Ascertaining causes of neonatal deaths using verbal autopsy: current methods and challenges

Abstract

Objective: 'Verbal autopsy' (VA) is used to ascertain cause of death in countries where vital registration systems are lacking. Current VA methods for neonatal deaths vary widely and suffer from several limitations. We aimed to: (1) review current neonatal VA methods, (2) identify gaps and limitations, (3) illustrate some limitations using VA data and (4) identify new approaches in methodology and analysis.Study Design: Rolling techniques and database search terms were used to identify articles that described neonatal VA administration, validation and cause of death assignment.Result: Current VA interviews include open and close-ended modules and are administered by trained interviewers. Causes of death are determined using physician review and/or computer algorithms for various neonatal causes of death. Challenges include lack of a standardized VA instrument and administration of methods, difficulty in identifying gold standards for validation studies, lack of validated algorithms for causes of death, poor existing algorithms, lack of standardized death classification terminology and the use of hierarchy to assign causes of death. Newer probabilistic methods of analysis such as Bayes Theorem or the Symptom Pattern method may improve accuracy for cause of death estimation and alleviate some of the challenges with traditional physician and algorithmic approaches, although additional research is needed.Conclusion: Given the continued reliance on VA to determine cause of death in settings with inadequate registration systems, it is important to understand the gaps in current VA methods and explore how methods can be improved to accurately reflect neonatal disease burden in the global community. Journal of Perinatology (2009) 29, 187-194; doi:10.1038/jp.2008 published online 25 December 2008 Keywords: verbal autopsy; cause of death; neonatal mortality; algorithms; hierarchy; challenges Background Data on causes of death are important for health sector planning, including assessing programmatic needs, monitoring progress of interventions and reassessing health priorities. However, little is known about causes of death in many developing countries because vital registration systems are lacking. Many deaths occur at home, outside the formal health sector, and few are attended by qualified medical professionals. Verbal autopsy (VA) has been used to assign cause of death in such settings.VA is a post-mortem in-depth interview with the primary caregiver of the deceased. In the case of child deaths, this is usually the mother. Underlying assumptions are that (1) each cause of death investigated has a set of observable symptoms that can be recognized and recalled by the primary caregiver, and (2) the characteristics of one cause of death can be distinguished from those of all others.The majority of the estimated 4 million annual global neonatal deaths occur in developing countries outside of the formal health care system. 1 Previous research on cause of death for children <5 often excluded neonatal cases due to poor rep...

Causes of community stillbirths and early neonatal deaths in low-income countries using verbal autopsy: an International, Multicenter Study

“…We interviewed mothers within two weeks of a death, and it is conceivable that the mothers’ grief may have precluded accurate responses to VA. This possibility has not been borne out in other VA studies, where recall bias has been noted to sometimes occur if mothers are interviewed one year or later than the death 14, 21, 38 . There is also no validation component of this study per se with the use of laboratory, radiologic or microbiologic investigations; however, VA has been widely used and subjected to rigorous investigation.…”

“…Complex statistical models are not a panacea and cannot replace the sensitivity of counting births and deaths. As the shift continues from global and regional estimates of COD to national and sub-national estimates for monitoring progress towards MDG4 and providing evidence for backing national policies, increasing numbers of VA validation studies to ascertain cause of SB and neonatal death are emerging in the literature 13, 15–17, 21 . The findings from these studies have generally been favorable and VA has been found to reliably identify several of the most common causes of neonatal illness and death, although generalizability is limited by the differences in methods and procedures used in different settings.…”

Cause-specific mortality in the Kombewa health and demographic surveillance systems site, rural Western Kenya from 2011–2015

“…VA is a useful tool for establishing the probable cause of death (COD) by interviewing a caregiver or a close person who witnessed the death event [1]. The usefulness of the VA tool for filling the information gap on causes of death in low and middle income countries has been discussed extensively [7–10]. In the present study, we describe the main causes of death in the Kombewa HDSS, in rural Western Kenya, in the years 2011–2015.…”

Two million intrapartum-related stillbirths and neonatal deaths: Where, why, and what can be done?

“…Verbal autopsy methods (questionnaires used with family members after the death) are the only option for causeof-death data for the majority of neonatal deaths and stillbirths [28]. There have been advances in case definitions and algorithms for use in verbal autopsy, but full consensus and consistent use is still lacking, particularly for hierarchical attribution if the baby died with signs suggestive of several possible causes-of-death [29][30][31][32][33][34][35][36].…”