Population cause of death estimation using verbal autopsy methods in large-scale field trials of maternal and child health: lessons learned from a 20-year research collaboration in Central Ghana

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.

Verbal autopsy (VA) is an attractive method for ascertaining causes of death in settings where the proportion of people who die under medical care is low. VA has been widely used to determine causes of childhood and maternal deaths, but has had limited use in assessing causes in adults and across all age groups. The objective was to test the feasibility of using VA to determine causes of death for all ages in Bavi District, Vietnam, in 1999, leading to an initial analysis of the mortality pattern in this area. Trained lay field workers interviewed a close caretaker of the deceased using a combination closed/open-ended questionnaire. A total of 189 deaths were studied. Diagnoses were made by two physicians separately, with good agreement (kappa = 0.84) and then combined to reach one single underlying cause of death for each case. The leading causes of death were cardiovascular and infectious diseases (accounting for 20.6% and 17.9% of the total respectively). Drowning was very prevalent in children under 15 (seven out of nine cases of drowning were in this age group). One month seemed an acceptable minimum recall period to ensure mourning procedures were over. A combination VA questionnaire was an appropriate instrument provided it was supported by adequate training of interviewers. Two physicians were appropriate for making the diagnoses but predefined diagnostic methods for common causes should be developed to ensure more replicable results and comparisons, as well as to observe trends of mortality over time. The causes of death in this study area reflect a typical pattern for developing countries that are in epidemiological transition. No maternal deaths and a low infant mortality rate may be the result of improvements in maternal and child health in this study area. Using the VA gave more precise causes of death than those reported at death registration. Although the validity of the VA method used has not been fully assessed, it appeared to be an appropriate method for ascertaining causes of death in the study area.

BackgroundVerbal autopsy has been widely used to estimate causes of death in settings with inadequate vital registries, but little is known about its validity. This analysis was part of Addis Ababa Mortality Surveillance Program to examine the validity of verbal autopsy for determining causes of death compared with hospital medical records among adults in the urban setting of Ethiopia.MethodsThis validation study consisted of comparison of verbal autopsy final diagnosis with hospital diagnosis taken as a “gold standard”. In public and private hospitals of Addis Ababa, 20,152 adult deaths (15 years and above) were recorded between 2007 and 2010. With the same period, a verbal autopsy was conducted for 4,776 adult deaths of which, 1,356 were deceased in any of Addis Ababa hospitals. Then, verbal autopsy and hospital data sets were merged using the variables; full name of the deceased, sex, address, age, place and date of death. We calculated sensitivity, specificity and positive predictive values with 95% confidence interval.ResultsAfter merging, a total of 335 adult deaths were captured. For communicable diseases, the values of sensitivity, specificity and positive predictive values of verbal autopsy diagnosis were 79%, 78% and 68% respectively. For non-communicable diseases, sensitivity of the verbal autopsy diagnoses was 69%, specificity 78% and positive predictive value 79%. Regarding injury, sensitivity of the verbal autopsy diagnoses was 70%, specificity 98% and positive predictive value 83%. Higher sensitivity was achieved for HIV/AIDS and tuberculosis, but lower specificity with relatively more false positives.ConclusionThese findings may indicate the potential of verbal autopsy to provide cost-effective information to guide policy on communicable and non communicable diseases double burden among adults in Ethiopia. Thus, a well structured verbal autopsy method, followed by qualified physician reviews could be capable of providing reasonable cause specific mortality estimates in Ethiopia. However, the limited generalizability of this study due to the fact that matched verbal autopsy deaths were all in-hospital deaths in an urban center, thus results may not be generalizable to rural home deaths. Such application and refinement of existing verbal autopsy methods holds out the possibility of obtaining replicable, sustainable and internationally comparable mortality statistics of known quality. Similar validation studies need to be undertaken considering the limitation of medical records as “gold standard” since records may not be confirmed using laboratory investigations or medical technologies. The validation studies need to address child and maternal causes of death and possibly all underlying causes of death.

