Maternal interventions to decrease stillbirths and neonatal mortality in Tanzania: evidence from the 2017-18 cross-sectional Tanzania verbal and social autopsy study.

BACKGROUND: Reduction of Tanzania's neonatal mortality rate has lagged behind that for all under-fives, and perinatal mortality has remained stagnant over the past two decades. We conducted a national verbal and social autopsy (VASA) study to estimate the causes and social determinants of stillbirths and neonatal deaths with the aim of identifying relevant health care and social interventions. METHODS: A VASA interview was conducted of all stillbirths and neonatal deaths in the prior 5 years identified by the 2015-16 Tanzania Demographic and Health Survey. We evaluated associations of maternal complications with antepartum and intrapartum stillbirth and leading causes of neonatal death; conducted descriptive analyses of antenatal (ANC) and delivery care and mothers' careseeking for complications; and developed logistic regression models to examine factors associated with delivery place and mode. RESULTS: There were 204 stillbirths, with 185 able to be classified as antepartum (88 [47.5%]) or intrapartum (97 [52.5%]), and 228 neonatal deaths. Women with an intrapartum stillbirth were 6.5% (adjusted odds ratio (aOR) = 1.065, 95% confidence interval (CI) 1.002, 1.132) more likely to have a C-section for every additional hour before delivery after reaching the birth attendant. Antepartum hemorrhage (APH), maternal anemia, and premature rupture of membranes (PROM) were significantly positively associated with early neonatal mortality due to preterm delivery, intrapartum-related events and serious infection, respectively. While half to two-thirds of mothers made four or more ANC visits (ANC4+), a third or fewer received quality ANC (Q-ANC). Women with a complication were more likely to deliver at hospital only if they received Q-ANC (neonates: aOR = 4.5, 95% CI 1.6, 12.3) or ANC4+ (stillbirths: aOR = 11.8, 95% CI 3.6, 38.0). Nevertheless, urban residence was the strongest predictor of hospital delivery. CONCLUSIONS: While Q-ANC and ANC4 + boosted hospital delivery among women with a complication, attendance was low and the quality of care is critical. Quality improvement efforts in urban and rural areas should focus on early detection and management of APH, maternal anemia, PROM, and prolonged labor, and on newborn resuscitation.

Social determinants of health pave the path to maternal deaths in rural Sri Lanka: reflections from social autopsies.

BACKGROUND: Ending preventable maternal deaths remains a challenge in low- and middle-income countries (LMICs). Society perceived causes and real-life observations can reveal the intangible causes of maternal deaths irrespective of formal maternal death investigations. This study reports complex patterns in which social determinants act towards paving the path to maternal deaths in a rural Sri Lankan setting. METHODS: We conducted social autopsies for 15/18 maternal deaths (in two consecutive years during the past decade) in district A (pseudonymized). In-depth interviews of 43 respondents and observations were recorded in the same field sites. During thematic analysis, identified themes were further classified according to the World Health Organization framework for social determinants of health (SDH). The patterns between themes and clustering of social determinants based on the type of maternal deaths were analyzed using mixed methods. RESULTS: Discernable social causes underpinned 12 out of 15 maternal deaths. Extreme poverty, low educational level, gender inequity, and elementary or below-level occupations of the husband were the characteristic structural determinants of most deceased families. Social isolation was the commonest leading cause manifesting as a reason for many other social factors and resulted in poor social support paving the path to most maternal deaths. A core set of poverty, social isolation, and poor social support acted together with alcohol usage, and violence leading to suicides. These core determinants mediating through neglected self-health care led to delay in health-seeking. Deficits in quality of care and neglect were noted at health institutions and the field. CONCLUSION: Social autopsies of maternal deaths revealed complex social issues and social determinants of health leading to maternal deaths in Sri Lanka, indicating the need for a socially sensitive health system.

A Eulogy for Jane Robinson: A Social Autopsy of Uncare Policies.

Shortly after losing her health insurance in 2018, Jane Robinson died of a treatable respiratory infection. This article argues that Jane's death occurred at the nexus of two different approaches to care: the necropolitics of uncare and the micropolitics of generative care labor. Both of these approaches to care increased Jane's health and social vulnerability, in turn quickening her death. We adopt the necropolitics of uncare framework to identify and name the harmful policies and attitudes of disregard that control access to life saving medical care. In the micropolitics of care in Jane's life, she became the safety net for others, which left little over when her health began to deteriorate. This social autopsy reveals that her care networks were insufficient to undo the uncare enshrined in state policy. Jane's unnecessary death foreshadowed the excess mortality that the United States has experienced from COVID-19.

