ppt 7 iyer etal final

8/12/2019 Ppt 7 Iyer Etal Final

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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

ppt 7 iyer etal final

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