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Women search for normality in birth: Solutions empowering resilience and reproductive agency while reducing adverse outcomes for Somaliland women
Dalarna University, School of Health and Welfare, Care Sciences. Dalarna University, School of Health and Welfare, Caring Science/Nursing.
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 [en]
Maternal death, maternal near miss, midwifery care, reproductive agency, sexual and reproductive health, Somaliland
National Category
Nursing
Identifiers
URN: urn:nbn:se:du-45729ISBN: 978-91-88679-41-3 (print)OAI: oai:DiVA.org:du-45729DiVA, id: diva2:1746485
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
List of papers
1. 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.
Open this publication in new window or tab >>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.
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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.

Keywords
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:nbn:se:du-41379 (URN)10.1002/ijgo.14236 (DOI)000798717300001 ()35490394 (PubMedID)2-s2.0-85134059846 (Scopus ID)
Available from: 2022-05-06 Created: 2022-05-06 Last updated: 2023-08-11Bibliographically approved
2. A lack of reproductive agency in facility-based births makes home births a first choice regardless of potential risks and medical needs: a qualitative study among multiparous women in Somaliland
Open this publication in new window or tab >>A lack of reproductive agency in facility-based births makes home births a first choice regardless of potential risks and medical needs: a qualitative study among multiparous women in Somaliland
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2022 (English)In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 15, no 1, article id 2054110Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Around 20% of births in Somaliland take place at health facilities staffed by trained healthcare professionals; 80% take place at home assisted by Traditional Birth Attendants (TBAs) with no formal training. There has been no research into women's choice of place of birth.

OBJECTIVE: In this study, we explore multipara women's needs and preferences when choosing the place of birth.

METHOD: An explorative qualitative study using individual in-depth interviews analysed inductively using content analysis. The interviews were conducted in Somaliland with 25 multiparous women who had experience of giving birth both at home and at a health facility within the past three years.

RESULTS: The results provide a description of how, for women in Somaliland, a lack of reproductive agency in facility-based births makes home births a first choice regardless of potential risks and medical need. The women in this study desired intentionality in their role as mothers and sought some measure of control over the environment where they planned to give birth, depending on the circumstances of that particular birth. The results describe what quality care means for multipara women in Somaliland and how women choose birthplace based on previous experiences of care. The expectation of respectful care was a vital part for women when choosing a place of birth.

CONCLUSION: To meet women's needs and preferences in Somaliland, further investments are needed to strengthen the midwifery profession and to define and test a context specific midwife-led continuity of care model to be scaled up. A dialogue to create new roles and responsibilities for the TBAs who attend most home births is further needed to link them to the formal healthcare system and assure timely healthcare seeking during pregnancy and birth.

Keywords
Home-based birth, decision-making, facility-based birth, reproductive agency
National Category
Nursing
Identifiers
urn:nbn:se:du-41366 (URN)10.1080/16549716.2022.2054110 (DOI)000779156500001 ()35389334 (PubMedID)2-s2.0-85128249435 (Scopus ID)
Available from: 2022-05-05 Created: 2022-05-05 Last updated: 2023-05-08Bibliographically approved

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