Over the past 70 years, significant advances have been made in determining the causes of death in populations not served by official medical certification of cause at the time of death using a technique known as Verbal Autopsy (VA). VA involves an interview of the family or caregivers of the deceased after a suitable bereavement interval about the circumstances, signs and symptoms of the deceased in the period leading to death. The VA interview data are then interpreted by physicians or, more recently, computer algorithms, to assign a probable cause of death. VA was originally developed and applied in field research settings. This paper traces the evolution of VA methods with special emphasis on the World Health Organization’s (WHO)’s efforts to standardize VA instruments and methods for expanded use in routine health information and vital statistics systems in low- and middle-income countries (LMICs). These advances in VA methods are culminating this year with the release of the 2022 WHO Standard Verbal Autopsy (VA) Toolkit. This paper highlights the many contributions the late Professor Peter Byass made to the current VA standards and methods, most notably, the development of InterVA, the most commonly used automated computer algorithm for interpreting data collected in the WHO standard instruments, and the capacity building in low- and middle-income countries (LMICs) that he promoted. This paper also provides an overview of the methods used to improve the current WHO VA standards, a catalogue of the changes and improvements in the instruments, and a mapping of current applications of the WHO VA standard approach in LMICs. It also provides access to tools and guidance needed for VA implementation in Civil Registration and Vital Statistics Systems at scale.

Reducing maternal mortality is a key focus of development strategies and one of the indicators used to measure progress towards achieving the Sustainable Development Goals. In the absence of medical certification of the cause of deaths that occur in the community, verbal autopsy (VA) methods are the only available means to assess levels and trends of maternal deaths that occur outside health facilities. The 2016 World Health Organization VA Instrument facilitates the identification of eight specific causes of maternal death, yet maternal deaths are often unsupervised, leading to sparse and generally poor symptom reporting to inform a reliable diagnosis using VAs. There is little research evidence to support the reliable identification of specific causes of maternal death in the context of routine VAs. We recommend that routine VAs are only used to capture the event of a maternal death and that more detailed follow-up interviews are used to identify the specific causes.

Commentary In recent decades, verbal autopsy (VA) methods have been increasingly used to identify likely causes of death in settings where the majority of deaths occur without medical attention or certification as to cause [1]. Developments in the 1980s and 1990s advanced the conceptual and methodological aspects of the science considerably but fell short of providing a clear message about best practices for those who rely on VA data [2-10]. There has been a hiatus of methodological development since then, due in part to persistent, narrow assumptions as to the desire and need for cause of death data and unrealistic evaluation standards. This has not limited the application of VA methods in the world’s poorest settings, but it has almost certainly limited the usefulness and comparability of the data. There remains scarce evidence on which to base choice of methods at the various stages of the VA data process. However, the first ever Global Congress on Verbal Autopsy, held in Bali, Indonesia in February 2011, represents a resurgence of methodological and conceptual developments VA is arguably one of the most important fields in global health today. Methodological development in recent years, particularly in relation to probabilistic interpretation of VA data, has brought VA into an exciting era that is creating new opportunities for reliable, timely, and useful cause-specific mortality measurement. A shift away from limited individual-level and clinical paradigms towards population-based epidemiological thinking and public health utility has been characterized by a flurry of new methodological thinking and innovations from relatively small groups of researchers. Among these like-minded researchers, however, there is risk of a divide between pragmatic optimists and optimistic theorists. The pragmatic optimists are driven by the realities, perils, and pitfalls of real-life health measurement in low-income settings and strive to enhance health knowledge with methods that are good enough to fill data gaps reliably and efficiently. The optimistic theorists, whose methodological developments are often theoretically superior, are often far from offering practical solutions to those on the ground who need to know the major burdens of cause-specific mortality in their populations simply, quickly, and cheaply in the absence of pre-existing data and where “true validity” is difficult to establish. Such dichotomization is perhaps somewhat artificial, but there is a real risk that unrealistic standards and expectations in method development and evaluation will become the enemy of good enough methods that are able to provide essential data to those who need it. The Global Congress on VA was attended by over 100 delegates representing numerous agencies and academic institutions from around the globe. This level of participation illustrates not only the persistent desire to know who died from what in the world’s poorest settings, but also a desire for clear leadership on what the best methods are and how to use them. Whilst methodological favoritism, ideology, and competition can be a threat to an objective answer to this question, such factors are, in reality, likely to be minor and secondary to the more fundamental difficulty of recognizing the range of users who need cause of death data and what data they need. Differing cause of death data needs have been well described previously and the nonexistence of a one-sizefits-all solution to all needs is likely to persist [11]. This statement is grounded in recognition of the realities of health metrics in the world’s poorest populations and the imperfect world of lay-reported signs and symptoms, dubious record keeping, and biases in remembering, reporting, and recording certain events. It is in recognition of these realities that the gap between the pragmatic optimists and the optimistic theorists may grow: the first believing that method development cannot necessarily rely on pre-existing data and should be evaluated in terms of comparability to reference (but not Correspondence: Edward.Fottrell@epiph.umu.se Umea Centre for Global Health Research, Department of Public Health and Clinical Medicine, Umea University, Sweden Full list of author information is available at the end of the article Fottrell Population Health Metrics 2011, 9:24 http://www.pophealthmetrics.com/content/9/1/24

