Verbal/Social Autopsy in Niger 2012-2013: A new tool for a better understanding of the neonatal and child mortality situation

Uncovering the causes and socio-demographic constructs of stillbirths and neonatal deaths in an urban slum of Karachi

INTRODUCTION

Neonatal deaths and stillbirths are significant public health concerns in Pakistan, with an estimated stillbirth rate of 43 per 1,000 births and a neonatal mortality rate of 46 deaths per 1,000 live births. Limited access to obstetric care, poor health seeking behaviors and lack of quality healthcare are the leading root causes for stillbirths and neonatal deaths. Rehri Goth, a coastal slum in Karachi, faces even greater challenges due to extreme poverty, and inadequate infrastructure. This study aims to investigate the causes and pathways leading to stillbirths and neonatal deaths in Rehri Goth to develop effective maternal and child health interventions.

METHODS

A mixed-method cohort study was nested with the implementation of large maternal, neonatal and child health program, captured all stillbirths and neonatal death during the period of May 2014 till June 2018. The Verbal and Social Autopsy (VASA) tool (WHO 2016) was used to collect primary data from all death events to determine the causes as well as the pathways. Interviews were conducted both retrospectively and prospectively with mothers and caregivers. Two trained physicians reviewed the VASA form and the medical records (if available) and coded the cause of death blinded to each other. Descriptive analysis was used to categorize stillbirth and neonatal mortality data into high- and low-mortality clusters, followed by chi-square tests to explore associations between categories, and concluded with a qualitative analysis.

RESULTS

Out of 421 events captured, complete VASA interviews were conducted for 317 cases. The leading causes of antepartum stillbirths were pregnancy-induced hypertension (22.4%) and maternal infections (13.4%), while obstructed labor was the primary cause of intrapartum stillbirths (38.3%). Neonatal deaths were primarily caused by perinatal asphyxia (36.1%) and preterm birth complications (27.8%). The qualitative analysis on a subset of 40 death events showed that health system (62.5%) and community factors (37.5%) contributing to adverse outcomes, such as delayed referrals, poor triage systems, suboptimal quality of care, and delayed care-seeking behaviors.

CONCLUSION

The study provides an opportunity to understand the causes of stillbirths and neonatal deaths in one of the impoverished slums of Karachi. The data segregation by clusters as well as triangulation with qualitative analysis highlight the needs of evidence-based strategies for maternal and child health interventions in disadvantaged communities.

Validation of CHERG'S Verbal Autopsy-Social Autopsy (VASA) tool for ascertaining determinants and causes of under-five child mortality in Pakistan

The majority (40%) of the world's under-five mortality burden is concentrated in nations like Nigeria (16.5%), India (16%), Pakistan (8%), and the Democratic Republic of the Congo (6%), where an undetermined number of under-five deaths go unrecorded. In low-resource settings throughout the world, the Verbal Autopsy-Social Autopsy (VASA) technique may assist assess under-five mortality estimates, assigning medical and social causes of death, and identifying relevant determinants. Uncertainty regarding missing data in high-burden nations like Pakistan necessitates a valid and reliable VASA instrument. This is the first study to validate Child Health Epidemiology Reference Group-CHERG's VASA tool globally. In Pakistan, data from such a valid and reliable tool is vital for policy. This paper reports on the VASA tool in Karachi, Pakistan. Validity and reliability of the CHERG VASA tool were tested using face, content, discriminant validation, and reliability tests on one hundred randomly selected mothers who had recently experienced an under-five child death event. Data were computed on SPSS (version-21) and R software. Testing revealed high Item-content Validity Index (I-CVI) (>81.43%); high Cronbach's Alpha (0.843); the accuracy of between 75-100% of the discriminants classifying births to live and stillbirths; and I-CVI (>82.07% and 88.98% respectively) with high accuracy (92% and 97% respectively) for assigning biological and social causes of child deaths, respectively. The CHERG VASA questionnaire was found relevant to the conceptual framework and valid in Pakistan. This valid tool can assign accurate medical and non-medical causes of child mortality cases occurring in Pakistan.