Causes of preterm and low birth weight neonatal mortality in a rural community in Kenya: evidence from verbal and social autopsy.

BACKGROUND: Under-five mortality in Kenya has declined over the past two decades. However, the reduction in the neonatal mortality rate has remained stagnant. In a country with weak civil registration and vital statistics systems, there is an evident gap in documentation of mortality and its causes among low birth weight (LBW) and preterm neonates. We aimed to establish causes of neonatal LBW and preterm mortality in Migori County, among participants of the PTBI-K (Preterm Birth Initiative-Kenya) study. METHODS: Verbal and social autopsy (VASA) interviews were conducted with caregivers of deceased LBW and preterm neonates delivered within selected 17 health facilities in Migori County, Kenya. The probable cause of death was assigned using the WHO International Classification of Diseases (ICD-10). RESULTS: Between January 2017 to December 2018, 3175 babies were born preterm or LBW, and 164 (5.1%) died in the first 28 days of life. VASA was conducted among 88 (53.7%) of the neonatal deaths. Almost half (38, 43.2%) of the deaths occurred within the first 24 h of life. Birth asphyxia (45.5%), neonatal sepsis (26.1%), respiratory distress syndrome (12.5%) and hypothermia (11.0%) were the leading causes of death. In the early neonatal period, majority (54.3%) of the neonates succumbed to asphyxia while in the late neonatal period majority (66.7%) succumbed to sepsis. Delay in seeking medical care was reported for 4 (5.8%) of the neonatal deaths. CONCLUSION: Deaths among LBW and preterm neonates occur early in life due to preventable causes. This calls for enhanced implementation of existing facility-based intrapartum and immediate postpartum care interventions, targeting asphyxia, sepsis, respiratory distress syndrome and hypothermia.

Effect of Delays in Maternal Access to Healthcare on Neonatal Mortality in Sierra Leone: A Social Autopsy Case-Control Study at a Child Health and Mortality Prevention Surveillance (CHAMPS) Site.

INTRODUCTION: In low-resource settings, a social autopsy tool has been proposed to measure the effect of delays in access to healthcare on deaths, complementing verbal autopsy questionnaires routinely used to determine cause of death. This study estimates the contribution of various delays in maternal healthcare to subsequent neonatal mortality using a social autopsy case-control design. METHODS: This study was conducted at the Child Health and Mortality Prevention Surveillance (CHAMPS) Sierra Leone site (Makeni City and surrounding rural areas). Cases were neonatal deaths in the catchment area, and controls were sex- and area-matched living neonates. Odds ratios for maternal barriers to care and neonatal death were estimated, and stratified models examined this association by neonatal age and medical complications. RESULTS: Of 53 neonatal deaths, 26.4% of mothers experienced at least one delay during pregnancy or delivery compared to 46.9% of mothers of stillbirths and 18.6% of control mothers. The most commonly reported delay among neonatal deaths was receiving care at the facility (18.9%). Experiencing any barrier was weakly associated (OR 1.68, CI 0.77, 3.67) and a delay in receiving care at the facility was strongly associated (OR 19.15, CI 3.90, 94.19) with neonatal death. DISCUSSION: Delays in healthcare are associated with neonatal death, particularly delays experienced at the healthcare facility. Heterogeneity exists in the prevalence of specific delays, which has implications for local public health policy. The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Neonatal mortality in rural northern Ghana and the three delays model: are we focusing on the right delays?

OBJECTIVE: The Three Delays Model outlines, three common delays that lead to poor newborn outcomes: (i) recognising symptoms and deciding to seek care; (ii) getting to care and; (iii) receiving timely, high-quality care. We gathered data for all newborn deaths within four districts in Ghana to explore how well the Three Delays Model explains outcomes. METHODS: In this cross-sectional, observational study, trained field workers conducted verbal and social autopsies with the closest surviving relative (typically mothers) of all neonatal deaths across four districts in northern Ghana from September 2015 until April 2017. Data were collected using Survey CTO and analysed using StataSE 15.0. Frequencies and descriptive statistics were calculated for key variables. RESULTS: 247 newborn deaths were identified. Nearly 77% (190) of newborns who died were born at a health facility, and 48.9% (93) of those who died before discharge. Of the 149 newborns who were discharged or born at home, 71.8% (107) sought care at a facility for illness, and 72.9% (N = 78) of those did so within the same day of illness recognition. Of the 83 respondents who arranged for transportation, 82% (68) did so within 1 h. Newborns received prompt care but insufficient interventions - 25% or fewer received IV fluids, oral medications, antibiotics or oxygen. CONCLUSIONS: These data suggest that women are following recommendations for safe delivery and prompt care-seeking. In rural northern Ghana, behaviour change interventions focused on mothers and families may not be as pressing as interventions focused on the Third Delay - obtaining timely, high-quality care.

