Combining Vital Events Registration, Verbal Autopsy and Electronic Medical Records in
Rural Ghana for Improved Health Services Delivery
Seth Ohemeng-Dapaaha, Paul Pronykb, Eric Akosaa, Bennett Nemserb and Andrew S. Kanterb,c,d
a Millennium Villages Project, Bonsasso, Ashanti Region, Ghana
b Millennium Villages Project, Earth Institute, Columbia University, New York, NY, USA
c Department of Biomedical Informatics, Columbia University, New York, NY, USA
d Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA


Abstract
This paper describes the process of implementing a low-cost
µUHDl-WLPH¶ YLWDO UHJLVWUDWLRQ DQG YHUEDO Dutopsy system inte-
grated within an electronic medical record within the Millen-
nium Village cluster in rural Ghana. Using MGV-Net, an
open source health information architecture built around the
OpenMRS platform, a total of 2378 births were registered
between January 2007 and June 2009. The percentage of
births registered in the health facility under supervision of a
skilled attendant increased substantially over the course of the
project from median of 35% in 2007 to 64% in 2008 and 85%
midway through 2009. Building additional clinics to reduce
distance to facility and using the CHEWs to refer women for
delivery in the clinics are possible explanations for the suc-
cess in the vital registration. The integration of vital registra-
tion and verbal autopsies with the MGV-Net information sys-
tem makes it possible for rapid assessment of effectiveness and
provides important feedback to local providers and the Mil-
lennium Villages Project.
Keywords:
Africa, Birth records, Community health information sys-
tems, Electronic health records, Ghana, Health information
systems, OpenMRS, Verbal autopsy, Vital statistics.
Introduction
A global agenda to address the overlapping vulnerabilities of
poverty, underdevelopment and ill-health has recently been
articulated in the United Nations Millennium Development
Goal (MDG) framework [1]. Reducing premature death among
children and among women during childbirth have been identi-
fied as urgent priorities, with specific time-bound MDG tar-
gets. The Millennium Villages Project (MVP) has been pre-
viously described and involves the systematic delivery of a
package of proven health and development interventions, with
the aim of accelerating progress towards the Millennium De-
velopment Goals [2].
The MVP is among the first applications of a multi-sector
community health and development intervention. Interven-
tions in agriculture, infrastructure, economics, education and
health are being simultaneously introduced to village units of
1,000-10,000 households. This intensity and scale, combined
with the diversity of MVP contexts, provide an unprecedented
opportunity for better understanding the contribution of eco-
nomics, infrastructure and health to human development. Les-
sons learned from the project have enormous potential to in-
form policy and program development in Africa and elsewhere
for the coming decades.
In parallel to enhancing access to proven interventions, global
health gains require the generation of high quality health in-
formation that can be used to guide program delivery [3].
5HFHQW FDOOV IRU µLQIRUPDWLRQ UHIRUP¶ WR LPSURYH ERWWRP-up
approaches to the generation and use of information has the
potential to revitalize locally-based health information systems
and provide data on access of care, and critical health out-
comes that can be used directly to improve local practice and
reduce deaths [4].
While addressing maternal and child death rates are overriding
concerns of two of the MDG targets, tools for the systematic
measurement of mortality have evolved relatively recently.
Currently more than half of deaths in developing countries go
unregistered. With vital registration data often missing, in-
complete and inaccurate, informed decisions regarding how
and where to best intervene are often difficult to make [5].
Vital registration (monitoring of births and deaths) and verbal
autopsies have been put forth as a potential strategy to address
the need for real-time information to inform the targeting and
improve coverage with essential public health interventions.
9HUEDODXWRSVLHV9$VDUH³DSURFHGXUH WRH[SORLW WKHLQIRr-
mation provided by the relatives of a deceased person to re-
construct the events and symptoms that preceded the death so
as to deduce a medically acFHSWDEOHFDXVHRUFDXVHVRIGHDWK´
[6, 7].
Despite the potential for vital events monitoring and VAs to
inform intervention strategies, there has been much less inter-
MEDINFO 2010
C. Safran et al. (Eds.)
IOS Press, 2010
© 2010 IMIA and SAHIA. All rights reserved.
doi:10.3233/978-1-60750-588-4-416
416

