The paradox of verbal autopsy in cause of death assignment: symptom question unreliability but predictive accuracy

Cardiovascular disease mortality based on verbal autopsy in low- and middle-income countries: a systematic review

Objective

To conduct a systematic review of verbal autopsy studies in low- and middle-income countries to estimate the fraction of deaths due to cardiovascular disease.

Method

We searched MEDLINE®, Embase® and Scopus databases for verbal autopsy studies in low- and middle-income countries that reported deaths from cardiovascular disease. Two reviewers screened the studies, extracted data and assessed study quality. We calculated cause-specific mortality fractions for cardiovascular disease for each study, both overall and according to age, sex, geographical location and type of cardiovascular disease.

Findings

We identified 42 studies for inclusion in the review. Overall, the cardiovascular disease cause-specific mortality fractions for people aged 15 years and above was 22.9%. This fraction was generally higher for males (24.7%) than females (20.9%), but the pattern varied across World Health Organization regions. The highest cardiovascular disease mortality fraction was reported in the Western Pacific Region (26.3%), followed by the South-East Asia Region (24.1%) and the African Region (12.7%). The cardiovascular disease mortality fraction was higher in urban than rural populations in all regions, except the South-East Asia Region. The mortality fraction for ischaemic heart disease (12.3%) was higher than that for stroke (8.7%). Overall, 69.4% of cardiovascular disease deaths were reported in people aged 65 years and above.

Conclusion

The burden of cardiovascular disease deaths outside health-care settings in low- and middle-income countries is substantial. Increasing coverage of verbal autopsies in these countries could help fill gaps in cardiovascular disease mortality data and improve monitoring of national, regional and global health goals.

Why parents agree or disagree for minimally invasive tissue sampling (MITS) to identify causes of death in under-five children and stillbirth in North India: a qualitative study

Background

Information on exact causes of death and stillbirth are limited in low and middle income countries. Minimally invasive tissue sampling (MITS) is increasingly practiced in place of autopsy across several settings. A formative research documented the experiences of counselling and consenting for MITS in north India.

Methods

This exploratory qualitative study was conducted at a tertiary care hospital in Delhi. During the early implementation of MITS, observations of the counselling and consenting process (n = 13) for under-five child death and stillbirths were conducted. In-depth interviews with MITS team members (n = 3) were also conducted. Observation and interview data were transcribed and inductively analysed using thematic content analysis to identify emerging themes and codes.

Results

The MITS team participated in daily ward rounds for familiarisation with parents/families. Following death declaration the counselling was done in counselling corner of the ward or adjacent corridor. Mostly the counselling was targeted at the father and family members present, using verbal explanation and the consent document in local language. The key concerns raised by parents/family were possible disfigurement, time needed and possible benefits. Most of the parents consulted family members before consent. Among those who consented, desire for next pregnancy, previous pregnancy or neonatal loss and participation of treating senior doctor were the key factors. The negative experience of hospital care, poor comprehension and distance from residence were the factors for consent refusal. Lesser number of parents of deceased children consented for MITS compared to the neonates and stillbirths.

Conclusions

The initial experiences of obtaining consent for MITS were encouraging. Consent for MITS may be improved with active involvement of the treating doctors and nurses, better bereavement support, private counselling area along with improvement in quality of care and communication during hospitalisation. Special efforts and refinement in counselling are needed to improve consent for MITS in older children.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02993-6.

Information about exact cause of death and stillbirth are essential for appropriate care of children and pregnant women. Autopsy assists in establishing exact cause of death, but not preferred by the parents/families. Minimally invasive tissue sampling (MITS) is a suitable alternate to autopsy for establishing causes of death and stillbirth. A pilot project on MITS was initiated at a tertiary care hospital in north India (New Delhi). An exploratory formative research was conducted to document the experiences of counselling and consenting for MITS. Under this study, observation of the counselling and consenting process for conduct of MITS in under-five children (including neonates) and stillbirths were done. Additionally, in-depth interviews with MITS team members were also conducted. Counselling for MITS was done in one corner of the ward or adjacent corridor and mostly targeted at the father and family members present. Counselling was primarily verbal explanation in local language. The key concerns from parents/family were disfigurement, time needed and possible benefits. Most of the parents consulted family members before decision. Benefit during next pregnancy, past previous pregnancy or neonatal loss and senior treating doctor’s involvement were key factors for consent. Poor quality of care and comprehension were the reasons for refusal.

