1. Verbal Autopsies:
Data Analysis
May 2012, CORE Group Spring Meeting
Tom Davis, MPH
Senior Director of Program Quality Improvement

2. Introduction

3. What is a Verbal Autopsy?
• Interview with a parent of a child that
has died (or family of a woman who
died in pregnancy or childbirth)
concerning the circumstances
surrounding the death.
• An investigation to learn how we can
prevent deaths.

4. When are Verbal Autopsies Done
and with Whom?
• Allow for period of mourning: Conduct at 2-4
weeks after death
• Done with mother of the child that died or
another person who was around child during
the illness / death (if mother was not).
• Supervisor (preferable, but not always
feasible) or CHW / Promoter

5. Verbal Autopsy ≠ Mortality Tracking Form
IMPORTANT:
• Not all programs use the VA forms to track mortality
rates (which is often done with a separate form, or not
at all).
• Verbal Autopsies can be collected in only a sample of
programs areas (e.g., one Care Group or Community
per district).
• Data from only a few areas can still be instructive in
making system changes that lead to improvement, but
better to have representative data.

6. What’s the burden on the
Supervisor or CHW?
• FH/Moz: 148,444 U5 children • More typical project
(SAWSO/Zambia): 25,000 U5
• 7 districts w/65 Promoters and
children
5 Supervisors
• 21 Facilitators and 5 Supervisors
• U5MR: 150/1,000
• U5MR: ~150/1,000
• 148,444*0.15/5/12 = 371
• 25,000*0.15/5/12 = 63
deaths/month
deaths/month
• 5.7 VAs / Promoter / month
• 3 VAs / Facilitator / month
• If only doing VAs in 10% of
• If only doing VAs in 10% of
Promoter's coverage area: 0.6 Facilitator's area: 0.3 VAs /
VAs / Promoter / month, or 7.5 Facilitator / month, or 1.3 VAs /
VAs / Supervisor / month Supervisor / month

7. What is your Experience?
• What has been your experience with
Verbal Autopsies?
• Has your organization used them? Did
you get useful data?
• What challenges did you have?

8. Benefits of Verbal Autopsies
• To understand ages when children are dying
• To understand the causes of death (e.g., diseases)
• To understand delays that may lead to some deaths.
• delays in recognizing signs/symptoms of disease,
• delays in seeking medical attention,
• delays in reaching a health provider,
• delays in receiving care once they reached a health provider,
• delays in starting treatment.
• To understand home care and follow-up care provided
• To offer condolences to the family

9. Overview of Rationale and Use
of Verbal Autopsies
Henry Perry
Department of International Health
Johns Hopkins Bloomberg School of Public
Health
CORE Group Spring Meeting, 4 April 2012

10. Outline
• Origins of verbal autopsies
• Examples of the practical value of verbal
autopsy information for strengthening
program implementation
• Examples of the practical values of knowing
the age at death
• A few methodological points
• Conclusions

11. Origins of Verbal Autopsy:
John Gordon and John Wyon

12. Early Use of Verbal Autopsies 3 Decades Ago
by Andean Rural Health Care
• Home visitation to deliver services and to
register vital events
• Verbal autopsy by higher-level field staff to
identify cause of death

13. Early Findings on Cause of Death in
Two Areas of Bolivia, 1990-1993

14. Practical Implications
• Led to focus on diarrhea prevention and
control and on nutrition in Montero (tropical
lowlands) and to pneumonia in Carabuco (in
the mountains)
• It should have led us to more investigation of
what “asphyxia” was – likely to have been
hypothermia

15. Percentage of Deaths by Age Group in World
Relief/Cambodia Child Survival Project,
March 2004-February 2005
N=174

16. Cause of Death, 1-11 Months of Age,
March 2004-February 2005, World
Relief/Cambodia Child Survival Project
Umbilical cord
hemorrhage
1.6%
Neonatal tetanus
3.9% Pneumonia, other
Other resp. conditions
27.3% 36.7%
Malnutrition Diarrhea/dehydra-
5.2% tion
1.0%
Dengue
5.2% Other infections
17.8%
Accident/injury
1.0%

