Maternal near-miss and death incidences - Frequencies, causes and the referral chain in Somaliland: A pilot study using the WHO near-miss approach

The Challenges of Implementing a Health Referral System in South Africa: A Qualitative Study

Introduction

Health system strengthening efforts also entails streamlining an existing referral system in a particular context to improve quality of health care offered to people. Conceptually, the referral system in South Africa, is seemingly sound. Nevertheless, gaps exist in its implementation. The aim of this study was to explore health care professionals' perceptions of referral system implementation in the Buffalo City Metropolitan Municipality (BCMM) in the Eastern Cape Province of South Africa.

Methods

This qualitative study included 12 health care professionals as participants. Each participant was interviewed using a semi-structured interview guide; with their consent, the interviews were audio recorded and transcribed verbatim. For data analysis, a thematic content analysis was used.

Results

The participants identified many impediments to the effective implementation of the referral system in BCCM. The main obstacles were deteriorating infrastructure, inadequate staffing, lack of transportation, and inadequate medical supplies and medications.

Conclusion

In mitigation, the participants proposed suggestions such as increasing the capacity of the health workforce, allocating personnel appropriately, increasing the availability of transportation, and providing essential medications to all levels of care. They also suggested involving all stakeholders in the referral process, providing education and training to health professionals on the referral system, and enhancing communication and feedback between the various levels of care. These challenges emphasised in this study highlight the need for targeted interventions to improve the referral system in this setting.

Incidence of Adverse Perinatal Outcomes among Women Exposed to Maternal Near-Misses in Arsi Zone in Ethiopia: Prospective Cohort Study in 2022

Background

Exposure to maternal near-misses has a massive effect on adverse perinatal outcomes. Hence, investigating the effect of maternal near-misses on perinatal outcomes can aid in the reduction of perinatal morbidity and mortality. The study is aimed at assessing the incidence of adverse perinatal outcomes among women exposed to maternal near-misses at Arsi Zone public hospitals in Ethiopia in 2022.

Method

The study included a prospective cohort of 335 women at Arsi Zone public hospitals from December 2021 to June 2022. Women who were admitted for management of pregnancy were followed. The exposed group was women with maternal near-misses screened based on disease-validated criteria. The nonexposed group was made up of women who delivered without complications. Trained data collectors used pretested, structured questionnaires to collect data from women. Pertinent data was also extracted from the clients' logbooks. Data was transferred from EpiData version 3.1 to SPSS version 25 for analysis, logistic regression was computed, and 95% confidence intervals were declared at a p value of 5% significance level.

Result

The incidence of adverse perinatal outcomes was higher in the exposed women than in the nonexposed women (56% versus 16%). Contrasted with the nonexposed, women exposed to maternal near-misses had a higher incidence of stillbirth (22% vs. 0.5%), low birth weight (13% vs. 3%), and preterm birth (12% vs. 2%). After adjusting for confounders, exposed women had a twofold increased risk of adverse perinatal outcomes compared to nonexposed women. Delivery mode, delay in seeking care, transport mode, and delay in receiving treatment were the risk factors for negative pregnancy outcomes.

Conclusion

In exposed women, a higher incidence of adverse perinatal outcomes was linked to aforementioned risk factors. Evidence-based practice intended to decrease delays in providing maternal care services does indeed improve perinatal outcomes.

Facility-based maternal deaths: Their prevalence, causes and underlying circumstances. A mixed method study from the national referral hospital of Somaliland

OBJECTIVE

Somaliland has one of the highest rates of maternal deaths in the world. An estimated 732 women die for every 100,000 live births. This study aims to identify the prevalence of facility-based maternal deaths, the causes and their underlying circumstances by interviewing relatives and health care providers at the main referral hospital.

METHOD

A hospital-based mixed method study. The prospective cross-sectional design of the WHO Maternal Near Miss tool was combined with narrative interviews with 28 relatives and 28 health care providers in direct contact with maternal deaths. The quantitative data was analysed with descriptive statistics using SPSS and the qualitative part of the study was analysed with content analysis using NVivo.

