Mortality in India established through verbal autopsies (MINErVA): Strengthening national mortality surveillance system in India

Causes and determinants of infant mortality using verbal autopsy and social autopsy methods in a rural population of Odisha: a community-based matched case-control study

BACKGROUND

The avoidable causes of infant mortality should be identified, and interventions should be made to improve the infant mortality rate. The cause of infant deaths should be assessed in both medical and social contexts.

OBJECTIVES

We aimed to determine the medical causes of infant mortality by verbal autopsy and its determinants in two rural blocks of the Khordha district of Odisha and assess the pathway of care and delay in seeking care for the illness preceding infant death using the three-delay model.

DESIGN

We conducted this community-based matched case-control study to identify the medical causes of infant mortality using the verbal autopsy method along with the identification of delay and pathway of care related to infant deaths using a social autopsy method.

SETTINGS

Two rural blocks of Odisha, India.

PARTICIPANTS

We enumerated 100 infant deaths by active surveillance and data triangulation from Accredited Social Health Activists, Auxiliary Nurse Midwives and block-level health information systems. We selected an equal number of alive infants matched with cases in a 1:1 ratio with regard to age, gender and residential address.

OUTCOME MEASURES

We conducted the verbal autopsy using the Sample Registration System verbal autopsy tool, where the cause of death ascertainment was done by two independently trained physicians followed by adjudication by one senior trained physician in case of conflicts. We used the prevalidated International Network for the Demographic Evaluation of Population and Their Health tool to assess three delays and pathways of care related to infant deaths.

RESULTS

Most infant deaths (70%) happened during the first day of life, and almost 50% of neonatal deaths occurred during the first week of life. The three most common causes of infant mortality were birth asphyxia (30%), pneumonia (18%), prematurity and low birth weight (14%). Larger family size (>5) and the education status of fathers till class 10 were significant determinants of infant mortality. Among the 49 infants whose illnesses were identified at home, 2 died at home without receiving any care. Formal or informal care was sought for 32 and 8 infants, respectively. The median delay was found to be 24 hours for level 1 delay. Level 1 delay was observed for 20 cases (40.8%), with more than 24 hours in decision-making in care-seeking. Thirty-seven (75.5%) sick infants reached the healthcare facility 30 min after deciding to seek care.

CONCLUSION

Birth asphyxia, pneumonia prematurity and low birth weight were found to be the common causes of infant mortality, with larger family sizes and lower education status among fathers being the significant determinants of infant mortality. We observed a significant delay in decision-making regarding seeking care among caregivers of sick infants.

Unified Mobile App for Streamlining Verbal Autopsy and Cause of Death Assignment in India: Design and Development Study

Background

Verbal autopsy (VA) has been a crucial tool in ascertaining population-level cause of death (COD) estimates, specifically in countries where medical certification of COD is relatively limited. The World Health Organization has released an updated instrument (Verbal Autopsy Instrument 2022) that supports electronic data collection methods along with analytical software for assigning COD. This questionnaire encompasses the primary signs and symptoms associated with prevalent diseases across all age groups. Traditional methods have primarily involved paper-based questionnaires and physician-coded approaches for COD assignment, which is time-consuming and resource-intensive. Although computer-coded algorithms have advanced the COD assignment process, data collection in densely populated countries like India remains a logistical challenge.

Objective

This study aimed to develop an Android-based mobile app specifically tailored for streamlining VA data collection by leveraging the existing Indian public health workforce. The app has been designed to integrate real-time data collection by frontline health workers and seamless data transmission and digital reporting of COD by physicians. This process aimed to enhance the efficiency and accuracy of COD assignment through VA.

Methods

The app was developed using Android Studio, the primary integrated development environment for developing Android apps using Java. The front-end interface was developed using XML, while SQLite and MySQL were employed to streamline complete data storage on the local and server databases, respectively. The communication between the app and the server was facilitated through a PHP application programming interface to synchronize data from the local to the server database. The complete prototype was specifically built to reduce manual intervention and automate VA data collection.

Results

The app was developed to align with the current Indian public health system for district-level COD estimation. By leveraging this mobile app, the average duration required for VA data collection to ascertainment of COD, which typically ranges from 6 to 8 months, is expected to decrease by approximately 80%, reducing it to about 1-2 months. Based on annual caseload projections, the smallest administrative public health unit, health and wellness centers, is anticipated to handle 35-40 VA cases annually, while medical officers at primary health centers are projected to manage 150-200 physician-certified VAs each year. The app's data collection and transmission efficiency were further improved based on feedback from user and subject area experts.

Conclusions

The development of a unified mobile app could streamline the VA process, enabling the generation of accurate national and subnational COD estimates. This mobile app can be further piloted and scaled to different regions to integrate the automated VA model into the existing public health system for generating comprehensive mortality statistics in India.

Surveillance of Excess Mortality Based on Community Perceptions of Funeral Frequency in Northern Malawi during the COVID-19 Pandemic

Supplementary methods of mortality surveillance are needed in settings with incomplete death registration. Local perceptions of mortality levels might be useful indicators of excess deaths. Early in the COVID-19 pandemic, we developed a survey question asking respondents to evaluate the recent frequency of funerals in their community relative to a pre-pandemic baseline. We asked this question of more than 400 residents of Karonga district in Malawi, who were interviewed up to five times during a panel survey conducted by mobile phone between June 2020 and May 2021. The proportion of respondents reporting more funerals than usual in their community increased in early 2021, indicating excess mortality not otherwise detected by case-based surveillance and only partially visible in reports of inpatient deaths at health facilities. Systems assessing changes in perceptions of mortality can be rapidly established during an epidemic and may help detect excess deaths at local levels.

