Accuracy of Death Certificates for Children: A Population-Based Retrospective Analysis

Background/Objective: Accurate determination and documentation of causes of death in children are essential for generating reliable mortality statistics and guiding public health strategies. Previous studies have reported frequent inaccuracies in pediatric death certificates (DCs), including the use of vague terms, omissions of relevant conditions, and variability across physician specialties. This study evaluated the accuracy of pediatric DCs in Shiga Prefecture, Japan; identified common errors in these DCs; and examined changes in the underlying causes of pediatric death before and after the COVID-19 pandemic. Methods: We performed a population-based retrospective review of 391 DCs for individuals under 18 years issued between 2015 and 2023. Two pediatricians and two forensic pathologists independently reviewed each DC, assessed accuracy, and classified errors using predefined criteria. Error rates were compared by physician specialty. Underlying causes of death were reassessed into ten categories, and their distributions were compared between 2015-2019 and 2020-2023. Results: Overall, 30.9% of DCs contained errors. The error rates differed by physician specialty: obstetricians had the highest error rate (92.9%), whereas forensic physicians had the lowest (8.4%). The most common error type was the use of non-specific mechanisms such as "cardiac arrest" or "respiratory failure", rather than the actual causes of death. Congenital anomalies were often listed under other significant conditions contributing to death and not as an underlying cause of death. After the onset of the COVID-19 pandemic, deaths from acute diseases declined from 16.8% to 4.0%, while deaths from congenital disorders increased from 12.6% to 24.3%. Conclusions: Pediatric DCs often contain errors, particularly those completed by obstetricians. Misclassifying mechanisms as causes of death and underreporting congenital anomalies remain the main challenges. Strengthening physician education and introducing systematic review processes are essential to improve accuracy, clarify regional mortality trends, and guide effective public health interventions.