What is the optimal recall period for verbal autopsies? Validation study based on repeat interviews in three populations

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.

Exploring challenges and recommendations for verbal autopsy implementation in low-/middle-income countries: a cross-sectional study of Iringa Region-Tanzania

BACKGROUND

Verbal autopsy (VA) plays a vital role in providing cause-of-death information in places where such information is not available. Many low-/middle-income countries (LMICs) including Tanzania are still struggling to yield quality and adequate cause-of-death data for Civil Registration and Vital Statistics (CRVS).

OBJECTIVE

To highlight challenges and recommendations for VA implementation to support LMICs yield quality and adequate mortality statistics for informed decisions on healthcare interventions.

DESIGN

Cross-sectional study.

STUDY SETTING

Iringa region in Tanzania.

PARTICIPANTS

41 people including 33 community health workers, 1 VA national coordinator, 5 national task force members, 1 VA regional coordinator and 1 member of the VA data management team.

RESULTS

The perceived challenges of key informants include a weak death notification system, lengthy VA questionnaire, poor data quality and inconsistent responses, lack of clarity in the inclusion criteria, poor commitment to roles and responsibilities, poor coordination, poor financial mechanism and no or delayed feedback to VA implementers. Based on these findings, we recommend the following strategies for effective adaptation and use of VAs: (1) reinforce or implement legislative procedures towards the legal requirement for death notification. (2) Engage key stakeholders in the overall implementation of VAs. (3) Build capacity for data collection, monitoring, processing and use of VA data. (4) Improve the VA questionnaire and quality control mechanism for optimal use in data collection. (5) Create sustainable financing mechanisms and institutionalisation of VA implementation. (6) Integrating VA Implementation in CRVS.

CONCLUSION

Effective VA implementation demands through planning, stakeholder engagement, upskilling of local experts and fair compensation for interviewers. Such coordinated endeavours will overcome systemic, technical and behavioural challenges hindering VA's successful implementation.

Ethical and cultural implications for conducting verbal autopsies in South and Southeast Asia: a qualitative study

INTRODUCTION

Causes of deaths often go unrecorded in lower income countries, yet this information is critical. Verbal autopsy is a questionnaire interview with a family member or caregiver to elicit the symptoms and circumstances preceding a death and assign a probable cause. The social and cultural aspects of verbal autopsy have gotten less attention than the technical aspects and have not been widely explored in South and Southeast Asia settings.

METHODS

Between October 2021 and March 2023, prior to implementing a verbal autopsy study at rural sites in Bangladesh, Cambodia, Laos, Myanmar and Thailand, focus group discussions were conducted with village heads, religious leaders and community members from varied demographic backgrounds. Thematic analysis elucidated customs and traditional views surrounding death to understand local ethnocultural sensitivities.

RESULTS

We found that death rituals varied greatly among religions, ethnicities and by socioeconomic status. Mourning periods were reported to last 3-100 days and related to the cause of death, age and how close the deceased person was to the family. Participants advised that interviews should happen after mourning periods to avoid emotional distress, but not long after so as to avoid recall bias. Interviewers should be introduced to respondents by a trusted local person. To provide reassurance and confidentiality, a family's residence is the preferred interview location. Interview questions require careful local language translation, and community sensitisation is important before data collection.

CONCLUSION

Verbal autopsy is acceptable across a wide range of cultural settings in Southeast Asia, provided that local norms are preidentified and followed.

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.

Validating the InterVA-5 cause of death analytical tool: using mortality data from the Comprehensive Health and Epidemiological Surveillance System in Papua New Guinea

OBJECTIVE

InterVA-5 is a new version of an analytical tool for cause of death (COD) analysis at the population level. This study validates the InterVA-5 against the medical review method, using mortality data in Papua New Guinea (PNG).

DESIGN AND SETTING

This study used mortality data collected from January 2018 to December 2020 in eight surveillance sites of the Comprehensive Health and Epidemiological Surveillance System (CHESS), established by the PNG Institute of Medical Research in six major provinces.

METHODS

The CHESS demographic team conducted verbal autopsy (VA) interviews with close relatives of the deceased, who died in communities within the catchment areas of CHESS, using the WHO 2016 VA instrument. COD of the deceased was assigned by InterVA-5 tool, and independently certified by the medical team. Consistency, difference and agreement between the InterVA-5 model and medical review were assessed. Sensitivity and positive predictive value (PPV) of the InterVA-5 tool were calculated with reference to the medical review method.

RESULTS

Specific COD of 926 deceased people was included in the validation. Agreement between the InterVA-5 tool and medical review was high (kappa test: 0.72; p<0.01). Sensitivity and PPV of the InterVA-5 were 93% and 72% for cardiovascular diseases, 84% and 86% for neoplasms, 65% and 100% for other chronic non-communicable diseases (NCDs), and 78% and 64% for maternal deaths, respectively. For infectious diseases and external CODs, sensitivity and PPV of the InterVA-5 were 94% and 90%, respectively, while the sensitivity and PPV of the medical review method were both 54% for classifying neonatal CODs.