Community- based maternal and newborn interventions in Africa: Systematic review

AIM AND OBJECTIVES

This review analysed the implementation and integration into healthcare systems of maternal and newborn healthcare interventions in Africa that include community health workers to reduce maternal and newborn deaths.

BACKGROUND

Most neonatal deaths (99%) occur in low- and middle-income countries, with approximately half happening at home. In resource-constrained settings, community-based maternal and newborn care is regarded as a sound programme for improving newborn survival. Health workers can play an important role in supporting families to adopt sound health practices, encourage delivery in healthcare facilities and ensure timeous referral. Maternal and newborn mortality is a major public health problem, particularly in sub-Saharan Africa, where the Millennium Development Goals 4, 5 and 6 were not achieved at the end of 2015.

METHODS

The review includes quantitative, qualitative and mixed-method studies, with a data-based convergent synthesis design being used, and the results grouped into categories and trends. The review took into account the participants, interventions, context and outcome frameworks (PICO), and followed the adapted PRISMA format for reporting systematic reviews of the qualitative and quantitative evidence guide checklist.

RESULTS

The results from the 17 included studies focused on three themes: antenatal, delivery and postnatal care interventions as a continuum. The main components of the interventions were inadequate, highlighting the need for improved planning before each stage of implementation. A conceptual framework of planning and implementation was elaborated to improve maternal and newborn health.

CONCLUSION

The systematic review highlight the importance of thoroughly planning before any programme implementation, and ensuring that measures are in place to enable continuity of services.

RELEVANT TO THE CLINICAL PRACTICE

Conceptual framework of planning and implementation of maternal and newborn healthcare interventions by maternal community health workers.

Effect of Delays in Maternal Access to Healthcare on Neonatal Mortality in Sierra Leone: A Social Autopsy Case-Control Study at a Child Health and Mortality Prevention Surveillance (CHAMPS) Site

INTRODUCTION

In low-resource settings, a social autopsy tool has been proposed to measure the effect of delays in access to healthcare on deaths, complementing verbal autopsy questionnaires routinely used to determine cause of death. This study estimates the contribution of various delays in maternal healthcare to subsequent neonatal mortality using a social autopsy case-control design.

METHODS

This study was conducted at the Child Health and Mortality Prevention Surveillance (CHAMPS) Sierra Leone site (Makeni City and surrounding rural areas). Cases were neonatal deaths in the catchment area, and controls were sex- and area-matched living neonates. Odds ratios for maternal barriers to care and neonatal death were estimated, and stratified models examined this association by neonatal age and medical complications.

RESULTS

Of 53 neonatal deaths, 26.4% of mothers experienced at least one delay during pregnancy or delivery compared to 46.9% of mothers of stillbirths and 18.6% of control mothers. The most commonly reported delay among neonatal deaths was receiving care at the facility (18.9%). Experiencing any barrier was weakly associated (OR 1.68, CI 0.77, 3.67) and a delay in receiving care at the facility was strongly associated (OR 19.15, CI 3.90, 94.19) with neonatal death.

DISCUSSION

Delays in healthcare are associated with neonatal death, particularly delays experienced at the healthcare facility. Heterogeneity exists in the prevalence of specific delays, which has implications for local public health policy. The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Integrated management of neonatal and childhood illness strategy in Zimbabwe: An evaluation

