The study’s primary outcome was a registrable ceiling for each country, calculated as the WHO-estimated number of suicide deaths multiplied by that country’s all-cause death registration completeness, drawn from the International Completeness of Death Registration dataset. Among the 13 countries where completeness could be measured, the median was 14.1 percent, but the range was enormous: from 0.5 percent in Nigeria to 89.0 percent in Cabo Verde. For three countries, Ghana, Senegal, and Mali, registered death counts could not be obtained at all. Nigeria, which accounts for the largest share of the region’s estimated suicide burden at 10,912 deaths, or 46 percent of the 23,637 total, had a registrable ceiling of just 57 deaths. Because the ceiling assumes perfect cause certification for every registered death, the true number of suicides identifiable through registration in these countries is, by construction, no higher and likely lower.

Beneath these numbers lies a more fundamental problem: the quality of the data on which the region’s published suicide statistics rest. WHO classifies the empirical basis of its suicide estimates as very low quality for 15 of the 16 West African countries and low quality for Cabo Verde; no country in the region reaches a higher classification. In practical terms, this means the suicide rates that appear in international tables for most of West Africa are model-based estimates rather than direct measurements derived from registration data. The analysis also examined whether reported suicide rates track registration capacity, using ecological correlations between completeness and age-standardised suicide rates. The relationship proved unstable: the unweighted Pearson correlation was 0.51, but it fell to 0.14 when Cabo Verde was excluded and rose to 0.61 when countries were weighted by population. A statistical association that swings this widely depending on how countries are weighted or whether a single outlier is removed offers little basis for treating published rates as comparable measures of true suicide mortality across the region.

The authors conclude that death registration, as currently constituted, cannot serve as the foundation for suicide surveillance in most of West Africa. They argue that meaningful monitoring requires triangulation across multiple sources: health facility data, verbal autopsy methods, and surveys, rather than reliance on registration systems alone. They further identify priorities for strengthening civil registration and vital statistics infrastructure in the region, and note that other WHO regions have yet to conduct comparable analyses quantifying how much suicide mortality their own registration systems could capture. The cross-sectional design of the study means it captures registration capacity at a single point in time, and the ceiling calculations rest on WHO model estimates whose own empirical basis the study shows to be weak across the region.

The findings carry implications well beyond West Africa’s borders. Suicide mortality statistics are used to set prevention priorities, allocate resources, and evaluate interventions, yet this analysis demonstrates that in a region home to tens of thousands of estimated suicide deaths annually, the systems nominally responsible for counting those deaths would miss roughly 94 percent of them even under ideal assumptions. The gap between estimated burden and detectable mortality, the authors argue, is not a marginal data-quality issue but a structural limitation of surveillance itself, one that will persist until registration coverage expands substantially or complementary methods for ascertaining suicides are integrated into national health information systems.

Subject of Research: Suicide mortality surveillance capacity and death registration completeness in West Africa

Article Title: Counting the uncounted: suicide mortality and the limits of death registration in West Africa, a cross-sectional surveillance capacity analysis

Article References: Okereke, P. U., Alaaya, B. K., Abdulwasiu, K., Umeh, C. V., Okereke, O. W., Ikegwuonu, O., Okeke, A. C., Popoola, Y., Emovon, O. A., Osakue, S. E., & Akinwale, O. D. (2026). Counting the uncounted: suicide mortality and the limits of death registration in West Africa, a cross-sectional surveillance capacity analysis. BMC Public Health. https://doi.org/10.1186/s12889-026-29989-0

Image Credits: AI Generated

DOI: 10.1186/s12889-026-29989-0

Keywords: suicide mortality, death registration, civil registration and vital statistics, West Africa, surveillance capacity, WHO suicide estimates, data quality, verbal autopsy, Nigeria, cross-sectional analysis, Counting, uncounted

The study was led by Caroline B. Osoro of the KEMRI-Wellcome Trust Research Programme in Nairobi, together with colleagues from KEMRI, the African Population and Health Research Center, Kenya’s Department of Civil Registration Services, New York University Abu Dhabi, and the University of Oxford. The team conducted household surveys at the three surveillance sites, sampling 1,363 households that had experienced a recent death. Because these sites maintain long-running population registers that independently record births, deaths, and migrations, the researchers could anchor their survey findings in well-characterised communities, reducing the risk that unrecorded deaths would go entirely unnoticed.

The technical approach was equally rigorous. Rather than simply reporting a headline percentage, the investigators used random-effects regression analysis to quantify how individual, household, and contextual characteristics shaped the odds that a death would be registered. This statistical framework accounts for clustering of outcomes within households and sites, allowing the team to estimate adjusted odds ratios with confidence intervals for a wide range of potential determinants, from the age and marital status of the deceased to household wealth, place of death, and the interval between the death and the survey interview.

