Autopsia verbal: una herramienta para determinar las causas de mortinatalidad y mortinatalidad en la comunidad

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Abstract

Objetivo: este estudio, realizado en redes de salud urbanas y rurales de Bolivia (El Alto, Potosí y Cochamba), tuvo los siguientes objetivos: conocer las causas biológicas y sociales de mortinatalidad y mortalidad neonatal; identificar la proporción de muertes evitables y analizar el proceso de cada muerte neonatal. Métodos: el estudio fue transversal y descriptivo, con muestreo no probabilístico. Se empleó el cuestionario desarrollado por la OMS el año 2003, con adaptaciones menores y se desarrolló un instrumento de autopsia social. Para la identificación de 'casos' se organizaron redes de informantes comunitarios. La información fue analizada por un panel de expertos y fue introducida en una base de datos. Resultados: se estudiaron 88 mortinatos y 137 neonatos fallecidos durante los primeros 28 días de vida. Las principales causas de muerte fueron: asfixia perinatal (mortinatos) y las infecciones (recién nacidos vivos). Las causas "sociales" fueron la falta de reconocimiento del problema por parte del cuidador y el manejo inapropiado del proveedor de salud. Según los paneles de expertos, la "evitabilidad" de las muertes fue del 85% y 96% para mortinatos y recién nacidos respectivamente. Conclusiones: la autopsia verbal, complementada con la autopsia social, brinda insumos importantes para el análisis local de las muertes neonatales y de los mortinatos, lo cual facilita el desarrollo de intervenciones adecuadas a diferentes contextos. La definición de 'mortalidad evitable' requiere ser mejor desarrollada. Las estrategias para reducir la mortalidad neonatal y perinatal, además de estar basadas en evidencias, deben ser factibles de ser aplicadas y deben responder a las necesidades locales.

Translated abstract

Objectives: this study, in health networks in urban and rural Bolivia (El Alto, Potosí and Cochabamba) had the following objectives: to know the biological and social causes of stillbirths and neonatal mortality, the proportion of preventable deaths and analyze the process of each neonatal death. Methods: the study was cross-sectional and descriptive, non-probability sampling. Used the questionnaire developed by WHO in 2003, with minor adjustments and developed a social autopsy instrument. For the identification of 'cases' were organized networks of community informants. Data were analyzed by a panel of experts and was introduced in a database. Results: we studied 88 stillbirths and 137 infants died during the first 28 days of life. The leading causes of death were: perinatal asphyxia (stillbirths) and infections (alive new born babies). "Social" causes were the lack of recognition of the problem by the caregiver and the inappropriate handling of the health care provider. According to the expert panels, the preventability of deaths was 85% and 96% for stillbirths and newborns respectively. Conclusions: verbal autopsy, complemented by social autopsy, provides important inputs for the local analysis of neonatal deaths and of stillbirths, which facilitates the development of interventions appropriate to different contexts. The definition of 'preventable mortality' needs to be better developed. Strategies to reduce neonatal and perinatal mortality, as well as being based on evidence, must be feasible and should be implemented to respond to local needs.

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Most cited references 31

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Encuesta Nacional de Demografía y Salud

M Barroso, LA Montes, H Raggers … (2005)

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Avoidable stillbirths and neonatal deaths in rural Tanzania.

Gunnar Kvåle, Jakob Havnen, Jonathan Olsen … (2003)

To determine the causes of stillbirths and neonatal deaths in the community in rural Tanzania and to evaluate whether the deaths were avoidable under the prevailing circumstances. Review of stillbirths and neonatal deaths. Rural northern Tanzania, Mbulu and Hanang districts. One hundred and nineteen stillbirth and neonatal deaths identified in a prospective cohort of antenatal attendees and 21 stillbirths and neonatal deaths identified retrospectively in a household survey in seven rural communities. Verbal autopsy was done to reach a diagnosis, in many cases supplemented with information from antenatal records and hospital records. The avoidability of deaths under the prevailing circumstances was assessed for each case. An account of risk factors detectable at antenatal clinic was done and compared with the woman's recall of the risk assessment and recall of being referred. Avoidability of stillbirths and neonatal deaths. There were 60 stillbirths, 49 early neonatal deaths and 27 late neonatal deaths. Infection-related deaths were most common (n = 53), followed by asphyxia-related deaths (n = 32) and immaturity-related deaths (n = 20). Malaria was the most common infectious agent observed (21 children and 20 mothers). Twenty-one deaths (15%) were probably avoidable and 13 (10%) were possibly avoidable. A patient-oriented avoidable factor was identified in 17 (51%) and a provider-oriented avoidable factor was identified in 22 cases (65%). Twenty-six of the 34 avoidable deaths had risk factors, but only two of the women were aware of it and only one recalled being referred to a hospital for the risk factor. There were eight deaths among the 133 mothers who experienced a perinatal death. Our data indicate that prevention and adequate treatment of infections and asphyxia in the newborn should have high priority in low-income settings. The relatively low proportion of avoidable stillbirths and neonatal deaths may be partly due to accessible emergency obstetric care in the area. Future efforts should emphasise improving the communication between midwife and women at the antenatal clinics, preparing the women-and their families-for the delivery and to be ready for complications.

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Value and quality of perinatal and infant postmortem examinations: cohort analysis of 400 consecutive deaths.

Rebecca Dawson, Norma J. Stewart, G Vujanic … (1995)

To evaluate the contribution that perinatal and infant necropsy makes to clinical practice and to see how this might be influenced by the quality of the investigation. Cohort analysis, with data from the all Wales perinatal survey, of perinatal and infant deaths during 1993 of babies born to mothers usually resident in Wales. The clinicopathological classification of death based on clinical details was compared with the classification after necropsy. Similarly, cases in which necropsy yielded new information were identified. The quality of the necropsy was assessed by scoring six aspects of the examination. 400 consecutive deaths at 20 weeks of gestation to 1 year of age. Necropsy rate, effect of necropsy on clinicopathological classification, new information disclosed by necropsy, quality of necropsies, and the link between new information and quality of the necropsy. Necropsy was performed in 232 cases (58%). The clinicopathological classification was altered by necropsy in 29 cases (13%). New information was obtained in 60 cases (26%), and in 42 (18%) it disclosed the cause of death. The quality of necropsy was substantially higher when the main cause of death was detected than when nothing new was found. Necropsy is underused. Clinicians should be more positive about necropsies and realise how much clinically relevant information can be obtained from a good quality examination.