Perceptions of family, community and religious leaders and acceptability for minimal invasive tissue sampling to identify the cause of death in under-five deaths and stillbirths in North India: a qualitative study

Background

Minimal invasive tissue sampling (MITS) has emerged as a suitable alternative to complete diagnostic autopsy (CDA) for determination of the cause of death (CoD), due to feasibility and acceptability issues. A formative research was conducted to document the perceptions of parents, community and religious leaders on acceptability of MITS.

Methods

This qualitative study was conducted at and around the Safdarjung Hospital, Delhi, India. Participants for in-depth interview included the parents who had either child or neonatal death or stillbirth and the key community and religious representatives. The focus group discussions (FGDs) involved community members. Process of obtaining consent for MITS was observed. Data were analyzed inductively manually for emerging themes and codes.

Results

A total of 104 interviews (parents of deceased children, neonates or stillbirths, n = 93; community members, n = 8 and religious leaders, n = 7), 8 FGDs (n = 72) were conducted and process of obtaining consent for MITS (n = 27) was observed. The participants were positive and expressed willingness to accept MITS. The key determinants for acceptance of MITS were: (1) understanding and willingness to know the cause of death or stillbirth, (2) experience of the healthcare received and trust, (3) the religious and sociocultural norms. Parents and community favored for MITS over CDA when needed, especially where in cases with past stillbirths and child deaths. The experience of treatment, attitude and communication from healthcare providers emerged as important for consent. The decision making process was collective involving the elders and family. No religious leader was against the procedure, as both, the respect for the deceased and need for medical care were satisfied.

Conclusions

Largely, MITS appeared to be acceptable for identifying the causes of child deaths and stillbirths, if the parents and family are counseled appropriately considering the sociocultural and religious aspects. They perceived the quality of care, attitude and communication by the healthcare providers as critical factors for acceptance of MITS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01218-4.

India tops the chart of childhood deaths and stillbirths globally. The causes of many childhood deaths and stillbirths remain unknown or ill-defined in India. For planning the health policies, program and clinical practices, the cause of death (CoD) and stillbirth are primarily determined by verbal autopsy (VA) method, which has several inherent limitations. The acceptance and implementation of complete diagnostic autopsy (CDA) or full autopsy for CoD determination is limited. Minimally invasive tissue sampling (MITS) is a suitable alternative to full autopsy for CoD determination. MITS has been found to be acceptable and being implemented in some low and middle income countries. Considering the multi-religion and sociocultural contexts of India, an understanding about the perceptions, practices, acceptance and barriers among the parents, community members and religious leaders regarding MITS was necessary for designing appropriate communication strategies and materials for consent. A qualitative study was undertaken in New Delhi, India using in-depth interviews with the parents of deceased children and stillbirths, community leaders, community health workers and religious leaders and focus group discussions with the community members and observation of obtaining consent for MITS. The parents and community members were positive about MITS and expressed willingness to accept it over full autopsy to know the CoD and stillbirths. The factors like past stillbirths and child deaths, experience of the healthcare received and trust, the religious and sociocultural norms emerged as important determinants for acceptance of MITS. The religious leaders were also positive about MITS if needed for treatment and benefit of the family.

Perceptions of the healthcare providers regarding acceptability and conduct of minimal invasive tissue sampling (MITS) to identify the cause of death in under-five deaths and stillbirths in North India: a qualitative study

Background

India contributes the highest share of under-five and neonatal deaths and stillbirths globally. Diagnostic autopsy, although useful for cause of death identification, have limited acceptance. Minimally invasive tissue sampling (MITS) is an alternative to autopsy for identification of the cause of death (CoD). A formative research linked to pilot MITS implementation was conducted to document the perceptions and attitudes of the healthcare professionals and the barriers for implementation.

