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Institute for International Programs

Verbal Autopsy and Social Autopsy Studies (VASA)

Through a grant to the U.S. Fund for UNICEF on behalf of the WHO/UNICEF-supported Child Health Epidemiology Reference Group (CHERG), the Bill and Melinda Gates Foundation (BMGF) supported a set of 14 activities to provide improved global estimates and measures of the causes and determinants of maternal, neonatal and child morbidity and mortality, of intervention coverage, and of the effectiveness of health interventions. Many of these activities entailed gathering and reviewing existing data and building models to develop estimates; while two activities partly involved gathering new verbal and social autopsy (VASA) data in several high priority countries. Post the CHERG grant, this work continues through the Maternal and Child Epidemiology Estimation (MCEE) grant from the Gates Foundation to the Johns Hopkins Institute for International Programs.

The main purpose of a VASA study is to directly estimate the causes and determinants of neonatal and child mortality, in contrast to the World Health Organization’s modeled estimates of causes of death that most developing countries rely on. The VASA estimates are used to help improve global, regional and country estimates through their incorporation into updates of the modeled estimates, and are also used by countries that conduct a VASA study to improve their own mortality estimates and for health policy and program development.

Verbal autopsy (VA) – causes of death

Verbal autopsy is the most useful tool available to determine cause of death in settings with limited access to health care. A VA inquiry of a child’s death consists of interviewing the main caregiver about the fatal illness. The cause of death is determined from predefined combinations of the reported illness signs; by independent classification of the interview findings by one or more study physicians; or by statistical methods that examine the associations between particular signs and illnesses. Verbal Autopsy is not intended to make a gold standard diagnosis of an individual’s cause of death, however it is the best available method for diagnosing cause of death in settings where many deaths occur outside of medical care and lack proper medical certification. Globally, common causes of death that verbal autopsy can diagnose include birth injury/asphyxia, diarrhea, congenital malformation, preterm delivery, serious infections (sepsis, pneumonia, meningitis) and tetanus in neonates, and AIDS, diarrhea, dysentery, injury, malaria, malnutrition, measles, meningitis, Pertussis and pneumonia in children (1-59 month). Important uses of verbal autopsy cause of death findings include identifying health priorities, allocating sparse resources and evaluating health program impact

Social autopsy (SA) – social and behavioral determinants of death 

While knowledge of the biological causes of child death is important, effective delivery of child survival interventions depends on improved understanding of modifiable cultural, social and health system factors affecting health care access and utilization. Social Autopsy findings detail the most common household (e.g., mother’s and father’s education, pregnancy and wellness care, care seeking and constraints), community (e.g., residence place, time to reach  health care in an emergency, social capital) and health system (e.g., ANC content, delivery care, newborn and child care, child illness care) factors that contributed to the deaths. The “Pathway to Survival” conceptual framework (figure), organizes the steps that families, communities and health systems must take to prevent illness and return sick children to health. Social autopsy findings are useful for guiding effective delivery of child survival technologies by informing health policy and program development for increased access and utilization of preventive and curative health care.

For the VASA activity, countries with high burden of child mortality and inadequate data on the causes and determinants of child death were selected with the objective that VASA results can contribute to a national initiative and to global or regional evidence on mortality causes and trends. To-date, VASA studies have been conducted in the following four countries:

Publications

Koffi AK, Kalter HD, Loveth EN, Quinley J, Monehin J, Black RE (2017) Beyond causes of death: The social determinants of mortality among children aged 1-59 months in Nigeria from 2009 to 2013. PLoS ONE 12(5): e0177025. https://doi.org/10.1371/journal.pone.0177025.

Adewemimo A, Kalter HD, Perin J, Koffi AK, Quinley J, Black RE (2017) Direct estimates of cause-specific mortality fractions and rates of under-five deaths in the northern and southern regions of Nigeria by verbal autopsy interview. PLoS ONE 12(5): e0178129. https://doi.org/10.1371/journal.pone.0178129.

Sociodemographic, behavioral, and environmental factors of child mortality in Eastern Region of Cameroon: results from a social autopsy study. Koffi AK, Wounang RS, Nguefack F, Moluh S, Libite PR, Kalter HD. J Glob Health. 2017. doi: 10.7189/jogh.07.010601.
Understanding misclassification between neonatal deaths and stillbirths: empirical evidence from Malawi. Liu L, Kalter HD, Chu Y, Kazmi N, Koffi AK, Amouzou A, Joos O, Munos M, Black RE. PLOS ONE. 2016. doi: doi:10.1371/journal.pone.0168743

Validating hierarchical verbal autopsy expert algorithms in a large data set with known causes of death. Kalter HD, Perin J, Black RE. JOGH. 2016. doi: 10.7189/jogh.06.010601

Verbal/Social Autopsy in Niger 2012–2013: a new tool for a better understanding of the neonatal and child mortality situation. Bensaid K, Yaroh AG, Kalter HD, Koffi AK, Amouzou A, Maina A, Kazmi N. JOGH. 2016. doi: 10.7189/jogh.06.010602 

Social determinants of child mortality in Niger: results from the 2012 National Verbal and Social Autopsy Study. Koffi AK, Maina A, Yaroh AG, Habi O, Bensaid K, Kalter HD. JOGH. 2016. doi: 10.7189/jogh.06.010603

Verbal/social autopsy study helps explain the lack of decrease in neonatal mortality in Niger, 2007–2010. Kalter HD, Yaroh AG, Maina A, Koffi AK, Bensaid K, Amouzou A, Black RE. JOGH. 2016. doi: 10.7189/jogh.06.010604

Factors associated with delay in care–seeking for fatal neonatal illness in the Sylhet district of Bangladesh: results from a verbal and social autopsy study. Nonyane BAS, Kazmi N, Koffi AK, Begum N, Ahmed S, Baqui AH, Kalter HD. JOGH. 2016. doi: 10.7189/jogh.06.010605

Social autopsy study identifies determinants of neonatal mortality in Doume, Nguelemendouka and Abong–Mbang health districts, eastern region of Cameroon. Koffi AK, Libite PR, Moluh S, Wounang R, Kalter HD. JOGH. 2015. doi: 10.7189/jogh.05.010413

Deriving causes of child mortality by re–analyzing national verbal autopsy data applying a standardized computer algorithm in Uganda, Rwanda and Ghana. Liu L, Li M, Cummings S, Black RE. JOGH. 2015. doi: 10.7189/jogh.05.010414

Direct estimates of national neonatal and child cause–specific mortality proportions in Niger by expert algorithm and physician–coded analysis of verbal autopsy interviews. Kalter HD, Roubanatou AM, Koffi A, Black RE. JOGH. 2015. doi: 10.7189/jogh.05.010415

Social autopsy of neonatal mortality suggests needed improvements in maternal and neonatal interventions in Balaka and Salima districts of Malawi. Koffi AK, Mleme T, Nsona H, Banda B, Amouzou A, Kalter HD. JOGH. 2015. doi: 10.7189/jogh.05.010416

Increased use of social autopsy is needed to improve maternal, neonatal and child health programmes in low-income countries. Waiswa P, Kalter HD, Jakob R, Black RE for the Social Autopsy Working Group. Bull World Health Organ. 2012.  doi:10.2471/BLT.12.105718

Social autopsy for maternal and child deaths: a comprehensive literature review to examine the concept and the development of the method. Kalter HD, Salgado R, Babille M, Koffi AK, Black RE. Population Health Metrics. 2011. doi:10.1186/1478-7954-9-45