Incidence of maternal near-miss in Kenya in 2018: findings from a nationally representative cross-sectional study in 54 referral hospitals

Postpartum recovery after severe maternal morbidity in Kilifi, Kenya: a grounded theory of recovery trajectories beyond 42 days

INTRODUCTION

The burden of severe maternal morbidity is highest in sub-Saharan Africa, and its relative contribution to maternal (ill) health may increase as maternal mortality continues to fall. Women's perspective of their long-term recovery following severe morbidity beyond the standard 42-day postpartum period remains largely unexplored.

METHODS

This woman-centred, grounded theory study was nested within the Pregnancy Care Integrating Translational Science Everywhere (PRECISE) study in Kilifi, Kenya. Purposive and theoretical sampling was used to recruit 20 women who experienced either a maternal near-miss event (n=11), potentially life-threatening condition (n=6) or no severe morbidity (n=3). Women were purposively selected between 6 and 36 months post partum at the time of interview to compare recovery trajectories. Using a constant comparative approach of line-by-line open codes, focused codes, super-categories and themes, we developed testable hypotheses of women's postpartum recovery trajectories after severe maternal morbidity.

RESULTS

Grounded in women's accounts of their lived experience, we identify three phases of recovery following severe maternal morbidity: 'loss', 'transition' and 'adaptation to a new normal'. These themes are supported by multiple, overlapping super-categories: loss of understanding of own health, functioning and autonomy; transition in women's identity and relationships; and adaptation to a new physical, psychosocial and economic state. This recovery process is multidimensional, potentially cyclical and extends far beyond the standard 42-day postpartum period.

CONCLUSION

Women's complex needs following severe maternal morbidity require a reconceptualisation of postpartum recovery as extending far beyond the standard 42-day postpartum period. Women's accounts expose major deficiencies in the provision of postpartum and mental healthcare. Improved postpartum care provision at the primary healthcare level, with reach extended through community health workers, is essential to identify and treat chronic mental or physical health problems following severe maternal morbidity.

Risk factors for maternal near-miss in an undeveloped province in south-central China, 2012-2022

OBJECTIVE

To explore the risk factors for maternal near-miss (MNM) using the WHO near-miss approach.

METHODS

Data were obtained from the Maternal Near-Miss Surveillance System in Hunan Province, China, 2012-2022. Multivariate logistic regression analysis (method: Forward, Wald, α = 0.05) and adjusted odds ratios (aORs) were used to identify risk factors for MNM.

RESULTS

Our study included 780,359 women with 731,185 live births, a total of 2461 (0.32%) MNMs, 777,846 (99.68%) non-MNMs, and 52 (0.006%) maternal deaths were identified. The MNM ratio was 3.37‰ (95%CI: 3.23-3.50). Coagulation/hematological dysfunction was the most common cause of MNM (75.66%). Results of multivariate logistic regression analysis showed risk factors for MNM: maternal age > = 30 years old (aOR > 1, P < 0.05), unmarried women (aOR = 2.21, 95%CI: 1.71-2.85), number of pregnancies > = 2 (aOR > 1, P < 0.05), nulliparity (aOR = 1.51, 95%CI: 1.32-1.72) or parity > = 3 (aOR = 1.95, 95%CI: 1.50-2.55), prenatal examinations < 5 times (aOR = 1.13, 95%CI: 1.01-1.27), and number of cesarean sections was 1 (aOR = 1.83, 95%CI: 1.64-2.04) or > = 2 (aOR = 2.48, 95%CI: 1.99-3.09).

CONCLUSION

The MNM ratio was relatively low in Hunan Province. Advanced maternal age, unmarried status, a high number of pregnancies, nulliparity or high parity, a low number of prenatal examinations, and cesarean sections were risk factors for MNM. Our study is essential for improving the quality of maternal health care and preventing MNM.

