Causes of under-five mortality using verbal autopsies in urban slum areas in Bangladesh: a cross-sectional analysis of surveillance data

To determine the comparability between cause of death (COD) by a single physician coder and a two-physician panel, using verbal autopsy. The study was conducted between May 2007 and June 2008. Within a week of a perinatal death in 38 rural remote communities in Guatemala, the Democratic Republic of Congo, Zambia and Pakistan, VA questionnaires were completed. Two independent physicians, unaware of the others decisions, assigned an underlying COD, in accordance with the causes listed in the chapter headings of the International classification diseases and related health problems, 10th revision (ICD-10). Cohen's kappa statistic was used to assess level of agreement between physician coders. There were 9461 births during the study period; 252 deaths met study enrolment criteria and underwent verbal autopsy. Physicians assigned the same COD for 75% of stillbirths (SB) (K = 0.69; 95% confidence interval: 0.61-0.78) and 82% early neonatal deaths (END) (K = 0.75; 95% confidence interval: 0.65-0.84). The patterns and proportion of SBs and ENDs determined by the physician coders were very similar compared to causes individually assigned by each physician. Similarly, rank order of the top five causes of SB and END was identical for each physician. This study raises important questions about the utility of a system of multiple coders that is currently widely accepted and speculates that a single physician coder may be an effective and economical alternative to VA programmes that use traditional two-physician panels to assign COD.

To investigate causes of and contributors to newborn deaths in eastern Uganda using a three delays audit approach. Methods Data collected on 64 neonatal deaths from a demographic surveillance site were coded for causes of deaths using a hierarchical model and analysed using a modified three delays model to determine contributing delays. A survey was conducted in 16 health facilities to determine capacity for newborn care. Of the newborn babies, 33% died in a hospital/health centre, 13% in a private clinic and 54% died away from a health facility. 47% of the deaths occurred on the day of birth and 78% in the first week. Major contributing delays to newborn death were caretaker delay in problem recognition or in deciding to seek care (50%, 32/64); delay to receive quality care at a health facility (30%; 19/64); and transport delay (20%; 13/64). The median time to seeking care outside the home was 3 days from onset of illness (IQR 1-6). The leading causes of death were sepsis or pneumonia (31%), birth asphyxia (30%) and preterm birth (25%). Health facilities did not have capacity for newborn care, and health workers had correct knowledge on only 31% of the survey questions related to newborn care. Household and health facility-related delays were the major contributors to newborn deaths, and efforts to improve newborn survival need to address both concurrently. Understanding why newborn babies die can be improved by using the three delays model, originally developed for understanding maternal death.

BackgroundNigeria has one of the highest under-five mortality rates in the world. Identifying the causes of these deaths is crucial to inform changes in policy documents, design and implementation of appropriate interventions to reduce these deaths. This study aimed to provide national and zonal-level estimates of the causes of under-five death in Nigeria in the 2013–2018 periods.MethodsWe conducted retrospective inquiries into the cause of deaths of 948 neonates and 2,127 children aged 1–59 months as identified in the 2018 Nigeria Demographic and Health Survey (NDHS). The verbal autopsy asked about signs and symptoms during the final illness. The Physician Coded Verbal Autopsy (PCVA) and Expert Algorithm Verbal Autopsy (EAVA) methods were employed to assign the immediate and underlying cause of deaths to all cases.ResultFor the analysis, sampling weights were applied to accommodate non-proportional allocation. Boys accounted for 56 percent of neonatal deaths and 51.5 percent of the 1–59-months old deaths. About one-quarter of under-5 mortality was attributed to neonatal deaths, and 50 percent of these neonatal deaths were recorded within 48 h of delivery. Overall, 84 percent of the under-5 deaths were in the northern geopolitical zones. Based on the two methods for case analysis, neonatal infections (sepsis, pneumonia, and meningitis) were responsible for 44 percent of the neonatal deaths, followed by intrapartum injury (PCVA: 21 percent vs. EAVA: 29 percent). The three main causes of death in children aged 1–59 months were malaria (PCVA: 23 percent vs. EAVA: 35 percent), diarrhoea (PCVA: 17 percent vs. EAVA: 23 percent), and pneumonia (PCVA: 10 percent vs. EAVA: 12 percent). In the North West, where the majority of under-5 (1–59 months) deaths were recorded, diarrhoea was the main cause of death (PCVA: 24.3 percent vs. EAVA: 30 percent).ConclusionThe causes of neonatal and children aged 1–59 months deaths vary across the northern and southern regions. By homing on the specific causes of mortality by region, the study provides crucial information that may be useful in planning appropriately tailored interventions to significantly reduce under-five deaths in Nigeria.