17. Practical Implications
• Pneumonia among children 1-11 months of
age is a target for reducing mortality
• Neonates are also a target for reducing
under-5 mortality
• Children over year of age have a low risk of
death and are therefore not a target

18. World Relief/Mozambique Child
Survival Project, 2004-2009
• Level of effort:
– Malaria, 20%
– Nutrition, 20%
– Diarrhea, 20%
– STDs/HIV, 15%
– Pneumonia, 10%
– Immunization,
10%
– Exclusive BF, 5%

19. Practical Implications
• Malaria should be given top priority

20. Curamericas/Guatemala Child Survival
Project, 2003-2007

24. Age at Death

26. Methodological Points

27. The Current “Gold
Standard” for Verbal
Autopsies for All Age
Groups
http://www.who.int/healthinf
o/statistics/verbalautopsysta
ndards/en/index.html

29. • Shortened version in preparation now

30. Computerized Diagnosis
• Helps to standardize the process
• Lowers the level of person required
• Simplifies it – in terms of time involved
• InterVA – computerized algorithm
– Peter Byass

31. Malaria
• Difficult to diagnose precisely with verbal
autopsy and can often be confused with
pneumonia
• Many illnesses produce fever
• Fever produces rapid respirations
• Malaria is a difficult diagnosis to make even in
hospitalize patients
– Having circulating parasites does not prove that a
patient’s symptoms are from malaria

32. • In malaria-endemic areas, it might be best to
consider malaria and pneumonia and joint
diagnoses and target both

33. Conclusions
• The goal of child survival programs is to reduce
mortality in under-5 mortality
• Obtaining information about cause of death
and the conditions under which that death
occurred is an important step in empowering
program staffs to more effectively target
interventions
• By obtaining information on cause of death,
you are also obtaining information about age
at death, and this is important for
programming as well

34. Conclusions (cont.)
• National-level data on cause of death are
better than no data, but local-level data better
than national data since the situation can vary
from place to place (but attention to quality is
important!)
– There is variation in cause of death (and age at
death) from one socio-ecological setting to another
• Verbal autopsy data not perfect, but it is the
best we can get – and it must be interpreted
appropriately

35. Using the Verbal Autopsy
Questionnaire
• (Go through questionnaire.)
• (See Tom for maternal form.)

36. If doing a Sample:
Avoiding Selection Bias
NOTE: It does not matter if the child died from a
birth defect after two days or from diarrhea when
she was 8 months old – if a child dies in the area
chosen for Vas, fill out the form. AVOID
SELECTION BIAS.
But do not fill out a form if the child was born dead
– only for children who were born alive and later
died.

37. Analysis of Verbal Autopsy Data:
Examining Patterns & Exploring Hypotheses
Look for patterns of deaths in….
• Home care
• Preventive care
• Care seeking
• Treatment
• Delays
• Gender and age of the child
• Co-morbidity, clusters of symptoms (e.g., malnutrition)
• Etc.

38. How to Analyze Verbal Autopsy Data –
The Mortality Review Meeting
a. If tracking mortality rates, review the total number of deaths
of children (0-23m, 0-59m) in the project area compared to
the previous period (using tracking form) and rates.
b. Determine the principal causes of death, the age pattern for
deaths for each cause of death, and other patterns. Write
out statements on patterns, for example:
• "42% of deaths were in the first month of life;"
• "52% of deaths of children 0-11m were due to malaria";
• “71% of children were seen by a CHW and referred";
• “23% of mothers knew 2+ danger signs.”

39. How to Analyze Verbal Autopsy Data –
The Mortality Review Meeting
a. If your numbers are large enough and representative
enough, you may be able to look for possible
associations. For example, association between
malnutrition and deaths (using 2x2 tables).

