Community participation in improving maternal health: a grounded theory study in Aceh, IndonesiaNovember 2013Indonesia has one of the highest rates of maternal mortality in Southeast Asia. Community participation has been known to reduce maternal mortality in some areas in Indonesia. However, in Aceh Province, the prevalence remains higher than the general Indonesian maternal mortality rate. The aim of this research was to gain an understanding of pregnancy and childbirth experiences from multiple perspectives, in relation to the use of maternal health services in Aceh, Indonesia. The conceptual framework was based on the importance of community engagement in improving maternal health. A qualitative study design with a grounded theory approach was utilised. This approach was chosen in order to gain an understanding of the social processes and ways in which experiences of pregnancy and childbirth are related to maternal death incidents. The process inherent in the method enabled the emergence of important theoretical concepts. A theoretical sampling strategy was employed. The data collection used multiple methods that involved a series of in-depth interviews, observations and focus group discussions with women, family members, a village leader and health professionals. The sample size was determined by data saturation (19 women, 15 family members, 7 health professionals, 3 kaders, 4 student midwives and 1 village leader participated). Ethical approval was gained and the research setting was in the two villages of Aceh Besar District, Aceh Province, Indonesia. Data were coded and analysed by following a constant comparison process.The emergent core category, entitled "maternal death: the elephant in the room" explains the views of the community about maternal death incidents in the research setting. The research findings highlighted that despite the maternal mortality rate still being high in the region, maternal death was not focused upon, as a problem within the community. The research findings revealed that maternal mortality was a hidden problem within the community, and was related to inadequate maternity practices in the village. The core category "maternal death: the elephant in the room" was found to consist of four interrelated categories. The categories of the value of midwifery in the community, desicion-making of maternity care, social control of the childbearing and distancing of maternal deaths; explain maternity practices in the community. Understanding of social processes related to maternal health can assist in informing strategies to improve the quality of maternal healthcare in Aceh Indonesia.