ABSTRACTBackground: In Ethiopia, though all kinds of mortality due to external causes are an important component of overall mortality often not counted or documented on an individual basis.Objective: The aim of this study was to describe the patterns of mortality from external causes using verbal autopsy (VA) method at the Ethiopian HDSS Network sites.Methods: All deaths at Ethiopian HDSS sites were routinely registered and followed up with VA interviews. The VA forms comprised deaths up to 28 days, between four weeks and 14 years and 15 years and above. The cause of a death was ascertained based on an interview with next of families or other caregivers using a standardized questionnaire that draws information on signs, symptoms, medical history and circumstances preceding death after 45 days mourning period. Two physician assigned probable causes of death as underlying, immediate and contributing factors independently using information in VA forms based on the WHO ICD-10 and VA code system. Disagreed cases sent to third physician for independent review and diagnosis. The final cause of death considered when two of the three physicians assigned underlying cause of death; otherwise, labeled as undetermined.Results: In the period from 2009 to 2013, a total of 9719 deaths were registered. Of the total deaths, 623 (6.4%) were from external causes. Of these, accidental drowning and submersion, 136 (21.8%), accidental fall, 113 (18.1%) and transport-related accidents, 112 (18.0%) were the topmost three leading external causes of deaths. About 436 (70.0%) of deaths were from the age group above 15 years old. Drowning and submersion and transport-related accidents were high in age group between 5 and 14 years old.Conclusion: In this study, external causes of death are significant public health problems and require attention as one of prior health agenda.

BackgroundThe health problems of adults have been neglected in many developing countries, yet many studies in these countries show high rates of premature mortality in adults. Measuring adult mortality and its cause through verbal autopsy (VA) methods is becoming an important process for mortality estimates and is a good indicator of the overall mortality rates in resource-limited settings. The objective of this analysis is to describe the levels, distribution, and trends of adult mortality over time (2008-2013) and causes of adult deaths using VA in Kersa Health and Demographic Surveillance System (Kersa HDSS).MethodsKersa HDSS is a demographic and health surveillance and research center established in 2007 in the eastern part of Ethiopia. This is a community-based longitudinal study where VA methods were used to assign probable cause of death. Two or three physicians independently assigned cause of death based on the completed VA forms in accordance with the World Health Organization’s International Classification of Diseases. In this analysis, the VA data considered were of all deaths of adults age 15 years and above, over a period of six years (2008–2013). The mortality fractions were determined and the causes of death analyzed. Analysis was done using STATA and graphs were designed using Microsoft Excel.ResultsA total of 1535 adult deaths occurred in the surveillance site during the study period and VA was completed for all these deaths. In general, the adult mortality rate over the six-year period was 8.5 per 1000 adult population, higher for males (9.6) and rural residents (8.6) than females (7.5) and urban residents (8.2). There is a general decrease in the mortality rates over the study period from 9.4 in 2008–2009 to 8.1 in 2012–2013. Out of the total deaths, about one-third (32.4%) occurred due to infectious and parasitic causes, and the second leading cause of death was diseases of circulatory system (11.4%), followed by gastrointestinal disorders (9.2%). Tuberculosis (TB) showed an increasing trend over the years and has been the leading cause of death in 2012 and 2013 for all adult age categories (15–49, 50–64, and 65 years and over). Chronic liver disease (CLD) was indicated as leading cause of death among adults in the age group 15–49 years.ConclusionThe increasing TB-related mortality in the study years as well as the relative high mortality due to CLD among adults of age 15–49 years should be further investigated and triangulated with health service data to understand the root cause of death.

