Can verbal autopsies be used on a national scale? Key findings and lessons from the South Africa National Cause-of-Death Validation Study.

Abstract Background The quality of cause of death (COD) statistics in South Africa has room for improvement. It is possible that supplementary use of verbal autopsy (VA) interviews for the deaths that occur outside of health facilities might be useful. This study describes the challenges and successes of collecting a national sample of VA interviews. Methods We recruited next of kin who registered deaths in 27 randomly sampled sub-districts across South Africa between September 2017 – April 2018. Trained fieldworkers (84) conducted face-to-face interviews using the WHO2016 verbal autopsy (VA) instrument. A team of physicians (51), trained in medical certification of cause of death and reading VAs, certified the underlying causes of death. Feasibility was assessed considering response rates, participation and quality of data. Cause specific-mortality fractions (CSMF) based on physician reviews and InterVA-5 automated software were compared with 2017 Statistics South Africa (Stats SA) data and assessed for plausibility against burden of disease estimates. Results Only 26% of the 36,976 total deaths registered in the sample area were identified during recruitment and 65% of the next of kin agreed to be contacted. A total of 5,375 VA were conducted (overall response rate of 55%) and 83% of physician reviewed VAs were judged to have good quality data for assigning underlying cause of death. Fifty-nine percent of the VAs occurred in the 27 sampled sub-districts, with the remainder ones coming from adjacent areas. Comparing the CSMFs, the physician reviewed VA identified 22.3% HIV/AIDS and InterVA-5 18.5% deaths, in line with burden of disease estimates, while Stats SA identified 4.9% HIV/AIDS deaths. Conclusions The study demonstrated feasibility of using VA on a national scale, but immense challenges in identifying and recruiting next of kin highlights the importance of formalising VAs within the country’s death notification system.