CONCLUSION

The InterVA-5 tool works well in the PNG context to assign specific CODs of infectious diseases, cardiovascular diseases, neoplasms and injuries. Further improvements with respect to chronic NCDs, maternal deaths and neonatal deaths are needed.

Are non-invasive or minimally invasive autopsy techniques for detecting cause of death in prenates, neonates and infants accurate? A systematic review of diagnostic test accuracy

OBJECTIVES

To assess the diagnostic accuracy of non-invasive or minimally invasive autopsy techniques in deaths under 1 year of age.

DESIGN

This is a systematic review of diagnostic test accuracy. The protocol is registered on PROSPERO.

PARTICIPANTS

Deaths from conception to one adjusted year of age.

SEARCH METHODS

MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO), the Cochrane Library, Scopus and grey literature sources were searched from inception to November 2021.

DIAGNOSTIC TESTS

Non-invasive or minimally invasive diagnostic tests as an alternative to traditional autopsy.

DATA COLLECTION AND ANALYSIS

Studies were included if participants were under one adjusted year of age, with index tests conducted prior to the reference standard.Data were extracted from eligible studies using piloted forms. Risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies-2. A narrative synthesis was conducted following the Synthesis without Meta-Analysis guidelines. Vote counting was used to assess the direction of effect.

MAIN OUTCOME MEASURES

Direction of effect was expressed as percentage of patients per study.

FINDINGS

We included 54 direct evidence studies (68 articles/trials), encompassing 3268 cases and eight index tests. The direction of effect was positive for postmortem ultrasound and antenatal echography, although with varying levels of success. Conversely, the direction of effect was against virtual autopsy. For the remaining tests, the direction of effect was inconclusive.A further 134 indirect evidence studies (135 articles/trials) were included, encompassing 6242 perinatal cases. The addition of these results had minimal impact on the direct findings yet did reveal other techniques, which may be favourable alternatives to autopsy.Seven trial registrations were included but yielded no results.

CONCLUSIONS

Current evidence is insufficient to make firm conclusions about the generalised use of non-invasive or minimally invasive autopsy techniques in relation to all perinatal population groups.PROSPERO registration numberCRD42021223254.

Leading causes of deaths in the mortality transition in Papua New Guinea: evidence from the Comprehensive Health and Epidemiological Surveillance System

Background

Changing causes of deaths in the mortality transition in Papua New Guinea (PNG) are poorly understood. This study analysed community-level data to identify leading causes of death in the population and variations across age groups and sexes, urban-rural sectors and provinces.

Method

Mortality surveillance data were collected from 2018–20 as part of the Comprehensive Health and Epidemiological Surveillance System (CHESS), using the World Health Organization 2016 verbal autopsy (VA) instrument. Data from 926 VA interviews were analysed, using the InterVA-5 cause of death analytical tool to assign specific causes of death among children (0–14 years), those of working age (15–64 years) and the elderly (65+ years).

Result

Nearly 50% of the total deaths were attributed to non-communicable diseases (NCDs), followed by infectious and parasitic diseases (35%), injuries and external causes (11%) and maternal and neonatal deaths (4%). Leading causes of death among children were acute respiratory tract infections (ARTIs) and diarrhoeal diseases, each contributing to 13% of total deaths. Among the working population, tuberculosis (TB) contributed to 12% of total deaths, followed by HIV/AIDS (11%). TB- and HIV/AIDS-attributed deaths were highest in the age group 25–34 years, at 20% and 18%, respectively. These diseases killed more females of working age (n = 79, 15%) than males (n = 52, 8%). Among the elderly, the leading causes of death were ARTIs (13%) followed by digestive neoplasms (10%) and acute cardiac diseases (9%).

Conclusion

The variations in leading causes of death across the populations in PNG suggest diversity in mortality transition. This requires different strategies to address specific causes of death in particular populations.

Conducting verbal autopsy by telephone interview during the pandemic to support mortality surveillance: a feasibility study in Malaysia

OBJECTIVE

Verbal autopsy (VA) through face-to-face interviews with caregivers is a way to determine cause of death without medical certification. In Malaysia, the use of VA has improved mortality statistics. However, during the coronavirus disease 2019 (COVID-19) pandemic, face-to-face interviews were delayed, reducing VA data collection and affecting data for mortality surveillance. This study aims to investigate the feasibility and acceptability of conducting VA interviews via telephone calls, and the quality of the data gathered.

METHODS

The study was conducted in Malaysia from September to October 2020 using a cross-sectional design. Participants were health-care workers from established VA teams across the country. They conducted VA interviews via telephone and provided feedback through a customized online form. Data collected from the form were used to assess the feasibility, acceptability and quality of the telephone interviews using IBM SPSS version 23.

RESULTS

Responses were received from 113 participants. There were 74 (65.5%) successful interviews, representing 91% of the 81 cases who were able to be contacted. More than two thirds of health-care workers provided positive feedback on the telephone interview method for themselves and the interviewees. Only 10.8% of causes of death were unusable.