The results reveal a steep social gradient in who gets counted. Deaths among infants were the least likely of all to be registered, with an adjusted odds ratio of 0.09 compared with adults aged 65 to 84 years, meaning infants had roughly one-eleventh the odds of adult registration. Children aged one to four fared almost as poorly, with an adjusted odds ratio of 0.14. Unmarried decedents were less likely to be registered than married ones, with an adjusted odds ratio of 0.38, and unemployed decedents were also disadvantaged, at 0.60. Deaths that occurred at home were less likely to be registered than those in facilities, with an adjusted odds ratio of 0.65, a pattern that likely reflects the greater involvement of health workers and documentation pathways when someone dies under medical care.

At the same time, several factors increased the likelihood of registration. Deaths in urban settings had higher odds than rural ones, with an adjusted odds ratio of 1.55. Households in the wealthiest categories were substantially more likely to register deaths, with an adjusted odds ratio of 2.50, and decedents who had been employed or retired had 1.87 times the odds of registration compared with those who were unemployed. Perhaps most tellingly, deaths that had occurred very recently, within the preceding six months, were the least likely to have been registered, with an adjusted odds ratio of 0.26, indicating that registration in Kenya is not only incomplete but also heavily delayed, with many families completing the process only when a specific need arises.

That need, the study found, is most often inheritance. When respondents explained why a death had been registered, the most frequently cited reason was inheritance-related requirements, meaning that the death certificate functions less as a civic document and more as a legal key to property and assets. This dynamic helps explain the demographic pattern: adult deaths, particularly among married, employed people who own property, trigger inheritance processes that compel registration, while the deaths of infants, children, and the very poor generate no such legal pressure and therefore slip through the system unrecorded.

On the other side of the ledger, the leading reasons for non-registration were lack of awareness of the requirement, the high costs involved in obtaining a death certificate, and a perceived lack of benefit from registering at all. These barriers compound one another. Families who do not know registration is mandatory are unlikely to absorb the transport and administrative costs of travelling to a registration office, especially when they see no tangible return. For the deaths of young children, grief and stigma may add further disincentives. The result is a self-reinforcing cycle in which the absence of perceived benefit suppresses registration, which in turn keeps mortality statistics incomplete and weakens the case that communities might otherwise see for engaging with the system.

The consequences of this undercount extend far beyond individual families. Civil registration and vital statistics systems are the backbone of national health planning, providing the cause-of-death and mortality data that governments need to allocate resources, evaluate interventions, and monitor progress toward the Sustainable Development Goals. When only a fifth of deaths are registered, and when the unregistered deaths are concentrated among infants, children, and the poorest households, the resulting statistics do not merely understate mortality; they systematically erase the populations with the worst health outcomes. Policies designed on such data will be calibrated to the visible, registered minority rather than the true burden of disease and death.

The study’s findings carry particular weight because they come from Kenya, a country often regarded as a regional leader in health information systems, and because the authors included a representative from the Department of Civil Registration Services itself, suggesting institutional awareness of the problem at the highest level. The research was supported by the Wellcome Trust through senior and principal fellowships and the Kenya Major Overseas Programme, and it received ethical approval from the Kenya Medical Research Institute Scientific and Ethics Review Unit, the national science commission, and county health authorities at all three sites. The authors note that the funders had no role in study design, analysis, or the decision to publish.

The policy implications are clear. The authors argue that strengthening awareness and advocacy for timely registration, particularly of infant and under-five deaths, must be paired with targeted efforts to reach poor and unemployed households, whose members are disproportionately excluded from the civil record. Practical reforms suggested by the data include integrating registration prompts into facility and community-based death notification, reducing or eliminating fees for death certification, deploying community health promoters to sensitise families at the time of bereavement, and simplifying procedures so that registration does not depend on an impending inheritance dispute. Without such measures, Kenya’s most vulnerable citizens will remain statistical ghosts, their deaths invisible to the systems charged with protecting the living, and the promise of universal civil registration, a cornerstone of health equity and social inclusion, will remain unfulfilled.

Subject of Research: Completeness and determinants of death registration in Kenya

Article Title: Prevalence and determinants of death registration across three demographic surveillance sites in Kenya

Article References: Osoro, C. B., Bukosia, J., Waluke, I., Sifuna, P., Omolo, K., Nyaguara, A., Were, V., Rajwayi, M., Mwanzia, B., Onyango, S. A., Odipo, E., Chepkurui, V., Nyundo, C., Kamau, J., Helleringer, S., Snow, R. W., & Okiro, E. A. (2026). Prevalence and determinants of death registration across three demographic surveillance sites in Kenya. BMC Medicine. https://doi.org/10.1186/s12916-026-05278-w

Image Credits: AI Generated

DOI: 10.1186/s12916-026-05278-w

Keywords: death registration, civil registration and vital statistics, Kenya, demographic surveillance, health equity, mortality statistics, infant mortality, Sustainable Development Goals, BMC Medicine, household survey, inheritance, health systems