RESULTS

From the 6658 women included 28 women died. The highest direct cause of maternal death was severe obstetric haemorrhage (46.4%), followed by hypertensive disorders (25%) and severe sepsis (10.7%). An indirect obstetric cause of death was medical complications (17.9%). Twenty-five per cent of these cases were admitted to ICU and 89% had referred themselves to the hospital for treatment. The qualitative data identifies two categories of missed opportunities that could have prevented these maternal mortalities: poor risk awareness in the community and inadequate interprofessional collaboration at the hospital.

CONCLUSION

The referral system needs to be strengthened utilizing Traditional Birth Attendants as community resource supporting the community facilities. The communication skills and interprofessional collaboration of the health care providers at the hospital needs to be addressed and a national maternal death surveillance system needs to be commenced.

Qualitative study of the roles of midwives in the provision of sexual and reproductive healthcare services in the Somaliland health system

OBJECTIVES

To explore midwives' perspectives in providing sexual reproductive healthcare services in the Somaliland health system.

METHODS

An exploratory qualitative design using focus group discussions (n=6) was used. The study was conducted in the capital of Somaliland, Hargeisa, at six maternal and child healthcare centres that provide sexual and reproductive healthcare (SRH) services. Qualified midwives (n=44) who had been working in the maternal and child health centres for a minimum of 1 year were recruited to participate, and only one did not participate due to illness.

RESULTS

The results showed that Somaliland midwives face multiple challenges from a lack of formal arrangements, primarily written guidelines and policies, that explicitly define their role as healthcare professionals, which impact the quality of care they provide. They also reported feeling unsafe when practising according to their professional scope of practice due to challenging cultural norms, customary traditions and Somaliland's legal system. Finally, the midwives called for support, including training, institutional protection and psychological support, to enhance their ability and fulfil their role in SRH services in Somaliland.

CONCLUSION

Midwives are essential to the provision of equitable SRH services to women and girls, yet are not fully supported by policies, laws or institutions, often living in fear of the consequences of their behaviours. Our research highlights the importance of understanding the context of Somaliland midwifery in order to better support the development of the midwifery workforce, stronger governance structures and midwifery leadership. Appropriately addressing these challenges faced by midwives can better sustain the profession and help to improve the quality of care provided to women and girls and ultimately enhance their reproductive health outcomes.

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

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 were 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 ratios were 56 (SSA criteria) and 13 (WHO criteria) per 1000 live births. The mortality index was highest among women with medical complications (63%), followed by obstetric hemorrhage (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 hemorrhage prevention (97%), and most laparotomies (60%) for ruptured uterus were conducted after 3 h.

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 healthcare providers. Using the SSA MNM criteria could facilitate such preventive measures in this setting as well as similar low-resource contexts.

Health Care Workers' Experiences, Challenges of Obstetric Referral Processes and Self-Reported Solutions in South Western Uganda: Mixed Methods Study

Introduction

In resource limited settings, the highest burden of adverse maternal-fetal outcomes at referral hospitals is registered from emergency obstetric referrals from lower health facilities. Implementation of referral protocols has not been optimally successful possibly attributed to lack of understanding of profile of obstetric referrals and local challenges faced during implementation process.

Objective

This study described the profile of emergency obstetric referrals, challenges faced in implementation of obstetric referral processes and explored self-reported solutions by health workers.

Methods

This was a mixed methods study done at Mbarara Regional Referral Hospital (MRRH) and health centre IVs in South-Western Uganda. We consecutively recruited emergency obstetric referrals from Isingiro district for delivery at MRRH. Using a pre-tested questionnaire, we collected demographics, obstetric and referral characteristics. We described the profile of referrals using frequencies and proportions based on demographics, obstetric and referral characteristics. We conducted focus group discussions and in-depth interviews with health workers using discussion/interview guides. Using thematic analysis, we ascertained the challenges and health worker self-reported solutions.

