Verbal Autopsy in Health Research

Many Researchers have been using verbal autopsies method to estimate the number of deaths in the community and to determine underlying causation of death.

Some examples of the study that have adopted Verbal Autopsy:

1. NEPAL Maternal Mortality and Morbidity Study 2008/2009 had used verbal autopsy method to find out the underlying causes of mortality and morbidity.
2. Khanal S, Gc VS, Dawson P, Houston R. Verbal autopsy to ascertain causes of neonatal deaths in a community setting: a study from Morang, Nepal. JNMA J Nepal Med Assoc. 2011 Jan-Mar;51(181):21-7.
3. Stefania Vergnano, Edward Fottrell, David Osrin, Peter N Kazembe, Charles Mwansambo, Dharma S Manandhar, Stephan P Munjanja, Peter Byass, Sonia Lewycka, and Anthony Costello. Adaptation of a probabilistic method (InterVA) of verbal autopsy to improve the interpretation of cause of stillbirth and neonatal death in Malawi, Nepal, and Zimbabwe. Population Health Metrics. 2011; 9: 48.

 

 Verbal autopsy can be used as a complementary method in a research and as a sole method for identifying the death and its causes. In the first aforementioned study of Maternal mortality and Morbidity, verbal autopsy has been used as a complementary method to find the maternal mortality and in the second study verbal autopsy is the solitary method to find the cause of death among neonatal deaths.

What is verbal Autopsy (VA)?

AUTOPSY/POST MORTEM/NECROPSY: Scared!!!! Here a certified doctor performs examination on dead body to find out the causes of death. The purpose of Autopsy and verbal autopsy is same, however, the process is entirely different. Trained medical professionals as well as non-medical professionals can perform verbal Autopsy. However, both of the groups need training for conducting verbal autopsy procedure beforehand.

Verbal Autopsy (VA) is an indirect method of ascertaining biomedical causes of death from information on symptoms, signs and circumstances preceding death, obtained from the deceased’s caretakers. Usually the person, who looked after the deceased during the final illness are asked the details of the dead person.  However, the process of identifying an appropriate respondent is not formalized. Few studies reported interviewing friends or neighbors if a caretaker was not available.

The accuracy of the information obtained through verbal autopsy is essentially affected by the skills of the interviewers, respondents, recall period, languages (required for translation of questionnaires).  In most of research or process, the interviewers are health care professionals, including doctors, nurses and paramedics whereas some employ non-medical professionals. It needs training prior to field work. At a time people might suffer emotional break out when they talk about deceased one, making counseling training and techniques essential part of verbal autopsy process though commonly not practiced.

Timing: Even though verbal autopsies are done as soon as possible after the death to indefinite period.  Most has agreed that a minimum of  4 weeks is required to reduce the distress and emotional disturbance of the respondents. The maximum recall period can vary from six months to an indefinite amount of time. Nevertheless, The period following one month to 12 month is generally considered acceptable.

There is a standard tool for verbal autopsy. In 2007, needs and demands for standardization led to the 2007 publication of the WHO VA standards, which many researchers have adopted. The standards included:

• Verbal autopsy questionnaires for three age groups (under four weeks; four weeks to 14 years; and 15 years and above); 
• Cause of death certification and coding resources consistent with the International Classification of Diseases and Related Health Problems, tenth revision (ICD-10); and 
• A cause-of-death list for verbal autopsy prepared according to the ICD-10.

Why we are employing Verbal Autopsy?

Ideal circumstances: The standard method to determine the cause of death is certification by an attending physician, based on valid medical documents. There should have been updated vital registration system (includes birth certification, marriage certification, death certification and adequate records, migration)

Reality: we don’t have well functioning vital registration system due to many reasons. I would like to focus on death registration: low level of awareness about its relevance, lack of well established vital registration system, limitation in proper diagnosis, limited qualified health care professionals, Rural settings, which is devoid of all of these and most death occur at home, the lack of infrastructure and the high cost of collecting the data, which limit access to information from diagnostic tests and post-mortem pathology services. Mortality data from developing countries are therefore limited and potentially biased.

Why do we need the information regarding the cause of death?

Have you ever thought why did National health programme focus on improving maternal health, improving child health and other endemic infectious tropical diseases? Have you ever scratched your head and asked to yourself why did International community, donors, policy makers invested on AIDS, African and Southeast region?

Because they had reasons in terms of global disease burden, mortality and disability rate and the conditions leading to it. Without those information, we wouldn’t have direction for public health planning, resource allocation and the impact of interventions. 

USAID is funding SUAAHARA project after corroborating the fact that under-nutrition is the underlying cause of many childhood death and maternal death.Our safe motherhood programme is focusing on access to attendance of skilled birth attendants and increasing institutional birth after the realization that home delivery is associated with high maternal and neonatal death. Information on the cause of mortality is crucial for future implications for reducing mortality.

VA has limitations

Nevertheless, Verbal autopsy is not free of limitations. They require recollection of events at the time of death, rely on understanding and reporting of signs and symptoms by interviewees, and may be influenced by interviewer skills. The result can be affected at any time of collection, Analysis &diagnosis, Reporting.

 

Download PDF for verbal autopsy questionnaire

Sources:

Frank Baiden, Ayaga Bawah, Sidu Biai, Fred Binka, Ties Boerma, Peter Byass, Daniel Chandramohan, Somnath Chatterji, Cyril Engmann, Dieltiens Greet, Robert Jakob, Kathleen Kahn, Osamu Kunii, Alan D Lopez, Christopher J L Murray, Bernard Nahlen, Chalapati Rao, Osman Sankoh, Philip W Setel, Kenji Shibuya, Nadia Soleman, Linda Wright, Gonghuan Yang. Bulletin of the World Health Organization. Setting international standards for verbal autopsy. http://www.who.int/bulletin/volumes/85/8/07-043745/en/

Hooman Khademi, Arash Etemadi, Farin Kamangar, Mehdi Nouraie, Ramin Shakeri, Behrooz Abaie, Akram Pourshams, Mohammad Bagheri, Afshin Hooshyar, Farhad Islami, Christian C. Abnet, Paul Pharoah, Paul Brennan, Paolo Boffetta, Sanford M. Dawsey, Reza Malekzadeh. Verbal Autopsy: Reliability and Validity Estimates for Causes of Death in the Golestan Cohort Study in Iran. Plos one. 2010. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0011183

Nadia Soleman, Daniel Chandramohan, & Kenji Shibuya. Verbal autopsy: current practices and challenges. Bulletin of the World Health Organization 2006;84:239-245.