DISCUSSION

This study provides preliminary evidence that VA via telephone interview is feasible, acceptable and can be used as an alternative to face-to-face interviews without affecting data quality. During times when face-to-face interviews are not advisable, VA telephone interviews can be used for data collection for mortality surveillance.

Tuberculosis and HIV/AIDS-attributed mortalities and associated sociodemographic factors in Papua New Guinea: evidence from the comprehensive health and epidemiological surveillance system

OBJECTIVE

Tuberculosis (TB) and HIV/AIDS are public health concerns in Papua New Guinea (PNG). This study examines TB and HIV/AIDS mortalities and associated sociodemographic factors in PNG.

METHOD

As part of a longitudinal study, verbal autopsy (VA) interviews were conducted using the WHO 2016 VA Instrument to collect data of 926 deaths occurred in the communities within the catchment areas of the Comprehensive Health and Epidemiological Surveillance System from 2018 to 2020.InterVA-5 cause of deaths analytical tool was used to assign specific causes of death (COD). Multinomial logistic regression analyses were conducted to identify associated sociodemographic factors, estimate adjusted ORs (AOR), 95% CIs and p values.

RESULT

TB and HIV/AIDS were the leading CODs from infectious diseases, attributed to 9% and 8% of the total deaths, respectively.Young adults (25-34 years) had the highest proportion of deaths from TB (20%) and the risk of dying from TB among this age group was five times more likely than those aged 75+ years (AOR: 5.5 (95% CI 1.4 to 21.7)). Urban populations were 46% less likely to die from this disease compared rural ones although the difference was not significant (AOR: 0.54 (95% CI 0.3 to 1.0)). People from middle household wealth quintile were three times more likely to die from TB than those in the richest quintile (AOR: 3.0 (95% CI 1.3 to 7.4)).Young adults also had the highest proportion of deaths to HIV/AIDS (18%) and were nearly seven times more likely to die from this disease compared with those aged 75+years (AOR: 6.7 (95% CI 1.7 to 25.4)). Males were 48% less likely to die from HIV/AIDS than females (AOR: 0.52 (95% CI 0.3 to 0.9)). The risk of dying from HIV/AIDS in urban population was 54% less likely than their rural counterparts (AOR: 0.46 (95% CI 0.2 to 0.9)).

CONCLUSION

TB and HIV/AIDS interventions are needed to target vulnerable populations to reduce premature mortality from these diseases in PNG.

Validation of physician certified verbal autopsy using conventional autopsy: a large study of adult non-external causes of death in a metropolitan area in Brazil

Background

Reliable mortality data are essential for the development of public health policies. In Brazil, although there is a well-consolidated universal system for mortality data, the quality of information on causes of death (CoD) is not even among Brazilian regions, with a high proportion of ill-defined CoD. Verbal autopsy (VA) is an alternative to improve mortality data. This study aimed to evaluate the performance of an adapted and reduced version of VA in identifying the underlying causes of non-forensic deaths, in São Paulo, Brazil. This is the first time that a version of the questionnaire has been validated considering the autopsy as the gold standard.

Methods

The performance of a physician-certified verbal autopsy (PCVA) was evaluated considering conventional autopsy (macroscopy plus microscopy) as gold standard, based on a sample of 2060 decedents that were sent to the Post-Mortem Verification Service (SVOC-USP). All CoD, from the underlying to the immediate, were listed by both parties, and ICD-10 attributed by a senior coder. For each cause, sensitivity and chance corrected concordance (CCC) were computed considering first the underlying causes attributed by the pathologist and PCVA, and then any CoD listed in the death certificate given by PCVA. Cause specific mortality fraction accuracy (CSMF-accuracy) and chance corrected CSMF-accuracy were computed to evaluate the PCVA performance at the populational level.

Results

There was substantial variability of the sensitivities and CCC across the causes. Well-known chronic diseases with accurate diagnoses that had been informed by physicians to family members, such as various cancers, had sensitivities above 40% or 50%. However, PCVA was not effective in attributing Pneumonia, Cardiomyopathy and Leukemia/Lymphoma as underlying CoD. At populational level, the PCVA estimated cause specific mortality fractions (CSMF) may be considered close to the fractions pointed by the gold standard. The CSMF-accuracy was 0.81 and the chance corrected CSMF-accuracy was 0.49.

Conclusions

The PCVA was efficient in attributing some causes individually and proved effective in estimating the CSMF, which indicates that the method is useful to establish public health priorities.