Results

We recruited 161 referrals: 104(65%) were below 26 years, 16(10%) had no formal education, 11(7%) reported no income, 151(94%) had no professional-escort, 137(85%) used taxis, 151(96%) were referred by midwives. Common diagnoses were previous cesarean scar (24% [n=39]) and prolonged labour (21% [n=33]). There was no communication prior to referral and no feedback from MRRH to lower health facilities. Other challenges included inconsistencies of ambulance and anesthesia services, electric power, medical supplies, support supervision, and harassment by colleagues. Self-reported solutions included the use of phone call technology for communication, audit meetings, support supervision and increasing staffing level.

Conclusion

Most referrals are of poor social-economic status, use taxis, and lack professional-escort. Health workers suffer harassment, lack of communication and shortage of supplies. We need to experiment whether mobile phone technology could solve the communication gap.

Factors impacting antenatal care utilization: a systematic review of 37 fragile and conflict-affected situations

BACKGROUND

It is estimated that over 930 million people live in fragile and conflict-affected situations (FCAS) worldwide. These regions, characterized by violence, civil unrest, and war, are often governed by corrupt administrations who are unwilling to provide their citizens with basic human rights. Individuals living in FCAS face health inequities; however, women are disproportionally affected and face additional barriers to accessing sexual and reproductive services, including antenatal care (ANC). This systematic review aims to identify the factors that impact ANC usage in the 37 countries or regions classified as FCAS in 2020 by The World Bank.

METHODS

Using the PRISMA guidelines, a systematic search of five databases (SCOPUS, Web of Science, PubMed, EMBASE, and CINAHL) was conducted. Results were limited to human studies, written in English, and published between January 2002 and January 2022. Studies that identified factors affecting utilization of ANC or maternal health services were included for review and critically appraised using the National Institute of Health's Quality Assessment Tools. Findings were summarized using a narrative synthesis approach.

RESULTS

The database search yielded 26,527 studies. After title, abstract and full-text review, and exclusion of duplicate articles, 121 studies remained. Twenty-eight of the 37 FCAS were represented in the included studies. The studies highlighted that women in FCAS' are still not meeting the World Health Organization's 2002 recommendation of four ANC visits during pregnancy, a recommendation which has since been increased to eight visits. The most cited factors impacting ANC were socioeconomic status, education, and poor quality of ANC. Despite all studies being conducted in conflict-affected regions, only nine studies explicitly identified conflict as a direct barrier to accessing ANC.

CONCLUSION

This review demonstrated that there is a paucity in the literature examining the direct and indirect impacts of conflict on ANC utilization. Specifically, research should be conducted in the nine FCAS that are not currently represented in the literature. To mitigate the barriers that prevent utilization of maternal health services identified in this review, policy makers, women utilizing ANC, and global organizations should attempt to collaborate to enact policy change at the local level.

Maternal mortality: near-miss events in middle-income countries, a systematic review

OBJECTIVE

To describe the incidence and main causes of maternal near-miss events in middle-income countries using the World Health Organization's (WHO) maternal near-miss tool and to evaluate its applicability in these settings.

METHODS

We did a systematic review of studies on maternal near misses in middle-income countries published over 2009-2020. We extracted data on number of live births, number of maternal near misses, major causes of maternal near miss and most frequent organ dysfunction. We extracted, or calculated, the maternal near-miss ratio, maternal mortality ratio and mortality index. We also noted descriptions of researchers' experiences and modifications of the WHO tool for local use.

FINDINGS

We included 69 studies from 26 countries (12 lower-middle- and 14 upper-middle-income countries). Studies reported a total of 50 552 maternal near misses out of 10 450 482 live births. Median number of cases of maternal near miss per 1000 live births was 15.9 (interquartile range, IQR: 8.9-34.7) in lower-middle- and 7.8 (IQR: 5.0-9.6) in upper-middle-income countries, with considerable variation between and within countries. The most frequent causes of near miss were obstetric haemorrhage in 19/40 studies in lower-middle-income countries and hypertensive disorders in 15/29 studies in upper-middle-income countries. Around half the studies recommended adaptations to the laboratory and management criteria to avoid underestimation of cases of near miss, as well as clearer guidance to avoid different interpretations of the tool.

