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

Abstract

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.

Incorporating early pregnancy mental health screening and management into routine maternal care: experience from the Rajarata Pregnancy Cohort (RaPCo), Sri Lanka

“…Based on our learnings from this implementation experience in Sri Lanka and combining previous evidence8 13 26 27 with our observations and experiences, we suggest a conceptual model for maternal mental health (online supplemental figure 1) that could be incorporated into maternal care programmes for mental health screening and service provision.…”

“…Identifying vulnerable women in early pregnancy is important to prevent maternal deaths in LMICs with cultural tendencies of impulsive self-harm and suicide. 8 Sri Lanka is a lower-middle-income country with a better maternal care programme compared with other developing countries. 9 Nonetheless, recent data indicate that maternal mental health is a growing problem, with a reported postpartum depression of 27% 10 and antenatal depression of 16%, 11 leading to many undesirable outcomes, including self-harm and suicide in the country.…”

“…This approach demands early identification, action and follow-up for the prevention of mental health problems. Identifying vulnerable women in early pregnancy is important to prevent maternal deaths in LMICs with cultural tendencies of impulsive self-harm and suicide 8…”

“…A cross-sectional hospital-based study in Anuradhapura indicates that 0.8% of women had attempted intentional self-harm (ISH) during the pregnancy period 13. Suicide has been identified as a leading cause of maternal death in Sri Lanka 8 14. Studies on antenatal depression are mostly carried out in the latter part of pregnancy, with scanty evidence of early pregnancy mental health.…”

“…Identifying vulnerable women in early pregnancy is important to prevent maternal deaths in LMICs with cultural tendencies of impulsive self-harm and suicide. 8 …”