Road to maternal death: the pooled estimate of maternal near-miss, its primary causes and determinants in Africa: a systematic review and meta-analysis

BACKGROUND

Maternal near-miss (MNM) is defined by the World Health Organization (WHO) working group as a woman who nearly died but survived a life-threatening condition during pregnancy, childbirth, or within 42 days of termination of pregnancy due to getting quality of care or by chance. Despite the importance of the near-miss concept in enhancing quality of care and maternal health, evidence regarding the prevalence of MNM, its primary causes and its determinants in Africa is sparse; hence, this study aimed to address these gaps.

METHODS

A systematic review and meta-analysis of studies published up to October 31, 2023, was conducted. Electronic databases (PubMed/Medline, Scopus, Web of Science, and Directory of Open Access Journals), Google, and Google Scholar were used to search for relevant studies. Studies from any African country that reported the magnitude and/or determinants of MNM using WHO criteria were included. The data were extracted using a Microsoft Excel 2013 spreadsheet and analysed by STATA version 16. Pooled estimates were performed using a random-effects model with the DerSimonian Laired method. The I2 test was used to analyze the heterogeneity of the included studies.

RESULTS

Sixty-five studies with 968,555 participants were included. The weighted pooled prevalence of MNM in Africa was 73.64/1000 live births (95% CI: 69.17, 78.11). A high prevalence was found in the Eastern and Western African regions: 114.81/1000 live births (95% CI: 104.94, 123.59) and 78.34/1000 live births (95% CI: 67.23, 89.46), respectively. Severe postpartum hemorrhage and severe hypertension were the leading causes of MNM, accounting for 36.15% (95% CI: 31.32, 40.99) and 27.2% (95% CI: 23.95, 31.09), respectively. Being a rural resident, having a low monthly income, long distance to a health facility, not attending formal education, not receiving ANC, experiencing delays in health service, having a previous history of caesarean section, and having pre-existing medical conditions were found to increase the risk of MNM.

CONCLUSION

The pooled prevalence of MNM was high in Africa, especially in the eastern and western regions. There were significant variations in the prevalence of MNM across regions and study periods. Strengthening universal access to education and maternal health services, working together to tackle all three delays through community education and awareness campaigns, improving access to transportation and road infrastructure, and improving the quality of care provided at service delivery points are key to reducing MNM, ultimately improving and ensuring maternal health equity.

Global burden of potentially life-threatening maternal conditions: a systematic review and meta-analysis

BACKGROUND

Potentially life-threatening maternal conditions (PLTCs) is an important proxy indicator of maternal mortality and the quality of maternal health services. It is helpful to monitor the rates of severe maternal morbidity to evaluate the quality of maternal care, particularly in low- and lower-middle-income countries. This study aims to systematically identify and synthesize available evidence on PLTCs.

METHODS

We searched studies in English from 2009‒2023 in PubMed, the National Library of Medicine (NLM) Gateway, the POPLINE database, and the Science Direct website. The study team independently reviewed the illegibility criteria of the articles. Two reviewers independently appraised the included articles using the Joanna Briggs Instrument for observational studies. Disputes between the reviewers were resolved by consensus with a third reviewer. Meta-analysis was conducted in Stata version 16. The pooled proportion of PLTCs was calculated using the random effects model. The heterogeneity test was performed using the Cochrane Q test, and its level was determined using the I2 statistical result. Using Egger's test, the publication bias was assessed.

RESULT

Thirty-two cross-sectional, five case-control, and seven cohort studies published from 2009 to 2023 were included in the meta-analysis. The highest proportion of PLTC was 17.55% (95% CI: 15.51, 19.79) in Ethiopia, and the lowest was 0.83% (95% CI: 0.73, 0.95) in Iraq. The pooled proportion of PLTC was 6.98% (95% CI: 5.98-7.98). In the subgroup analysis, the pooled prevalence varied based on country income level: in low-income 13.44% (95% CI: 11.88-15.00) I2 = 89.90%, low-middle income 7.42% (95% CI: 5.99-8.86) I2 = 99.71%, upper-middle income 6.35% (95% CI: 4.21-8.50) I2 = 99.92%, and high-income 2.67% (95% CI: 2.34-2.99) I2 = 99.57%. Similarly, it varied based on the diagnosis criteria; WHO diagnosis criteria used 7.77% (95% CI: 6.10-9.44) I2 = 99.96% at P = 0.00, while the Centers for Disease Controls (CDC) diagnosis criteria used 2.19% (95% CI: 1.89-2.50) I2 = 99.41% at P = 0.00.

