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Incidence and causes of severe maternal outcomes in Somaliland using the sub-Saharan Africa maternal near-miss criteria: A prospective cross-sectional study in a national referral hospital.
Dalarna University, School of Health and Welfare, Care Sciences. Dalarna University, School of Health and Welfare, Caring Science/Nursing. College of Medicine and Health Science, University of Hargeisa, Hargeisa, Somaliland.
Dalarna University, School of Health and Welfare, Care Sciences. College of Medicine and Health Science, University of Hargeisa, Hargeisa, Somaliland.
Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden; Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
Dalarna University, School of Health and Welfare, Caring Science/Nursing. Department of Public Health and Caring Science, Uppsala University, Uppsala, Sweden.ORCID iD: 0000-0002-0038-9402
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2022 (English)In: International Journal of Gynecology & Obstetrics, ISSN 0020-7292, E-ISSN 1879-3479, Vol. 159, no 3, p. 856-864Article in journal (Refereed) Published
Abstract [en]

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.

Place, publisher, year, edition, pages
2022. Vol. 159, no 3, p. 856-864
Keywords [en]
WHO maternal near-miss, low-income country, maternal death, sub-Saharan Africa criteria
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:du-41379DOI: 10.1002/ijgo.14236ISI: 000798717300001PubMedID: 35490394Scopus ID: 2-s2.0-85134059846OAI: oai:DiVA.org:du-41379DiVA, id: diva2:1656464
Available from: 2022-05-06 Created: 2022-05-06 Last updated: 2023-08-11Bibliographically approved
In thesis
1. Women search for normality in birth: Solutions empowering resilience and reproductive agency while reducing adverse outcomes for Somaliland women
Open this publication in new window or tab >>Women search for normality in birth: Solutions empowering resilience and reproductive agency while reducing adverse outcomes for Somaliland women
2023 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

This thesis aimed to explore the causes of severe pregnancy outcomes and maternal deaths in Somaliland (studies I and II) and how these causes are influenced by the context of the wider health system (studies III and IV). 

Methodology: Both quantitative and qualitative methodologies were used. A prospective cross-sectional design was used to collect data for studies I and II. Study II focused on maternal deaths using a mixed method design. Studies III and IV used individual interviews to explore the needs of women when choosing a place of birth and the role of traditional birth attendants (TBAs) in maternity services in Somaliland. 

Analysis: Data were analysed using descriptive statistics and percentages. An inductive content analysis was used for study III, and a qualitative thematic analysis was used for study IV.

Results: Study I showed that the maternal near-miss (MNM) ratio was 56 MNMs per 1,000 live births according to the Sub-Saharan Africa (SSA) criteria and 13 MNMs per 1,000 live births according to the WHO criteria. The mortality index was highest among women with medical complications. Study II highlighted that 89% of these women self-referred to the hospital and that only 25% were admitted to the intensive care unit. Poor risk awareness and inadequate interprofessional collaboration contributed to missed opportunities. Study III showed that the lack of reproductive agency involved in facility-based births makes home births a first choice, regardless of potential risks and medical needs. Study IV demonstrated that TBAs need to be better connected with health facilities and skilled birth attendants (SBAs) to reduce maternal and neonatal mortality and morbidities in Somaliland.

Conclusion: Women search for normality in birth, and the midwifery profession could provide this normality by facilitating resilience and reproductive agency while reducing adverse outcomes of pregnancy, birth and the postpartum period. There is a need to improve the quality of maternal health services by implementing evidence-based obstetric interventions and continuous in-service training. The referral system needs to be strengthened by utilising TBAs as a community resource to support community maternal and child health centres.

