Verbal and Social Autopsies: Implications on the future of maternal and newborn health in Uganda’s Luuka District
By Elizabeth Hentschel
I am currently interning at the Community in Which Mothers and Newborns Thrive (COMONETH) through Makerere’s Centre for Excellence in Maternal Newborn and Child Health. The COMONETH Project is based in the rural district of Luuka and is composed of three main components- the facility, community, and monitoring and evaluation components. Based on Uganda’s MoH Annual Health Sector Performance Report, Luuka District has consistently been ranked in the bottom 15 of 98 districts in health sector performance.
I have had an opportunity to explore the community component when I accompanied project staff to conduct verbal and social autopsies (VASA). VASA is a tool that’s used to assess the cause of death of children and women within this community and helps to establish what social determinants are associated with the death. When Susan (one of the research assistants) and I arrived at the first home, the family was so welcoming offering us stools and chairs to sit on. After conducting the 30-page VASA, the last page asks the women to describe, in their own words, what they think caused their child to die. The first woman we spoke with believed that the loss of her child was due to contraception that she had used earlier in life. Susan later explained to me that contraception was not responsible for the loss of her child, but it indicates how negatively contraception and family planning in general is perceived within this community. This led me to wonder, what other barriers to proper maternal care are women in this community facing?
I then became curious about the qualitative part of this study, what did women within this community think was killing their children and what was actually killing them? I began to analyze the qualitative aspect of the VASA tool, and quickly identified some overarching themes. According to the mothers and the research assistants, the cause of death was usually either a result of negligence by healthcare workers, a lack of health education within the family, an untreated disease (such as HIV, syphilis, candidiasis, fever or malaria), or a transportation issue. Many of these themes overlap- for example, one woman who had an untreated sexually transmitted infection, that she believed was responsible for her child’s death, said that her husband had forbidden her to seek treatment for her STI. This woman suffered from a lack of education and an untreated disease, both of which resulted in the death of her baby. Among the 52 VASA reports that I randomly selected out of the 237 that have been collected to date, only two of the deaths appeared to not be preventable.
Among those who believed the death of their child was due to negligence by health staff, I read about a woman who immediately went to a health facility when she started labor- the same health facility that I visited during a support supervision visit. When she arrived at midnight, the Health Center was closed. She knocked on all the health workers’ houses, but they refused to open their doors because it was too late at night and they did not want to deliver a mother. At 4:00am, four hours after she arrived at the Health Centre, she pushed out a dead baby just outside the facility. I now understood how vital the meeting COMONETH had with this health facility was. This woman did all the right things, when she felt that she was going into labour she immediately went to a health facility, but her baby still died a preventable death because of gross negligence by healthcare workers.
Throughout my qualitative data analysis, I identified many women with traditional – and often incorrect – views about contraception similar to the woman I met in Luuka. There were even women that claimed that midwives and traditional birth attendants told them that their baby died because of contraception. Many couples lacked the health education to identify danger signs, such as bleeding of the umbilical cord, and therefore didn’t seek needed care. Furthermore, many women gave birth with traditional birth attendants (TBAs) and when their baby suffered complications that the TBA was not equipped to handle, their baby passed away.
This internship has helped me to understand how vital health education is- for not only the mothers and fathers, but also for midwives, VHTs, nurses and all other healthcare professionals. COMONETH’s work to empower women via health education, design and implement high coverage preventative care, and improve quality and equity of care continues to have a positive impact on the community. Through the field work I’ve done and the data I’ve analyzed I’ve seen first hand how poverty impacts every aspect of these women’s lives, and how important it is to work towards improving maternal, newborn and child outcomes within this community.
*The author is a Master of Science Student Studying Global Health and Population at the Harvard T.H. Chan School of Public Health.