Methods

This exploratory qualitative study conducted at a tertiary care hospital in New Delhi, India included the hospital staffs. In-depth interviews were conducted with the doctors, nurses and support staffs from pediatrics, neonatology, obstetrics and forensic medicine departments. Inductive data analysis was done to identify the emerging themes and codes.

Results

A total of 26 interviews (doctors, n = 10; nurses, n = 9 and support staffs, n = 7) were conducted. Almost all professional and support staffs were positive about the MITS and its advantage for CoD identification including co-existing and underlying illnesses. Some opined conduct of MITS for the cases without clear diagnosis. All participants perceived that MITS would be acceptable for parents due to the non-disfigurement and preferred by those who had unexplained child deaths or stillbirths in past. The key factors for MITS acceptance were appropriate communication, trust building, involvement of senior doctors, and engagement of the counselor prior to deaths and training of the personnel. For implementation and sustenance of MITS, involvement of the institute authority and government stakeholders would be essential.

Conclusions

MITS was acceptable for the doctors, nurses and support staffs and critical for better identification of the causes of death and stillbirths. The key facilitating factors and challenges for implementing MITS at the hospital in Indian context were identified. It emphasized on appropriate skill building, counseling, system organization and buy-in from institution and health authorities for sustenance of MITS.

Congenital heart disease in low-and-middle-income countries: Focus on sub-Saharan Africa

The etiology of congenital heart disease (CHD) is multifactorial. The birth prevalence of CHD is shaped by a wide variety of maternal, fetal, and neonatal risk factors, along with the rates of prenatal diagnosis and terminations of pregnancy, all of which have geographic variability Epidemiology data availability from low-and-middle-income countries (LMIC) on CHD prevalence, morbidity, and mortality are far more limited than from high income countries. Data on specific genetic, environmental, and prenatal risk associated with CHD are almost nonexistent. In this article, we will focus on defining what data are available, genetic risk factors, birth and overall prevalence, morbidity, and the impact of limited access to interventions, both surgery and cardiac catheterizations. We will highlight CHD in sub-Saharan Africa to detail epidemiology studies in the poorest regions of the world. Existing literature as well as estimates from the Global Burden of Disease Study (http://ghdx.healthdata.org) form the basis for this review. The intersection of poverty, high fertility rates, and limited access to care results in a unique profile of CHD in LMIC. CHD is not a preventable disease (by most standards), so early detection and access are our key interventions to improve the dire outcomes for children in low-resources settings of the world.

Robustness of the Tariff method for diagnosing verbal autopsies: impact of additional site data on the relationship between symptom and cause

Background

Verbal autopsy (VA) is increasingly being considered as a cost-effective method to improve cause of death information in countries with low quality vital registration. VA algorithms that use empirical data have an advantage over expert derived algorithms in that they use responses to the VA instrument as a reference instead of physician opinion. It is unclear how stable these data driven algorithms, such as the Tariff 2.0 method, are to cultural and epidemiological variations in populations where they might be employed.

Methods

VAs were conducted in three sites as part of the Improving Methods to Measure Comparable Mortality by Cause (IMMCMC) study: Bohol, Philippines; Chandpur and Comila Districts, Bangladesh; and Central and Eastern Highlands Provinces, Papua New Guinea. Similar diagnostic criteria and cause lists as the Population Health Metrics Research Consortium (PHMRC) study were used to identify gold standard (GS) deaths. We assessed changes in Tariffs by examining the proportion of Tariffs that changed significantly after the addition of the IMMCMC dataset to the PHMRC dataset.

Results

The IMMCMC study added 3512 deaths to the GS VA database (2491 adults, 320 children, and 701 neonates). Chance-corrected cause specific mortality fractions for Tariff improved with the addition of the IMMCMC dataset for adults (+ 5.0%), children (+ 5.8%), and neonates (+ 1.5%). 97.2% of Tariffs did not change significantly after the addition of the IMMCMC dataset.