40. How to Analyze Verbal Autopsy Data –
The Mortality Review Meeting
Look for possible associations and problem areas:
• Nutritional status (#12)
• Knowledge of Danger Signs (#14).
• Social status of family (#15)
• Signs / symptoms (#16)
• Who attended child (#19)
• Location of death during illness / death (#20)
• Care seeking outside of home (#21)
• Care providers sought (#22)
• Hydration (#23)
• Medications given (#24)

41. How to Analyze Verbal Autopsy Data –
The Mortality Review Meeting
a. Identify the delays / barriers to identification and care and
explore what can be changed concerning those delays /
blocks.
• Delay in recognition that the child had a problem requiring medical
attention (see questions #28/29)
• Delay in seeking medical care (after recognizing that care required
medical attention). (see questions #30/31)
• Delay in reaching a health facility (after decision to seek care). (See
questions #32)
• Delay in receiving care once at health facility & starting treatment (see
questions #33/34)
• You should also see if there were problems with home care or follow-up
care after receiving medical care/advice (see questions #35/36)

42. How to Analyze Verbal Autopsy Data –
The Mortality Review Meeting
• Determine areas where the family can improve their
management of child illness (including values and
attitudes).
• Determine areas where health staff can improve their
management of child illness (including values and
attitudes).
• Propose new methods and strategies to prevent
future child deaths.

43. How to Analyze Verbal Autopsy Data –
The Mortality Review Meeting
a. Follow-up on previous methods and strategies
proposed at earlier Mortality Review Meetings.
b. Possible actions to take using the VA results.
• Improvements / changes in behavior change communication
• Improvements / changes in protocols (e.g., referral, f/u, tx)
• Improvements / changes in monitoring
• Improvements / changes in access to care
• Improvements / changes in quality of care
• Report findings from the Mortality Review Meeting to the
MOH and Other Stakeholders who are not already in
attendance.

44. Your Turn: Analysis of Verbal Autopsy
Data: Example #1
Pneumonia deaths in FOCAS/Haiti project area:
• 60% in urban slum, 40% rural areas (same as project distrib.).
• 30% of pneum. deaths were in the first month of life, 30% in 1-11m
period, and 40% in the 12-59m period.
• About half of children who died from pneumonia were males.
• In general, children who died with pneumonia were not malnourished.
• Only 60% of mothers took the child to a health facility during the
illness.
• High proportion of these mothers knew danger signs (gen'l and of
pneumonia).
• Some Health Agents who worked with children were more highly
trained than others, but children were no more likely to die if they were
seen by a more-highly trained Agent than a lesser-trained Agent.

45. Analysis of Verbal Autopsy Data:
Example #1
• Health Agents only saw 6 of the 10 children who died during the
illness preceding the child’s death. (Mothers were supposed to
bring their children to either the clinic or the Health Agent if they had
signs of pneumonia.)
• Sometimes there were stock-outs of antibiotics because Health
Agents would give away (to poor families) antibiotics that they were
supposed to sell, and then not have money to buy enough
antibiotics to replenish their boxes.
• An “ARI Case Management Form” was used to track CHW activities
in terms of ARI. Looking at those forms for all children in the
registers (not just those who died) we found:

46. Analysis of Verbal Autopsy Data:
Example #1
• 19% of children with pneumonia, severe pneumonia, or severe
disease were followed up within two days.
• 43% of children (3 of 7) who should have been referred during the
initial contact were not referred.
• 33% of children (2 of 6) who were the same or worse at follow-up
(according to what the agent marked on the form) were not referred.
• 40% of children whose respiration rate had increased were not
referred.
• Over half (52%) either had follow-up at one month or later, or did not
show follow-up documented on the form.

47. Analysis of Verbal Autopsy Data:
Questions to Examine
Questions to Examine (small groups, 10-15 mins +
report out):
• Given this information, what do you think the problems
are? On what improvements should the project focus?
• What specific things should be considered to prevent
similar deaths in the future there?

48. Haiti: Analysis of Verbal Autopsy
Data: What were the Problems?
• Health Agents who saw the children were not following the
protocols.
• Many children who needed referral (initially and at follow-up)
were not referred, and
• very few (19%) received any follow-up visits in the home.
Important since sometimes the first-line antibiotic does not work
or the mother does not use it properly.
• The staff also need to explore why mothers are not taking
children to clinic even when the child has danger signs and they
know danger signs (e.g., through Barrier Analysis).