Engaging community health workers in maternal and infant death identification in Khayelitsha, South Africa: a pilot study.

BACKGROUND: Engaging community health workers in a formalised death review process through verbal and social autopsy has been utilised in different settings to estimate the burden and causes of mortality, where civil registration and vital statistics systems are weak. This method has not been widely adopted. We piloted the use of trained community health workers (CHW) to investigate the extent of unreported maternal and infant deaths in Khayelitsha and explored requirements of such a programme and the role of CHWs in bridging gaps. METHODS: This was a mixed methods study, incorporating both qualitative and quantitative methods. Case identification and data collection were done by ten trained CHWs. Quantitative data were collected using a structured questionnaire. Qualitative data were collected using semi-structured interview guides for key informant interviews, focus group discussions and informal conversations. Qualitative data were analysed thematically using a content analysis approach. RESULTS: Although more than half of the infant deaths occurred in hospitals (n = 11/17), about a quarter that occurred at home (n = 4/17) were unreported. Main causes of deaths as perceived by family members of the deceased were related to uncertainty about the quality of care in the facilities, socio-cultural and economic contexts where people lived and individual factors. Most unreported deaths were further attributed to weak facility-community links and socio-cultural practices. Fragmented death reporting systems were perceived to influence the quality of the data and this impacted on the number of unreported deaths. Only two maternal deaths were identified in this pilot study. CONCLUSIONS: CHWs can conduct verbal and social autopsy for maternal and infant deaths to complement formal vital registration systems. Capacity development, stakeholder's engagement, supervision, and support are essential for a community-linked death review system. Policymakers and implementers should establish a functional relationship between community-linked reporting systems and the existing system as a starting point. There is a need for more studies to confirm or build on our pilot findings.

Home deaths of children under 5 years in rural South Africa: a population-based longitudinal study.

OBJECTIVES: To determine the proportion of under-5 deaths that occurred at home in rural South Africa, whether care was sought prior to death, and determinants of home deaths amongst those who sought care. METHODS: Verbal autopsy data were used for all under-5 deaths, 2000-2015, in two health and demographic surveillance system sites. Trends in place of death and care-seeking were assessed. Associations between sociodemographic factors and home death despite seeking care were assessed by multivariate logistic regressions. RESULTS: There were 3760 under-5 deaths; 1954 (53%) at home and 1510 (41%) in health facilities. Eighty-four per cent of children who died at home accessed healthcare during their final illness. Amongst neonates for whom care was sought, those who were 8-27 days old were more likely to die at home than those who were 0-7 days old (OR = 5.56, 95%CI 2.69-11.55, P < 0.001). Factors associated with home death of infants and young children despite seeking care included low maternal education (OR = 1.71, 95%CI 1.31-2.24, P < 0.001), larger household size (OR = 1.56, 95%CI 1.17-2.06, P = 0.002), traditional medicine use (OR = 2.33, 95%CI 1.75-3.12, P < 0.001) and Mozambican descent (OR = 1.47, 95%CI 1.06-2.03, P = 0.020). The proportion of HIV-related deaths that occurred at home fell from 60% in 2008-2011 to 39% in 2012-2015 ( χ2  = 13.86, P < 0.001). CONCLUSION: More than half of under-5 deaths in rural South Africa occurred at home although healthcare was sought for most children, highlighting that home deaths are not simply a function of poor care-seeking. Interventions should target high-risk sociodemographic groups.