More than five million children under the age of five die each year worldwide, primarily from preventable and treatable causes. In response, the World Health Organization's Integrated Management of Childhood Illnesses (IMNCI) strategy has been adopted in more than 95 low- and middle-income countries, 41 of them from Africa. Despite IMNCI's widespread implementation, evidence on its impact on child mortality and institutional deliveries is limited. This study examined the effect of IMNCI strategy in the context of Zimbabwe, where neonatal and infant mortality rates are among the highest in the world. We used binary logistic regression to analyze cross-sectional data from the 2015 Zimbabwe Demographic and Health Survey. Zimbabwe implemented the IMNCI strategy in 2012. Our empirical strategy involved comparing neonatal and infant mortality and institutional deliveries within the same geographic area before and after IMNCI implementation in a nationally representative sample of children born between 2010 and 2015. Exposure to IMNCI was significantly associated with a reduction in neonatal mortality (adjusted odds ratio (95% CI): 0.70 (0.50, 0.98)) and infant mortality (adjusted odds ratio (95% CI): 0.69 (0.54, 0.91)). The strategy also helped increase institutional deliveries significantly (adjusted odds ratio (95% CI): 1.95 (1.67, 2.28)). Further analyses revealed that these associations were concentrated among educated women and in rural areas.The IMNCI strategy in Zimbabwe seems to be successful in delivering its intended goals. Future programmatic and policy efforts should target women with low education and those residing in urban areas. Furthermore, sustaining the positive impact and achieving the child health-related Sustainable Development Goals will require continued political will in raising domestic financial investments to ensure the sustainability of maternal and child health programs.

Analysis of causes of death among brought-in-dead cases in a third-level Hospital in Lusaka, Republic of Zambia, using the tariff method 2.0 for verbal autopsy: a cross-sectional study

BACKGROUND

Over one third of deaths in Zambian health facilities involve someone who has already died before arrival (i.e., Brough in Dead), and in most BiD cases, the CoD have not been fully analyzed. Therefore, this study was designed to evaluate the function of automated VA based on the Tariff Method 2.0 to identify the CoD among the BiD cases and the usefulness by comparing the data on the death notification form.

METHODS

The target site was one third-level hospital in the Republic of Zambia's capital city. All BiD cases who reached the target health facility from January to August 2017 were included. The deceased's closest relatives were interviewed using a structured VA questionnaire and the data were analyzed using the SmartVA to determine the CoD at the individual and population level. The CoD were compared with description on the death notification forms by using t-test and Cohen's kappa coefficient.

RESULTS

One thousand three hundred seventy-eight and 209 cases were included for persons aged 13 years and older (Adult) and those aged 1 month to 13 years old (Child), respectively. The top CoD for Adults were infectious diseases followed by non-communicable diseases and that for Child were infectious diseases, followed by accidents. The proportion of cases with a determined CoD was significantly higher when using the SmartVA (75% for Adult and 67% for Child) than the death notification form (61%). A proportion (42.7% for Adult and 46% for Child) of the CoD-determined cases matched in both sources, with a low concordance rate for Adult (kappa coefficient = 0.1385) and a good for Child(kappa coefficient = 0.635).

CONCLUSIONS

The CoD of the BiD cases were successfully analyzed using the SmartVA for the first time in Zambia. While there many erroneous descriptions on the death notification form, the SmartVA could determine the CoD among more BiD cases. Since the information on the death notification form is reflected in the national vital statistics, more accurate and complete CoD data are required. In order to strengthen the death registration system with accurate CoD, it will be useful to embed the SmartVA in Zambia's health information system.

Four delays of child mortality in Rwanda: a mixed methods analysis of verbal social autopsies

OBJECTIVES

We sought to understand healthcare-seeking patterns and delays in obtaining effective treatment for rural Rwandan children aged 1-5 years by analysing verbal and social autopsies (VSA). Factors in the home, related to transport and to quality of care in the formal health sector (FHS) were thought to contribute to delays.

DESIGN

We collected quantitative and qualitative cross-sectional data using the validated 2012 WHO VSA tool. Descriptive statistics were performed. We inductively and deductively coded narratives using the three delays model, conducted thematic content analysis and used convergent mixed methods to synthesise findings.

SETTING

The study took place in the catchment areas of two rural district hospitals in Rwanda-Kirehe and Southern Kayonza. Participants were caregivers of children aged 1-5 years who died in our study area between March 2013 and February 2014.

