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Healthcare providers' experiences of comprehensive emergency obstetric care in Somaliland: An explorative study with focus on cesarean deliveries
Dalarna University, School of Health and Welfare, Care Sciences. Dalarna University, School of Health and Welfare, Caring Science/Nursing.
Uppsala University, Uppsala, Sweden.
Dalarna University, School of Health and Welfare, Sexual Reproductive Perinatal Health.ORCID iD: 0000-0002-6910-7047
Dalarna University, School of Health and Welfare, Caring Science/Nursing.ORCID iD: 0000-0002-8947-2949
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2022 (English)In: Sexual & Reproductive HealthCare, ISSN 1877-5756, E-ISSN 1877-5764, Vol. 34, article id 100768Article in journal (Refereed) Published
Abstract [en]

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.

Place, publisher, year, edition, pages
2022. Vol. 34, article id 100768
Keywords [en]
Cesarean section, Consent, Emergency obstetric care, Healthcare providers, Somaliland
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:du-42701DOI: 10.1016/j.srhc.2022.100768ISI: 000861182600002PubMedID: 36087546Scopus ID: 2-s2.0-85137382953OAI: oai:DiVA.org:du-42701DiVA, id: diva2:1695408
Available from: 2022-09-13 Created: 2022-09-13 Last updated: 2023-08-11Bibliographically approved
In thesis
1. 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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Kiruja, JonahErlandsson, KerstinKlingberg-Allvin, MarieOsman, Fatumo

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