OBJECTIFS: Déterminer la proportion de décès d'enfants de moins de 5 ans survenus à domicile dans les zones rurales d'Afrique du Sud, si des soins ont été recherchés avant le décès et les déterminants des décès à domicile chez ceux qui ont recherché des soins. MÉTHODES: Les données d'autopsie verbale ont été utilisées pour tous les décès d'enfants de moins de 5 ans entre 2000 et 2015, dans deux sites du système de surveillance démographique et de santé. Les tendances en matière de lieu de décès et de recherche de soins ont été évaluées. Les associations entre les facteurs sociodémographiques et le décès à domicile malgré les soins recherchés ont été évaluées par des régressions logistiques multivariées. RÉSULTATS: Il y a eu 3.760 décès de moins de 5 ans; 1.954 (53%) à domicile et 1.510 (41%) dans les établissements de santé. 84% des enfants décédés à domicile ont eu accès à des soins de santé au cours de leur dernière maladie. Parmi les nouveau-nés pour lesquels des soins ont été recherchés, ceux âgés de 8 à 27 jours étaient plus susceptibles de mourir à domicile que ceux âgés de 0 à 7 jours (OR = 5,56; IC95% 2,69-11,55; p <0,001). Les facteurs associés au décès des nourrissons et des jeunes enfants à domicile malgré la recherche de soins comprenaient un niveau d'éducation maternelle faible (OR = 1,71; IC95%: 1,31-2,24; p <0,001), une taille du ménage plus grande (OR = 1,56; IC95%: 1,17-2,06; p = 0,002), l'utilisation de la médecine traditionnelle (OR = 2,33; IC95%: 1,75-3,12; p <0,001) et l'origine mozambicaine (OR = 1,47; IC95%: 1,06-2,03; p = 0,020). La proportion de décès liés au VIH survenus à domicile est passée de 60% en 2008-2011 à 39% en 2012-2015 (Chi2 = 13,86; p <0,001). CONCLUSION: Plus de la moitié des décès des moins de 5 ans dans les zones rurales d'Afrique du Sud sont survenus à domicile bien que pour la plupart des enfants une recherche de soins de santé a été effectuée, soulignant que les décès à domicile ne sont pas simplement liés à un mauvais recours aux soins. Les interventions devraient cibler les groupes sociodémographiques à haut risque.

Maternal Mortality in Rural Varanasi: Delays, Causes, and Contributing Factors.

BACKGROUND: Pregnancy and motherhood are natural processes and considered to be full of positive experiences. However, for various reasons many women end up dying during pregnancy, childbirth, and the postpartum period. Improving maternal health and reducing maternal mortality have been prioritized in several international declarations and national policies. OBJECTIVES: The objective of the study is to assess delays, cause, and its contributing factors related to maternal deaths in rural Varanasi. METHODOLOGY: Verbal and Social Autopsy have been done for each maternal death occurred between April 2015 and March 2016 in four randomly selected blocks of rural Varanasi. The "3 Delay Model" and "Pathway analysis" concept was used in collection and analysis of data through in-depth interview of three people (family member, neighbor, and a health worker) for each maternal death. Cause of death and delays was identified by two reviewers (obstetrician) independently. RESULTS: In almost half of the autopsied cases two different delays were found, and in one-third case, only one delay was found. Direct obstetric cause found in more than half (54%) cases. Hemorrhage and anemia were found major direct and indirect obstetric cause, respectively. Other causes identified were sepsis (direct), jaundice, and meningitis. A number of social, behavioral, and cultural factors were identified, that had been contributed to different delays related to the maternal deaths. CONCLUSIONS: First delay was present in most of (90%) cases. Nonbiological (social, behavioral, and cultural) and health service factors were also identified in this study.

The rebellious man: Next-of-kin accounts of the death of a male relative on antiretroviral therapy in sub-Saharan Africa.

The HIV response is hampered by many obstacles to progression along the HIV care cascade, with men, in particular, experiencing different forms of disruption. One group of men, whose stories remain untold, are those who have succumbed to HIV-related illness. In this paper, we explore how next-of-kin account for the death of a male relative. We conducted 26 qualitative after-death interviews with family members of male PLHIV who had recently died from HIV in health and demographic surveillance sites in Malawi, Tanzania, Kenya, Uganda, Zimbabwe and South Africa. The next-of-kin expressed frustration about the defiance of their male relative to disclose his HIV status and ask for support, and attributed this to shame, fear and a lack of self-acceptance of HIV diagnosis. Next-of-kin painted a picture of their male relative as rebellious. Some claimed that their deceased relative deliberately ignored instructions received by the health worker. Others described their male relatives as unable to maintain caring relationships that would avail day-to-day treatment partners, and give purpose to their lives. Through these accounts, next-of-kin vocalised the perceived rebellious behaviour of these men, and in the process of doing so neutralised their responsibility for the premature death of their relative.