CONCLUSION

The pooled prevalence of PLTC is high globally, predominantly in low-income countries. The large disparity of potentially life-threatening conditions among different areas needs targeted intervention, particularly for women residing in low-income countries. The WHO diagnosis criteria minimize the underreporting of severe maternal morbidity.

TRIAL REGISTRATION

CRD42023409229.

Health care provider decision-making and the quality of maternity care: An analysis of postpartum care in Kenyan hospitals

Evidence suggests that health care providers' non-adherence to clinical guidelines is widespread and contributes to poor patient outcomes across low- and middle-income countries. Through observations of maternity care in Kenya, we found limited adherence to guideline-recommended active monitoring of patients for signs of postpartum hemorrhage, the leading cause of maternal mortality, despite providers' having the necessary training and equipment. Using survey vignettes conducted with 144 maternity providers, we documented evidence consistent with subjective risk and perceived uncertainty driving providers' decisions to actively monitor patients. Motivated by these findings, we introduced a simple model of providers' decision-making about whether to monitor a patient, which may depend on their perceptions of risk, diagnostic uncertainty, and the value of new information. The model highlights key trade-offs between gathering diagnostic information through active monitoring versus waiting for signs and symptoms of hemorrhage to manifest. Our work provides a template for understanding provider decision-making and could inform interventions to encourage more proactive obstetric care.

Prevalence and determinants of maternal near miss in Ethiopia: a systematic review and meta-analysis, 2015-2023

BACKGROUND

One of the most challenging problems in developing countries including Ethiopia is improving maternal health. About 303,000 mothers die globally, and one in every 180 is at risk from maternal causes. Developing regions account for 99% of maternal deaths. Maternal near miss (MNM) resulted in long-term consequences. A systematic review and meta-analysis was performed to assess the prevalence and predictors of maternal near miss in Ethiopia from January 2015 to March 2023.

METHODS

A systematic review and meta-analysis cover both published and unpublished studies from different databases (PubMed, CINHAL, Scopus, Science Direct, and the Cochrane Library) to search for published studies whilst searches for unpublished studies were conducted using Google Scholar and Google searches. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. Duplicated studies were removed using Endnote X8. The paper quality was also assessed based on the JBI checklist. Finally, 21 studies were included in the study. Data synthesis and statistical analysis were conducted using STATA Version 17 software. Forest plots were used to present the pooled prevalence using the random effect model. Heterogeneity and publication bias was evaluated using Cochran's Q test, (Q) and I squared test (I²). Subgroup analysis based on study region and year of publication was performed.

RESULT

From a total of 705 obtained studies, twenty-one studies involving 701,997 pregnant or postpartum mothers were included in the final analysis. The national pooled prevalence of MNM in Ethiopia was 140/1000 [95% CI: 80, 190]. Lack of formal education [AOR = 2.10, 95% CI: 1.09, 3.10], Lack of antenatal care [AOR = 2.18, 95% CI: 1.33, 3.03], history of cesarean section [AOR = 4.07, 95% CI: 2.91, 5.24], anemia [AOR = 4.86, 95% CI: 3.24, 6.47], and having chronic medical disorder [AOR = 2.41, 95% CI: 1.53, 3.29] were among the predictors of maternal near misses from the pooled estimate.