CONCLUSION

In several countries, adaptations of the WHO near-miss tool to the local context were suggested, possibly hampering international comparisons, but facilitating locally relevant audits to learn lessons.

How to ensure policies and interventions rely on strong supporting facts to improve women's health: The case of female genital cutting, using Rosling's Factfulness approach

Rosling et al’s book Factfulness aims to inspire people to use strong supporting facts in their decision‐making, with 10 rules of thumb to fight dramatic instincts. In this paper, the Factfulness framework is applied to female genital cutting (FGC), in order to identify possible biases and promote evidence‐based thinking in studies on FGC, clinical guidelines on management of FGC, and interventions aimed at abolishing FGC. The Factfulness framework helps to acknowledge that FGC is not a uniform practice and helps address that variability. This framework also highlights the importance of multidisciplinarity to understand causalities of the FGC issue, which the authors argue is essential. This paper highlights the fact that FGC is a dynamic practice, with changes in the practice that are ongoing, and that those changes are different in different contexts. The “zero tolerance” discourses on FGC fail to acknowledge this. Factfulness encourages us to be more critical of methodologies used in the area of FGC, for example when estimating girls at risk of FGC in migration contexts. Factfulness provides the tools to calculate risks rather than judgments based on fear. This may help limit stigmatization of women with FGC and to allocate resources to health problems of migrant women based on real risks. The framework also calls for more research and production of less biased facts in the field of FGC, in order to improve interventions aimed at abolishing FGC, and clinical guidelines for the treatment of FGC. Factfulness is a useful and structured foundation for reflection over constructs, biases and disputes surrounding FGC, and can help improve the quality of future evidence‐based interventions and education that address the actual needs of women with FGC and girls at risk of FGC.

Maternal near miss: reaching the last mile

Maternal mortality misses the morbidity associated with pregnancy and delivery. Maternal Near Miss is an alternate measure that reflects maternal morbidity and in areas with low maternal mortality improves comparability. Maternal Near Miss is a proxy indicator of the quality of healthcare services and helps in understanding health system failures with relation to obstetric care and addressing them. But regional variations in availability of resources have led to a dozen different adapted versions of WHO Maternal Near Miss criteria. This creates confusion and reduces comparability, nationally and internationally. A review of articles defining maternal near miss was conducted using a PubMed search to compare and assess the various definitions of MNM. The present article summarises the available criteria and discusses the advantages and drawbacks of WHO MNM criteria as compared to others. The objective is to impress the need to have comprehensive criteria that can be applied in different settings and ensure comparability.Impact statementWhat is already known on this subject? Many different definitions and criteria to diagnose Maternal Near Miss are available. They are diverse, thereby reducing comparability both nationally and internationally.What do the results of this study add? This article summarises the differences in the available definitions and classifying criteria. It also highlights the difficulty in usage of the criteria in different settings.What are the implications of these findings for clinical practice and/or further research? This calls for researchers working in areas of maternal health to further simplify the definitions and criteria used for identification of Maternal Near Miss to improve comparability and uniformity.

Quality and women's satisfaction with maternal referral practices in sub-Saharan African low and lower-middle income countries: a systematic review

Background

sub-Saharan African Low and Lower-Middle Income Countries (sSA LLMICs) have the highest burden of maternal and perinatal morbidity and mortality in the world. Timely and appropriate maternal referral to a suitable health facility is an indicator of effective health systems. In this systematic review we aimed to identify which referral practices are delivered according to accepted standards for pregnant women and newborns in sSA LLMICs by competent healthcare providers in line with the needs of pregnant women.

Methods

Six electronic databases were systematically searched for primary data studies (2009–2018) in English reporting on maternal referral practices and their effectiveness. We conducted a content analysis guided by a framework for assessing the quality of maternal referral. Quality referral was defined as: timely identification of signal functions, established guidelines or standards, adequate documentation, staff accompaniment and prompt care by competent healthcare providers in the receiving facility.

