Social autopsy triggers community response for averting maternal and neonatal death in Bangladesh
Experience from ‘Maternal and Perinatal Death Review in 10 Districts’
Prepared by: Riad Mahmud1, MPH, DPS, MBBS, Health Specialist (Maternal and Neonatal Health), UNICEF Bangladesh
Reviewers: Habib Abdullah Sohel2, Mohammed Sharif3, Lianne Kuppens1, Shukhrat Rakhimdjanov1, Abu Sadat Md Sayem 1, Mahbuba Khan4, Animesh Biswas5.
Envisioning sustainability of the gains achieved in reducing under-five child and maternal mortality over the last decades, the Ministry of Health & Family Welfare (MOH&FW) and UNICEF initiated Maternal & Perinatal Death Review (MPDR) through the existing health system in Thakurgaon district of Bangladesh as a pilot in 20106.
UNICEF partnered with CIPRB5 to provide technical and implementation assistance to the government. Obstetric and Neonatal societies, WHO & UNFPA were engaged during designing, implementation and monitoring of MPDR with financial support from Global Affairs Canada, UKAID & EC.
The system was designed to be able to report each of the maternal, neonatal deaths and stillbirths from community and facility.
Following notification of deaths, verbal autopsy is conducted in the community and death review performed in facility to identify causes and factors associated to a death. Local MPDR committees review the data and identify and undertake health system actions. MPDR also triggers responses from community to improve the availability, access and quality of health services.
The MOH&FW gradually scaled up MPDR to all sub districts in four districts in 2011 and then to 14 districts by 2015. Death notification, verbal autopsy, facility-based death review and social autopsy of MPDR are carried out by the government system.
MPDR enabled the health system to report 4449 maternal and 22 487 newborn deaths and 20 185 still births during 2011 to 2015 in 10 districts.
Quantitative data from death notification and verbal autopsies provide in-depth information on cause, time and place of death as well information on facility and community readiness. This information is being used for death mapping, developing evidence based plan and augmenting both health system and community responses to avert future maternal and neonatal deaths.
In four phase-one districts, annual numbers of maternal deaths have been reduced from 305 to 163 between 2011 and 2015* (up to September). Similar declining trend was observed for neonatal deaths (3361 deaths in 2011 and 1670 in 2015).
MPDR national guideline has been developed, scale-up of MPDR system reflected in 4th health sector program ( 2016 -2021), knowledge hubs established at subnational teaching hospitals and data integrated in web based Health Management Information System. Countrywide scale up of entire MPDR system has been planned by 2021 to further strengthen quality MNH services and thereby reducing preventable maternal and neonatal death and achieve MDG and post MDG targets of Bangladesh.
Social Autopsy (SA)
Social Autopsy (SA) is a unique innovation which is an effective dialogue between community and government frontline workers to identify bottlenecks in the family and community level not for seeking timely care and increase and facilitate response by the community. SA was introduced for the first time in injury prevention programme in Bangladesh by UNICEF & CIPRB7. SA creates an enabling environment in the community to understand the social barriers and errors behind the deaths. The interaction within the community people during a social autopsy create platform to digging out their own mistake and eventually taking actions to avert future deaths.
A mother who participated in the social autopsy
“This my second pregnancy. I received care from ‘Khala’- a traditional birth attendant in the community who advised me about what to do during pregnancy period. My mother in law also suggested and I followed. I never went to any hospitals. One of the ‘Apa’ come to me who is from hospital mentioned to go to hospital. I couldn’t understand why it’s necessary. My first child born at home, it was so painful, I had bleeding after childbirth, Khala tried for a long and it stopped after many hours that cannot remember now. After joining this meeting, I now understand, I was at risk and it was a serious complication but I survived. I am determined this time that I will go to the hospital for antennal care and deliver baby at hospital, I am now five months pregnant. I don’t want face any risks, I shall share with my mother in law and with my husband. I am sure they will understand.”
Process and scale of implementation of SA
SA is an important social intervention carried out at community level following a maternal or neonatal death. SA was introduced as integral part MPDR since 2010 and has been scaled up in all 14 districts.
It cross-examines social bottlenecks related to a maternal or neonatal death and device mechanism to create a congenial environment in the community that creates a platform to identify the bottlenecks around a death as well identify social actions to prevent similar death in future.
