set out in the Constitution,^[17] is warranted. The steps to improve the quality of injury mortality data are clear, yet we have seen no action from government to address this. In a country with high levels of violence and road traffic fatalities and a high injury burden,^[18] this is unacceptable.

Pam Groenewald

Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa. pamela.groenewald@mrc.ac.za

Richard Matzopoulos

Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa; School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa

Estevão Afonso

Division of Forensic Medicine, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa

Debbie Bradshaw

Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa

 

References

1. Dorrington RE, Bradshaw D, Laubscher R, Nannan N. Rapid Mortality Surveillance report 2019 & 2020. Cape Town: South African Medical Research Council, 2021. https://www.samrc.ac.za/sites/default/files/attachments/2022-08/Rapid%20Mortality%20Surveillance%20Report%202019%262020.pdf (accessed 6 March 2023).         [ Links ]

2. Bradshaw D, Dorrington R, Laubscher R, Groenewald P, Moultrie T. COVID-19 and all-cause mortality in South Africa - the hidden deaths in the first four waves. S Afr J Sci 2022;118(5/6). https://doi.org/10.17159/sajs.2022/13300        [ Links ]

3. Barron K, Parry CDH, Bradshaw D, et al. Alcohol, violence and injury-induced mortality: Evidence from a modern-day prohibition. Rev Econ Stat 2022;1-45. https://direct.mit.edu/rest/article/doi/10.1162/rest_a_01228/112423/Alcohol-Violence-and-Injury-Induced-Mortality (accessed 6 March 2023).         [ Links ]

4. Moultrie TA, Dorrington RE, Laubscher R, et al. Unnatural deaths, alcohol bans and curfews: Evidence from a quasi-natural experiment during COVID-19. S Afr Med J 2021;111(9):834-837. https://doi.org/10.7196/SAMJ.2021.v111i9.15813        [ Links ]

5. Matzopoulos R, Walls H, Cook S, London L. South Africa's COVID-19 alcohol sales ban: The potential for better policy-making. Int J Health Policy Manag 2020;9(11):486-487. https://doi.org/10.34172/ijhpm.2020.93        [ Links ]

6. United Nations General Assembly. Transforming our world: The 2030 Agenda for Sustainable Development. New York: United Nations, 2015. http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=E (accessed 6 March 2023).         [ Links ]

7. Matzopoulos R, Bowman B. Sustainable development goals put violence prevention on the map. J Public Health Policy 2016;37(2):260-262. https://doi.org/10.1057/jphp.2016.13        [ Links ]

8. Prinsloo M, Bradshaw D, Joubert J, Matzopoulos R, Groenewald P. South Africa's vital statistics are currently not suitable for monitoring progress towards injury and violence Sustainable Development Goals. S Afr Med J 2017;107(6):470-471. https://doi.org/10.7196/SAMJ.2017.v107i6.12464        [ Links ]

9. Matzopoulos R, Prinsloo M, Pillay-van Wyk V, et al Injury-related mortality in South Africa: A retrospective descriptive study of postmortem investigations. Bull World Health Organ 2015;93(5):303-313. https://doi.org/10.2471/BLT.14.145771        [ Links ]

10. Prinsloo M, Mhlongo S, Dekel B, et al. The 2nd Injury Mortality Survey: A national study of injury mortality levels and causes in South Africa in 2017. Cape Town: South African Medical Research Council, 2021. https://www.samrc.ac.za/sites/default/files/attachments/2022-08/The%202nd%20Injury%20Mortality%20Survey%20Report_Final.pdf (accessed 6 March 2023).         [ Links ]

11. Groenewald P, Kallis N, Holmgren C, et al. Further evidence of misclassification of the injury deaths in South Africa: When will the barriers to accurate injury death statistics be removed? S Afr Med J 2023;113(9):e836. https://doi.org/10.7196/SAMJ.2023.v113i9.836        [ Links ]

12. World Health Organization. International Statistical Classification of Diseases and Related Health Problems, 10th revision, version for 2016. Geneva: WHO, 2016. http://apps.who.int/classifications/icd10/browse/2016/en (accessed 6 March 2023).         [ Links ]

13. South Africa. Births and Deaths Registration Act 51 of 1992. https://www.gov.za/sites/default/files/gcis_document/201409/a511992.pdf (accessed 6 March 2023).         [ Links ]

14. South Africa. Inquests Act 58 of 1959. https://www.gov.za/documents/inquests-act-3-jul-1959-0000 (accessed 6 March 2023).         [ Links ]

15. Groenewald P, Azvedo V, Daniels J, Evans J, Naledi T, Bradshaw D. The importance of identified cause-of-death information being available for public health surveillance, actions and research. S Afr Med J 2015;105(7):528-530. https://doi.org/10.7196/SAMJnew.8019        [ Links ]

16. Matzopoulos R, Groenewald P, Abrahams N, Bradshaw D. Where have all the gun deaths gone? S Afr Med J 2016;106(6):589-591. https://doi.org/10.7196/SAMJ.2016.v106i6.10379        [ Links ]

17. South Africa. Constitution of the Republic of South Africa, Act 108 of 1996. https://www.gov.za/sites/default/files/images/a108-96.pdf (accessed 6 March 2023).         [ Links ]

18. Norman R, Norman R, Matzopoulos R, Groenewald P, Bradshaw D. The high burden of injuries in South Africa. Bull World Health Organ 2007;85(9):695-702. https://doi.org/10.2471/blt.06.037184        [ Links ]