CONCLUSION

The national prevalence of maternal near miss was still substantial. Antenatal care is found to be protective against maternal near miss. Emphasizing antenatal care to prevent anemia and modifying other chronic medical conditions is recommended as prevention strategies. Avoiding primary cesarean section is recommended unless a clear indication is present. Finally, the country should place more emphasis on strategies for reducing MNM and its consequences, with the hope of improving women's health.

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.

The impact of professional midwives and mentoring on the quality and availability of maternity care in government sub-district hospitals in Bangladesh: a mixed-methods observational study

Background

This study compared government sub-district hospitals in Bangladesh without globally standard midwives, with those with recently introduced midwives, both with and without facility mentoring, to see if the introduction of midwives was associated with improved quality and availability of maternity care. In addition, it analysed the experiences of the newly deployed midwives and the maternity staff and managers that they joined.

Methods

This was a mixed-methods observational study. The six busiest hospitals from three pre-existing groups of government sub-district hospitals were studied; those with no midwives, those with midwives, and those with midwives and mentoring. For the quantitative component, observations of facility readiness (n = 18), and eight quality maternity care practices (n = 641) were carried out using three separate tools. Willing maternity staff (n = 237) also completed a survey on their knowledge, perceptions, and use of the maternity care interventions. Descriptive statistics and logistic regression were used to identify differences between the hospital types. The qualitative component comprised six focus groups and 18 interviews involving midwives, other maternity staff, and managers from the three hospital types. Data were analysed using an inductive cyclical process of immersion and iteration to draw out themes. The quantitative and qualitative methods complemented each other and were used synergistically to identify the study’s insights.

Results

Quantitative analysis found that, of the eight quality practices, hospitals with midwives but no mentors were significantly more likely than hospitals without midwives to use three: upright labour (94% vs. 63%; OR = 22.57, p = 0.001), delayed cord clamping (88% vs. 11%; OR = 140.67, p < 0.001), skin-to-skin (94% vs. 13%; OR = 91.21, p < 0.001). Hospitals with mentors were significantly more likely to use five: ANC card (84% vs. 52%; OR = 3.29, p = 0.002), partograph (97% vs. 14%; OR = 309.42, p = 0.002), upright positioning for labour (95% vs. 63%; OR = 1850, p < 0.001), delayed cord clamping (98% vs. 11%; OR = 3400, p = 0.003), and skin-to-skin contact following birth (93% vs. 13%; OR = 70.89, p < 0.001) Qualitative analysis identified overall acceptance of midwives and the transition to improved quality care; this was stronger with facility mentoring. The most resistance to quality care was expressed in facilities without midwives. In facilities with midwives and mentoring, midwives felt proud, and maternity staff conveyed the greatest acceptance of midwives.

Conclusion

Facilities with professional midwives had better availability and quality of maternity care across multiple components of the health system. Care quality further improved with facility mentors who created enabling environments, and facilitated supportive relationships between existing maternity staff and managers and the newly deployed midwives.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05096-x.

Trends of and Factors Associated with Maternal Near-Miss in Selected Hospitals in North Shewa Zone, Central Ethiopia

Maternal near-miss (MNM) refers to a woman who nearly died but survived a complication that occurred during pregnancy, childbirth, or within 42 days of termination of pregnancy. Studies in Ethiopia showed an inconsistent proportion of MNM across time and in different setups. This study is aimed at assessing the magnitude, trends, and correlates of MNM at three selected hospitals in North Shewa Zone, Central Ethiopia. A hospital-based cross-sectional study was conducted among 905 mothers who gave birth from 2012 to 2017 in three hospitals using the WHO criteria for MNM. Medical records of the study subjects were selected using a systematic sampling technique. Data were retrieved using a pretested data extraction tool. Association between MNM and independent variables was assessed by using a binary logistic regression model. An odds ratio with a 95% confidence interval (CI) and p value of <0.05 were used to declare the level of significance. Of the 905 medical records reviewed, the prevalence of MNM was 14.3% (95%CI = 11.9 − 16.6) and similar over the last six years (2012-2017). The magnitude of life-threatening pregnancy complications was found to be 12.7%; severe preeclampsia (31%) and postpartum hemorrhage (26%) account for the highest proportion. Admission at a higher level of obstetric care like referral hospital (AOR = 4.85; 95% CI: 1.82-12.94) and general hospital (AOR = 3.76; 95% CI: 1.37-10.33), not using partograph for labor monitoring (AOR = 1.89; 95% CI: 1.17-3.04), history of abortion (AOR = 2.52; 95% CI: 1.18-5.37), and any other pregnancy complications (AOR = 6.91; 95% CI: 3.89-12.28) were factors significantly associated with higher MNM. Even though lower than the national figure, the proportion of MNM in the study area was very high, and there were no significant changes over the last six consecutive years. Giving special emphasis to women with prior history of pregnancy complications, hypertensive disorders of pregnancy, and obstetric hemorrhage with strict and quick management protocols and the use of partograph for labor monitoring are recommended to reduce the burden of severe maternal outcomes in the study area and Ethiopia.

