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Quality of maternal healthcare: Exploring severe maternal outcomes and the influence of delays and decision-making on caesarean sections in a low-resource setting
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]

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 [en]
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: urn:nbn:se:du-46280ISBN: 978-91-88679-54-3 (print)OAI: oai:DiVA.org:du-46280DiVA, id: diva2:1772933
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
List of papers
1. Healthcare providers' experiences of comprehensive emergency obstetric care in Somaliland: An explorative study with focus on cesarean deliveries
Open this publication in new window or tab >>Healthcare providers' experiences of comprehensive emergency obstetric care in Somaliland: An explorative study with focus on cesarean deliveries
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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.

Keywords
Cesarean section, Consent, Emergency obstetric care, Healthcare providers, Somaliland
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:du-42701 (URN)10.1016/j.srhc.2022.100768 (DOI)000861182600002 ()36087546 (PubMedID)2-s2.0-85137382953 (Scopus ID)
Available from: 2022-09-13 Created: 2022-09-13 Last updated: 2023-08-11Bibliographically approved
2. Association between delayed cesarean section and severe maternal and adverse newborn outcomes in the Somaliland context: a cohort study in a national referral hospital
Open this publication in new window or tab >>Association between delayed cesarean section and severe maternal and adverse newborn outcomes in the Somaliland context: a cohort study in a national referral hospital
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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.

Keywords
Delayed caesarean section, Somaliland, adverse newborn outcomes, barriers, severe maternal outcomes
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:du-46057 (URN)10.1080/16549716.2023.2207862 (DOI)000983597100001 ()37158206 (PubMedID)2-s2.0-85158163977 (Scopus ID)
Available from: 2023-05-16 Created: 2023-05-16 Last updated: 2023-08-11Bibliographically approved
3. 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

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