RESULTS

We analysed 77 VSAs. Although 74% of children (n=57) had contact with the FHS before dying, most (59%, n=45) died at home. Many caregivers (44%, n=34) considered using traditional medicine and 23 (33%) actually did. Qualitative themes reflected difficulty recognising the need for care, the importance of traditional medicine, especially for 'poisoning' and poor perceived quality of care. We identified an additional delay-phase IV-which occurred after leaving formal healthcare facilities. These delays were associated with caregiver dissatisfaction or inability to adhere to care plans.

CONCLUSION

Delays in deciding to seek care (phase I) and receiving quality care in FHS (phase III) dominated these narratives; delays in reaching a facility (phase II) were rarely discussed. An unwillingness or inability toadhere to treatment plans after leaving facilities (phase IV) were an important additional delay. Improving quality of care, especially provider capacity to communicate danger signs/treatment plans and promote adherence in the presence of alternative explanatory models informed by traditional medicine, could help prevent childhood deaths.

Enhancing the value of mortality data for health systems: adding Circumstances Of Mortality CATegories (COMCATs) to deaths investigated by verbal autopsy

Half of the world's deaths and their causes pass unrecorded by routine registration systems, particularly in low- and middle-income countries. Verbal autopsy (VA) collects information on medical signs, symptoms and circumstances from witnesses of a death that is used to assign likely medical causes. To further contextualise information on mortality, understanding underlying determinants, such as logistics, barriers to service utilisation and health systems responses, is important for health planning. Adding systematic methods for categorising circumstantial determinants of death to conventional VA tools is therefore important. In this context, the World Health Organization (WHO) leads the development of international standards for VA, and added questions on the social and health systems circumstances of death in 2012. This paper introduces a pragmatic and scalable approach for assigning relevant Circumstances Of Mortality CATegories (COMCATs) within VA tools, and examines their consistency, reproducibility and plausibility for health policy making, as well as assessing additional effort and cost to the routine VA process. This innovative COMCAT model is integrated with InterVA-5 software (which processes WHO-2016 VA data), for assigning numeric likelihoods to six circumstantial categories for each death. VA data from 4,116 deaths in the Agincourt Health and Socio-Demographic Surveillance System in South Africa from 2012 to 2016 were used to demonstrate proof of principle for COMCATs. Lack of resources to access health care, poor recognition of diseases and inadequate health systems responses ranked highest among COMCATs in the demonstration dataset. COMCATs correlated plausibly with age, sex, causes of death and local knowledge of the demonstration population. The COMCAT approach appears to be plausible, feasible and enhances the functionality of routine VA to account for critical limiting circumstances at and around the time of death. It is a promising tool for evaluating progress towards the Sustainable Development Goals and the roll-out of Universal Health Coverage.

Causes of death and predictors of childhood mortality in Rwanda: a matched case-control study using verbal social autopsy

Background

Rwanda has dramatically reduced child mortality, but the causes and sociodemographic drivers for mortality are poorly understood.

Methods

We conducted a matched case-control study of all children who died before 5 years of age in eastern Rwanda between 1st March 2013 and 28th February 2014 to identify causes and risk factors for death. We identified deaths at the facility level and via a community health worker reporting system. We used verbal social autopsy to interview caregivers of deceased children and controls matched by area and age. We used InterVA4 to determine probable causes of death and cause-specific mortality fractions, and utilized conditional logistic regression to identify clinical, family, and household risk factors for death.