To validate verbal autopsy (VA) procedures for use in sample vital registration. Verbal autopsy is an important method for deriving cause-specific mortality estimates where disease burdens are greatest and routine cause-specific mortality data do not exist. Verbal autopsies and medical records (MR) were collected for 3123 deaths in the perinatal/neonatal period, post-neonatal <5 age group, and for ages of 5 years and over in Tanzania. Causes of death were assigned by physician panels using the International Classification of Disease, revision 10. Validity was measured by: cause-specific mortality fractions (CSMF); sensitivity; specificity and positive predictive value. Medical record diagnoses were scored for degree of uncertainty, and sensitivity and specificity adjusted. Criteria for evaluating VA performance in generating true proportional mortality were applied. Verbal autopsy produced accurate CSMFs for nine causes in different age groups: birth asphyxia; intrauterine complications; pneumonia; HIV/AIDS; malaria (adults); tuberculosis; cerebrovascular diseases; injuries and direct maternal causes. Results for 20 other causes approached the threshold for good performance. Verbal autopsy reliably estimated CSMFs for diseases of public health importance in all age groups. Further validation is needed to assess reasons for lack of positive results for some conditions.

Clinical registration of the cause of death is available for less than one-third of the global newborn deaths, but the need for good quality data on causes of death for public health planning has renewed the interest in the Verbal Autopsy (VA). We aimed to determine the cause of neonatal deaths by VA in Morang district of Nepal. Caretakers of the deceased were interviewed using a semi-structured VA questionnaire by female community health volunteers. The cause of death was assigned by two senior pediatricians independently and disagreements in ascertaining the proximate cause of death were resolved by consensus. The proximate causes of deaths were infections (41%), birth asphyxia (37.2%), prematurity (11.5%), and low birth weight related causes (6.9%). There was no significant statistical difference in deaths due to infection seen in non-institutional deliveries (43.5%) than institutional deliveries (34.6%). More than half of the deaths (58.5%) occurred within the first three days of life where the predominant cause of death was birth asphyxia (60.7%). Analysis of verbal autopsies demonstrates that the major causes of death still are infections and birth asphyxia. The timing of deaths suggests that neonatal interventions should be aimed at the first week of life. There is no comparative advantage between institutional deliveries at below district level institutions and non-institutional deliveries to prevent neonatal infection. Thus, further study on the quality of care at institutes below the district level should be conducted. Disparities still occur in deaths, with most deaths in Morang occurring in non-institutional deliveries and in disadvantaged groups.

BackgroundInformation on causes of death (COD) is crucial for measuring the health outcomes of populations and progress towards the Sustainable Development Goals. In many countries such as Vietnam where the civil registration and vital statistics (CRVS) system is dysfunctional, information on vital events will continue to rely on verbal autopsy (VA) methods. This study assesses the validity of VA methods used in Vietnam, and provides recommendations on methods for implementing VA validation studies in Vietnam.MethodsThis validation study was conducted on a sample of 670 deaths from a recent VA study in Quang Ninh province. The study covered 116 cases from this sample, which met three inclusion criteria: a) the death occurred within 30 days of discharge after last hospitalisation, and b) medical records (MRs) for the deceased were available from respective hospitals, and c) the medical record mentioned that the patient was terminally ill at discharge. For each death, the underlying cause of death (UCOD) identified from MRs was compared to the UCOD from VA. The validity of VA diagnoses for major causes of death was measured using sensitivity, specificity and positive predictive value (PPV).ResultsThe sensitivity of VA was at least 75% in identifying some leading CODs such as stroke, road traffic accidents and several site-specific cancers. However, sensitivity was less than 50% for other important causes including ischemic heart disease, chronic obstructive pulmonary diseases, and diabetes. Overall, there was 57% agreement between UCOD from VA and MR, which increased to 76% when multiple causes from VA were compared to UCOD from MR.ConclusionsOur findings suggest that VA is a valid method to ascertain UCOD in contexts such as Vietnam. Furthermore, within cultural contexts in which patients prefer to die at home instead of a healthcare facility, using the available MRs as the gold standard may be meaningful to the extent that recall bias from the interval between last hospital discharge and death can be minimized. Therefore, future studies should evaluate validity of MRs as a gold standard for VA studies in contexts similar to the Vietnamese context.