Integrating community-based verbal autopsy into civil registration and vital statistics: lessons learnt from five countries

This paper describes the lessons from scaling up a verbal autopsy (VA) intervention to improve data about causes of death according to a nine-domain framework: governance, design, operations, human resources, financing, infrastructure, logistics, information technologies and data quality assurance. We use experiences from China, Myanmar, Papua New Guinea, Philippines and Solomon Islands to explore how VA has been successfully implemented in different contexts, to guide other countries in their VA implementation. The governance structure for VA implementation comprised a multidisciplinary team of technical experts, implementers and staff at different levels within ministries. A staged approach to VA implementation involved scoping and mapping of death registration processes, followed by pretest and pilot phases which allowed for redesign before a phased scale-up. Existing health workforce in countries were trained to conduct the VA interviews as part of their routine role. Costs included training and compensation for the VA interviewers, information technology (IT) infrastructure costs, advocacy and dissemination, which were borne by the funding agency in early stages of implementation. The complexity of the necessary infrastructure, logistics and IT support required for VA increased with scale-up. Quality assurance was built into the different phases of the implementation. VA as a source of cause of death data for community deaths will be needed for some time. With the right technical and political support, countries can scale up this intervention to ensure ongoing collection of quality and timely information on community deaths for use in health planning and better monitoring of national and global health goals.

Development of the Verbal Autopsy Instrument for COVID-19 (VAIC)

BACKGROUND

Improving accuracy of identification of COVID-19-related deaths is essential to public health surveillance and research. The verbal autopsy, an established strategy involving an interview with a decedent's caregiver or witness using a semi-structured questionnaire, may improve accurate counting of COVID-19-related deaths.

OBJECTIVE

To develop and pilot-test the Verbal Autopsy Instrument for COVID-19 (VAIC) and a death adjudication protocol using it.

METHODS/KEY RESULTS

We used a multi-step process to design the VAIC and a protocol for its use. We developed a preliminary version of a verbal autopsy instrument specifically for COVID. We then pilot-tested this instrument by interviewing respondents about the deaths of 15 adults aged ≥65 during the initial COVID-19 surge in New York City. We modified it after the first 5 interviews. We then reviewed the VAIC and clinical information for the 15 deaths and developed a death adjudication process/algorithm to determine whether the underlying cause of death was definitely (40% of these pilot cases), probably (33%), possibly (13%), or unlikely/definitely not (13%) COVID-19-related. We noted differences between the adjudicated cause of death and a death certificate.

CONCLUSIONS

The VAIC and a death adjudication protocol using it may improve accuracy in identifying COVID-19-related deaths.

Development and Evaluation of a Community Surveillance Method for Estimating Deaths Due to Injuries in Rural Nepal

Almost 10% of global deaths are secondary to injuries, yet in the absence of routine injury surveillance and with few studies of injury mortality, the number and cause of injury deaths in many countries are not well understood. This study aimed to develop and evaluate the feasibility of a method to identify injury deaths in rural Nepal. Working with local government authorities, health post staff and female community health volunteers (FCHVs), we developed a two-stage community fatal injury surveillance approach. In stage one, all deaths from any cause were identified. In stage two, an interview with a relative or friend gathered information about the deceased and the injury event. The feasibility of the method was evaluated prospectively between February 2019 and January 2020 in two rural communities in Makwanpur district. The data collection tools were developed and evaluated with 108 FCHVs, 23 health post staff and two data collectors. Of 457 deaths notified over one year, 67 (14.7%) fatal injury events were identified, and interviews completed. Our method suggests that it is feasible to collect data on trauma-related deaths from rural areas in Nepal. These data may allow the development of injury prevention interventions and policy.

Factors associated with delays in the search for care in under-5 deaths in Yucatán, Mexico

OBJECTIVE

We examined delays during the search for care and associations with mother, child, or health services characteristics, and with symptoms reported prior to death.

MATERIALS AND METHODS

Cross-sectional study compris-ing household interviews with 252 caregivers of children under-5 who died in the state of Yucatán, Mexico, during 2015-2016. We evaluated the three main delays: 1) time to identify symptoms and start search for care, 2) transport time to health facility, and 3) wait time at health facility.

RESULTS

Children faced important delays including a mean time to start the search for care of 4.1 days. The mean transport time to the first facility was longer for children enrolled in Seguro Popular and there were longer wait times at public facilities, especially among children who also experienced longer travel time.

CONCLUSIONS

Providing resources to enable caregiv-ers to access health services in a timely manner may reduce delays in seeking care.

Improving the Policy Utility of Cause of Death Statistics in Sri Lanka: An Empirical Investigation of Causes of Out-of-Hospital Deaths Using Automated Verbal Autopsy Methods

Background: Setting public health policies and effectively monitoring the impact of health interventions requires accurate, timely and complete cause of death (CoD) data for populations. In Sri Lanka, almost half of all deaths occur outside hospitals, with questionable diagnostic accuracy, thus limiting their information content for policy. Objectives: To ascertain whether SmartVA is applicable in improving the specificity of cause of death data for out-of-hospital deaths in Sri Lanka, and hence enhance the value of these routinely collected data for informing public policy debates. Methods: SmartVA was applied to 2610 VAs collected between January 2017 and March 2019 in 22 health-unit-areas clustered in six districts. Around 350 community-health-workers and 50 supervisory-staffs were trained. The resulting distribution of Cause-Specific-Mortality-Fractions (CSMFs) was compared to data from the Registrar-General's-Department (RGD) for out-of-hospital deaths for the same areas, and to the Global-Burden-of-Disease (GBD) estimates for Sri Lanka. Results: Using SmartVA, for only 15% of deaths could a specific-cause not be assigned, compared with around 40% of out-of-hospital deaths currently assigned garbage codes with "very high" or "high" severity. Stroke (M: 31.6%, F: 35.4%), Ischaemic Heart Disease (M: 13.5%, F: 13.0%) and Chronic Respiratory Diseases (M: 15.4%, F: 10.8%) were identified as the three leading causes of home deaths, consistent with the ranking of GBD-Study for Sri Lanka for all deaths, but with a notably higher CSMF for stroke. Conclusions: SmartVA showed greater diagnostic specificity, applicability, acceptability in the Sri Lankan context. Policy formulation in Sri Lanka would benefit substantially with national-wide implementation of VAs.

