Moving from medical to health systems classifications of deaths: extending verbal autopsy to collect information on the circumstances of mortality

Lucia D'Ambruoso, Kathleen Kahn, Ryan G. Wagner, Rhian Twine, Barry Spies, Maria Van Der Merwe, F. Xavier Gomez-Olive, Stephen Tollman, Peter Byass

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BACKGROUND: Verbal autopsy (VA) is a health surveillance technique used in low
and middle-income countries to establish medical causes of death (CODs) for people who die outside hospitals and/or without registration. By virtue of the deaths it investigates, VA is also an opportunity to examine social exclusion from access to health systems. The aims were to develop a system to collect and interpret information on social and health systems determinants of deaths investigated in VA.
METHODS: A short set of questions on care pathways, circumstances and events at and around the time of death were developed and integrated into the WHO 2012 short form VA (SFVA). Data were subsequently analysed from two census rounds in the Agincourt Health and Socio-Demographic Surveillance Site (HDSS), South Africa in 2012 and 2013 where the SF-VA had been applied. InterVA and descriptive analysis were used to calculate cause-specific mortality fractions (CSMFs), and to examine responses to the new indicators and whether and how they varied by medical CODs and age/sex subgroups.
RESULTS: 1,249 deaths were recorded in the Agincourt HDSS censuses in 2012-13 of which 1,196 (96%) had complete VA data. Infectious and noncommunicable conditions accounted for the majority of deaths (47% and 39%
respectively) with smaller proportions attributed to external, neonatal and maternal causes (5%, 2% and 1% respectively). 5% of deaths were of indeterminable cause. The new indicators revealed multiple problems with access to care at the time of death: 39% of deaths did not call for help, 36% found care unaffordable overall, and 33% did not go to a facility. These problems were reported consistently across age and sex sub-groups. Acute conditions and younger age groups had fewer problems with overall costs but more with not calling for help or going to a facility. An illustrative health systems interpretation suggests extending and promoting existing provisions for transport and financial access in this setting.
CONCLUSIONS: Supplementing VA with questions on the circumstances of mortality provides complementary information to CSMFs relevant for health planning. Further contextualisation of the method and results are underway with health systems stakeholders to develop the interpretation sequence as part of a health policy and systems research approach.
Original languageEnglish
Article number2
Pages (from-to)1-15
Number of pages15
JournalGlobal Health Research and Policy
Publication statusPublished - 15 Jun 2016

Bibliographical note

The authors would also like to acknowledge the field staff at the MRC, SA/Wits Agincourt Unit, particularly Sizzy Ngobeni. The authors also acknowledge Drs Malin Eriksson and Edward Fottrell at Umeå Centre for Global Health Research *UCGHR) who contributed to the development of the SF-VA indicators, Dr Nawi Ng at UCGHR who advised on the cause of death categories, and Dr Kerstin Edin at UCGHR who provided comments on the manuscript categories, and Dr Kerstin Edin who provided comments on the manuscript.

A Health Systems Research Initiative Development Grant from the UK
Department for International Development (DFID), Economic and Social
Research Council (ESRC), Medical Research Council (MRC (and the Wellcome
Trust (MR/N005597/1) funds the research presented in this paper. Support
for the Agincourt HDSS including verbal autopsies was provided by The
Wellcome Trust, UK (grants 058893/Z/99/A; 069683/Z/02/Z; 085477/Z/08/Z;
085477/B/08/Z), and the University of the Witwatersrand and Medical
Research Council, South Africa.


  • verbal autopsy
  • social determinants
  • health systems
  • civil registrations and vital statistics
  • health surveillance
  • South Africa


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