Results

We identified 618 deaths including 174 (28.2%) in neonates and 444 (71.8%) in non-neonates. The most commonly identified causes of death were pneumonia, birth asphyxia, and meningitis among neonates and malaria, acute respiratory infections, and HIV/AIDS-related death among non-neonates. Among neonates, 54 (31.0%) deaths occurred at home and for non-neonates 242 (54.5%) deaths occurred at home. Factors associated with neonatal death included home birth (aOR: 2.0; 95% CI: 1.4–2.8), multiple gestation (aOR: 2.1; 95% CI: 1.3–3.5), both parents deceased (aOR: 4.7; 95% CI: 1.5–15.3), mothers non-use of family planning (aOR: 0.8; 95% CI: 0.6–1.0), lack of accompanying person (aOR: 1.6; 95% CI: 1.1–2.1), and a caregiver who assessed the medical services they received as moderate to poor (aOR: 1.5; 95% CI: 1.2–1.9). Factors associated with non-neonatal deaths included multiple gestation (aOR: 2.8; 95% CI: 1.7–4.8), lack of adequate vaccinations (aOR: 1.7; 95% CI: 1.2–2.3), household size (aOR: 1.2; 95% CI: 1.0–1.4), maternal education levels (aOR: 1.9; 95% CI: 1.2–3.1), mothers non-use of family planning (aOR: 1.6; 95% CI: 1.4–1.8), and lack of household electricity (aOR: 1.4; 95% CI: 1.0–1.8).

Conclusion

In the context of rapidly declining childhood mortality in Rwanda and increased access to health care, we found a large proportion of remaining deaths occur at home, with home deliveries still representing a significant risk factor for neonatal death. The major causes of death at a population level remain largely avoidable communicable diseases. Household characteristics associated with death included well-established socioeconomic and care-seeking risk factors.

Verbal autopsy in health policy and systems: a literature review

Introduction

Estimates suggest that one in two deaths go unrecorded globally every year in terms of medical causes, with the majority occurring in low and middle-income countries (LMICs). This can be related to low investment in civil registration and vital statistics (CRVS) systems. Verbal autopsy (VA) is a method that enables identification of cause of death where no other routine systems are in place and where many people die at home. Considering the utility of VA as a pragmatic, interim solution to the lack of functional CRVS, this review aimed to examine the use of VA to inform health policy and systems improvements.

Methods

A literature review was conducted including papers published between 2010 and 2017 according to a systematic search strategy. Inclusion of papers and data extraction were assessed by three reviewers. Thereafter, thematic analysis and narrative synthesis were conducted in which evidence was critically examined and key themes were identified.

Results

Twenty-six papers applying VA to inform health policy and systems developments were selected, including studies in 15 LMICs in Africa, Asia, the Middle East and South America. The majority of studies applied VA in surveillance sites or programmes actively engaging with decision makers and governments in different ways and to different degrees. In the papers reviewed, the value of continuous collection of cause of death data, supplemented by social and community-based investigations and underpinned by electronic data innovations, to establish a robust and reliable evidence base for health policies and programmes was clearly recognised.

Conclusion

VA has considerable potential to inform policy, planning and measurement of progress towards goals and targets. Working collaboratively at sub-national, national and international levels facilitates data collection, aggregation and dissemination linked to routine information systems. When used in partnerships between researchers and authorities, VA can help to close critical information gaps and guide policy development, implementation, evaluation and investment in health systems.

Sociocultural and health system factors associated with mortality among febrile inpatients in Tanzania: a prospective social biopsy cohort study

INTRODUCTION

Communicable diseases are the leading causes of death in Tanzania despite the existence of effective treatment tools. We aimed to assess the sociocultural and health system factors associated with mortality from febrile illness in northern Tanzania.

METHODS

We interviewed febrile inpatients to determine prevalence of barriers in seeking or receiving care and grouped these barriers using the Three Delays model (delays at home, in transport and at healthcare facilities). We assessed 6-week mortality and, after matching on age, gender and severity of illness, measured the association between delays and mortality using conditional logistic regression.

RESULTS

We enrolled 475 children, of whom 18 (3.8%) died, and 260 adults, of whom 34 (13.0%) died. For children, home delays were not associated with mortality. Among adults, a delay in care-seeking due to not recognising severe symptoms was associated with mortality (OR: 3.01; 95% CI 1.24 to 7.32). For transport delays, taking >1 hour to reach a facility increased odds of death in children (OR: 3.27; 95% CI 1.11 to 9.66) and adults (OR: 3.03; 95% CI 1.32 to 6.99). For health system delays, each additional facility visited was associated with mortality for children (OR: 1.59; 95% CI 1.06 to 2.38) and adults (OR: 2.00; 95% CI 1.17 to 3.41), as was spending >4 days between the first facility visit and reaching tertiary care (OR: 4.39; 95% CI 1.49 to 12.93).

