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.

 

Transition from MDGs to Sustainable development goals (SDGs)

We must acknowledge the fact that our health programmes, efforts and actions were largely shaped by the  Millennium development goals (MDGs). MDGs directed resources including man, money, materials based on its prioritization. MDGs adopted in 2000 had three goals directly related to health to be met by 2015: reduction in child (under 5 years) mortality (Goal 4); improving maternal health and increasing access to reproductive health care (Goal 5); and reversing the spread of HIV/AIDS, tuberculosis and malaria (Goal 6). It served to identify the niche contributing major disease and mortality burden in the world. In its time frame of 15 years of duration, we have achieved huge success in bringing down mortality rates associated with maternal complication, newborn and infants, and control certain epidemics like HIV. Now, International community has developed sustainable development goals as a successor framework to millennium development goals.

Some imperative Visible achievement in our country 'Nepal':

Maternal mortality ratio:

• 1996- 539 maternal deaths per 100,000 live births (Nepal Family Health Survey, 1996)
• 2006- 281 deaths per 100,000 live births(NDHS, 2006)
• 2008- 229 per 100,000 live births (based on study done in eight districts: Nepal Maternal            Mortality and Morbidity study 2008/2009)
• 2013- 190 per 100,000 live births (WHO, UNICEF, UNFPA and The World Bank estimates. Trends in Maternal mortality: 1990-2013.) 

Infant mortality rate:

• 1996- 79 per 1000 live births (NFHS, 1996)
• 2001- 64 per 1000 live births (NDHS, 2001)
• 2006- 48 per 1000 live births (NDHS, 2006)
• 2011- 46 per 1000 live births (NDHS, 2011)
• 2013- 32.2 per 1000 live births (UNICEF/WHO/The World Bank/UN Pop Div. Levels and Trends in Child Mortality. Report 2014 )

 Trends of children's nutritional status:

Percent of children under age 5 in Nepal

Sustainable Development goals :

The SDGs are categorized under the five Ps — people, planet, prosperity, peace, and partnership — and include 17 goals and 169 targets. 

Health clearly does not occupy the central role in the SDGs that it did in the MDGs. There is only one specifically health-focused goal  (Goal 3, “Ensure healthy lives and promote well-being for all at all ages”) — though a number of  other factors that affect health  (such as water, sanitation, poverty,  and gender equality) are targets  in other goals, leading to a total  of 23 health-related targets.

Inevitably, health’s lower profile in the goals will mean less national-level political attention beyond the health sector. Its true that there should be holistic development for sustainable achievement in health, but being only one health specific goal among 17 other goals, it may acquire less attention from the international community.

Promoting health and well-being is one of 17 Global Goals that make up the 2030 Agenda for Sustainable Development. We can assume that sustainable development goals have been developed from the lessons of millennium development goals. It tends to cover many areas at a same time, which really needs a focused indicators.

Goal 3: Ensure healthy lives and promote well-being for all at all ages

  Goal 3 Targets:

1. By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births
2. By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births

3. By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases

4. By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being

5. Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol

6. By 2020, halve the number of global deaths and injuries from road traffic accidents

7. By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes

8. Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all

9. By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination

10. Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate

11. Support the research and development of vaccines and medicines for the communicable and noncommunicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which affirms the right of developing countries to use to the full the provisions in the Agreement on Trade Related Aspects of Intellectual Property Rights regarding flexibilities to protect public health, and, in particular, provide access to medicines for all

12. Substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries and small island developing States
13. Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks

     Other Health related SDG targets in other goals: 

1. By 2030, end all forms of malnutrition, including achieving, by 2025, the internationally agreed-on targets of stunting and wasting in children under 5 year of age, and address the nutritional needs of adolescent girls, pregnant and lactating women, and older persons.
2. Eliminate all forms of violence against all women and girls in the public and private spheres, including trafficking and sexual and other types of exploitation.  
3. Ensure universal access to sexual and reproductive health and reproductive rights as agreed in accordance with the Program of Action of the International Conference on Population and Development and the Beijing Platform for Action and the outcome documents of their review conferences.
4. By 2030, achieve universal and equitable access to safe and affordable drinking water for all.
5. By 2030, achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations.
6. By 2030, improve water quality by reducing pollution, eliminating dumping, and minimizing release of hazardous chemicals and materials, halving the proportion of untreated waste water and substantially increasing recycling and safe reuse globally.
7. By 2030, significantly reduce the number of deaths and the number of people affected and substantially decrease the direct economic losses relative to global gross domestic product caused by disasters, including water-related disasters, with a focus on protecting the poor and people in vulnerable situations.
8. Strengthen resilience and adaptive capacity to climate-related hazards and natural disasters in all countries.
9. Significantly reduce all forms of violence and related death rates everywhere.
10. By 2030, provide legal identity for all, including birth registration. 

This time sustainable development goals is more broad and more vague, however the precise indicators formulated under these targets to track its progress would be helpful in directing our efforts and actions. We have years to see its development and achievement.

Pros: Achievement/ targets in absolute number will drive the resources and international attention to hard stricken countries. Inclusion and Continuation of previous MDG health targets, Health inequalities and universal access have been center of the SDG targets. focused on sustainable and long term achievement of good health. 

Sources:

NDHS, 2006

NDHS, 2011

Christopher J.L. Murray, M.D., D.Phil. Shifting to Sustainable Development Goals — Implications for Global Health. The New England Journal of Medicine. October 2015.

MDG 4: reduce child mortality. http://www.who.int/topics/millennium_development_goals/child_mortality/en/ 

MDG 5: improve maternal health. http://www.who.int/topics/millennium_development_goals/maternal_health/en/

MDG 6: combat HIV/AIDS, malaria and other diseases. http://www.who.int/topics/millennium_development_goals/diseases/en/ 

Marie Paule Kieny. The sustainable development goals: the place of health in post 2015 agenda. http://graduateinstitute.ch/files/live/sites/iheid/files/sites/globalhealth/ghp-new/events%202015/Ties%20Boerma_The%20Sustainable%20Development%20Goals%20-%20The%20place%20of%20health%20in%20the%20post-2015%20agenda_17%20May.pdf. May 2015.