Results

Seventeen articles were included in the study. Most studies were quantitative (n = 11). Two studies reported that women were dissatisfied due to delays in referral processes that affected their health. Most articles (10) reported that women were not accompanied to higher levels of care, delays in referral processes, transport challenges and poor referral documentation. Some healthcare providers administered essential drugs such as misoprostol prior to referral.

Conclusions

Efforts to improve maternal health in LLMICs should aim to enhance maternity care providers’ ability to identify conditions that demand referral. Low cost transport is needed to mitigate barriers of referral. To ensure quality maternal referral, district level health managers should be trained and equipped with the skills needed to monitor and evaluate referral documentation, including quality and efficiency of maternal referrals.

Trial registration

Systematic review registration: PROSPERO registration CRD42018114261.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12884-020-03339-3.

Analysis of the Severe Maternal Outcomes between Resource-Poor and Resource-Rich Hospitals in China’s Hunan Province from 2012 to 2018

Background. This facility-based study analyzed the epidemiology and incidence of maternal near miss (MNM) and mortality by hospital level as part of Hunan Province’s efforts to raise the quality of hospital care for women. Methods. We used data for MNM and mortality cases for 2012–2018 from 17 hospitals (12 resource-poor facilities, five resource-rich facilities) that receive referrals for obstetric complications in Hunan Province. Data were drawn from China’s National Maternal Near Miss Surveillance System and collected using the World Health Organization near miss tool. We calculated the ratio of severe maternal outcomes (SMO) (i.e., MNM and maternal death (MD) cases), mortality index (MI), and MNM to mortality ratio (MNM : MD), and epidemiological factors, organ dysfunction, and maternal complications stratified by hospital level. The chi-square tests to examine differences between groups and total ratios and 95% CI were calculated. Results. There were 518 SMO cases (489 MNM and 29 MD) among 279407 live births (LBs) and 1299 SMO cases (1262 MNM and 37 MD) among 232386 LBs in resource-poor and resource-rich facilities. The total MNM ratio in resource-poor and resource-rich hospitals was 1.75 (95% CI: 1.60–1.91) and 5.43 (95% CI: 5.14–5.74) per 1000 LBs, respectively. There were differences in SMO cases between resource-poor and resource-rich hospitals in maternal age, education, parity, antenatal visits, and history of cesarean sections. In MNM cases, coagulation dysfunction was the main organ dysfunction (resource-poor hospitals: 59.10%; resource-rich hospitals: 79.32%), and the main maternal complications were obstetric hemorrhage (resource-poor hospitals: 71.98%) and hepatopathy (resource-rich hospitals: 69.49%). For MD cases, the main maternal complications were neurologic dysfunction (resource-poor hospitals: 41.38%) and coagulation dysfunction (resource-rich hospitals: 42.55%). Anemia was the main maternal complication for SMO cases in both resource-poor (69.69%) and resource-rich (68.59%) hospitals. Conclusions. MNM and MD are higher in resource-rich hospitals compared with resource-poor hospitals. The obstetric emergency capacity of resource-rich hospitals is higher than that of resource-poor hospitals. Future government policies should consider upgrading the obstetric emergency treatment capacity in resource-poor hospitals or to redistinguish the social functions of different medical institutions.

Women's sexual health six months after a severe maternal morbidity event

OBJECTIVE

to investigate female sexual function in women six months postpartum and to compare sexual function among women who had and who did not have severe maternal morbidity (SMM).

METHOD

a cross-sectional study conducted with 110 women in the postpartum period, with and without SMM. Two instruments were used, one for the characterization of sociodemographic and obstetric variables and the Female Sexual Function Index (FSFI) for sexual function. Univariate, bivariate and regression model analyses were performed.

RESULTS

FSFI scores showed 44.5% of female sexual dysfunction, of which 48.7% were among women who had SMM and 42.0% among those who had not. There were significant differences between age (P=0.013) and duration of pregnancy (P<0.001) between women with or without SMM. Among the cases of SMM, hypertensive disorders were the most frequent (83%). An association was obtained between some domains of the FSFI and the following variables: orgasm and self-reported skin color, satisfaction and length of relationship, and pain and SMM.