CONCLUSION

Our findings suggest that delays at home, in transport and in accessing tertiary care are risk factors for mortality from febrile illness in northern Tanzania. Interventions that may reduce mortality include community education regarding severe symptoms, expanding transportation infrastructure and streamlining referrals to tertiary care for the sickest patients.

Exploring Drivers of Infant Deaths in Rural Rwanda Through Verbal Social Autopsy

BACKGROUND

Rwanda has been a leader in the global effort to reduce infant mortality, particularly in regions of sub-Saharan Africa. Although rates have dropped, deaths still occur.

OBJECTIVE

To explore the care pathways and barriers taken by infant caregivers before the death of their infant through a verbal social autopsy study in 2 districts in eastern Rwanda.

METHODS

We adapted the World Health Organization verbal socialautopsy tools to reflect local context and priorities. Caregivers of infants in the 2 districts were interviewed using the adapted quantitative survey and semistructured interview guide. Interviews were recorded and thematic analysis employed on a subsample (n = 133) to extract the content relevant to understanding the drivers of infant death and inform results of the quantitative data until saturation was reached (66). Results were interpreted through a driver diagram framework to explore caregiver-reported challenges in knowledge and experiences with care access and delivery.

FINDINGS

Most study participants (82%) reported accessing the formal health system at some point before the infant's death. The primary caregiver-reported drivers for infant death included challenges in accessing care in a timely manner, concerns about the technical quality of care received, and poor responsiveness of the system and providers. The 2 most commonly discussed drivers were gaps in communication between providers and patients and challenges obtaining and using the community-based health insurance. The framework of the driver diagram was modified to identify the factors where change was needed to further reduce mortality.

CONCLUSION

This study provides important information on the experiential quality of care received by infants and their caregivers within the current health care space in rural Rwanda. By listening to the individual stories of so many caregivers regarding the gaps and challenges they faced, appropriate action may be taken to bolster the existing health care system.

Causes of and contributors to infant mortality in a rural community of North India: evidence from verbal and social autopsy

OBJECTIVE

To identify the medical causes of death and contribution of non-biological factors towards infant mortality by a retrospective analysis of routinely collected data using verbal and social autopsy tools.

SETTING

The study site was Health and Demographic Surveillance System (HDSS), Ballabgarh, North India PARTICIPANTS: All infant deaths during the years 2008-2012 were included for verbal autopsy and infant deaths from July 2012 to December 2012 were included for social autopsy.

OUTCOME MEASURES

Cause of death ascertained by a validated verbal autopsy tool and level of delay based on a three-delay model using the INDEPTH social autopsy tool were the main outcome measures. The level of delay was defined as follows: level 1, delay in identification of danger signs and decision making to seek care; level 2, delay in reaching a health facility from home; level 3, delay in getting healthcare at the health facility.

RESULTS

The infant mortality rate during the study period was 46.5/1000 live births. Neonatal deaths contributed to 54.3% of infant deaths and 39% occurred on the first day of life. Birth asphyxia (31.5%) followed by low birth weight (LBW)/prematurity (26.5%) were the most common causes of neonatal death, while infection (57.8%) was the most common cause of post-neonatal death. Care-seeking was delayed among 50% of neonatal deaths and 41.2% of post-neonatal deaths. Delay at level 1 was most common and occurred in 32.4% of neonatal deaths and 29.4% of post-neonatal deaths. Deaths due to LBW/prematurity were mostly followed by delay at level 1.

CONCLUSION

A high proportion of preventable infant mortality still exists in an area which is under continuous health and demographic surveillance. There is a need to enhance home-based preventive care to enable the mother to identify and respond to danger signs. Verbal autopsy and social autopsy could be routinely done to guide policy interventions aimed at reduction of infant mortality.