BackgroundAscertainment of cause for deaths that occur in the absence of medical attention is a significant problem in many countries, including Thailand, where more than 50% of such deaths are registered with ill-defined causes. Routine implementation of standardized, rigorous verbal autopsy methods is a potential solution. This paper reports findings from field research conducted to develop, test, and validate the use of verbal autopsy (VA) methods in Thailand.MethodsInternational verbal autopsy methods were first adapted to the Thai context and then implemented to ascertain causes of death for a nationally representative sample of 11,984 deaths that occurred in Thailand in 2005. Causes of death were derived from completed VA questionnaires by physicians trained in ICD-based cause-of-death certification. VA diagnoses were validated in the sample of hospital deaths for which reference diagnoses were available from medical record review. Validated study findings were used to adjust VA-based causes of death derived for deaths in the study sample that had occurred outside hospitals. Results were used to estimate cause-specific mortality patterns for deaths outside hospitals in Thailand in 2005.ResultsVA-based causes of death were derived for 6,328 out of 7,340 deaths in the study sample that had occurred outside hospitals, constituting the verification arm of the study. The use of VA resulted in large-scale reassignment of deaths from ill-defined categories to specific causes of death. The validation study identified that VA tends to overdiagnose important causes such as diabetes, liver cancer, and tuberculosis, while undercounting deaths from HIV/AIDS, liver diseases, genitourinary (essential renal), and digestive system disorders.ConclusionsThe use of standard VA methods adapted to Thailand enabled a plausible assessment of cause-specific mortality patterns and a substantial reduction of ill-defined diagnoses. Validation studies enhance the utility of findings from the application of verbal autopsy. Regular implementation of VA in Thailand could accelerate development of the quality and utility of vital registration data for deaths outside hospitals.

In many countries most deaths occur at home. Such countries often have civil registration systems that are limited or non-existent and therefore most deaths go unrecorded. Countries that cannot record the number of people who die or why they die cannot realize the full potential of their health systems. Health systems need reliable numbers and causes of death to function properly. But in these circumstances – in the absence of a complete picture of the population’s health – there are tools and techniques that can be used to obtain a fairly accurate representation of mortality trends. It takes a long time for countries to achieve a fully functioning civil registration system with medical certification of cause of death. In the meantime, more and more countries are using verbal autopsies (VA) to meet the information needs of their health systems.1 Verbal autopsy is a method of ascertaining probable causes of a death based on an interview with primary caregivers about the signs, symptoms and circumstances preceding that death. Different institutions have been researching and developing all aspects of the verbal autopsy process over the past two decades. We have also been working on this process, particularly to improve the questionnaire and the methods of analysing the resulting information. However, this has been a largely uncoordinated effort and one that has not reached consensus on what to cover in the interview and how to analyse the results, despite previous attempts to promote standard tools.2–4 The main consequence of this failure to agree on a standard approach is that now we cannot compare results from different countries. Currently, 36 Demographic Surveillance Sites (DSS) in 20 countries, the Sample Registration System (SRS) sites in India, and the Disease Surveillance Points (DSP) in China regularly use VA on a large scale, primarily to assess the causes-of-death structure of a defined population.1 Despite such a widespread use of verbal autopsy, we are unable to assess how consistent and reliable the data are. We are also unable to replicate procedures used to assign cause of death. Because verbal autopsy data sets are not widely shared, it is impossible to independently assess the quality of the assignment. Really useful validation studies are rare and verbal autopsy research is often done on small and non-representative samples of the population. The Millennium Development Goals (MDG) have put pressure on countries to track their progress in terms of population health. But to track that progress, countries need reliable numbers. In other words, they need a strong empirical basis for cause-specific mortality data. This is essential for evaluating the impact of disease control programmes and major global health initiatives. One way of dealing with incomplete information is to use models of mortality patterns. But cause-of-death information predicted by such models is not suitable for monitoring progress on what works and what does not.5 That leaves verbal autopsy as the only practical option in these countries and one that will play a key role in tracking progress towards the MDGs. Agreement on a core set of verbal autopsy tools (including technical standards and guidelines for their use) and their widespread adoption is needed now. To tackle this challenge, WHO led an expert group of researchers, data users, and other stakeholders, with sponsorship from the Health Metrics Network (HMN), in developing the necessary standards. The expert group systematically reviewed, debated, and condensed the accumulated experience and evidence from the most widely-used and validated procedures. This synthesis was done to achieve a high degree of consistency and comparability across verbal autopsy data sets. WHO has now published the results of this collaboration as: Verbal autopsy standards: ascertaining and attributing cause of death. The new standards include: Verbal autopsy questionnaires for three age groups (under four weeks; four weeks to 14 years; and 15 years and above); Cause-of-death certification and coding resources consistent with the International Classification of Diseases and Related health Problems, tenth revision (ICD-10); and A cause-of-death list for verbal autopsy prepared according to the ICD-10. The content is freely available on the WHO web site (www.who.int) and will be distributed in print; and incorporated into HMN’s resource kit. This is an important publication, but it is not the last word on verbal autopsy methods. Research is needed to validate these standard core procedures in several countries with different patterns of mortality. Other areas of research include further development of items included in questionnaires, and automated methods for assigning causes of death from verbal autopsy that remove human bias, while producing replicable and valid results.6 Operational issues need addressing: sampling methods and size when using verbal autopsy tools in research demographic surveillance sites; sample or sentinel registration; censuses; and household surveys. Research is also required when adapting these questionnaires to specific situations in different countries, taking into account relevant cultural, epidemiological and administrative considerations. WHO is working with partners to do this research and develop guidelines on these issues. With time, this guidance and experience will better inform the users of verbal autopsy, and improve the comparability and consistency of its results. For the present, we urge that these new international consensus standards become the foundation of verbal autopsy practices wherever possible. ■