Place, publisher, year, edition, pages
Falun: Dalarna University, 2023
Series
Dalarna Doctoral Dissertations ; 25
Keywords
Maternal death, maternal near miss, midwifery care, reproductive agency, sexual and reproductive health, Somaliland
National Category
Nursing
Identifiers
urn:nbn:se:du-45729 (URN)978-91-88679-41-3 (ISBN)
Public defence
2023-06-07, lecture hall Fö 6, campus Falun, and online, 10:00 (English)
Opponent
Supervisors
Available from: 2023-05-08 Created: 2023-03-28 Last updated: 2023-08-17Bibliographically approved
2. Quality of maternal healthcare: Exploring severe maternal outcomes and the influence of delays and decision-making on caesarean sections in a low-resource setting
Open this publication in new window or tab >>Quality of maternal healthcare: Exploring severe maternal outcomes and the influence of delays and decision-making on caesarean sections in a low-resource setting
2023 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Somaliland has one of the highest maternal mortality rates worldwide, yet there is limited evidence for severe maternal outcomes and challenges with the provision and utilisation of emergency obstetric care (EmOC). This thesis studied quality of maternal healthcare by exploring severe maternal outcomes and the influences of delays and decision-making on caesarean sections in Somaliland.

In Paper I, incidences of severe maternal outcomes and unmet need for emergency obstetric care interventions were investigated at the national hospital using a cross sectional study. The maternal mortality ratio was 462 per 100,000 live births and the maternal near miss ratio 56.5 per 1000 live births, according to sub-Saharan Africa criteria. Most laparotomies (60%) were performed after more than 3 hours. Medical complications (63%) had the highest mortality index.

In Paper II, an explorative qualitative study using focus group discussions was conducted with healthcare providers. A collective decision-making process at the family rather than individual level by the woman; poverty and lack of awareness; and healthcare system factors such as miscommunication, infrastructure and inadequate collaboration were experienced as factors contributing to delays with the utilisation of EmOC.

In Paper III, a cohort study examined whether there was an association between delayed caesarean section (CS) and adverse maternal and newborn outcomes and the type of barrier leading to delayed CS. A delay in CS of more than 3 hours was associated with higher odds of severe maternal outcomes (aOR 1.58, (95% CI [1.13–2.21]). Moreover, family decision-making for consent was the most important barrier leading to delays of more than 3 hours (48%). 

In Paper IV, a mixed methods study was conducted to investigate barriers to and facilitators of timely family consent for CS. Women with hypertensive disorders (aOR 8.491, 95% [1.076–66.991]) and obstetric hemorrhage (aOR 3.209, 95% CI [1.159–8.887]) were likely to have late family consent for CS. Poor communication and understanding, differences in understanding between family members on the need for CS and absence of the person giving consent were barriers to timely family consent for CS to be performed. Husband’s autonomous decision-making for CS, adequate disclosure of all relevant information about CS and previous CS aided timely family consent for CS performance.

There is need to improve the overall quality of maternal healthcare to reduce severe maternal outcomes. A proactive-orientated model is suggested with strategies targeting the community and healthcare system including training of healthcare providers on intracultural communication competence, obtaining consent and using associated protocols and guidelines, interprofessional collaboration and the use of alternative birth methods other than CS. Antenatal care should be used to prepare families for potential obstetric emergencies and obtain written informed consent. Moreover, women should be allowed to give consent in maternal health emergencies.

Place, publisher, year, edition, pages
Falun: Dalarna University, 2023
Series
Dalarna Doctoral Dissertations ; 27
Keywords
Somaliland, maternal mortality, delayed caesarean section, maternal near miss, severe maternal outcomes, emergency obstetric care, low resource setting
National Category
Nursing Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:du-46280 (URN)978-91-88679-54-3 (ISBN)
Public defence
2023-10-06, lecture hall Fö 4 campus Falun and online, 10:00 (English)
Opponent
Supervisors
Available from: 2023-09-05 Created: 2023-06-22 Last updated: 2023-12-08Bibliographically approved

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Egal, Jama AliKiruja, JonahOsman, FatumoErlandsson, KerstinKlingberg-Allvin, Marie

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