Perceptions of healthcare workers on implementing the 2022 WHO verbal autopsy instrument in rural India through the existing public health system

Background

Cause-of-death (CoD) information is crucial for health policy formulation, planning, and program implementation. Verbal Autopsy (VA) is an approach employed for the collection and analysis of CoD estimates at the population level where medical certification of cause of death is low and, secondly, for integrating it with the existing public health system by utilizing the grassroots level workforce.

Objective

The study aims to understand the field perspectives on implementing the 2022 WHO VA instrument in rural India through the existing public health system.

Methods

This article is derived from a qualitative arm of study that was conducted in one of the blocks of Kanpur district, Uttar Pradesh. Frontline health workers (FHWs), as well as Medical Officers (MOs) serving in the Community Health Centre (CHC) area, were selected as study participants. A 5-day training and orientation workshop was conducted to train the FHWs to conduct computer-assisted personal interview VA using the 2022 WHO VA instrument. MOs have been trained to assign the CoD via Physician-Certified VA (PCVA). In-depth interviews (IDIs) were conducted with FHWs involved in conducting VA and physicians involved in conducting PCVA within the field practice area.

Results

A total of 13 IDIs were conducted, consisting of 10 FHWs and 3 MOs, within the selected CHC area of Ghatampur. Based on the responses received, five major themes were identified. Although VA is being used to collect CoD information from the community in India through a Sample Registration Survey (SRS), the key findings suggest that this activity could be scaled up by utilizing the existing public health system. However, additional manpower may be required for constant monitoring and evaluation of the program. Incentivization of FHWs would aid in the timely completion of VAs and coordination with local and higher health authorities.

Conclusion

The perception of healthcare workers about the feasibility and acceptability of VA in this study highlighted some of the challenges and possible solutions that could aid in developing a comprehensive model to improve CoD information at the population level through the existing public health system.

Temporal Mortality Trends Attributable to Stroke in South Asia: An Age-Period-Cohort Analysis

South Asia contributes the most to stroke mortality worldwide. This study aimed to determine the long-term trends in stroke mortality across four South Asian countries and its associations with age, period, and birth cohort. In 2019, nearly one million stroke deaths occurred across South Asia, and the associated age-standardized mortality rate (ASMR) was 80.2 per 100,000. Between 1990 and 2019, India had the largest decrease in the ASMR (-35.8%) across the four South Asian countries. While Pakistan had the smallest decrease in the ASMR (-7.6%), an increase was detected among males aged 15 to 34 years and females aged 15 to 19 years. Despite a 22.8% decrease in the ASMR, Bangladesh had the highest ASMR across the four South Asian countries. Nepal reported a witness increase in the stroke ASMR after 2006. Improved period and cohort effects on stroke mortality were generally indicated across the analyzed countries, except for recent-period effects in males from Nepal and cohort effects from those born after the 1970s in Pakistan. Stroke mortality has decreased in the four South Asian countries over the past 30 years, but potentially unfavorable period and cohort effects have emerged in males in Nepal and both sexes in Pakistan. Governmental and societal efforts are needed to maintain decreasing trends in stroke mortality.

Analysis of death causes of residents in poverty-stricken Areas in 2020: take Liangshan Yi Autonomous Prefecture in China as an example

Background

Continuous surveillance of death can measure health status of the population, reflect social development of a region, thus promote health service development in the region and improve the health level of local residents. Liangshan Yi Autonomous Prefecture was a poverty-stricken region in Sichuan province, China. While at the end of 2020, as the announcement of its last seven former severely impoverished counties had shaken off poverty, Liangshan declared victory against poverty. Since it is well known that the mortality and cause of death structure will undergo some undesirable changes as the economy develops, this study aimed to reveal the distribution of deaths, as well as analyze the latest mortality and death causes distribution characteristics in Liangshan in 2020, so as to provide references for the decision-making on health policies and the distribution of health resources in global poverty-stricken areas.

Methods

Liangshan carried out the investigation on underreporting deaths among population in its 11 counties in 2018, and combined with the partially available data from underreporting deaths investigation data in 2020 and the field experience, we have estimated the underreporting rates of death in 2020 using capture-recapture (CRC) method. The crude mortality rate, age-standardized mortality rate, proportion and rank of the death causes, potential years of life lost (PYLL), average years of life lost (AYLL), potential years of life lost rate (PYLLR), standardized potential years of life lost (SPYLL), premature mortality from non-communicable diseases (premature NCD mortality), life expectancy and cause-eliminated life expectancy were estimated and corrected.

Results

In 2020, Liangshan reported a total of 16,850 deaths, with a crude mortality rate of 608.75/100,000 and an age-standardized mortality rate of 633.50/100,000. Male mortality was higher than female mortality, while 0-year-old mortality of men was lower than women’s. The former severely impoverished counties’ age-standardized mortality and 0-year-old mortality were higher than those of the non-impoverished counties. The main cause of death spectrum was noncommunicable diseases (NCDs), and the premature NCD mortality of four major NCDs were 14.26% for the overall population, 19.16% for men and 9.27% for women. In the overall population, the top five death causes were heart diseases (112.07/100,000), respiratory diseases (105.85/100,000), cerebrovascular diseases (87.03/100,000), malignant tumors (73.92/100,000) and injury (43.89/100,000). Injury (64,216.78 person years), malignant tumors (41,478.33 person years) and heart diseases (29,647.83 person years) had the greatest burden on residents in Liangshan, and at the same time, the burden of most death causes on men were greater than those on women. The life expectancy was 76.25 years for overall population, 72.92 years for men and 80.17 years for women, respectively, all higher than the global level (73.3, 70.8 and 75.9 years).

Conclusions

Taking Liangshan in China as an example, this study analyzed the latest death situation in poverty-stricken areas, and proposed suggestions on the formulation of health policies in other poverty-stricken areas both at home and abroad.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12504-6.