BackgroundBecause of a physician shortage in many low-income countries, the use of nonphysicians to classify perinatal mortality (stillbirth and early neonatal death) using verbal autopsy could be useful.ObjectiveTo determine the extent to which underlying perinatal causes of deaths assigned by nonphysicians in Guatemala, Pakistan, Zambia, and the Democratic Republic of the Congo using a verbal autopsy method are concordant with underlying perinatal cause of death assigned by physician panels.MethodsUsing a train-the-trainer model, 13 physicians and 40 nonphysicians were trained to determine cause of death using a standardized verbal autopsy training program. Subsequently, panels of two physicians and individual nonphysicians from this trained cohort independently reviewed verbal autopsy data from a sample of 118 early neonatal deaths and 134 stillbirths. With the cause of death assigned by the physician panel as the reference standard, sensitivity, specificity, positive and negative predictive values, and cause-specific mortality fractions were calculated to assess nonphysicians' coding responses. Robustness criteria to assess how well nonphysicians performed were used.ResultsCauses of early neonatal death and stillbirth assigned by nonphysicians were concordant with physician-assigned causes 47% and 57% of the time, respectively. Tetanus filled robustness criteria for early neonatal death, and cord prolapse filled robustness criteria for stillbirth.ConclusionsThere are significant differences in underlying cause of death as determined by physicians and nonphysicians even when they receive similar training in cause of death determination. Currently, it does not appear that nonphysicians can be used reliably to assign underlying cause of perinatal death using verbal autopsy.

BackgroundThe avoidable causes of infant mortality should be identified, and interventions should be made to improve the infant mortality rate. The cause of infant deaths should be assessed in both...

BackgroundLack of valid and reliable data on malaria deaths continues to be a problem that plagues the global health community. To address this gap, the verbal autopsy (VA) method was developed to ascertain cause of death at the population level. Despite the adoption and wide use of VA, there are many recognized limitations of VA tools and methods, especially for measuring malaria mortality. This study synthesizes the strengths and limitations of existing VA tools and methods for measuring malaria mortality (MM) in low- and middle-income countries through a systematic literature review.MethodsThe authors searched PubMed, Cochrane Library, Popline, WHOLIS, Google Scholar, and INDEPTH Network Health and Demographic Surveillance System sites’ websites from 1 January 1990 to 15 January 2016 for articles and reports on MM measurement through VA. Inclusion criteria: article presented results from a VA study where malaria was a cause of death; article discussed limitations/challenges related to measurement of MM through VA. Two authors independently searched the databases and websites and conducted a synthesis of articles using a standard matrix.ResultsThe authors identified 828 publications; 88 were included in the final review. Most publications were VA studies; others were systematic reviews discussing VA tools or methods; editorials or commentaries; and studies using VA data to develop MM estimates. The main limitation were low sensitivity and specificity of VA tools for measuring MM. Other limitations included lack of standardized VA tools and methods, lack of a ‘true’ gold standard to assess accuracy of VA malaria mortality.ConclusionsExisting VA tools and methods for measuring MM have limitations. Given the need for data to measure progress toward the World Health Organization’s Global Technical Strategy for Malaria 2016–2030 goals, the malaria community should define strategies for improving MM estimates, including exploring whether VA tools and methods could be further improved. Longer term strategies should focus on improving countries’ vital registration systems for more robust and timely cause of death data.