Estimating causes of out-of-hospital deaths in China: application of SmartVA methods

Background

Most deaths in China occur at home, making it difficult to collect reliable cause of death (CoD) information. Verbal autopsy (VA) was applied using the SmartVA tool to a sample of home deaths in China to explore its feasibility as a means of improving the quality of CoD data.

Methods

The study was carried out in 22 districts in 9 provinces, located in north-east, central, and western areas of China during 2017 and 2018. Trained interviewers selected suitable respondents in each household to collect information using the Population Health Metrics Research Consortium (PHMRC) shortened and validated electronic VA questionnaire on tablets. The CoD was diagnosed from the interview data using the SmartVA-Analyze 2.0 software (Tariff 2.0).

Results

Non-communicable diseases (NCDs) dominated the leading causes of death in all age groups and for both sexes. After redistribution of undetermined causes, stroke (24%), ischemic heart diseases (IHD) (21%), chronic respiratory diseases (11%), and lung cancer (6%) were the leading causes of death. The cause fractions for level-one cause categories and ranking of specific causes were similar between SmartVA and results from the Global Burden of Disease (GBD) study.

Conclusion

Evidence from this large pilot study suggests that SmartVA is a feasible and plausible tool and could be a valuable tool to improve the quality and standardization of CoD information across China.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12963-021-00256-1.

Community surveillance and response to maternal and child deaths in low- and middle-income countries: A scoping review

BACKGROUND

Civil registration and vital statistics (CRVS) systems do not produce comprehensive data on maternal and child deaths in most low- and middle-income countries (LMICs), with most births and deaths which occur outside the formal health system going unreported. Community-based death reporting, investigation and review processes are being used in these settings to augment official registration of maternal and child deaths and to identify death-specific factors and associated barriers to maternal and childcare. This study aims to review how community-based maternal and child death reporting, investigation and review processes are carried out in LMICs.

METHODS

We conducted a scoping review of the literature published in English from January 2013 to November 2020, searching PubMed, EMBASE, PsycINFO, Joanna Briggs, The Cochrane Library, EBM reviews, Scopus, and Web of Science databases. We used descriptive analysis to outline the scope, design, and distribution of literature included in the study and to present the content extracted from each article. The scoping review is reported following the PRISMA reporting guideline for systematic reviews.

RESULTS

Of 3162 screened articles, 43 articles that described community-based maternal and child death review processes across ten countries in Africa and Asia were included. A variety of approaches were used to report and investigate deaths in the community, including identification of deaths by community health workers (CHWs) and other community informants, reproductive age mortality surveys, verbal autopsy, and social autopsy. Community notification of deaths by CHWs complements registration of maternal and child deaths missed by routinely collected sources of information, including the CRVS systems which mostly capture deaths occurring in health facilities. However, the accuracy and completeness of data reported by CHWs are sub-optimal.

CONCLUSIONS

Community-based death reporting complements formal registration of maternal and child deaths in LMICs. While research shows that community-based maternal and child death reporting was feasible, the accuracy and completeness of data reported by CHWs are sub-optimal but amenable to targeted support and supervision. Studies to further improve the process of engaging communities in the review, as well as collection and investigation of deaths in LMICs, could empower communities to respond more effectively and have a greater impact on reducing maternal and child mortality.

Does recall time matter in verbal autopsies? Evidence from urban informal settlements in Nairobi, Kenya

Background: To assign a cause of death to non-medically certified deaths, verbal autopsies (VAs) are widely used to determine the cause of death. The time difference between the death and the VA interview, also referred to as recall time, varies depending on social and operational factors surrounding the death. We investigated the effect of recall time on the assignment of causes of death by VA. Methods: This is a secondary analysis of 2002-2015 survey data of the Nairobi Urban Health Demographic Surveillance System (NUHDSS). The independent variable recall time was derived from the date of death and the date when the VA was conducted. Univariate and multivariate logistic regression methods were used to calculate odds ratios of assigning a cause of death in defined categories of recall time. Results: There were 6218 deaths followed up between 2002 and 2016, out of which 5495 (88.3%) had VAs done. Recall time varied from 1-3001 days (median  92 days, IQR 44-169 days). Majority of the VAs (45.7%) were conducted between 1-3 months after death. The effect of recall time varied for different diseases. Compared to VAs conducted between 1-3 months, there was a 24% higher likelihood of identifying HIV/AIDS as the cause of death for VAs conducted 4-6 months after death (AOR 1.24; 95% CI 1.01-1.54; p-value = 0.043) and a 40% increased chance of identifying other infectious diseases as the cause of death for VAs conducted <1 month after death (AOR 1.4; 95% CI 1.02-1.92, p-value = 0.024). Conclusions: Recall time affected the assignment of VA cause of death for HIV/AIDS, other infectious diseases,maternal/neonatal and indeterminate causes. Our analysis indicates that in the urban informal setting, VAs should be conducted from one month up to 6 months after the death to improve the probability of accurately assigning the cause of death.

