Who dies where? Estimating the percentage of deaths that occur at home

The majority of low-income and middle-income countries (LMICs) have incomplete death registration systems and so the proportion of deaths that occur at home (ie, home death percentage) is generally unknown. However, home death percentage is important to estimate population-level causes of death from integration of data of deaths at home (verbal autopsies) and in hospitals (medical certification), and to monitor completeness of death notification and verbal autopsy data collection systems. This study proposes a method to estimate home death percentage using data readily available at the national and subnational level.

Data on place of death from 152 country-years in 49 countries from 2005 to 2019, predominantly from vital registration systems, were used to model home death percentage standardised for population age and cause distribution. A national-level model was developed using Bayesian model averaging to estimate national, regional and global home death percentage. A subnational-level model was also developed and assessed in populations where alternative data on home death percentage were available.

Globally, it is estimated that 53.4% (95% uncertainty interval (UI) 50.8%-55.9%) of deaths occur at home, slightly higher (59.7%, 95% UI 56.5%-62.7%) in LMICs, substantially higher in low-income countries (79.5%, 95% UI 77.3%-81.5%) and much lower (27.3%, 95% UI 25.2%-29.6%) in high-income countries. Countries with the highest home death percentage are mostly found in South, East and Southeast Asia and sub-Saharan Africa (above 90% in Ethiopia, Chad and South Sudan). As expected, the national model has smaller error than the subnational model.

The study demonstrates substantial diversity in the location of deaths in LMICs and fills a significant gap in knowledge about where people die, given its importance for health systems and policies. The high proportion of deaths in LMICs that occur at home reinforces the need for routine verbal autopsy to determine the causes of death.