BackgroundEthiopia has made remarkable progress in reducing child mortality over the last two decades. However, the under-5 mortality rate in Ethiopia is still higher than the under-5 mortality rates of several low- and middle-income countries (LMIC). On the other hand, the patterns and causes of child mortality have not been well investigated in Ethiopia. The objective of this study was to investigate the mortality trend, causes of death, and risk factors among children under 5 in Ethiopia during 1990–2013.MethodsWe used Global Burden of Disease (GBD) 2013 data. Spatiotemporal Gaussian Process Regression (GPR) was applied to generate best estimates of child mortality with 95% uncertainty intervals (UI). Causes of death by age groups, sex, and year were measured using Cause of Death Ensemble modeling (CODEm). For estimation of HIV/AIDS mortality rate, the modified UNAIDS EPP-SPECTRUM suite model was used.ResultsBetween 1990 and 2013 the under-5 mortality rate declined from 203.9 deaths/1000 live births to 74.4 deaths/1000 live births with an annual rate of change of 4.6%, yielding a total reduction of 64%. Similarly, child (1–4 years), post-neonatal, and neonatal mortality rates declined by 75%, 64%, and 52%, respectively, between 1990 and 2013. Lower respiratory tract infection (LRI), diarrheal diseases, and neonatal syndromes (preterm birth complications, neonatal encephalopathy, neonatal sepsis, and other neonatal disorders) accounted for 54% of the total under-5 deaths in 2013. Under-5 mortality rates due to measles, diarrhea, malaria, protein-energy malnutrition, and iron-deficiency anemia declined by more than two-thirds between 1990 and 2013. Among the causes of under-5 deaths, neonatal syndromes such as sepsis, preterm birth complications, and birth asphyxia ranked third to fifth in 2013.Of all risk-attributable deaths in 1990, 25% of the total under-5 deaths (112,288/435,962) and 48% (112,288/232,199) of the deaths due to diarrhea, LRI, and other common infections were attributable to childhood wasting. Similarly, 19% (43,759/229,333) of the total under-5 deaths and 45% (43,759/97,963) of the deaths due to diarrhea and LRI were attributable to wasting in 2013. Of the total diarrheal disease- and LRI-related deaths (n = 97,963) in 2013, 59% (57,923/97,963) of them were attributable to unsafe water supply, unsafe sanitation, household air pollution, and no handwashing with soap.ConclusionsLRI, diarrheal diseases, and neonatal syndromes remain the major causes of under-5 deaths in Ethiopia. These findings call for better-integrated newborn and child survival interventions focusing on the main risk factors.

To describe causes of under-5 deaths occurring in the health care system in Mafikeng region and modifiable factors related to these deaths. A prospective descriptive study. The four public sector hospitals in Mafikeng health region in North West province (Gelukspan, Zeerust-Lehurutshe, Thusong, and Mafikeng Provincial Hospital). This study of under-5 deaths used and piloted the Under-5 health care Problem Identification Programme. 1 November 2000-31 October 2001. Two hundred and thirty-nine under-5 deaths occurred in the health system. The case fatality rate for the total of 4 226 under-5 admissions was 5.7%. Seventy-four per cent of the under-5 deaths occurred during the first year of life; 31% during the first 24 hours in hospital. The main causes of death were lower respiratory tract infections (31.4%), AIDS (21.3%) and sepsis (13.4%). When adding all causes of death and contributing conditions, 61.9% were AIDS- or HIV-related. Eighty-three per cent of cases had administrative modifiable factors, 67% had modifiable factors at primary care level, 47% during admission/emergency care in hospital, and 55% during routine care. Priority problems identified in this study were case management of lower respiratory tract infections, failure to thrive, and insufficient documentation of patient care. As most under-5 deaths in this study were HIV/AIDS-related, it is an urgent necessity to expand effective programmes to prevent mother-to-child transmission and HIV infection in adults and to advocate comprehensive treatment programmes for HIV/AIDS.