Effect of Mass Treatment with Azithromycin on Causes of Death in Children in Malawi: Secondary Analysis from the MORDOR Trial

Recent evidence indicates mass drug administration with azithromycin may reduce child mortality. This study uses verbal autopsy (VA) to investigate the causes of individual deaths during the Macrolides Oraux pour Réduire les Décès avec un Oeil sur la Résistance (MORDOR) trial in Malawi. Cluster randomization was performed as part of MORDOR. Biannual household visits were conducted to distribute azithromycin or placebo to children aged 1–59 months and update the census to identify deaths for VA. MORDOR was not powered to investigate mortality effects at individual sites, but the available evidence is presented here for hypothesis generation regarding the mechanism through which azithromycin may reduce child mortality. Automated VA analysis was performed to infer the likely cause of death using two major analysis programs, InterVA and SmartVA. A total of 334 communities were randomized to azithromycin or placebo, with more than 130,000 person-years of follow-up. During the study, there were 1,184 deaths, of which 1,131 were followed up with VA. Mortality was 9% lower in azithromycin-treated communities than in placebo communities (rate ratio 0.91 [95% CI: 0.79–1.05]; P = 0.20). The intention-to-treat analysis by cause using InterVA suggested fewer HIV/AIDS deaths in azithromycin-treated communities (rate ratio 0.70 [95% CI: 0.50–0.97]; P = 0.03) and fewer pneumonia deaths (rate ratio 0.82 [95% CI: 0.60–1.12]; P = 0.22). The use of the SmartVA algorithm suggested fewer diarrhea deaths (rate ratio 0.71 [95% CI: 0.51–1.00]; P = 0.05) and fewer pneumonia deaths (rate ratio 0.58 [95% CI: 0.33–1.00]; P = 0.05). Although this study is not able to provide strong evidence, the data suggest that the mortality reduction during MORDOR in Malawi may have been due to effects on pneumonia and diarrhea or HIV/AIDS mortality.

Does recall time matter in verbal autopsies? Evidence from urban informal settlements in Nairobi, Kenya

Background: To assign a cause of death to non-medically certified deaths, verbal autopsies (VAs) are widely used to determine the cause of death. The time difference between the death and the VA interview, also referred to as recall time, varies depending on social and operational factors surrounding the death. We investigated the effect of recall time on the assignment of causes of death by VA. Methods: This is a secondary analysis of 2002-2015 survey data of the Nairobi Urban Health Demographic Surveillance System (NUHDSS). The independent variable recall time was derived from the date of death and the date when the VA was conducted. Univariate and multivariate logistic regression methods were used to calculate odds ratios of assigning a cause of death in defined categories of recall time. Results: There were 6218 deaths followed up between 2002 and 2016, out of which 5495 (88.3%) had VAs done. Recall time varied from 1-3001 days (mean 115.5 days, sd216.8). Majority of the VAs (45.7%) were conducted between 1-3 months after death. The effect of recall time varied for different diseases. Compared to VAs conducted between 1-3 months, there was a 24% higher likelihood of identifying HIV/AIDS as the cause of death for VAs conducted 4-6 months after death (AOR 1.24; 95% CI 1.01-1.54; p-value = 0.043) and a 40% increased chance of identifying other infectious diseases as the cause of death for VAs conducted <1 month after death (AOR 1.4; 95% CI 1.02-1.92, p-value = 0.024). Conclusions: Recall time affected the assignment of VA cause of death for HIV/AIDS, other infectious diseases and maternal/neonatal causes. Our analysis indicates that in the urban informal setting, VAs should be conducted from one month up to 6 months after the death to improve the probability of accurately assigning the cause of death.

The epidemiological transition in Papua New Guinea: new evidence from verbal autopsy studies

BACKGROUND

Recent economic growth in Papua New Guinea (PNG) would suggest that the country may be experiencing an epidemiological transition, characterized by a reduction in infectious diseases and a growing burden from non-communicable diseases (NCDs). However, data on cause-specific mortality in PNG are very sparse, and the extent of the transition within the country is poorly understood.