49. Haiti: Analysis of Verbal Autopsy
Data: What were the Solutions?
• Follow-up with Health Agents more often to assure that
they are referring children properly and giving high
priority to follow-up of pneumonia cases.
• The CSP Manager started monitoring these forms more
closely.
• Made changes to their forms to make it easier for Health
Agents to know what they should do with a child with
pneumonia.
• Gave Health Agents extra stocks of antibiotics to use
with poor families who could not afford it.

50. Your Turn: Haiti Case History #2
• FOCAS Child Survival project in Haiti using
verbal autopsies (1997 – 2004)
• Operated in two project areas in Haiti.
• From 1999-2002, 31% reduction in the under
five mortality rate in first project area; 65%
reduction in second project area.

51. Haiti Case History #2
• 47% of deaths with VA form completed in
11m period were due to diarrhea and
pneumonia.
• Focused on these deaths associated with
diarrhea and pneumonia.

52. The Facts
• Ten month period (Jan – Nov 2002). (All facts pertain to children who died.)
• OBDC project area: Two deaths in 1-11m age group, 5 in 12-59m age group.
• MEI project area: 6 deaths, all among infants.
• Children who died were not malnourished.
• No relation to gender.
• Not related to transportation
• Most had diarrhea + vomiting
• Only ½ had been to a HF during illness.
• Most who went to HF received medications.
• Most mothers received counseling on ORS (either at home or clinic)
• Most saw a C-IMCI-trained Health Agent
• Many died day after Health Agent contact (before 2-day rtn visit).

53. What key facts would you focus on? Why?
What might you do to improve the situation?
• (10 mins in small groups:)
• OBDC project area: Two deaths in 1-11m age group, 5 in 12-59m age group.
• MEI project area: 6 deaths, all among infants.
• Children who died were not malnourished.
• No relation to gender.
• Not related to transportation
• Most had diarrhea + vomiting
• Only ½ had been to a HF during illness.
• Most who went to HF received medications.
• Most mothers received counseling on ORS (either at home or clinic)
• Most saw a C-IMCI-trained Health Agent
• Many died on day after Health Agent contact (before 2-day rtn visit).

54. Report Out
• What key facts would you focus on?
• Why?
• What might you do to try to change the
situation?

55. What was done: Changes to SBC and Protocols
• More emphasis and changed protocol on follow-up visits: Next-day
follow-up (not two day) of children with (1) diarrhea + signs of
dehydration or severe disease, (2) all children referred for treatment,
and (3) children with diarrhea + vomiting.
• Refer all children who had diarrhea + vomiting if child is unable to
tolerate liquids.
• Explain to every mother what to do when child vomits, and how to
give ORS after vomiting.
• CHW observes ORT if child vomited recently.
Also:
• Worked on purification of water.

56. What was done: Changes to
Administrative / M&E Procedures
• Developed a form to document case management,
referral, and follow-up of diarrheal cases.
• Made changes to Supervisor Monthly Report form
to report up case management.
• Added a section to the Program Manager Monthly
Report Form to report on the quality of these forms.

59. Remember to Examine Delays
Delay Delay was
Delay was a not a Total
problem problem
Recognition that the child had a problem
68% 32% 208
requiring medical attention
Seeking medical care 18% 82% 206
Reaching a health facility in a timely way 26% 74% 207
Receiving care once at health facility 7% 93% 208
Problems with follow-up care or home
care after receiving medical care/advice 86% 14% 208
• What’s the main problems that people are having here?
• What could be done to decrease these types of delays?

60. “Taking off your Health Glasses”:
Renew your Eyes
• Look for problems that the numbers don't
show. Read the narratives!
• Bolivia Verbal Autopsy Case History #1:
Wasted child
• Bolivia Verbal Autopsy Case History #2:
Smothered child

61. Verbal Autopsies Can Save Lives
• They help you and your staff to better
understand patterns of deaths.
• They help you and your staff to better
understand system failures.
• They help you to uncover causes of deaths
"hidden in the numbers."
• They help your staff to connect with families
who have lost children and show you care.