Verbal autopsy to assess child mortality in a humanitarian setting
Authors: Abdihamid Warsame, Abdinasir Yusuf Osman
Journal: The Lancet Global Health (2021)

In 2010, less than 3% of the children who died were medically certified.1Jha P Reliable direct-measurement of causes of death in low- and middle-income countries.BMC Med. 2014; 12: 19Crossref PubMed Scopus (57) Google Scholar In low and middle income countries, most deaths do not occur in health facilities but rather in the community, contributing to an extraordinary gap in vital statistics.2Leitao J Desai N Aleksandrowicz L et al.Comparison of physician-certified verbal autopsy with computer-coded verbal autopsy for cause of death assignment in hospitalized patients in low- and middle-income countries: systematic review.BMC Med. 2014; 12: 1-9Crossref Scopus (52) Google Scholar This gap is likely to be more pronounced in humanitarian settings where children are prone to elevated mortality, particularly in contexts of forced displacement.3Keely CB Reed HE Waldman RJ Understanding mortality patterns in complex humanitarian emergencies.in: Keely CB Reed HE Forced migration & mortality. National Academies Press, Washington, DC2001: 1-37Google Scholar Somalia, since the collapse of the central government in 1991, has had inadequate civil and vital registration systems. Therefore, information about population mortality is limited to sparse records within health facilities, or as part of periodic or ad-hoc small area population surveys. These surveys, most often undertaken as part of nutrition or food security assessments, provide information on the number of deaths but little information on the cause of death (except whether violence might have been a factor). Verbal autopsies are a standardised approach to assigning cause of death in settings where vital registration systems are weak or non-existent.4Checchi F Estimation of population mortality in crisis-affected populations: guidance for humanitarian coordination mechanisms.https://www.who.int/health-cluster/resources/publications/LSHTM-Mortality-Estimation-Options-oct2018.pdfDate: October, 2018Date accessed: June 3, 2021Google Scholar They are typically administered through the use of a standardised form with interpretation, initially done by physicians. However, analysis is increasingly undertaken through computer models.5Byass P Chandramohan D Clark SJ et al.Strengthening standardised interpretation of verbal autopsy data: the new InterVA-4 tool.Glob Health Action. 2012; 519281Crossref PubMed Scopus (147) Google Scholar The study by Andrew Seal and colleagues6Seal AJ Jelle M Grijalva-Eternod CS Mohamed H Ali R Fottrell E Use of verbal autopsy for establishing causes of child mortality in camps for internally displaced people in Mogadishu, Somalia: a population-based, prospective, cohort study.Lancet Glob Health. 2021; 9: e1286-e1295Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar in The Lancet Global Health expanded the availability of mortality information in Somalia through use of a modified verbal autopsy strategy to provide insight on the causes of death among an internally displaced population within Somalia. They used this approach, as part of a larger nutrition and health surveillance system, to estimate the mortality rate of children age 6–59 months and evaluate the probable cause-specific mortality fraction. The study found an increased death rate among the study population. They also identified measles and malnutrition as accounting for the largest fraction of mortality, in line with previous studies in Somalia7Warsame A Frison S Gimma A Checchi F Retrospective estimation of mortality in Somalia, 2014–2018: a statistical analysis.https://www.lshtm.ac.uk/media/40136Date: January, 2020Date accessed: June 2, 2021Google Scholar and on Somali refugee populations.8Polonsky JA Ronsse A Ciglenecki I Rull M Porten K High levels of mortality, malnutrition, and measles, among recently-displaced Somali refugees in Dagahaley camp, Dadaab refugee camp complex, Kenya, 2011.Confl Health. 2013; 7: 1Crossref PubMed Scopus (38) Google Scholar The study, a collaboration between an aid agency and research institution, highlights the importance of such partnerships in addressing outstanding research gaps, particularly in humanitarian crises.9Blanchet K Ramesh A Frison S et al.Evidence on public health interventions in humanitarian crises.Lancet. 2017; 390: 2287-2296Summary Full Text Full Text PDF PubMed Scopus (101) Google Scholar The verbal autopsy approach, enacted over a period of 2 years, can potentially be used to provide information on the estimated 2·6 million internally displaced people in Somalia.10International Organization of MigrationSomalia's 2·6m internally displaced citizens in need of water, shelter and health.https://www.iom.int/news/somalias-26m-internally-displaced-citizens-need-water-shelter-and-healthDate: Oct 22, 2019Date accessed: June 4, 2021Google Scholar However, there are several key questions that require further study before verbal autopsy can be fully implemented. The study did not collect data on deaths in transit and deaths in children younger than 6 months, missing a crucial time period and cohort in which deaths are expected to be elevated. Additionally, the observed high population movement within camp settings makes it operationally challenging to accurately calculate population denominators, which restricts the applicability of such an approach more widely. Furthermore, this research was done in a small number of camps and required intensive surveillance efforts raising questions as to its sustainability and scalability. Given the availability of several computer coded verbal autopsy models with varying concordance with physician-certified verbal autopsies, standalone verbal autopsy results should be interpreted with caution.2Leitao J Desai N Aleksandrowicz L et al.Comparison of physician-certified verbal autopsy with computer-coded verbal autopsy for cause of death assignment in hospitalized patients in low- and middle-income countries: systematic review.BMC Med. 2014; 12: 1-9Crossref Scopus (52) Google Scholar However, verbal autopsies in conjunction with existing surveillance systems, as Seal and colleagues6Seal AJ Jelle M Grijalva-Eternod CS Mohamed H Ali R Fottrell E Use of verbal autopsy for establishing causes of child mortality in camps for internally displaced people in Mogadishu, Somalia: a population-based, prospective, cohort study.Lancet Glob Health. 2021; 9: e1286-e1295Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar have done, can provide valuable complementary information to guide rapid response. Moreover, use of social autopsy alongside verbal autopsies will expand understanding of the context in which these deaths are occurring and provide further avenues of response.11Thomas LM D'Ambruoso L Balabanova D Use of verbal autopsy and social autopsy in humanitarian crises.BMJ Glob Health. 2018; 3e000640Crossref PubMed Scopus (10) Google Scholar Potential opportunities of scaling up such an approach include exploring the feasibility of integrating the modified verbal autopsy approach to large scale surveys such as the nationally representative Somali Demographic and Health Survey or to the seasonal assessments undertaken by the Food Security and Nutrition Analysis Unit of Somalia. A robust understanding of causes of death is crucial for responding effectively and preventing excess mortality in the short term. Results from such studies could potentially be used to address gaps in packages of health services and to rapidly identify emerging health threats.4Checchi F Estimation of population mortality in crisis-affected populations: guidance for humanitarian coordination mechanisms.https://www.who.int/health-cluster/resources/publications/LSHTM-Mortality-Estimation-Options-oct2018.pdfDate: October, 2018Date accessed: June 3, 2021Google Scholar Ultimately, this effective response can be achieved through investing in the capacity of health systems to implement civil registration and vital statistics programmes. By ascertaining cause of death, the effect of global health programmes can better be evaluated, which would guide resource allocation and strengthen fragile health systems. We declare we have no competing interests. Use of verbal autopsy for establishing causes of child mortality in camps for internally displaced people in Mogadishu, Somalia: a population-based, prospective, cohort studyIt is feasible to establish a health and nutrition surveillance system that ascertains causes of death, using verbal autopsy, in this humanitarian context. These data can inform policy, response planning, and priority setting. The high mortality rate from infectious diseases and malnutrition among children younger than 5 years suggests the need for strengthening a range of public health interventions, including vaccination and provision of water, sanitation, and hygiene. Full-Text PDF Open Access