METHODS

Mortality surveillance was established in four small populations across PNG: West Hiri in Central Province, Asaro Valley in Eastern Highlands Province, Hides in Hela Province and Karkar Island in Madang Province. Verbal autopsies (VAs) were conducted on all deaths identified, and causes of death were assigned by SmartVA and classified into five broad disease categories: endemic NCDs; emerging NCDs; endemic infections; emerging infections; and injuries. Results from previous PNG VA studies, using different VA methods and spanning the years 1970 to 2001, are also presented here.

RESULTS

A total of 868 deaths among adolescents and adults were identified and assigned a cause of death. NCDs made up the majority of all deaths (40.4%), with the endemic NCD of chronic respiratory disease responsible for the largest proportion of deaths (10.5%), followed by the emerging NCD of diabetes (6.2%). Emerging infectious diseases outnumbered endemic infectious diseases (11.9% versus 9.5%). The distribution of causes of death differed across the four sites, with emerging NCDs and emerging infections highest at the site that is most socioeconomically developed, West Hiri. Comparing the 1970-2001 VA series with the present study suggests a large decrease in endemic infections.

CONCLUSIONS

Our results indicate immediate priorities for health service planning and for strengthening of vital registration systems, to more usefully serve the needs of health priority setting.

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.

Vulnerability to fatal drowning among the population in Southern Bangladesh: findings from a cross-sectional household survey

OBJECTIVES

This study aimed to determine the fatal drowning burden and associated risk factors in Southern Bangladesh.

SETTINGS

The survey was conducted in 39 subdistricts of all 6 districts of the Barisal division, Southern Bangladesh.

PARTICIPANTS

All residents (for a minimum 6 months prior to survey) of the Barisal division, Southern Bangladesh.

INTERVENTION/METHODS

A cross-sectional, divisionally representative household survey was conducted in all six districts of the Barisal division between September 2016 and February 2017, covering a population of 386 016. Data were collected by face-to-face interview with adult respondents using handheld electronic tablets. International Classification of Diseases (ICD)-v. 10 (ICD-10) Chapter XX: External causes of morbidity and mortality codes for drowning, W65-W74, X36-X39, V90, V92, X71 or X92, were used as the operational definition of a drowning event.

RESULTS

The overall fatal drowning rate in Barisal was 37.9/100 000 population per year (95% CI 31.8 to 43.9). The highest fatal drowning rate was observed among children aged 1-4 years (262.2/100 000/year). Mortality rates among males (48.2/100 000/year) exceeded that for females (27.9/100 000/year). A higher rate of fatal drowning was found in rural (38.9/100 000/year) compared with urban areas (29.3/100 000/year). The results of the multivariable logistic regression identified that the factors significantly associated with fatal drowning were being male (OR 1.7, 95% CI 1.2 to 2.3), aged 1-4 years (OR 3.0, 95% CI 1.4 to 6.4) and residing in a household with four or more children (four or more children OR 1.8, 95% CI 1.1 to 2.9; and five or more children OR 2.1, 95% CI 1.2 to 3.7).

CONCLUSION

Drowning is a public health problem, especially for children, in the Barisal division of Southern Bangladesh. Male gender, children 1-4 years of age and residing in a household with four or more children were associated with increased risk of fatal drowning events. The Barisal division demands urgent interventions targeted at high-risk groups identified in the survey.

Underreporting of deaths in the maternal deaths surveillance system in one region of Morocco

OBJECTIVE

To assess the reliability of maternal deaths surveillance system (MDSS) and to determine the factors that influence its completeness in one region of Morocco.

METHODS

We conducted a retrospective survey in "Gharb Chrarda Bni Hssen" region (GCBH) between January the 1st, 2013 and September the 30th, 2014 using multiple sources approach. All deaths of women of reproductive age (WRA) were investigated using certificates with medical cause, medical records and interviews with household members and relatives to ascertain a pregnancy-related or maternal death. An External Expert Committee reviewed the information collected to assign a cause for each death. Our results were compared to those reported in the same period by the MDSS.

FINDINGS

Our study identified 690 deaths of WRA and 69 maternal deaths of which 34.8% occurred outside health facilities. The MDSS recorded during the study period 538 deaths of WRA and 29 maternal deaths (including only one outside health facility) representing respectively an underreporting of 22.0% and 58.0%. Late maternal deaths represented 11.4% of all deaths of women with a registered pregnancy within 12 months prior to the death, while the MDSS identified none. The maternal mortality ratio (MMR) was estimated at 103, approximately 2.5 times higher than that reported in the MDSS.

CONCLUSION

Our study has shown weaknesses in the current notification system for maternal deaths in the region of GCBH. Therefore, more attention must be given to the regional committees in charge of auditing the cases and defining actions to be implemented to prevent further maternal deaths.

