Arnfried A. Kielmann

Verbal Autopsy

The term « Verbal Autopsy » was first coined in a project of the Department of International Health of Johns Hopkins School of Hygiene and Public Health which ran from 1965 to 1973 in Punjab, India. Two research projects were located in villages near Ludhiana, with headquarters in Narangwal village. Objectives of the projects were a) to assess the relationships between nutrition, infection and child development, and b) the acceptance of family planning services by rural communities in response to maternal and early child care service packages. Main providers of health care were Lady Health Visitors (LHV’s) and Auxiliairy Nurse Midwifes (ANM’s) resident in each of the study villages in the Nutrition- and Population studies, respectively. All had received a six week training prior to onset of the program, followed by monthly reviews, re-training and feed-back on service aspects specific to their group of villages. Input services in the Nutrition villages originally consisted of “feeding centres” plus health care for Under 5’s, and on maternal and newborn health care services in the population cells. Early 1971, results from the Nutrition villages showed no significant decrease in child mortality, and causes and circumstances of child deaths had remained largely unknown. In response, an information system was established, wherein all child deaths in the villages had to be reported to the Narangwal Project Office by the resident Health Worker within 5 days. One of the project physicians then went to the concerned family and through intense questioning of close relatives as to the signs and symptoms of the process leading to death, review of the child’s health records, supplemented by visits to the external health care provider if such was the case, established possible reasons for, and a most likely cause of death. Using this method and following an analysis of the initial 45 deaths, diarrheal disease, lower respiratory tract infections and malnutrition were identified as the three principal causes among the 8 days to 3 year old children. Among the 45, one had died from neonatal tetanus. Shortly thereafter, the same process was extended to all villages of the two projects featuring childcare as one of the service inputs. In response to the results, intervention methodologies specific to identified health care priorities were elaborated and introduced in both projects. In 1972, results from the investigation were presented for 124 child deaths during the first seven days of life, and 117 deaths from 8 days to 5 years of age at a conference in Srinagar, Kashmir. The term Verbal Autopsy was used ‘in irony’ by a visiting medical dignitary who not only questioned the results but also the method, labelling it ”unscientific”. The term was retained by the then director of the two projects, Carl E. Taylor, chairman of the Department of International Health who also chaired the conference. Through introduction of specific service packages specifically for the control of DD, ARI, and Neonatal Tetanus, child mortality dropped significantly in the study villages of both the Nutrition and Population projects.

Seven years later (1980), the Ministry of Health of Egypt conducted an investigation into prevention of child mortality from DD using a variety of intervention methods for a total population of 200’000, including 29000 children below the age of 5 in three different districts. The “Verbal Autopsy” method as originally developed in Narangwal was slightly modified to the Egyptian setting and again used to identify prevailing mortality patterns among preschoolers. Following implementation of different treatment schedules, child mortality rates dropped significantly in specific input villages over the period of study. The project site was re-visited six years following completion of the investigation confirming utility and effectiveness of the V.A. method, and applied intervention modalities respectively.