Determinants of Obstetric Near Miss in a Tertiary Hospital in Kenya: A Retrospective Study

BACKGROUND

Kenya has a high burden of facility maternal deaths but there is scarce utilization of the near miss approach to understand facility related determinants of maternal mortality. The aim of this study was to investigate determinants of near miss in a major refferal hospital in Kenya using the World Health Organization near miss approach.

METHODS

A retrospective study design was used in a referral hospital in Kenya. Prevalence, direct and indirect causes of near miss were determined. Binomial logistic regression was used to determine associations between maternal characteristics and maternal near miss.

RESULTS

Maternal near miss ratio was 8.7 per 1000 live births. The most prevalent direct factors were: Severe post-partum hemorrhage (35%), eclampsia (18.9%) severe pre-eclampsia (17.4%), blood transfusion (79%), and hepatic dysfunction (3.7%). Anemia, previous ceaserean section and prolonged/obstructed labor were the most important contributory factors. The prevalence of organ dysfunction at admission was 39%. Only 74% of eclampsia cases had received magnesium sulphate on referral. Higher gestation at delivery (AOR = 0.640, 95% C.I =0.477–0.858) and those who received antenatal care from a level two or three facility (AOR = 0.190, 95% CI = 0.042–0.856) were less likely to experience a near miss.

CONCLUSION

Obstetric hemorrhage and pregnancy induced hypertension were the most important direct determinants of near miss, while anemia was the most important indirect determinant. Organ dysfunction on admission to the tertiary referral facility was high, suggesting delays in interventions at lower level facilities. Interventions addressing obstetric hemorrhage, pregnancy induced hypertension and pre-natal anemia may reduce the burden of near miss and mortality.

The Prevalence and Risk Factors for Severe Maternal Morbidities: A Systematic Review and Meta-Analysis

Introduction

Maternal mortality and severe maternal morbidity remain major public health problems globally. Understanding their risk factors may result in better treatment solutions and preventive measures for maternal health. This review aims to identify the prevalence and risk factors of severe maternal morbidity (SMM) and maternal near miss (MNM).

Methods

A systematic review and meta-analysis was conducted to assess the prevalence and risk factors of SMM and MNM. The study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. A systematic search was performed in the MEDLINE (PubMed), CINAHL (EBSCOhost), and Science Direct databases for articles published between 2011 and 2020.

Results

Twenty-four of the 44 studies included were assessed as being of good quality and having a low risk of bias. The prevalence of SMM and MNM was 2.45% (95% CI: 2.03, 2.88) and 1.68% (95% CI: 1.42, 1.95), respectively. The risk factors for SMM included history of cesarean section (OR [95% CI]: 1.63 [1.43, 1.87]), young maternal age (OR [95% CI]: 0.71 [0.60, 0.83]), singleton pregnancy (OR [95% CI]: 0.42 [0.32, 0.55]), vaginal delivery (OR [95% CI]: 0.11 [0.02, 0.47]), coexisting medical conditions (OR [95% CI]: 1.51 [1.28, 1.78]), and preterm gestation (OR [95% CI]: 0.14 [0.08, 0.23]). The sole risk factor for MNM was a history of cesarean section (OR [95% CI]: 2.68 [1.41, 5.10]).

