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

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

Governments VA protocol: Tool for programmatic 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?

Comparative review
4 deaths investigated in Koppal district: Government VA protocol & GHE method Govt. protocol GHE method

Quick
Quantitative Doctors (RCHO/MO) Unstructured analysis

In-depth, time intensive

Qualitative Local investigator, doctor Structured analysis

Structured interview schedule Unstructured interview guide

Design, process and content reviewed via observation, extensive debriefing, content analysis

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

Quality of information: General

Known, not captured: Non-specific sequence of
events 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 nonadherence & delays; content and quality of care. pregnancies; sequencing of symptoms; care-seeking; treatment and outcomes.

Wrongly captured: (Case A) problems during prior

Quality of information: Medical causes

Case
A.

Government protocol
Bleeding recognised but no diagnosis of death

GHE Method
Septicaemia from cellulites of left forearm post-blood transfusion for mgt of severe anaemia caused by APH & PPH Congestive heart failure and pregnancy induced hypertension due to severe anaemia Congestive heart failure due to severe anaemia Internal post-partum haemorrhage due to tears or ruptured uterus

B.

Eclampsia (primary), economic factors (secondary) Left ventricular failure

C.

D.

No diagnosis

Quality of information: Social causes

Case A. Govt. protocol Delays due to decision making and economic factors. GHE Method

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; inadequate treatment of cellulitis (PHC); family reluctant to return to the tertiary hospital

Pre-emergency: Inadequate risk detection,

B.

Delays due to decision making and economic factors

Pre-emergency: Anaemia identified but no special rx,

monitoring, follow-up; poor IFA compliance; risk normalised by family Emergency: Delay seeking care, going where referred; no emergency prep; early discharge from tert. hosp (family pressure) & no rx post-discharge

Quality of information: Social causes

Case C. Govt. protocol Delays in decision making and lack of awareness of complications. GHE Method

(family); no detection of anaemia; no PNC Emergency: Treatment repeatedly sought from RMP by family; poor detection of emergency & inappropriate treatment (RMP); delay in going to the District Hospital (family)

Pre-emergency: Non-involvement in ANC

D.

Delay in securing transport

Pre-emergency: Non-involvement in ANC

(family); big baby not detected Emergency: Inappropriate delivery practice (RMP); no capacity to manage tears / ruptured uterus (RMP)

Why these differences?

Research tools: structured, discrete information
without 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 8stepped process); limitations of 3 Delays Model. GHE method entails use of a 5-tiered flowchart that identifies failures (non-action, inadequate actions, inappropriate actions, delayed actions) their timing and reasons.

Suggestions for strengthening the Governments protocol

Streamline the existing form and use to gather preliminary 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 the District Commissioners office by involvement of external experts and investigation team.

Acknowledgements
In Koppal
Phakiramma Budkunti Y. Poornima Sampath Kumari Mariyappa Shivanna Parashuram Samudaya Prerakas

In Bangalore
Dr. Anuradha Sreevathsa Somashekar Hawaldar Vasini Varadan