Verbal Autopsy and MPDSR - Public Health Notes

Table of Contents

What is Verbal Autopsy (VA)?

Verbal Autopsy is a method of determining individuals cause of death
Verbal autopsy(VA) is a method of collecting information about symptoms and circumstances for a deceased person to determine his/her cause of death.
According to the World Health Organization (WHO), Verbal Autopsy is ‘a method used to ascertain the cause of a death based on an interview with next of kin or other caregivers’ that can be applied for deaths without certification of medical causes
Verbal autopsy (VA) is a method of determining individuals’ causes of death and cause-specific mortality fractions in populations without a complete vital registration system.
Verbal autopsies is done through interview by trained personnel using standard questionnaire regarding demographic characteristics, signs and symptoms before the death of the patient.
The main objective of Verbal Autopsy (VA) is to assess the causes of death at the community level where civil registration and death certification systems are weak and where most people die at home without any contact with the health system or health facilities.
VA is particularly used in underdeveloped and developing countries where citizens contact with the health system is relatively weak and it is difficult to plan and implement public health programs without proper assessment of the cause of death.
Understanding the prevalent cause of deaths provide information to target preventive information and health services, thus there comes the rise of verbal autopsy. Therefore, Verbal Autopsy is also considered as a research method to solve the problem of identifying the probable causes of death.
VA has become a primary source of information about causes of death in populations lacking vital registration and medical certification.

Objectives of Verbal Autopsy

To identify the possible causes of death of the deceased person
To deliver a simple identification of cause of death at community/population level, especially in places where other functional registration doesn’t happen and/or where people die at home without any contact with health institution
To analyze community verbal autopsy data
To develop methods with the highest possible performance, as assessed by an explicit set of transparent metrics, that can accurately and expeditiously help estimate population-level causes of death
To create methods to improve population-level estimates for causes of death by combining verbal autopsy data with hospital records to further improve

Importance of Verbal Autopsy

Verbal Autopsy (VA) has significant potential to deliver robust and reliable evidence to help close gaps in statistics, and guide implementation, evaluation and investment.
VA can contribute to more holistic views of health systems performance combining evidence on burden of disease with social determinants and local knowledge.
VA can be used to investigate population health in selected contexts by examining sequences of events in detail, particularly rare events, for example, maternal deaths

Verbal Autopsy on Maternal and Neonatal Deaths

Verbal autopsy on maternal deaths determines the information on the levels and causes of maternal mortality
It is critical in determining the public health importance of specific maternal health problems and in designing appropriate interventions to reduce maternal mortality
Clinical registration of the cause of death is available for less than one-third of the global neonate deaths. Thus verbal autopsy on neonatal deaths provide this crucial information aiming to determine the cause of neonates deaths

Things to Consider While Conducting Verbal Autopsy

Advance information should be provided about the purpose of visit to the relatives of the deceased from the onset of complications till the death, and their consent must be received
A trained investigation officer should perform the verbal autopsies
Confidentiality should be ensured by the investigating official and assurance to the family should be obtain
Throughout the interview, the interviewer should be very polite and sensitive questions should be avoided
Before starting making sure that all the respondents are seated comfortably and explanation about the information that they are going to provide will prevent deaths in future
Allow the respondents to narrate the events leading to the death of the mother in their own word and prompting them to speak until the respondent says there was nothing more to say
Encouragement to the respondent to bring out all information related to the event
Please also write information in a narrative form
The interviewer should not be influenced by the information provided by the field health functionaries and doctors

Maternal and Perinatal Death Surveillance and Response (MPDSR)

MPDSR is a continuous surveillance cycle which is designed to provide real- time, quality and actionable data on maternal and perinatal deaths, their causes and contributing factors
It adds value for policy making and accountability which can be build on existing efforts to conduct maternal death reviews, verbal autopsies and confidential enquiries

Gaps/Challenges of MPDSR Programs

It is a complex process implementation
Lack of political buy-in and long-term vision has been identified as a challenge and barrier in implementation of MPDSR
No formal system for perinatal mortality audits because of priority has only been given to maternal mortality audits
Lack in standard guidance to audits of perinatal deaths has made the implementation part difficult
Reporting patients charts and records being incomplete the providers are burdened with entering unnecessary information. Accuracy of data has also been a challenge
Maternal deaths using labors and delivery registers were recorded and maternal deaths in other services were lost in the record system
No tracking for systemic implementation of action plans
Inefficient or incomplete systems of notification
Heavy workload to health workers, high number of perinatal deaths, and non-implementation of recommendations are the major challenges in MPDSR programs

Lessons Learnt from MPDSR Programs

MPDSR program runs throughout the world in different countries. However, the name of the program is slightly different in different countries. Some call it MPDSR while others have incorporated the same work under Maternal and Child Health (MCH).

Lessons learned from MPDSR programs throughout the globe are:

Tracking progress on maternal mortality ratios or rates is notoriously difficult with lack of reliable vital registration but MPDSR can assist in keeping the required rates and ratios
Using the MPDSR implementation framework allows for a deeper understanding on the factors influencing maternal and perinatal deaths
For this to happen, it requires health policy and system approach with broader programmatic focus
MPDSR primarily focuses only on tangible inputs from a service delivery lens
Systematic process for tracking implementation of actions plans should be an essential tool for measuring the progress
Immediate value addition to active surveillance of maternal and perinatal deaths can improve timely notification of events, assessment and confirmed of cases
MPDSR can improve accurate identification, counting, and reporting of deaths in settings where vital registration systems have low coverage
MPDSR can enhance accountability mechanisms by providing information on whether policies and actions meant to reduce maternal and perinatal mortality are effective or not

Ways to Improve MPDSR Programs

Strengthening active surveillance with active community participation
Strengthening capacity building and recruitment of additional health education workers with special focus to improve the quality of health service
Audit committees should display and analyze data and trends to understand better the quality of service delivery at their facilities, identify common causes of deaths, and help prioritize responses
Additional training on cause-of-death classification, aligned with International Classification of Disease ICD-MM (Maternal Mortality) and ICD-PM (Perinatal Mortality)
Documenting success stories from audits and disseminating them within facilities and communities as a motivational tool for audit committee members
Health providers should be supported in terms of supervision and financial motivation
Addressing the problem of blame culture in some places which have been inhibiting health professionals and others from participating fully in the MPDSR process