Social autopsy for maternal and perinatal deaths in Bangladesh: a tool for community dialog and decision making.

Bangladesh has an established comprehensive death review system for tracking and reviewing maternal and perinatal deaths. This death review system, established in 2010, was initially known as the "Maternal and Perinatal Death Review (MPDR) System." One of the key interventions of the MPDR system, social autopsy (SA), is generally undertaken following a maternal or perinatal death notification. Social autopsy is managed at the community level by government field health workers. The main purpose of SA is to enable community discussion and create awareness of the preventable causes of maternal or neonatal deaths. Through these conversations, it is hoped to reduce future maternal and neonatal deaths. During the scaling up of the system in Bangladesh in 2016, the Ministry of Health and Family Welfare (MoH&FW) included social autopsy as a useful intervention in reviewing death at the community level and named it "Maternal and Perinatal Death Surveillance and Response" (MPDSR). The new MPDSR tool is currently being administered for the the 2017 to 2021 period under the National Health and Nutrition Population Sector Program (HPNSP). This paper seeks to review the experiences of the social autopsy tool, from the initial MPDR system to the current MPDSR system and its role in reducing maternal and neonatal deaths in Bangladesh.

Social autopsy: a potential health-promotion tool for preventing maternal mortality in low-income countries.

Despite significant global improvements, maternal mortality in low-income countries remains unacceptably high. Increasing attention in recent years has focused on how social factors, such as family and peer influences, the community context, health services, legal and policy environments, and cultural and social values, can shape and influence maternal outcomes. Whereas verbal autopsy is used to attribute a clinical cause to a maternal death, the aim of social autopsy is to determine the non-clinical contributing factors. A social autopsy of a maternal death is a group interaction with the family of the deceased woman and her wider local community, where facilitators explore the social causes of the death and identify improvements needed. Although still relatively new, the process has proved useful to capture data for policy-makers on the social determinants of maternal deaths. This article highlights a second aspect of social autopsy - its potential role in health promotion. A social autopsy facilitates "community self-diagnosis" and identification of modifiable social and cultural factors that are attributable to the death. Social autopsy therefore has the potential not only for increasing awareness among community members, but also for promoting behavioural change at the individual and community level. There has been little formal assessment of social autopsy as a tool for health promotion. Rigorous research is now needed to assess the effectiveness and cost effectiveness of social autopsy as a preventive community-based intervention, especially with respect to effects on social determinants. There is also a need to document how communities can take ownership of such activities and achieve a sustainable impact on preventable maternal deaths.

Using social autopsy to understand maternal, newborn, and child mortality in low-resource settings: a systematic review of the literature.

BACKGROUND: Social, cultural, and behavioral factors are often potent upstream contributors to maternal, neonatal, and child mortality, especially in low- and middle-income countries (LMICs). Social autopsy is one method of identifying the impact of such factors, yet it is unclear how social autopsy methods are being used in LMICs. OBJECTIVE: This study aimed to identify the most common social autopsy instruments, describe overarching findings across populations and geography, and identify gaps in the existing social autopsy literature. METHODS: A systematic search of the peer-reviewed literature from 2005 to 2016 was conducted. Studies were included if they were conducted in an LMIC, focused on maternal/neonatal/infant/child health, reported on the results of original research, and explicitly mentioned the use of a social autopsy tool. RESULTS: Sixteen articles out of 1950 citations were included, representing research conducted in 11 countries. Five different tools were described, with two primary conceptual frameworks used to guide analysis: Pathway to Survival and Three Delays models. Studies varied in methods for identifying deaths, and recall periods for respondents ranged from 6 weeks to 5+ years. Across studies, recognition of danger signs appeared to be high, while subsequent care-seeking was inconsistent. Cost, distance to facility, and transportation issues were frequently cited barriers to care-seeking, however, additional barriers were reported that varied by location. Gaps in the social autopsy literature include the lack of: harmonized tools and analytical methods that allow for cross-study comparisons, discussion of complexity of decision making for care seeking, qualitative narratives that address inconsistencies in responses, and the explicit inclusion of perspectives from husbands and fathers. CONCLUSION: Despite the nascence of the field, research across 11 countries has included social autopsy methods, using a variety of tools, sampling methods, and analytical frameworks to determine how social factors impact maternal, neonatal, and child health outcomes.

