The study conducted social autopsy focusing maternal death due to haemorrhage and convulsion, mostly after the delivery. The case discussion note presented that there was delayed in decision making to transfer the mother immediately to referral facility. A number of social obstacles still persist in the society which largely influenced the family to act in a certain way during a critical situation.
Issues related to delivery by traditional birth attendant and delivery conduction at home
Home delivery and no-use of trained birth attendance during delivery are major problems. This finding also support previous finding of a national representative study [15]. The social autopsy in the current study also revealed that community people have a high dependency on the traditional birth attendant and village doctor during delivery who are not trained in the management of maternal complications. Maternal death review has been performed in many other countries in similar settings identified delivery by untrained people caused maternal deaths [16–21]. A recent study from Bangladesh also argued that majority of the cases who sough formal care for maternal complications were from informal care facilities [22]. A study conducted in Pakistan has shown that 42 % of deliveries are conducted at home and the majority of the mothers who died did so from haemorrhage and eclampsia. Most of the patients delayed arriving at hospital due to poor decision making made at home with the family [16]. Another study in India illustrated that there are a number of socio-cultural factors due to inadequate knowledge and ignorance which contributed to maternal deaths. This study also showed that 80 % of the mothers who died at home were being delivered by untrained birth attendant [21]. In this study, it was observed that those mother who were suffered from pre-eclampsia or haemorrhage were died at home in majority cases. While as maternal death review (verbal autopsy) findings of Bangladesh shown overall majority deaths occurred in mother at the facility or on the way to facility [5].
Community delays identified as a barrier
The study also identified that the deceased family were waited until the village doctor or traditional birth attendant spoke about referral as the community has great confidence in village doctors. Moreover, in the majority of cases, it was observed that delayed decision making contributed to the mother’s death and that most of the deaths could have been averted if the mother was treated at the right time. A Mexican study reported that of 19 mothers who died during complications, the family took a day to decide where to go [21]. However, the study also stated that the community had misconceptions about the standard of health care delivery at the hospital and it was this that made them delay their decision [12]. During social autopsy the community mentioned that one of the reasons they delayed the decision to travel to the hospital was because they worried the delivery might be done by caesarean section and that the operation would cause loss of productivity of work of the mother. One study in Ghana has used social autopsy as an umbrella to explore social dilemmas around a death. The study focused on delays in decision making in five deaths and identified social autopsy as an effective method to improve the understanding of the consequences before death [10]. A study in Kenya addressed the reasons for delays including transport, lack of money and how delays in receiving treatment at the health facility were a major contributor to maternal deaths [11].
Social autopsy in addressing social factors
In this study, social autopsy explored the social errors, barrier and factors related to death, rather than its capability to be a platform to share, discuss among the villagers on the issues related to death. Moreover, the meeting also raised commitment, encouragement and reinforcement of the villagers to decide upon what things they would do to in the future to prevent such events. A review article from India has identified social autopsy as a powerful tool for raising awareness in the community and some of the key decisions taken by a district utilizing social autopsy findings to accelerate and improve the quality of services [12]. This study reflected a number of decisions made by the community to prevent maternal death due to haemorrhage and pre-eclampsia/eclampsia and how lessons learnt from a death event can influence and mobilize an entire community to decide upon better actions to take in the future.
Policy issue
Bangladesh is approaching towards achieving sustainable developmental goal by 2030. Health is one of the key priority area for the government, where government is determined to reduce the burden of maternal death to 70/100000 livebirths or below. Identifying the social stigma in the community though social autopsy is a strong supportive document to take action plan at the local level by the health and family planning department and implement [2]. Therefore social autopsies in the current study may argue that awareness among expecting mothers and their family members or decision makers are highly warranted to control maternal death due to known complications. Thus, will help to reduce the burden of mortality. Moreover, sensitization at the community level stimulate the people to increase demand for seeking quality of care from the facility.
Strengths and limitations
The main strength of the current study is using 28 social autopsies consists of 761 participants to explore community responses to prevent future maternal deaths. SAs were conducted by highly experienced government health workers within government system involving family decision makers, and community people from all hierarchy in the rural context. Therefore the SAs were concerted efforts between community people, health system persons and researchers, which precisely indicated the system gap to reduce maternal deaths in social perspectives.
The information retrieved in this study is from community where a large group of people shared their notions. Homogeneous character such as the participants could be distant relative or from same ideology, they could be biased by some community leader’s presence are some potential bias of the SAs in the current study [23]. However, those limitations are beyond researchers’ control. Health system workers such as health Inspector, assistant health inspector and family planning inspector were the facilitators and tried to minimize the interpersonal influence by reiterating that the participants should express their views independently. There could be some other methodological issues, beyond researcher’s control. While as the study was first time being conducted and revealed so many important issues for reducing maternal death using SAs.