Social determinants of child mortality in Niger: Results from the 2012 National Verbal and Social Autopsy Study

Background

Understanding the determinants of preventable deaths of children under the age of five is important for accelerated annual declines – even as countries achieve the UN’s Millennium Development Goals and the target date of 2015 has been reached. While research has documented the extent and nature of the overall rapid decline in child mortality in Niger, there is less clear evidence to provide insight into the contributors to such deaths. This issue is the central focus of this paper.

Methods

We analyzed a nationally representative cross–sectional sample of 620 child deaths from the 2012 Niger Verbal Autopsy/Social Autopsy (VASA) Survey. We conducted a descriptive analysis of the data on preventive and curative care, guided by the coverage of proven indicators along the continuum of well child care and illness recognition and care–seeking for child illnesses encompassed by the BASICS/CDC Pathway to Survival model.

Results

Six hundred twenty deaths of children (1–59 months of age) were confirmed from the VASA survey. The majority of these children lived in households with precarious socio–economic conditions. Among the 414 children whose fatal illnesses began at age 0–23 months, just 24.4% were appropriately fed. About 24% of children aged 12–59 months were fully immunized. Of 601 children tracked through the Pathway to Survival, 62.4% could reach the first health care provider after about 67 minutes travel time. Of the 306 children who left the first health care provider alive, 161 (52.6%) were not referred for further care nor received any home care recommendations, and just 19% were referred to a second provider. About 113 of the caregivers reported cost (35%), distance (35%) and lack of transport (30%) as constraints to care–seeking at a health facility.

Conclusion

Despite Niger’s recent major achievements in reducing child mortality, the following determinants are crucial to continue building on the gains the country has made: improved socio–economic state of the poor in the country, investment in women’s education, adoption of the a law to prevent marriage of young girls before 18 years of age, and implementation of health programs that encourage breastfeeding and complementary feeding, immunization, illness recognition, prompt and appropriate care–seeking, and improved referral rates.

Moving from medical to health systems classifications of deaths: extending verbal autopsy to collect information on the circumstances of mortality

BACKGROUND

Verbal autopsy (VA) is a health surveillance technique used in low and middle-income countries to establish medical causes of death (CODs) for people who die outside hospitals and/or without registration. By virtue of the deaths it investigates, VA is also an opportunity to examine social exclusion from access to health systems. The aims were to develop a system to collect and interpret information on social and health systems determinants of deaths investigated in VA.

METHODS

A short set of questions on care pathways, circumstances and events at and around the time of death were developed and integrated into the WHO 2012 short form VA (SF-VA). Data were subsequently analysed from two census rounds in the Agincourt Health and Socio-Demographic Surveillance Site (HDSS), South Africa in 2012 and 2013 where the SF-VA had been applied. InterVA and descriptive analysis were used to calculate cause-specific mortality fractions (CSMFs), and to examine responses to the new indicators and whether and how they varied by medical CODs and age/sex sub-groups.

RESULTS

One thousand two hundred forty-nine deaths were recorded in the Agincourt HDSS censuses in 2012-13 of which 1,196 (96 %) had complete VA data. Infectious and non-communicable conditions accounted for the majority of deaths (47 % and 39 % respectively) with smaller proportions attributed to external, neonatal and maternal causes (5 %, 2 % and 1 % respectively). 5 % of deaths were of indeterminable cause. The new indicators revealed multiple problems with access to care at the time of death: 39 % of deaths did not call for help, 36 % found care unaffordable overall, and 33 % did not go to a facility. These problems were reported consistently across age and sex sub-groups. Acute conditions and younger age groups had fewer problems with overall costs but more with not calling for help or going to a facility. An illustrative health systems interpretation suggests extending and promoting existing provisions for transport and financial access in this setting.

CONCLUSIONS

Supplementing VA with questions on the circumstances of mortality provides complementary information to CSMFs relevant for health planning. Further contextualisation of the method and results are underway with health systems stakeholders to develop the interpretation sequence as part of a health policy and systems research approach.