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Association between delayed cesarean section and severe maternal and adverse newborn outcomes in the Somaliland context: a cohort 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. University of Hargeisa, Hargeisa, Somaliland.
Dalarna University, School of Health and Welfare, Caring Science/Nursing.ORCID iD: 0000-0002-0038-9402
Dalarna University, School of Health and Welfare, Care Sciences. Dalarna University, School of Health and Welfare, Caring Science/Nursing. University of Hargeisa, Hargeisa, Somaliland.
Dalarna University, School of Health and Welfare, Sexual Reproductive Perinatal Health. Karolinska Institutet, Stockholm.ORCID iD: 0000-0002-8947-2949
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2023 (English)In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 16, no 1, article id 2207862Article in journal (Refereed) Published
Abstract [en]

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.

Place, publisher, year, edition, pages
2023. Vol. 16, no 1, article id 2207862
Keywords [en]
Delayed caesarean section, Somaliland, adverse newborn outcomes, barriers, severe maternal outcomes
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
URN: urn:nbn:se:du-46057DOI: 10.1080/16549716.2023.2207862ISI: 000983597100001PubMedID: 37158206Scopus ID: 2-s2.0-85158163977OAI: oai:DiVA.org:du-46057DiVA, id: diva2:1757264
Available from: 2023-05-16 Created: 2023-05-16 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, JonahOsman, FatumoEgal, Jama AliKlingberg-Allvin, Marie

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