ObjectivesThis study was conducted to evaluate the performance of World Health Organisation (WHO) verbal autopsy tool in determining major causes of neonatal deaths.MethodsFrom a tertiary care hospital and a government multispecialty hospital, the attending paediatricians ascertained a clinical cause of death for 371 neonatal deaths. Trained field workers conducted verbal autopsy (VA) interviews. Two independent paediatricians, who had no access to the clinical information, assigned cause of death as per verbal autopsy. Analysis was based on 313 cases in which both clinical diagnosis and VA diagnosis was obtained.FindingsAs per the clinical diagnosis, four most common causes of neonatal deaths were sepsis (29.1%), preterm birth (27.8%), birth asphyxia (27.2%), and congenital anomalies (11.5%). Cause specific mortality fractions by VA diagnosis were statistically similar to those obtained by clinical diagnosis except for birth asphyxia (16.3%). Diagnostic accuracy of verbal autopsy diagnosis against clinical diagnosis ranged from 78% to 92% in ascertaining different underlying causes of death. Area under the Receiver-Operator Characteristics curve (95% confidence interval) was 0.75 (0.69–0.80) for sepsis, 0.74 (0.68–0.80) for preterm birth, 0.73 (0.65–0.82) for congenital anomaly and 0.70 (0.64–0.75) for birth asphyxia. Kappa for all four causes was moderate (0.46–0.55).InterpretationThe WHO verbal autopsy tools can provide reasonably good estimates of predominant causes of neonatal deaths in countries where neonatal mortality is high. Caution is required to interpret cause specific mortality fraction (CSMF) for birth asphyxia by VA because it is likely to be an underestimate.

Background Determination of death causes is an important building block for civil registration and vital statistics (CRVS). This study aimed at identifying the causes of under-five mortality (U5M) in Alexandria using verbal autopsy (VA). Methods Data of 645 under-fives (452 neonates &amp; 193 post-neonates and children) deaths were retrieved from records from January 2018 to June 2019, care-givers were interviewed using Verbal Autopsy and Social Autopsy Studies (VASA), version 1.5.1 developed by the World Health Organization. Questionnaires (neonatal and child forms) were uploaded to the Open Data Kit collector (ODK), analyzed by Smart-VA software to identify the underlying cause of death (UCOD). Results The response rate to VASA was 66%. Neonatal mortality, post-neonatal mortality, and child mortality represented 70.1%, 24.5%, and 5.4% of U5M respectively. There was no statistically significant difference between males and females in cause-specific mortality fraction (CSMF), P &gt; 0.05. The main UCODs among neonates were preterm delivery (57.3%), congenital malformation (17.3%), congenital pneumonia (10.8%), birth asphyxia (8.4%), and stillbirth (3.1%). The most-reported UCODs among post-neonates and children were pneumonia (25.9%), childhood cardiovascular diseases (22.8%), digestive system diseases (11.9%), and diarrhea and dysentery (7.8%). The main UCODs among under-five children were preterm delivery (40.2%), followed by congenital malformation (12.1%), pneumonia (7.8%), congenital pneumonia (7.6%), childhood cardiovascular diseases (6.8%), and birth asphyxia (5.9%). Communicable diseases, maternal, neonatal, and nutritional diseases caused 72.0% of U5M, while non-communicable diseases and injuries caused 25.7% and 2.4% of all U5M, respectively. Conclusions VASA declared that communicable diseases, maternal, nutritional, and neonatal diseases remain the main killer of U5C in Alexandria.

Is cerebral palsy a cause of death?

