A verbal and social autopsy study to improve estimates of mortality determinants in Pakistan: study design and methods

Background: Reducing newborn, child, adolescent, and maternal mortality is a global priority, yet Pakistan continues to bear a high burden of preventable deaths. Routine civil registration does not capture causes or social determinants for most of these deaths. The verbal and social autopsy (VASA) methodology fills this gap by combining symptom-based identification of the cause of death with structured assessment of social and care-seeking factors. Here we describe the methodological framework of a national VASA study conducted using the Pakistan National Nutrition Survey 2018 sampling frame, designed to estimate cause-specific mortality and social determinants of stillbirths and neonatal, post-neonatal, adolescent, and maternal deaths. Methods: We used the sampling frame of the Pakistan National Nutrition Survey 2018 and employed VASA techniques to identify biological causes and social determinants of stillbirths, neonatal, child, adolescent, and maternal deaths. By utilising adapted VASA tools and rigorous analytical methods, we sought to bridge the gap between health systems and mortality data by examining deaths that occurred in and outside of healthcare facilities. Our aim was to provide insights into preventable deaths to guide public health interventions and policymaking, such as integrating VASA into the national survey and building the capacity of community-level healthcare workers to conduct VASA. Conclusions: This study provides a vital contribution to improving health outcomes and reducing mortality in low- and middle-income countries by integrating sociocultural and systemic factors into mortality analysis.