CONCLUSION

white women have greater difficulty in reaching orgasm when compared to non-white women and women with more than 120 months of relationship feel more dissatisfied with sexual health than women with less time in a relationship. Women who have had some type of SMM have more dyspareunia when compared to women who have not had SMM.

Human Development Index of the maternal country of origin and its relationship with maternal near miss: A systematic review of the literature

Background

The reduction in maternal mortality worldwide has increased the interest in studying more frequent severe events such as maternal near miss. The Human Development Index is a sociodemographic country-specific variable that includes key human development indicators such as living a long and healthy life, acquiring knowledge, and enjoying a decent standard of living, allowing differentiation between countries. In a globalised environment, it is necessary to study whether the Human Development Index of each patient's country of origin can be associated with the maternal near-miss rate and thus classify the risk of maternal morbidity and mortality.

Methods

A systematic review of the literature published between 2008 and 2019 was conducted, including all articles that reported data about maternal near miss in their sample of pregnant women, in addition to describing the study countries of their sample population. The Human Development Index of the study country, the maternal near-miss rate, the maternal mortality rate, and other maternal-perinatal variables related to morbidity and mortality were used.

Results

After the systematic review, eighty two articles from over thirty countries were included, for a total of 3,699,697 live births, 37,191 near miss cases, and 4029 mortality cases. A statistically significant (p <0.05) inversely proportional relationship was observed between the Human Development Index of the study country and the maternal near-miss and mortality rates. The most common cause of maternal near miss was haemorrhage, with an overall rate of 38.5%, followed by hypertensive disorders of pregnancy (34.2%), sepsis (7.5%), and other undefined causes (20.9%).

Conclusions

The Human Development Index of the maternal country of origin is a sociodemographic variable allowing differentiation and classification of the risk of maternal mortality and near miss in pregnant women. The most common cause of maternal near miss published in the literature was haemorrhage.

Trial registration

PROSPERO ID: CRD 42019133464

Health workforce perspectives of barriers inhibiting the provision of quality care in Nepal and Somalia - A qualitative study

OBJECTIVE

In this paper settings from Nepal and Somalia are used to focus on the perspectives of healthcare providers within two fragile health systems. The objective of this study was to describe barriers inhibiting quality healthcare in Nepal and Somalia from a health workforce perspective.

METHODS

Data were collected through 19 semi-structured interviews with healthcare providers working in healthcare facilities. Ten interviews were conducted in Nepal and nine in Somalia.

RESULTS

Various structural barriers inhibiting the availability, accessibility, and acceptability of the quality care were similar in both countries. Barriers inhibiting the availability of quality care were linked to healthcare providers being overburdened with multiple concurrent jobs. Barriers inhibiting the accessibility to quality healthcare included long distances and the uncertain availability of transportation, and barriers to acceptability of quality healthcare was inhibited by a lack of respect from healthcare providers, characterised by neglect, verbal abuse, and lack of competence.

CONCLUSIONS

Inequality, poverty, traditional and cultural practices plus the heavy burden placed on healthcare providers are described as the underlying causes of the poor provision of quality care and the consequential shortcomings that emerge from it. In order to improve this situation adequate planning and policies that support the deployment and retention of the healthcare providers and its equitable distribution is required. Another important aspect is provision of training to equip healthcare providers with the ability to provide respectful quality care in order for the population to enjoy good standard of healthcare services.

Applicability of the WHO maternal near miss tool in sub-Saharan Africa: a systematic review

Background

Applicability of the World Health Organization (WHO) maternal near miss criteria in low-income settings is not systematically addressed in the literature. The objective of this review was to determine the applicability of the WHO maternal near miss tool in sub-Saharan Africa.