Conclusions

Tariffs generally remained consistent after adding the IMMCMC dataset. Population level performance of the Tariff method for diagnosing VAs improved marginally for all age groups in the combined dataset. These findings suggest that cause-symptom relationships of Tariff 2.0 might well be robust across different population settings in developing countries. Increasing the total number of GS deaths improves the validity of Tariff and provides a foundation for the validation of other empirical algorithms.

Exploring family, community and healthcare provider perceptions and acceptability for minimal invasive tissue sampling to identify the cause of death in under-five deaths and stillbirths in North India: a qualitative study protocol

BACKGROUND

Around 5.4 million under-five deaths occur globally annually. Over 2.5 million neonatal deaths and an equivalent stillbirths also occur annually worldwide. India is largest contributor to these under-five deaths and stillbirths. To meet the National Health Policy goals aligned with sustainable development targets, adoption of specific strategy and interventions based on exact causes of death and stillbirths are essential. The current cause of death (CoD) labelling process is verbal autopsy based and subject to related limitations. In view of rare diagnostic autopsies, the minimally invasive tissue sampling (MITS) has emerged as a suitable alternate with comparable efficiency to determine CoD. But there is no experience on perception and acceptance for MITS in north Indian context. This formative research is exploring the perceptions and view of families, communities and healthcare providers regarding MITS to determine the acceptability and feasibility.

METHODS

The cross-sectional study adopts exploratory qualitative research design. The study will be conducted in New Delhi linked to deaths and stillbirths occurring at a tertiary care hospital. The data from multiple stakeholders will be collected through 53-60 key-informant in-depth interviews (IDIs), 8 focus group discussions (FGDs) and 8-10 death or stillbirth event observations. The IDIs will be done with the parents, family members, community representatives, religious priests, burial site representatives and different health care providers. The FGDs will be conducted with the fathers, mothers, and elderly family members in the community. The data collection will focus on death, post-death rituals, religious practices, willingness to know CoD, acceptability of MITS and decision making dynamics. Data will be analysed following free listing, open coding, selective coding and theme identification. Subsequently 8-10 parents will be approached for consent to conduct MITS using the communication package to be developed using the findings.

DISCUSSION

The study will provide in-depth understanding of the cultural, social, religious practices related to child death and stillbirth and factors that potentially determine acceptance of MITS. The findings will guide development of communication and counselling package and strategies for obtaining consent for MITS. The pilot experience on obtaining consent for MITS will inform suitable refinement and future practice.

Validation of verbal autopsy: determination of cause of deaths in Malaysia 2013

Background

Mortality statistics by age, sex and cause are the foundation of basic health data required for health status assessment, epidemiological research and formation of health policy. Close to half the deaths in Malaysia occur outside a health facility, are not attended by medical personnel, and are given a lay opinion as to the cause of death, leading to poor quality of data from vital registration. Verbal autopsy (VA) is a very useful tool in diagnosing broad causes of deaths for events that occur outside health facilities. This article reports the development of the VA methods and our principal finding from a validation study.

Methods

A cross sectional study on nationally representative sample deaths that occurred in Malaysia during 2013 was used. A VA questionnaire suitable for local use was developed. Trained field interviewers visited the family members of the deceased at their homes and conducted face to face interviews with the next of kin. Completed questionnaires were reviewed by trained physicians who assigned multiple and underlying causes. Reference diagnoses for validation were obtained from review of medical records (MR) available for a sample of the overall study deaths.

Results

Corresponding MR diagnosis with matched sample of the VA diagnosis were available in 2172 cases for the validation study. Sensitivity scores were good (>75%) for transport accidents and certain cancers. Moderate sensitivity (50% - 75%) was obtained for ischaemic heart disease (64%) and cerebrovascular disease (72%). The validation sample for deaths due to major causes such as ischaemic heart disease, pneumonia, breast cancer and transport accidents show low cause-specific mortality fraction (CSMF) changes. The scores obtained for the top 10 leading site-specific cancers ranged from average to good.

Conclusion

We can conclude that VA is suitable for implementation for deaths outside the health facilities in Malaysia. This would reduce ill-defined mortality causes in vital registration data, and yield more accurate national mortality statistics.