Exploring Drivers of Infant Deaths in Rural Rwanda Through Verbal Social Autopsy.

BACKGROUND: Rwanda has been a leader in the global effort to reduce infant mortality, particularly in regions of sub-Saharan Africa. Although rates have dropped, deaths still occur. OBJECTIVE: To explore the care pathways and barriers taken by infant caregivers before the death of their infant through a verbal social autopsy study in 2 districts in eastern Rwanda. METHODS: We adapted the World Health Organization verbal socialautopsy tools to reflect local context and priorities. Caregivers of infants in the 2 districts were interviewed using the adapted quantitative survey and semistructured interview guide. Interviews were recorded and thematic analysis employed on a subsample (n = 133) to extract the content relevant to understanding the drivers of infant death and inform results of the quantitative data until saturation was reached (66). Results were interpreted through a driver diagram framework to explore caregiver-reported challenges in knowledge and experiences with care access and delivery. FINDINGS: Most study participants (82%) reported accessing the formal health system at some point before the infant's death. The primary caregiver-reported drivers for infant death included challenges in accessing care in a timely manner, concerns about the technical quality of care received, and poor responsiveness of the system and providers. The 2 most commonly discussed drivers were gaps in communication between providers and patients and challenges obtaining and using the community-based health insurance. The framework of the driver diagram was modified to identify the factors where change was needed to further reduce mortality. CONCLUSION: This study provides important information on the experiential quality of care received by infants and their caregivers within the current health care space in rural Rwanda. By listening to the individual stories of so many caregivers regarding the gaps and challenges they faced, appropriate action may be taken to bolster the existing health care system.

Why gone too soon? Examining social determinants of neonatal deaths in northwest Ethiopia using the three delay model approach.

BACKGROUND: Without improving the survival of newborns, meaningful reduction in under-five mortality is difficult. Most neonatal deaths are preventable when appropriate and timely care is sought. In Ethiopia, there is lack of evidence on the type and contribution of delays in treatment seeking to neonatal deaths. METHODS: A community based social autopsy (SA) of 39 neonatal deaths was conducted from March 16 to 24, 2016 in Dabat Health and Demographic Surveillance System (HDSS) in northwest Ethiopia. The result was linked with verbal autopsy (VA) information completed for each of the deaths as part of the ongoing HDSS. The SA tool was adapted from INDEPTH Network. Three delay model approach was used to classify the delay types that contributed for the deaths investigated. Descriptive statistics was used to analyze the data. RESULTS: SA was completed for 37 (94.9%) of the 39 neonatal deaths. Of all the deaths, 51.3% (19/37) of them occurred within the first 24 h, 75.6% (28/37) within the first 6 days and the remaining in 7-28 days. Birth asphyxia was the leading cause of death (34%) followed by bacterial sepsis (31%) and prematurity (16%). The median time from recognition of illness to initiation of modern treatment was 1 day (IQR 1-2.5 days). Delay in treatment seeking outside home (delay one) was associated with 81% of the deaths. Delay in receiving care at a health facility (delay three) and delay in transport (delay two) were associated with 16 and 3% of the deaths, respectively. The major contributors of death for delay one were bacterial sepsis (33.3%), birth asphyxia (30%), unspecified illness (20%) and acute lower respiratory tract illnesses (6.7%). For delay three, the major causes of death included birth asphyxia (50%), prematurity (33.3%) and bacterial sepsis (16.7%). CONCLUSIONS: Delays created at home and at health facility were the major delays contributing to the death of newborns. More focus has to be given in improving delays at home and at health facility.

Exploration of social factors associated to maternal deaths due to haemorrhage and convulsions: Analysis of 28 social autopsies in rural Bangladesh.

