External injuries, trauma and avoidable deaths in Agincourt, South Africa: a retrospective observational and qualitative study

Abstract
Objective Injury burden is highest in low-income and
middle-income countries. To reduce avoidable deaths,
it is necessary to identify health system deficiencies
preventing timely, quality care. We developed criteria to
use verbal autopsy (VA) data to identify avoidable deaths
and associated health system deficiencies.
Setting Agincourt, a rural Bushbuckridge municipality,
Mpumalanga Province, South Africa.
Participants Agincourt Health and Socio-Demographic
Surveillance System and healthcare providers (HCPs) from
local hospitals.
Methods A literature review to explore definitions of
avoidable deaths after trauma and barriers to access to
care using the ‘three delays framework’ (seeking, reaching
and receiving care) was performed. Based on these
definitions, this study developed criteria, applicable for use
with VA data, for identifying avoidable death and which of
the three delays contributed to avoidable deaths. These
criteria were then applied retrospectively to the VA-defined
category external injury deaths (EIDs—a subset of which
are trauma deaths) from 2012 to 2015. The findings
were validated by external expert review. Key informant
interviews (KIIs) with HCPs were performed to further
explore delays to care.
Results Using VA data, avoidable death was defined with
a focus on survivability, using level of consciousness at the
scene and ability to seek care as indicators. Of 260 EIDs
(189 trauma deaths), there were 104 (40%) avoidable EIDs
and 78 (30%) avoidable trauma deaths (41% of trauma
deaths). Delay in receiving care was the largest contributor
to avoidable EIDs (61%) and trauma deaths (59%),
followed by delay in seeking care (24% and 23%) and
in reaching care (15% and 18%). KIIs revealed contextspecific
factors contributing to the third delay, including
difficult referral systems.
Conclusions A substantial proportion of EIDs and
trauma deaths were avoidable, mainly occurring due
to facility-based delays in care. Interventions, including
strengthening referral networks, may substantially reduce
trauma deaths.