Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • State of the Art
  • Published:

State-of-the-Art

Ascertaining causes of neonatal deaths using verbal autopsy: current methods and challenges

Journal of Perinatology volume 29, pages 187–194 (2009)Cite this article

Abstract

Objective:

‘Verbal autopsy’ (VA) is used to ascertain cause of death in countries where vital registration systems are lacking. Current VA methods for neonatal deaths vary widely and suffer from several limitations. We aimed to: (1) review current neonatal VA methods, (2) identify gaps and limitations, (3) illustrate some limitations using VA data and (4) identify new approaches in methodology and analysis.

Study Design:

Rolling techniques and database search terms were used to identify articles that described neonatal VA administration, validation and cause of death assignment.

Result:

Current VA interviews include open and close-ended modules and are administered by trained interviewers. Causes of death are determined using physician review and/or computer algorithms for various neonatal causes of death. Challenges include lack of a standardized VA instrument and administration of methods, difficulty in identifying gold standards for validation studies, lack of validated algorithms for causes of death, poor existing algorithms, lack of standardized death classification terminology and the use of hierarchy to assign causes of death. Newer probabilistic methods of analysis such as Bayes Theorem or the Symptom Pattern method may improve accuracy for cause of death estimation and alleviate some of the challenges with traditional physician and algorithmic approaches, although additional research is needed.

Conclusion:

Given the continued reliance on VA to determine cause of death in settings with inadequate registration systems, it is important to understand the gaps in current VA methods and explore how methods can be improved to accurately reflect neonatal disease burden in the global community.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1

References

  1. Lawn JE, Cousens S, Zupan J . 4 million neonatal deaths: when? Where? Why? Lancet 2005; 365 (9462): 891–900.

    Article  PubMed  Google Scholar 

  2. Awasthi S, Pande VK, Glick H . Under fives mortality in the urban slums of Lucknow. Indian J Pediatr 1996; 63 (3): 363–368.

    Article  CAS  PubMed  Google Scholar 

  3. Morris SS, Black RE, Tomaskovic L . Predicting the distribution of under-five deaths by cause in countries without adequate vital registration systems. Int J Epidemiol 2003; 32 (6): 1041–1051.

    Article  PubMed  Google Scholar 

  4. Nykanen M, Tamaona W, Cullinan T, Van Oosterzee V, Ashorn P . Verbal autopsy as a technique to establish causes of infant and child mortality. East Afr Med J 1995; 72 (11): 731–734.

    CAS  PubMed  Google Scholar 

  5. Yassin KM . Indices and sociodemographic determinants of childhood mortality in rural Upper Egypt. Soc Sci Med 2000; 51 (2): 185–197.

    Article  CAS  PubMed  Google Scholar 

  6. Mirza NM, Macharia WM, Wafula EM, Agwanda RO, Onyango FE . Verbal autopsy: a tool for determining cause of death in a community. East Afr Med J 1990; 67 (10): 693–698.

    CAS  PubMed  Google Scholar 

  7. Marsh DR, Sadruddin S, Fikree FF, Krishnan C, Darmstadt GL . Validation of verbal autopsy to determine the cause of 137 neonatal deaths in Karachi, Pakistan. Paediatr Perinat Epidemiol 2003; 17 (2): 132–142.

    Article  PubMed  Google Scholar 

  8. Spika JS, Munshi MH, Wojtyniak B, Sack DA, Hossain A, Rahman M et al. Acute lower respiratory infections: a major cause of death in children in Bangladesh. Ann Trop Paediatr 1989; 9 (1): 33–39.

    Article  CAS  PubMed  Google Scholar 

  9. Terra de Souza AC, Peterson KE, Andrade FM, Gardner J, Ascherio A . Circumstances of post-neonatal deaths in Ceara, Northeast Brazil: mothers’ health care-seeking behaviors during their infants’ fatal illness. Soc Sci Med 2000; 51 (11): 1675–1693.