Methods

We searched PubMed, Embase, Popline, CINAHL, AJOL, and Google scholar using key words for maternal near miss and sub-Saharan Africa. Studies which applied the WHO maternal near miss criteria, containing clear definitions, and published between January 1st, 2009 and December 31st, 2017 were included. Two authors independently extracted data. Quantitative analysis and narrative synthesis were conducted, and medians with interquartile range (IQR) were calculated for summarizing the findings. Methodological quality of the studies was assessed using the Estabrook’s quality assessment and validity tool.

Results

Fifteen studies from nine countries comprising 227,077 participants were included. Median maternal near miss ratio was 24.2 (IQR: 12.4–35.8) per 1000 live births ranging from 4.4 in a population-based study in South Africa to 198 in a rural private hospital in Nigeria. Eight studies reported challenges in implementing the WHO maternal near miss tool, especially related to the threshold for blood transfusion, and availability of several laboratory-based criteria. In three studies, local adaptations were made.

Conclusion

This review showed that the WHO maternal near miss tool is not uniformly applied in sub-Saharan Africa. Therefore, a common adaptation for the region is required to increase its applicability.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2225-7) contains supplementary material, which is available to authorized users.

The views of Somali religious leaders on birth spacing - A qualitative study

BACKGROUND

Birth spacing is an important health intervention for women to attain good physical and mental health. In Somalia, religious leaders play a decisive role in approving or rejecting the use of family planning.

OBJECTIVE

The study aimed to investigate Somali Islamic religious leaders' views on birth spacing.

METHOD

Qualitative individual interviews were conducted with 17 Somali Islamic religious leaders aged 28-59 years and analysed through content analysis.

RESULTS

The main category that emerged from the analysis was that the concept "birth spacing should be used and nor family planning to be in accordance with the Islamic religion. Two perspectives of views of birth spacing were identified: accepted ways and unaccepted ways. The accepted ways include breastfeeding, use of contraceptives causing no harm to the women's health, and coitus interruptus. The preferred method should be determined by a joint agreement between the husband and wife, and that Muslim doctors should play a key role while the couples investigate their preferred method. Using contraceptives with the intention to limit the number of children was against Islamic values and practice. In addition, it was believed that using condoms promoted the temptation to engage in sex outside the marriage and was therefore prohibited.

CONCLUSION

According to the religious Islamic leaders, selected practice recommendations for contraceptive use is permitted in relation to birth spacing to promote the health of the mother and child. When providing professional contraceptive counselling to Muslim women, the word "birth spacing" is recommended to be used instead of "family planning".

"Change-makers in midwifery care": Exploring the differences between expectations and outcomes-A qualitative study of a midwifery net-based education programme in the Somali region

OBJECTIVE

The aim of this study is to explore midwifery educators' expected outcomes in the net-based master's programme, the programmes' realised outcomes and the reported difference regarding the increased choices for the graduates and the effect on their agency.

DESIGN

In this case study, we focused on a net-based master's programme in sexual and reproductive health in Somalia. Somalia suffers from a shortage of skilled birth attendants and there is a need for building up the capacity of midwifery educators.

SETTING AND PARTICIPANTS

Data was collected in focus group discussions at the start of the programme and eight months after the students graduated. The data were analysed through the lens of the choice framework, which is based on the capability approach.

FINDINGS

Findings show that many of the graduates' expectations were met, while some were more difficult to fulfil. While the midwives' choices and resource portfolios had improved because of their role as educators, the social structure prevented them from acting on their agency, specifically in regards to making changes at the social level. Several of the positive developments can be attributed to the pedagogy and structure of the programme.

CONCLUSION

The flexibility of net-based education gave the midwifery educators a new educational opportunity that they previously did not have. Students gained increased power and influence on some levels. However, they still lack power in government organisations where, in addition to their role as educators, they could use their skills and knowledge to change policies at the social level.

Rebuilding research capacity in fragile states: the case of a Somali-Swedish global health initiative

This paper presents an initiative to revive the previous Somali–Swedish Research Cooperation, which started in 1981 and was cut short by the civil war in Somalia. A programme focusing on research capacity building in the health sector is currently underway through the work of an alliance of three partner groups: six new Somali universities, five Swedish universities, and Somali diaspora professionals. Somali ownership is key to the sustainability of the programme, as is close collaboration with Somali health ministries. The programme aims to develop a model for working collaboratively across regions and cultural barriers within fragile states, with the goal of creating hope and energy. It is based on the conviction that health research has a key role in rebuilding national health services and trusted institutions.

