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Verbal autopsy for programmatic
review and planning:Strengthening the Government protocol
Aditi Iyer, Manasa Patna, Gita Sen
Consultative workshop on Maternal Health, FKIL Project,Indian Institute of Management Bangalore
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Verbal Autopsies: New Avatar
Conventionally used as classificatory devices:ICD-10 (medical causes), 3 Delays (social
causes) New Avatar: Tool for programmatic review and
planning:
Identify failures by health providers, families,individual women: What? When? Why?
Identify corrective actions to prevent similar deaths
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Governments VA protocol: Tool forprogrammatic review?
New VA form is a significant improvement over
the previous 2 page-largely-demographic form Designed through a consultative process
Mainstreamed
How accurate? Reliable? How useful?
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Comparative review
4 deaths investigated in Koppal district: Government VAprotocol & GHE method
Design, process and content reviewed via observation,
extensive debriefing, content analysis
Govt. protocol GHE method
Quick In-depth, time intensiveQuantitative Qualitative
Doctors (RCHO/MO) Local investigator, doctor
Structured interview schedule Unstructured interview guideUnstructured analysis Structured analysis
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Death profiles
A. Postnatal death: 35 years, poor, illiterate, overworked,8th gravida (6 living children, 1 stillbirth, 1 infant death),
APH & PPH, leg swelling (7th), normal deliveries (all)
B. Postnatal death: 18 years, low income, low education,
1st gravida, no adverse medical history
C. Postnatal death: 20 years, low income & education, 3rd
gravida (2 living children), no adverse pregnancy or
obstetric history, normal deliveries at home (all)
D. Death within 3 hours of delivery: 25 years, non-poor,
upper caste, family violence& tensions, 1st gravida, no
adverse medical history
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Quality of information: General
Known, not captured: Non-specific sequence ofevents leading to death; storyline.
Not known, not captured: Complexities of care-seeking and receiving; failures to save the woman (type,timing, reasons); explanations for treatment non-adherence & delays; content and quality of care.
Wrongly captured: (Case A) problems during priorpregnancies; sequencing of symptoms; care-seeking;treatment and outcomes.
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Quality of information: Medical causes
Case Government protocol GHE Method
A. Bleeding recognised butno diagnosis of death
Septicaemia from cellulites of left
forearm post-blood transfusion for
mgt of severe anaemia caused by
APH & PPHB. Eclampsia (primary),
economic factors(secondary)
Congestive heart failure and
pregnancy induced hypertension due
to severe anaemia
C. Left ventricular failure Congestive heart failure due to
severe anaemia
D. No diagnosis Internal post-partum haemorrhagedue to tears or ruptured uterus
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Quality of information: Social causes
Case Govt.
protocol
GHE Method
A. Delays dueto decisionmaking andeconomic
factors.
Pre-emergency:Inadequate risk detection,monitoring, follow-up; poor IFA compliance;
normalising of risk by family
Emergency:No active mgt of APH pre-delivery (RMP,Dist.Hosp); negligence & inhumane treatment
(tertiary hosp); no (AMA) discharge info; inadequatetreatment of cellulitis (PHC); family reluctant to
return to the tertiary hospital
B. Delays dueto decisionmaking andeconomicfactors
Pre-emergency:Anaemia identified but no special rx,monitoring, follow-up; poor IFA compliance; risk
normalised by family
Emergency:Delay seeking care, going wherereferred; no emergency prep; early discharge fromtert. hosp (family pressure) & no rx post-discharge
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Quality of information: Social causes
Case Govt. protocol GHE Method
C. Delays in decisionmaking and lack of
awareness of
complications.
Pre-emergency:Non-involvement in ANC(family); no detection of anaemia; no PNC
Emergency:Treatment repeatedly sought
from RMP by family; poor detection ofemergency & inappropriate treatment(RMP); delay in going to the District
Hospital (family)
D. Delay in securing
transport
Pre-emergency:Non-involvement in ANC
(family); big baby not detectedEmergency:Inappropriate delivery
practice (RMP); no capacity to managetears / ruptured uterus (RMP)
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Why these differences?
Research tools: structured, discrete informationwithout open-ended/follow-up questions, no questions &
probes to create a timeline
Research processes: one story; top-down Analytical approaches: no systematic differential
diagnosis of medical causes (unlike GHE methods 8-stepped process); limitations of 3 Delays Model. GHE
method entails use of a 5-tiered flowchart that identifiesfailures (non-action, inadequate actions, inappropriateactions, delayed actions) their timing and reasons.
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Suggestions for strengthening theGovernments protocol
Streamline the existing form and use to gatherpreliminary information.
Follow up with a more in-depth investigation by
a multidisciplinary, independent team. Review of suggested corrective actions by/with
programme managers.
Support for the maternal death audits at theDistrict Commissioners office by involvement ofexternal experts and investigation team.
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Acknowledgements
In Koppal
Phakiramma Budkunti
Y. Poornima
Sampath Kumari Mariyappa
Shivanna
Parashuram
Samudaya Prerakas
In Bangalore
Dr. Anuradha Sreevathsa
Somashekar Hawaldar
Vasini Varadan