    Article  CAS  PubMed  Google Scholar 

  10. Hammer GP, Some F, Muller O, Kynast-Wolf G, Kouyate B, Becher H . Pattern of cause-specific childhood mortality in a malaria endemic area of Burkina Faso. Malar J 2006; 5: 47.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Bakshi R . UNICEF unveils new tool to combat maternal mortality in India. In New Delhi: UNICEF 2006.

  12. Baqui AH, Darmstadt GL, Williams EK, Kumar V, Kiran TU, Panwar D et al. Rates, timing and causes of neonatal deaths in rural India: implications for neonatal health programmes. Bull World Health Organ 2006; 84 (9): 706–713.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Chowdhury ME, Akhter HH, Chongsuvivatwong V, Geater AF . Neonatal mortality in rural Bangladesh: an exploratory study. J Health Popul Nutr 2005; 23 (1): 16–24.

    PubMed  Google Scholar 

  14. Iriya N, Manji KP, Mbise RL . Verbal autopsy in establishing cause of perinatal death. East Afr Med J 2002; 79 (2): 82–84.

    Article  CAS  PubMed  Google Scholar 

  15. Kalter HD, Hossain M, Burnham G, Khan NZ, Saha SK, Ali MA et al. Validation of caregiver interviews to diagnose common causes of severe neonatal illness. Paediatr Perinat Epidemiol 1999; 13 (1): 99–113.

    Article  CAS  PubMed  Google Scholar 

  16. Baqui AH, Black RE, Arifeen SE, Hill K, Mitra SN, al Sabir A . Causes of childhood deaths in Bangladesh: results of a nationwide verbal autopsy study. Bull World Health Organ 1998; 76 (2): 161–171.

    CAS  PubMed  PubMed Central  Google Scholar 

  17. Baqui AH, Sabir AA, Begum N, Arifeen SE, Mitra SN, Black RE . Causes of childhood deaths in Bangladesh: an update. Acta Paediatr 2001; 90 (6): 682–690.

    Article  CAS  PubMed  Google Scholar 

  18. Fikree FF, Azam SI, Berendes HW . Time to focus child survival programmes on the newborn: assessment of levels and causes of infant mortality in rural Pakistan. Bull World Health Organ 2002; 80 (4): 271–276.

    PubMed  PubMed Central  Google Scholar 

  19. Shrivastava SP, Kumar A, Kumar Ojha A . Verbal autopsy determined causes of neonatal deaths. Indian Pediatr 2001; 38 (9): 1022–1025.

    CAS  PubMed  Google Scholar 

  20. Bhandari N, Bahl R, Taneja S, Martines J, Bhan MK . Pathways to infant mortality in urban slums of Delhi, India: implications for improving the quality of community- and hospital-based programmes. J Health Popul Nutr 2002; 20 (2): 148–155.

    PubMed  Google Scholar 

  21. Garrib A, Jaffar S, Knight S, Bradshaw D, Bennish ML . Rates and causes of child mortality in an area of high HIV prevalence in rural South Africa. Trop Med Int Health 2006; 11 (12): 1841–1848.

    Article  PubMed  Google Scholar 

  22. Hinderaker SG, Olsen BE, Bergsjo PB, Gasheka P, Lie RT, Havnen J et al. Avoidable stillbirths and neonatal deaths in rural Tanzania. BJOG 2003; 110 (6): 616–623.

    Article  PubMed  Google Scholar 

  23. Khoury SA, Massad D, Fardous T . Mortality and causes of death in Jordan 1995–96: assessment by verbal autopsy. Bull World Health Organ 1999; 77 (8): 641–650.

    CAS  PubMed  PubMed Central  Google Scholar 

  24. Marsh DR, Husein K, Lobo M, Shah MSL . Verbal autopsy in Karachi slums: comparing single and multiple causes of child deaths. Health Policy Plan 1995; 10 (4): 395–403.

