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OBJECTIVE: This study aimed to explore the experiences of healthcare providers (HCPs) regarding the provision of emergency obstetric care (EmOC) with a focus on cesarean deliveries in a referral hospital and maternal and child health centers in Somaliland.

METHODS: An exploratory qualitative approach using focus group discussions was employed at the main referral and teaching hospital and four maternal and child health centers in Hargeisa, Somaliland. Twenty-eight HCPs were divided into groups of 6-8 for discussions lasting 1 to 2 h. All HCPs included in the study had experiences with the provision of EmOC. Data were analyzed using thematic analysis.

RESULTS: Collective family decision making was identified by HCPs as a barrier to the provision of EmOC. This tradition of decision making at a group level was perceived as time-consuming and delayed HCPs from obtaining informed consent for EmOC. Low socioeconomic status and poor knowledge about maternal healthcare among users affected care seeking among women. Suboptimal EmOC at the hospital was reported to be due to miscommunication, inadequate interprofessional collaboration and lack of infrastructure.

CONCLUSIONS: HCPs encountered difficulties with the provision of EmOC. A broad array of strategies targeting the community and healthcare system is needed, including training of HCPs on intracultural communication competence, interprofessional collaboration and use of alternative birth methods other than CS. Antenatal care can be used to prepare families for potential obstetric emergencies and as an opportunity to obtain written informed consent.

BACKGROUND: In a critical obstetric situation, the time interval between the decision of performing a caesarean section (CS) and delivery can influence maternal and newborn outcomes. In Somaliland, consent for surgical procedures, such as CS needs to be sought from family members.

OBJECTIVE: To determine the association between a delay in performing a CS and severe maternal and newborn outcomes in a national referral hospital in Somaliland. The type of barriers leading to delayed performance of CS after a doctor's decision were also explored.

METHODS: Women were followed from the time of decision to perform CS until discharge from the hospital between 15 April 2019 and 30 March 2020. No delay was defined as < 1 hour and delayed CS was defined as 1-3 hours and >3 hours from decision of CS to delivery. Information was collected on barriers leading to delayed CS and maternal and newborn outcomes. Data was analysed using binary and multivariate logistic regression.

RESULTS: Overall, 1255 women were recruited from a larger cohort of 6658 women. A delay in CS >3 hours was associated with higher odds of severe maternal outcomes (aOR 1.58, 95% CI [1.13-2.21]). On the contrary, delay in performing a CS >3 hours was associated with lower odds of stillbirth (aOR 0.48, 95% CI [0.32-0.71]) compared to women without delay. Further, family decision-making for consent was the most important barrier leading to delays of >3 hours as compared to financial factors and barriers related to healthcare providers (48% vs 26% and 15%, respectively, p < 0.001).

CONCLUSIONS: In this setting, delay in performing CS >3 hours was associated with higher risk of severe maternal outcomes. A standardised system of performing a CS by primarily addressing the barriers associated with family decision-making, financial aspects and healthcare providers is needed.

OBJECTIVE: To describe the incidence and causes of severe maternal outcomes and the unmet need for life-saving obstetric interventions among women admitted for delivery in a referral hospital in Somaliland.

METHODS: A prospective cross-sectional study was conducted from April 15, 2019, to March 31, 2020, with women admitted during pregnancy or childbirth or within 42 days after delivery. Data was collected using the World Health Organization (WHO) and sub-Saharan Africa (SSA) maternal near-miss (MNM) tools. Descriptive analysis was performed by computing frequencies, proportions and ratios.

RESULTS: The MNM ratio were 56 (SSA criteria) and 13 (WHO criteria) per 1,000 live births. The mortality index was highest among women with medical complications (63%), followed by obstetric haemorrhage (13%), pregnancy-related infection (10%) and hypertensive disorders (7.9%) according to the SSA MNM criteria. Most women giving birth received prophylactic oxytocin for postpartum haemorrhage prevention (97%), and most laparotomies (60%) for ruptured uterus were conducted after three hours.

CONCLUSION: There is a need to improve the quality of maternal health services through implementation of evidence-based obstetric interventions and continuous in-service training for health care providers. Using the SSA MNM criteria could facilitate such preventive measures in this setting as well as similar low-resource contexts.