BACKGROUND: Social autopsy is an innovative approach to explore social barriers and factors associated to a death in the community. The process also sensitize the community people to avert future deaths. Social autopsy has been introduced in maternal deaths in Bangladesh first time in 2010. This study is to identify the social factors in the rural community associated to maternal deaths. It also looks at how the community responses in social autopsy intervention to prevent future maternal deaths. METHODS: The study was conducted in the Thakurgaon district of Bangladesh in 2010. We have purposively selected 28 social autopsy cases of which maternal deaths occurred due to either haemorrhage or due to convulsions. The autopsy was conducted by the Government health and family planning first line field supervisors in rural community. Family members and neighbours of the deceased participated in each autopsy and provided their comments and responses. RESULTS: A number of social factors including delivery conducted by the untrained birth attendant or family members, delays in understanding about maternal complications, delays in decision making to transfer the mother, lack of proper knowledge, education and traditional myth influences the maternal deaths. The community identified their own problems, shared within them and decide upon rectify themselves for future death prevention. CONCLUSIONS: Social autopsy is a useful tools to identify social community within the community by discussing the factors that took place during a maternal death. The process supports villagers to think and change their behavioural patterns and commit towards preventing such deaths in the future.

Social Autopsy of maternal, neonatal deaths and stillbirths in rural Bangladesh: qualitative exploration of its effect and community acceptance.

OBJECTIVES: Social Autopsy (SA) is an innovative strategy where a trained facilitator leads community groups through a structured, standardised analysis of the physical, environmental, cultural and social factors contributing to a serious, non-fatal health event or death. The discussion stimulated by the formal process of SA determines the causes and suggests preventative measures that are appropriate and achievable in the community. Here we explored individual experiences of SA, including acceptance and participant learning, and its effect on rural communities in Bangladesh. The present study had explored the experiences gained while undertaking SA of maternal and neonatal deaths and stillbirths in rural Bangladesh. DESIGN: Qualitative assessment of documents, observations, focus group discussions, group discussions and in-depth interviews by content and thematic analyses. RESULTS: Each community's maternal and neonatal death was a unique, sad story. SA undertaken by government field-level health workers were well accepted by rural communities. SA had the capability to explore the social reasons behind the medical cause of the death without apportioning blame to any individual or group. SA was a useful instrument to raise awareness and encourage community responses to errors within the society that contributed to the death. People participating in SA showed commitment to future preventative measures and devised their own solutions for the future prevention of maternal and neonatal deaths. CONCLUSIONS: SA highlights societal errors and promotes discussion around maternal or newborn death. SA is an effective means to deliver important preventative messages and to sensitise the community to death issues. Importantly, the community itself is enabled to devise future strategies to avert future maternal and neonatal deaths in Bangladesh.

Fatores de risco relacionados com suicidios em Palmas (TO), Brasil, 2006-2009, investigados por meio de autopsia psicossocial / Risk factors associated with suicides in Palmas in the state of Tocantins, Brazil, between 2006 and 2009 investigated by psycho-social autopsy

Este artigo objetiva analisar e descrever os fatores de risco e seus determinantes, associados a 24 casos de suicídios ocorridos na cidade de Palmas (TO), no período de 2006 a 2009. Utilizou-se o método de autópsia psicológica e psicossocial, a qual, por meio de entrevistas com familiares, busca investigar os suicídios consumados, contextualizando características da vida do sujeito, e compreender os processos familiares e as circunstâncias afetivas, sociais, econômicas e culturais, fundamentando-se na reconstrução da história e da personalidade da pessoa. Os fatores socioeconômicos associados foram: ser do sexo masculino, solteiro, de cor parda, estar na faixa etária de 20 a 40 anos e com ensino fundamental. Os principais fatores de risco identificados foram: transtornos mentais, abuso de álcool e outras drogas, relacionamento familiar conturbado e histórico de tentativas anteriores. Buscamos contextualizar e refletir sobre alguns casos relatados pelos familiares e sobre a resposta das equipes de saúde às demandas das famílias. A necessidade de implantar programas de prevenção e de capacitar os profissionais da atenção básica foi verificada. .

The scope of this article is to analyze and describe the risk factors and determinants linked to 24 suicides in the city of Palmas in the state of Tocantins between 2006 and 2009. The psychological and psycho-social autopsy method was used in order to investigate the consummated suicides by interviewing family members. It contextualized the subjects' life characteristics to understand the family dynamics and the affective, social, economic and cultural background, based on the reconstruction of the history and personality of the individuals. The associated socio-economic factors were: being male, aged between 20 and 40, single, with mixed ethnicity and basic education. The major risk factors identified were: mental disorder, alcohol and other drug abuse, disturbed family relationship and a history of previous suicide attempts. An attempt was made to contextualize and reflect on some cases reported by family members, as well as on the response of the health care teams to the demands of the families. The need to implement prevention programs and to train the primary health care professionals was considered a priority. .