    Article  Google Scholar 

  25. Adazu K, Lindblade KA, Rosen DH, Odhiambo F, Ofware P, Kwach J et al. Health and demographic surveillance in rural western Kenya: a platform for evaluating interventions to reduce morbidity and mortality from infectious diseases. Am J Trop Med Hyg 2005; 73 (6): 1151–1158.

    Article  PubMed  Google Scholar 

  26. Freeman JV, Christian P, Khatry SK, Adhikari RK, LeClerq SC, Katz J et al. Evaluation of neonatal verbal autopsy using physician review versus algorithm-based cause-of-death assignment in rural Nepal. Paediatr Perinat Epidemiol 2005; 19 (4): 323–331.

    Article  PubMed  Google Scholar 

  27. Nongkynrih B, Anand K, Kapoor SK . Use of verbal autopsy by health workers in under-five children. Indian Pediatr 2003; 40 (8): 766–771.

    PubMed  Google Scholar 

  28. Etard JF, Le Hesran JY, Diallo A, Diallo JP, Ndiaye JL, Delaunay V . Childhood mortality and probable causes of death using verbal autopsy in Niakhar, Senegal, 1989–2000. Int J Epidemiol 2004; 33 (6): 1286–1292.

    Article  PubMed  Google Scholar 

  29. Setal PW, Whiting DR, Hemed Y, Chandramohan D, Wolfson LJ, Alberti KG et al. Validity of verbal autopsy procedures for determining cause of death in Tanzania. Trop Med Int Health 2006; 11 (5): 681–696.

    Article  Google Scholar 

  30. Snow RW, Armstrong JR, Forster D, Winstanley MT, Marsh VM, Newton CR et al. Childhood deaths in Africa: uses and limitations of verbal autopsies. Lancet 1992; 340 (8815): 351–355.

    Article  CAS  PubMed  Google Scholar 

  31. Ministry of Health and Population (MOHP) N, New ERA and Macro International Inc. Nepal Demographic and Health Survey 2006. Kathmandu, Nepal; 2007 2007.

  32. Campbell O, Gipson R, el-Mohandes A, Issa AH, Matta N, Mansour E et al. The Egypt National Perinatal/Neonatal Mortality Study 2000. J Perinatol 2004; 24 (5): 284–289.

    Article  PubMed  Google Scholar 

  33. Perry HB, Ross AG, Fernand F . Assessing the causes of under-five mortality in the Albert Schweitzer Hospital service area of rural Haiti. Rev Panam Salud Publica 2005; 18 (3): 178–186.

    Article  PubMed  Google Scholar 

  34. Whiting DR, Setal PW, Chandramohan D, Wolfson LJ, Hemed Y, Lopez AD . Estimating cause-specific mortality from community- and facility-based data sources in the United Republic of Tanzania: options and implications for mortality burden estimates. Bull World Health Organ 2006; 84 (12): 940–948.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Lee AC, Mullany LC, Tielsch JM, Katz J, Khatry SK, LeClerq SC et al. Verbal autopsy methods to ascertain birth asphyxia deaths in a community-based setting in Southern Nepal. Pediatrics 2008 (under review).

  36. Lawn JE, Wilczynska-Ketende K, Cousens SN . Estimating the causes of 4 million neonatal deaths in the year 2000. Int J Epidemiol 2006; 35 (3): 706–718.

    Article  PubMed  Google Scholar 

  37. Soleman N, Chandramohan D, Shibuya K . Verbal autopsy: current practices and challenges. Bull World Health Organ 2006; 84 (3): 239–245.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Anker M, Black RE, Coldham C, Kalter HD, Quigley M, Ross D . A Standard Verbal Autopsy Method for Investigating Causes of Death in Infants and Children. World Health Organization: Geneva, 1999.

    Google Scholar 

  39. Stanton C, Lawn JE, Rahman H, Wilczynska-Ketende K, Hill K . Stillbirth rates: delivering estimates in 190 countries. Lancet 2006; 367 (9521): 1487–1494.