national experience in this regard [8]. VA data has limited
use, because of long time delay between vital event identifica-
tion, VA data collection, cause of death determination, and
data aggregation/analysis. However, some important prelimi-
nary work has been undertaken in a diversity of settings in-
cluding the use of VAs to inform programs to address diabetes
in the Ukraine [9], assess care seeking for malaria in Tanzania
[10], understanding health seeking behavior, to guide the tar-
geting health system interventions to improve TB diagnosis
and treatment initiation in South Africa [11], and to guide im-
provements in the quality of community and hospital care to
reduce infant mortality in India [12].
Medical records are often a key source of information to ob-
tain the complete picture about births and deaths. [13] Integra-
tion of vital registration with clinical systems such as hospital
records has been suggested using linkage software. [14] How-
ever, the work required to implement vital registration systems
in low resource, rural communities with historically low access
and/or utilization of health delivery systems should not be un-
derestimated. [15] Capturing the complete picture of vital
events often requires integration of multiple sources including
the community, health facilities and other sources. [16]
When viewed holistically, the importance of vital events in-
formation, the existence of multiple primary data sources, the
resources required to implement the system, and the value in
reusing the data to assist with program management and pa-
tient care, it is likely that integrating vital registration and ver-
bal autopsies with electronic medical records close to the
communities will be beneficial.
This paper describes the process of implementing a low-cost
µUHDO-time¶YLWDOUHJLVWUDWLRQDQG9$V\VWHPZLWKLQWKH0LOOHn-
nium Village cluster in rural Ghana. Implementation is cur-
rently in progress; however, we present preliminary data from
the system and underscore ways in which these data can be
used to inform and strengthen health systems and service deli-
very.
Materials and Methods
MVP Bonsasso, Ghana
Bonsaaso Millennium Village is located in the Amansie West
District in the Ashanti Region of Ghana. The village is an ag-
glomeration of 30 communities with 5769 households and has
an estimated population of 30,000 people, of which 23% are
women with reproductive age (15-49 years). When the project
started in 2006 there were only three health centers within the
cluster. The nearest hospital where surgery could be performed
is the Agroyesum Catholic Mission Hospital which is about 27
km away from the village. In Bonsaaso, the nurse-population
ratio in 2006 was 1:5,452. At the Regional level, nurse-
population ratio was 1:3,082 and the doctor-population ratio
was 1: 31,477. Due to the dispersed nature of the communities,
coupled with poor condition of roads, inadequate transport
services, access to the health facility posed enormous chal-
lenge to the people at the beginning of the project.
Currently there are 7 clinics and a medical store operating in
the village that have reduced the distances people have to tra-
vel to access health care (see Table 1). Other changes between
2006 and 2009 are also shown.
Table 1 ± Comparison of infrastructure between 2006-2009
Infrastructure/Human Resources 2006 2009
Number of Clinics in Cluster 3 7 + store
Average Distance to Reach Clinic 8.5 km 3.5 km
Health Clinic Staff 3 71
Midwives 2 7
Community Health Ext. Workers 0 28
Overview of the MGV-Net Vital Registration and Verbal
Autopsy (VRVA) System
The Millennium Global Village-Network (MGV-Net) has been
described previously and is an open source health information
architecture built around the OpenMRS platform. [17] In the
Ghana MVP site, vital registration and verbal autopsies are
being integrated into MGV-Net to provide this critical infor-
mation at the community level to facilitate decision-making
and assist in the delivery of care. The VRVA system has a
number of components that will be highlighted briefly below:

Community Health Extension Workers (CHEWs):
In all MVP sites, CHWs or CHEWs have been intro-
duced to maximize the delivery of health information
and services to households in the project clusters.
There currently a ratio of 1 CHW to every 100-200
households, with household visits taking place every 1-
2 months. CHWs are supported by an MVP Health
Coordinator (doctors or allied health professionals),
and provide a spectrum of health interventions to target
households. Furthermore, CHWs are aware of vital
events in households (births and deaths) very quickly.
Verbal autopsy specialist: the VA specialist is non-
clinical health worker specially trained in the VA me-
thodology. VA specialists have the primary responsibil-
ity for conducting VAs.
VRVA tools: have been developed for adults/maternal
deaths and child deaths with two main components:
Birth registration form: questions to evaluate
the circumstances of child birth, including loca-
tion, attendance of skilled professional, and
condition of the child.
Cause of death module: questions to assess
signs and symptoms experienced by the de-
ceased in the time preceding death. The module
was derived from previously validated VA tools
and consists of both close and open-ended sec-
tions as per best-practice guidelines.
S. Ohemeng-Dapaah et al. / Combining Vital Events Registration, Verbal Autopsy and Electronic Medical Records 417