New challenges for verbal autopsy: Considering the ethical and social implications of verbal autopsy methods in routine health information systems

Verbal autopsy (VA) methods are designed to collect cause-of-death information from populations where many deaths occur outside of health facilities and where death certification is weak or absent. A VA consists of an interview with a relative or carer of a recently deceased individual in order to gather information on the signs and symptoms the decedent presented with prior to death. These details are then used to determine and assign a likely cause-of-death. At a population level this information can be invaluable to help guide prioritisation and direct health policy and services. To date VAs have largely been restricted to research contexts but many countries are now venturing to incorporate VA methods into routine civil registration and vital statistics (CRVS) systems. Given the sensitive nature of death, however, there are a number of ethical, legal and social issues that should be considered when scaling-up VAs, particularly in the cross-cultural and socio-economically disadvantaged environments in which they are typically applied. Considering each step of the VA process this paper provides a narrative review of the social context of VA methods. Harnessing the experiences of applying and rolling out VAs as part of routine CRVS systems in a number of low and middle income countries, we identify potential issues that countries and implementing institutions need to consider when incorporating VAs into CRVS systems and point to areas that could benefit from further research and deliberation.

Measuring mortality due to HIV-associated tuberculosis among adults in South Africa: Comparing verbal autopsy, minimally-invasive autopsy, and research data

BACKGROUND

The World Health Organization (WHO) aims to reduce tuberculosis (TB) deaths by 95% by 2035; tracking progress requires accurate measurement of TB mortality. International Classification of Diseases (ICD) codes do not differentiate between HIV-associated TB and HIV more generally. Verbal autopsy (VA) is used to estimate cause of death (CoD) patterns but has mostly been validated against a suboptimal gold standard for HIV and TB. This study, conducted among HIV-positive adults, aimed to estimate the accuracy of VA in ascertaining TB and HIV CoD when compared to a reference standard derived from a variety of clinical sources including, in some, minimally-invasive autopsy (MIA).

METHODS AND FINDINGS

Decedents were enrolled into a trial of empirical TB treatment or a cohort exploring diagnostic algorithms for TB in South Africa. The WHO 2012 instrument was used; VA CoD were assigned using physician-certified VA (PCVA), InterVA-4, and SmartVA-Analyze. Reference CoD were assigned using MIA, research, and health facility data, as available. 259 VAs were completed: 147 (57%) decedents were female; median age was 39 (interquartile range [IQR] 33-47) years and CD4 count 51 (IQR 22-102) cells/μL. Compared to reference CoD that included MIA (n = 34), VA underestimated mortality due to HIV/AIDS (94% reference, 74% PCVA, 47% InterVA-4, and 41% SmartVA-Analyze; chance-corrected concordance [CCC] 0.71, 0.42, and 0.31, respectively) and HIV-associated TB (41% reference, 32% PCVA; CCC 0.23). For individual decedents, all VA methods agreed poorly with reference CoD that did not include MIA (n = 259; overall CCC 0.14, 0.06, and 0.15 for PCVA, InterVA-4, and SmartVA-Analyze); agreement was better at population level (cause-specific mortality fraction accuracy 0.78, 0.61, and 0.57, for the three methods, respectively).

CONCLUSIONS

Current VA methods underestimate mortality due to HIV-associated TB. ICD and VA methods need modifications that allow for more specific evaluation of HIV-related deaths and direct estimation of mortality due to HIV-associated TB.

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

Background

We believe that it is important that governments understand the reliability of the mortality data which they have at their disposable to guide policy debates. In many instances, verbal autopsy (VA) will be the only source of mortality data for populations, yet little is known about how the accuracy of VA diagnoses is affected by the reliability of the symptom responses. We previously described the effect of the duration of time between death and VA administration on VA validity. In this paper, using the same dataset, we assess the relationship between the reliability and completeness of symptom responses and the reliability and accuracy of cause of death (COD) prediction.

Methods

The study was based on VAs in the Population Health Metrics Research Consortium (PHMRC) VA Validation Dataset from study sites in Bohol and Manila, Philippines and Andhra Pradesh, India. The initial interview was repeated within 3–52 months of death. Question responses were assessed for reliability and completeness between the two survey rounds. COD was predicted by Tariff Method.

Results

A sample of 4226 VAs was collected for 2113 decedents, including 1394 adults, 349 children, and 370 neonates. Mean question reliability was unexpectedly low (kappa = 0.447): 42.5 % of responses positive at the first interview were negative at the second, and 47.9 % of responses positive at the second had been negative at the first. Question reliability was greater for the short form of the PHMRC instrument (kappa = 0.497) and when analyzed at the level of the individual decedent (kappa = 0.610). Reliability at the level of the individual decedent was associated with COD predictive reliability and predictive accuracy.

Conclusions

Families give coherent accounts of events leading to death but the details vary from interview to interview for the same case. Accounts are accurate but inconsistent; different subsets of symptoms are identified on each occasion. However, there are sufficient accurate and consistent subsets of symptoms to enable the Tariff Method to assign a COD.

Questions which contributed most to COD prediction were also the most reliable and consistent across repeat interviews; these have been included in the short form VA questionnaire. Accuracy and reliability of diagnosis for an individual death depend on the quality of interview. This has considerable implications for the progressive roll out of VAs into civil registration and vital statistics (CRVS) systems.

Electronic supplementary material

The online version of this article (doi:10.1186/s12963-016-0104-2) contains supplementary material, which is available to authorized users.