    Article  PubMed  Google Scholar 

  40. Hsu MT, Tseng YF, Banks JM, Kuo LL . Interpretations of stillbirth. J Adv Nurs 2004; 47 (4): 408–416.

    Article  PubMed  Google Scholar 

  41. Benara SK, Singh P . Validity of causes of infant death by verbal autopsy. Indian J Pediatr 1999; 66 (5): 647–650.

    Article  CAS  PubMed  Google Scholar 

  42. Datta N, Mand M, Kumar V . Validation of causes of infant death in the community by verbal autopsy. Indian J Pediatr 1988; 55 (4): 599–604.

    Article  CAS  PubMed  Google Scholar 

  43. Darmstadt GL, Black RE, Santosham M . Research priorities and postpartum care strategies for the prevention and optimal management of neonatal infections in less developed countries. Pediatr Infect Dis J 2000; 19 (8): 739–750.

    Article  CAS  PubMed  Google Scholar 

  44. WHO/UNICEF Informal Consultation. Measurement of overall and cause-specific mortality in infants and children: memorandum from a WHO/UNICEF meeting. Bull World Health Organ 1994; 72 (5): 707–713.

    Google Scholar 

  45. Jamison DT, Shahid-Salles SA, Jamison J, Lawn JE, Zupan J . Incorporating deaths near the time of birth into estimates of the global burden of disease. In: Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL (eds). Global Burden of Disease and Risk Factors, ed.. Oxford University Press: New York, 2006, pp 427–463.

    Google Scholar 

  46. WHO. International Statistical Classification of Diseases and Related Health Problems, 10th revision, vol. 2. World Health Organization: Geneva, Switzerland.

  47. WHO. ICD-10: International Statistical Classification of Diseases and Related Health Problems, 10th revision, 2nd edn. 2004.

  48. Khoury SA, Mas’ad DF . Causes of infant mortality in Jordan. Saudi Med J 2002; 23 (4): 432–435.

    PubMed  Google Scholar 

  49. Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L . Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet 2005; 365 (9463): 977–988.

    Article  PubMed  Google Scholar 

  50. Byass P, Fottrell E, Dao LH, Berhane Y, Corrah T, Kahn K et al. Refining a probabilistic model for interpreting verbal autopsy data. Scand J Public Health 2006; 34 (1): 26–31.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Fantahun M, Fottrell E, Berhane Y, Wall S, Hogberg U, Byass P . Assessing a new approach to verbal autopsy interpretation in a rural Ethiopian community: the InterVA model. Bull World Health Organ 2006; 84 (3): 204–210.

    Article  PubMed  PubMed Central  Google Scholar 

  52. King G, Ying L . Verbal autopsy mehtods with mulitple causes of death. Stat Sci 2008; 23 (1): 78–91.

    Article  Google Scholar 

  53. Murray CJL, Lopez AD, Feehan D, Peter ST, Yang G . Validation of the symptom pattern method for analyzing verbal autopsy data. PLOS Med 2007; 4 (11): 1739–1753.

    Google Scholar 

  54. Baiden F, Bawah A, Biai S, Binka F, Boerma T, Byass P et al. Setting international standards for verbal autopsy. Bull World Health Organ 2007; 85 (8): 570–571.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of International Health, International Center for Advancing Neonatal Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

    N Thatte, H D Kalter, A H Baqui, E M Williams & G L Darmstadt

Authors
  1. N Thatte
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. H D Kalter
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. A H Baqui
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. E M Williams
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. G L Darmstadt
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to G L Darmstadt.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Thatte, N., Kalter, H., Baqui, A. et al. Ascertaining causes of neonatal deaths using verbal autopsy: current methods and challenges. J Perinatol 29, 187–194 (2009). https://doi.org/10.1038/jp.2008.138

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/jp.2008.138

Keywords

This article is cited by

Search

Advanced search

Quick links