BackgroundIn developing countries, it is difficult to collect the data of the underlying cause of death (UCOD), especially when a death does not occur in a health facility. This study aimed to develop a short version of verbal autopsy (VA) and identify the UCOD of adults in Lao People’s Democratic Republic (Lao PDR).MethodsA short version of VA for deaths outside health facilities was developed. This study included all deaths of people aged 15 years old or older in Xaiyabouli Province in 2020. Socio-demographic factors, place of death, and UCOD of the deceased were collected from health facilities or from family members using a questionnaire including the short VA form. UCOD was compared between home deaths and hospital deaths, between the age group of 15–59 years old and the age group ≥ 60 years old, and between males and females.ResultsOf all the 1,235 deaths included in this study, 1,012 deaths (81.9%) occured at home and 223 deaths (18.1%) at hospitals. The most common UCOD was senility (13.3%), followed by heart/renal failure (10.5%), pneumonia (9.6%) and traffic accident (7.1%). Compared to hospital deaths, home deaths had more people who were females, 75 years old or older, and Lao-Tai. Home deaths had more deaths than hospital deaths due to accident/injury (16.0% vs. 8.1%), tumor (4.7% vs. 1.8%), and senility (16.2% vs. 0%); fewer deaths due to heart/renal disease (15.1% vs. 32.3%), respiratory disease (12.2% vs. 18.8%), liver/gastro-intestine disease (5.3% vs. 9.0%), and infection (3.1% vs. 14.3%). The age group of 15–59 years had more deaths in the categories of accident/injury (28.1% vs. 4.4%), liver/gastro-intestine disease (8.1% vs. 4.4%), infection (7.2% vs. 3.5%), and tumor (6.0% vs. 2.8%). Males had more deaths due to tumor (5.2% vs. 3.0%) and fewer natural deaths (11.2% vs. 15.9%) than females.ConclusionsThe major UCOD category was heart/renal disease in the adult generation in Xaiyabouli Province. Cost-effective interventions based on the multisectoral noncommunicable disease prevention plan should be appropriately implemented. Mortality surveillance using the short VA tool should be conducted for all home deaths in Lao PDR.

Data on adult mortality are very limited in sub-Saharan Africa where only small proportions of deaths occur in health facilities. In such settings, ascertainment of causes of death from data obtained from relatives or associates of the deceased through interviews in surveys or longitudinal surveillance systems appears to be an attractive option. This technique, known as verbal autopsy (VA) is based on the assumption that important causes of death have distinctive symptoms and signs, and these can be recognised, remembered and reported by lay respondents, and that based on the reported information causes of death can be reached. The existing experience of VA for adult death is limited mainly to maternal deaths and the validity of VA for adult death is unknown. We developed a VA questionnaire, mortality classification system and expert opinion based algorithms for reaching diagnoses for adult deaths and tested their validity on deaths occurring at hospitals in Tanzania (n=315), Ethiopia (n=249) and Ghana (n=232). Hospital records of adult deaths occurring at study hospitals from June 1993 to April 1995 were collected prospectively. VA interviews were conducted by trained non-medical interviewers. Caused of death from VA data were reached by a panel of three physicians and by a computerised algorithm. The validity of VA was assessed by comparing the VA diagnoses with hospital diagnoses. Specificity of VA fell below 95% only for few common causes of adult death. Sensitivity and kappa of VA for all common causes of adult death were low and this suggests that the accuracy of VA at the individual level is low. However, the misclassification of causes of death was bi-directional and the number of false positive and false negative diagnosis for most common causes of adult death tend to be similar. Thus there was robust agreement between the true and VA estimates of cause specific mortality fractions of common causes of adult death and VA is useful for assessing cause specific mortality fractions of common causes of adult death.

BackgroundAccurate and timely data on cause of death are critically important for guiding health programs and policies. Deaths certified by doctors are implicitly considered to be reliable and accurate, yet the quality of information provided in the international Medical Certificate of Cause of Death (MCCD) usually varies according to the personnel involved in certification, the diagnostic capacity of the hospital, and the category of hospitals. There are no published studies that have analysed how certifying doctors in Bangladesh adhere to international rules when completing the MCCD or have assessed the quality of clinical record keeping.MethodsThe study took place between January 2011 and April 2014 in the Chandpur and Comilla districts of Bangladesh. We introduced the international MCCD to all study hospitals. Trained project physicians assigned an underlying cause of death, assessed the quality of the death certificate, and reported the degree of certainty of the medical records provided for a given cause. We examined the frequency of common errors in completing the MCCD, the leading causes of in-hospital deaths, and the degree of certainty in the cause of death data.ResultsThe study included 4914 death certificates. 72.9% of medical records were of too poor quality to assign a cause of death, with little difference by age, hospital, and cause of death. 95.6% of death certificates did not indicate the time interval between onset and death, 31.6% required a change in sequence, 13.9% required to include a new diagnosis, 50.7% used abbreviations, 41.5% used multiple causes per line, and 33.2% used an ill-defined condition as the underlying cause of death. 99.1% of death certificates had at least one error. The leading cause of death among adults was stroke (15.8%), among children was pneumonia (31.7%), and among neonates was birth asphyxia (52.8%).ConclusionPhysicians in Bangladeshi hospitals had difficulties in completing the MCCD correctly. Physicians routinely made errors in death certification practices and medical record quality was poor. There is an urgent need to improve death certification practices and the quality of hospital data in Bangladesh if these data are to be useful for policy.