Within two to three weeks of a verbal autopsy, first line health supervisors of the MOH&FW facilitates SA in the village of a deceased mother or newborn. In the majority of cases, SA was conducted for all maternal deaths, whereas for neonatal deaths and stillbirths, a selected numbers are chosen considering geographical location, frequency and number of the deaths.
In each SA, 30-40 people participate including representatives of Community Groups8 formed by MOH&FW and people from the same community like husbands, in-laws, pregnant women, adolescents,local elites, representatives from the local government, school teachers, religious leaders & social workers.
Health workers requests the community to tell the story around a death, probe further to let community identify the gaps at the demand side as well as supply side which ultimately resulted in social actions to avert similar deaths in future.
First line health supervisors also deliver health messages using flip chart containing information on maternal and neonatal complications and importance of receiving health services from the facility. Engaging community leaders and elites mobilizes commitment and leverage resources to improve health seeking behavior which includes donation for emergency referral of poorest mothers and newborns.
During October 2013 - September, 2015 a total of 2665 social autopsies were conducted in 10 districts. Among 2665 social autopsies, 1,405 were conducted for maternal deaths, 851 cases were conducted for neonatal deaths while 409 were performed for stillbirths. Approximately a total of 94 000 community people participated (around 68% female, 26% male) in these SAs.
Examples of Responses from SA
On the 27th June 2014 a SA on a maternal death conducted in Pokatali village of Thakurgaon district. A mother died due to post-partum haemorrhage due to retained placenta when the delivery was conducted at home by a traditional birth attendant. Community groups and other members of the society identified that the mother who died did not have any antenatal care during pregnancy, her family did not have any birth planning and delivery took place at home.
Participants committed to correct themselves in coming days following this death and understood the importance about antenatal care and safe delivery at facility level.
During the meeting a mother named Mina Khatun (imaginary name) participated who was seven months pregnant. She and her mother in law became aware for the first time about the need of antenatal care and delivering at the facility to save lives. Mina and her family decided to take antenatal care and decided to give birth at the hospital.
On the 10th September, a healthy baby was born at Thakurgaon district hospital and both mother and the newborn returned back home healthy the day after the delivery.
Initiatives, grants or other facilitating factors
Existing Community Groups formed by MOH&FW has the mandate to create conducive environment, promote health message and increase access to health services. SA could engaged this community structure to identify the gap and facilitate to undertake social actions by family, community group and also increase the participation of local government.
Lessons learnt and other positive effects
Men usually could not present in the SA in the beginning, as it takes place during day time when they are busy with work. Therefore, the health workers then organize the SA in the early morning or in the afternoon. This resulted in increased awareness about maternal and neonatal deaths and improved attendance by the men in the community. Since the male are the decision makers in the families, therefore their involvement created positive environment in those sessions with a positive impact on future death prevention.
Initially, presence of deceased family in SA was mandatory. Later on it was dropped considering emotional status of the family following the death of the mother or newborn. Moreover, community engagement and community attachment to understanding social barriers and explore solutions through discussions are the key factors for success.
Furthermore, a SA also empowers the community to act on the commitment already taken to implement corrective actions, thus there is every possibility to improve overall health situation of the rural people.
Challenges, Future steps
Tracking and follow up of the decisions taken in the community from a SA and linking social actions with response from health system remains as key challenges. Scaling up and Institutionalization of SA through local government and existing community structures and document and follow up key actions through web based DHIS2 are under process.
1 Health Section, UNICEF Bangladesh
2 Director-PHC & Line Director –MNC&AH, DGHS, MOH&FW, Bangladesh
3Director (MCH Services) and Line Director (MCRAH), MOH&FW, Bangladesh
4 WHO, Bangladesh
6 Biswas, A., Rahman, F., Halim, A., Eriksson, C. and Dalal, K. (2014) Maternal and Neonatal Death Review (MNDR): A Useful Approach to Identifying Appropriate and Effective Maternal and Neonatal Health Initiatives in Bangladesh. Health, 6, 1669-1679. http://dx.doi.org/10.4236/health.2014.614198
7 Baset M, Towner E, Mashreky S, A Rahman, Biswas A, AKMF Rahman Social autopsy: a community based intervention in preventing road traffic injuries--experience from Bangladesh. Inj Prev 2012;18:A205–A205.
8 Community Groups ( CG) : MOH&FW, Bangladesh has formed 1 CG and 3 Community Support Groups (CSG) under each Community Clinic ( CC) which covers appx. 6000 population. CG & CSG encompassing volunteers from local community