A global view of severe maternal morbidity: moving beyond maternal mortality

BACKGROUND

Maternal mortality continues to be of great public health importance, however for each woman who dies as the direct or indirect result of pregnancy, many more women experience life-threatening complications. The global burden of severe maternal morbidity (SMM) is not known, but the World Bank estimates that it is increasing over time. Consistent with rates of maternal mortality, SMM rates are higher in low- and middle-income countries (LMICs) than in high-income countries (HICs).

SEVERE MATERNAL MORBIDITY IN HIGH-INCOME COUNTRIES

Since the WHO recommended that HICs with low maternal mortality ratios begin to examine SMM to identify systems failures and intervention priorities, researchers in many HICs have turned their attention to SMM. Where surveillance has been conducted, the most common etiologies of SMM have been major obstetric hemorrhage and hypertensive disorders. Of the countries that have conducted SMM reviews, the most common preventable factors were provider-related, specifically failure to identify "high risk" status, delays in diagnosis, and delays in treatment.

SEVERE MATERNAL MORBIDITY IN LOW AND MIDDLE INCOME COUNTRIES

The highest burden of SMM is in Sub-Saharan Africa, where estimates of SMM are as high as 198 per 1000 live births. Hemorrhage and hypertensive disorders are the leading conditions contributing to SMM across all regions. Case reviews are rare, but have revealed patterns of substandard maternal health care and suboptimal use of evidence-based strategies to prevent and treat morbidity.

EFFECTS OF SMM ON DELIVERY OUTCOMES AND INFANTS

Severe maternal morbidity not only puts the woman's life at risk, her fetus/neonate may suffer consequences of morbidity and mortality as well. Adverse delivery outcomes occur at a higher frequency among women with SMM. Reducing preventable severe maternal morbidity not only reduces the potential for maternal mortality but also improves the health and well-being of the newborn.

CONCLUSION

Increasing global maternal morbidity is a failure to achieve broad public health goals of improved women's and infants' health. It is incumbent upon all countries to implement surveillance initiatives to understand the burden of severe morbidity and to implement review processes for assessing potential preventability.

Incidence and causes of maternal near-miss in selected hospitals of Addis Ababa, Ethiopia

BACKGROUND

Because maternal mortality is a rare event, it is important to study maternal near-miss as a complement to evaluate and improve the quality of obstetric care. Thus, the study was conducted with the aim of assessing the incidence and causes of maternal near-miss.

METHODS

A facility-based cross-sectional study was conducted in five selected public hospitals of Addis Ababa, Ethiopia from May 1, 2015 to April 30, 2016. All maternal near-miss cases admitted to the selected hospitals during the study period were prospectively recruited. World Health Organization criteria were used to identify maternal near-miss cases. The number of maternal near-miss cases over one year per 1000 live births occurring during the same year was calculated to determine the incidence of maternal near-miss. Underlying and contributing causes of maternal near-miss were documented from each participant's record.

RESULTS

During the one-year period, there were a total of 238 maternal near-miss cases and 29,697 live births in all participating hospitals, which provides a maternal near-miss incidence ratio of 8.01 per 1000 live births. The underlying causes of the majority of maternal near-miss cases were hypertensive disorders and obstetric hemorrhage. Anemia was the major contributing cause reported for maternal near-miss. Most of the maternal near-miss cases occurred before the women's arrival at the participating hospitals.

CONCLUSION

The study demonstrated a lower maternal near-miss incidence ratio compared to previous country-level studies. The majority of the near-miss cases occurred before the women's arrival at the participating hospitals, which underscores the importance of improving pre-hospital barriers. Efforts made toward improvement in the management of life-threatening obstetric complications could reduce the occurrence of maternal near-miss problems that occur during hospitalization.