Conclusions

Maternal age, coexisting medical conditions, history of abortion and cesarean delivery, gestational age, parity, and mode of delivery are associated with SMM and MNM. This helps us better understand the risk factors and their strength of association with SMM and MNM. Thus, initiatives such as educational programs, campaigns, and early detection of risk factors are recommended. Proper follow-up is important to monitor the progression of maternal health during the antenatal and postnatal periods.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021226137, identifier: CRD42021226137.

Severe Maternal Outcomes and Quality of Maternal Health Care in South Ethiopia

Objective

To assess the incidence of severe maternal outcomes (SMO) and quality of maternal health care in south Ethiopia.

Methods

A facility-based prospective study was conducted in three hospitals among all women who presented while pregnant, during and after childbirth between 12 July and 26 November 2018. Participants were followed from the time of admission to discharge. The World Health Organization (WHO) maternal near-miss (MNM) approach was used to assess SMO indicators and quality of maternal health care.

Results

Of 2880 live births, 315 had potentially life-threatening conditions and 108 had SMOs (90 MNM and 18 maternal deaths). The SMO incidence ratio was 37.5 per 1000 live births (95% CI 30.6–44.4) and MNM incidence ratio was 31.3 per 1000 live births (95% CI 24.9–37.7). The ratio of near-miss to maternal deaths was 5:1. The hospitals’ maternal mortality ratio (MMR) was 625 per 100,000 live births. Most (82.1%) SMO cases were referred from other health facilities. The most common cause of SMO was eclampsia (37%) followed by postpartum haemorrhage (33.3%). The highest mortality index (MI) was among women with sepsis (27.3%). The intensive care unit (ICU) admission rate was 13% for women with SMO and 83.3% of maternal deaths occurred without ICU admission.

Conclusion

The SMO ratio was comparable to other studies in the country. Most women with SMO were referred from other health facilities, which demonstrate the presence of the first delay (seeking care) and/or the second delay (reaching care) in the study area. The study suggests that effectively using the ICU, reducing delays, and improving the referral system may reduce SMO and improve the quality of care in the hospitals. Furthermore, continuous reviewing of SMO is needed to learn what treatment was given to women who experienced complications in the hospitals.

Cost of maternal near miss and potentially life-threatening conditions, Kenya

OBJECTIVE

To estimate the direct costs of treating women with maternal near misses and potentially life-threatening conditions in Kenya and the factors associated with catastrophic health expenditure for these women and their households.

METHODS

As part of a prospective, nationally representative study of all women with near misses during pregnancy and childbirth or within 42 days of delivery or termination of pregnancy, we compared the cost of treating maternal near-miss cases admitted to referral facilities with that of women with potentially life-threatening conditions. We used logistic regression analysis to assess clinical, demographic and household factors associated with catastrophic health expenditure.

FINDINGS

Of 3025 women, 1180 (39.0%) had maternal near misses and 1845 (61.0%) had potentially life-threatening conditions. The median cost of treating maternal near misses was 7135 Kenyan shillings (71 United States dollars, US$) compared with 2690 Kenyan shillings (US$ 27) for potentially life-threatening conditions. Of the women who made out-of-pocket payments, 26.4% (122/462) experienced catastrophic expenditure. The highest median costs for treatment of near misses were in Nairobi and Central region (22 220 Kenyan shillings; US$ 222). Women with ectopic pregnancy complications and pregnancy-related infections had the highest median costs of treatment, at 7800 Kenyan shillings (US$ 78) and 3000 Kenyan shillings (US$ 30), respectively. Pregnancy-related infections, abortion, ectopic pregnancy, and treatment in secondary and tertiary facilities were significantly associated with catastrophic expenditure.