SummaryBackgroundSub-Saharan Africa and south Asia contributed 81% of 5·9 million under-5 deaths and 77% of 2·6 million stillbirths worldwide in 2015. Vital registration and verbal autopsy data are mainstays for the estimation of leading causes of death, but both are non-specific and focus on a single underlying cause. We aimed to provide granular data on the contributory causes of death in stillborn fetuses and in deceased neonates and children younger than 5 years, to inform child mortality prevention efforts.MethodsThe Child Health and Mortality Prevention Surveillance (CHAMPS) Network was established at sites in seven countries (Baliakandi, Bangladesh; Harar and Kersa, Ethiopia; Siaya and Kisumu, Kenya; Bamako, Mali; Manhiça, Mozambique; Bombali, Sierra Leone; and Soweto, South Africa) to collect standardised, population-based, longitudinal data on under-5 mortality and stillbirths in sub-Saharan Africa and south Asia, to improve the accuracy of determining causes of death. Here, we analysed data obtained in the first 2 years after the implementation of CHAMPS at the first five operational sites, during which surveillance and post-mortem diagnostics, including minimally invasive tissue sampling (MITS), were used. Data were abstracted from all available clinical records of deceased children, and relevant maternal health records were also extracted for stillbirths and neonatal deaths, to incorporate reported pregnancy or delivery complications. Expert panels followed standardised procedures to characterise causal chains leading to death, including underlying, intermediate (comorbid or antecedent causes), and immediate causes of death for stillbirths, neonatal deaths, and child (age 1–59 months) deaths.FindingsBetween Dec 10, 2016, and Dec 31, 2018, MITS procedures were implemented at five sites in Mozambique, South Africa, Kenya, Mali, and Bangladesh. We screened 2385 death notifications for inclusion eligibility, following which 1295 families were approached for consent; consent was provided for MITS by 963 (74%) of 1295 eligible cases approached. At least one cause of death was identified in 912 (98%) of 933 cases (180 stillbirths, 449 neonatal deaths, and 304 child deaths); two or more conditions were identified in the causal chain for 585 (63%) of 933 cases. The most common underlying causes of stillbirth were perinatal asphyxia or hypoxia (130 [72%] of 180 stillbirths) and congenital infection or sepsis (27 [15%]). The most common underlying causes of neonatal death were preterm birth complications (187 [42%] of 449 neonatal deaths), perinatal asphyxia or hypoxia (98 [22%]), and neonatal sepsis (50 [11%]). The most common underlying causes of child deaths were congenital birth defects (39 [13%] of 304 deaths), lower respiratory infection (37 [12%]), and HIV (35 [12%]). In 503 (54%) of 933 cases, at least one contributory pathogen was identified. Cytomegalovirus, Escherichia coli, group B Streptococcus, and other infections contributed to 30 (17%) of 180 stillbirths. Among neonatal deaths with underlying prematurity, 60% were precipitated by other infectious causes. Of the 275 child deaths with infectious causes, the most common contributory pathogens were Klebsiella pneumoniae (86 [31%]), Streptococcus pneumoniae (54 [20%]), HIV (40 [15%]), and cytomegalovirus (34 [12%]), and multiple infections were common. Lower respiratory tract infection contributed to 174 (57%) of 304 child deaths.InterpretationCause of death determination using MITS enabled detailed characterisation of contributing conditions. Global estimates of child mortality aetiologies, which are currently based on a single syndromic cause for each death, will be strengthened by findings from CHAMPS. This approach adds specificity and provides a more complete overview of the chain of events leading to death, highlighting multiple potential interventions to prevent under-5 mortality and stillbirths.FundingBill & Melinda Gates Foundation.