CONCLUSION

The cost of treating maternal near misses is high and leads to catastrophic spending through out-of-pocket payments. Universal health coverage needs to be expanded to guarantee financial protection for vulnerable women.

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.

'It was hell in the community': a qualitative study of maternal and child health care during health care worker strikes in Kenya

BACKGROUND

Health care workers in Kenya have launched major strikes in the public health sector in the past decade but the impact of strikes on health systems is under-explored. We conducted a qualitative study to investigate maternal and child health care and services during nationwide strikes by health care workers in 2017 from the perspective of pregnant women, community health volunteers (CHVs), and health facility managers.

METHODS

We conducted in-depth interviews and focus group discussions (FGDs) with three populations: women who were pregnant in 2017, CHVs, and health facility managers. Women who were pregnant in 2017 were part of a previous study. All participants were recruited using convenience sampling from a single County in western Kenya. Interviews and FGDs were conducted in English or Kiswahili using semi-structured guides that probed women's pregnancy experiences and maternal and child health services in 2017. Interviews and FGDs were audio-recorded, translated, and transcribed. Content analysis followed a thematic framework approach using deductive and inductive approaches.

RESULTS

Forty-three women and 22 CHVs participated in 4 FGDs and 3 FGDs, respectively, and 8 health facility managers participated in interviews. CHVs and health facility managers were majority female (80%). Participants reported that strikes by health care workers significantly impacted the availability and quality of maternal and child health services in 2017 and had indirect economic effects due to households paying for services in the private sector. Participants felt it was the poor, particularly poor women, who were most affected since they were more likely to rely on public services, while CHVs highlighted their own poor working conditions in response to strikes by physicians and nurses. Strikes strained relationships and trust between communities and the health system that were identified as essential to maternal and child health care.

CONCLUSION

We found that the impacts of strikes by health care workers in 2017 extended beyond negative health and economic effects and exacerbated fundamental inequities in the health system. While this study was conducted in one County, our findings suggest several potential avenues for strengthening maternal and child health care in Kenya that were highlighted by nationwide strikes in 2017.

A retrospective study of the impact of health worker strikes on maternal and child health care utilization in western Kenya

BACKGROUND

There have been dozens of strikes by health workers in Kenya in the past decade, but there are few studies of their impact on maternal and child health services and outcomes. We conducted a retrospective survey study to assess the impact of nationwide strikes by health workers in 2017 on utilization of maternal and child health services in western Kenya.

METHODS

We utilized a parent study to enroll women who were pregnant in 2017 when there were prolonged strikes by health workers ("strike group") and women who were pregnant in 2018 when there were no major strikes ("control group"). Trained research assistants administered a close-ended survey to retrospectively collect demographic and pregnancy-related health utilization and outcomes data. Data were collected between March and July 2019. The primary outcomes of interest were antenatal care (ANC) visits, delivery location, and early child immunizations. Generalized estimating equations were used to estimate risk ratios between the strike and control groups, adjusting for socioeconomic status, health insurance status, and clustering. Adjusted risk ratios (ARR) were calculated with 95% confidence intervals (95%CI).

RESULTS

Of 1341 women recruited in the parent study in 2017 (strike group), we re-consented 843 women (63%) to participate. Of 924 women recruited in the control arm of the parent study in 2018 (control group), we re-consented 728 women (79%). Women in the strike group were 17% less likely to attend at least four ANC visits during their pregnancy (ARR 0.83, 95%CI 0.74, 0.94) and 16% less likely to deliver in a health facility (ARR 0.84, 95%CI 0.76, 0.92) compared to women in the control group. Whether a child received their first oral polio vaccine did not differ significantly between groups, but children of women in the strike group received their vaccine significantly longer after birth (13 days versus 7 days, p = 0.002).

CONCLUSION

We found that women who were pregnant during nationwide strikes by health workers in 2017 were less likely to receive WHO-recommended maternal child health services. Strategies to maintain these services during strikes are urgently needed.