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Zewde HK. Determinants of severe maternal outcome in Keren hospital, Eritrea: An unmatched case-control study. PLoS One 2024; 19:e0299663. [PMID: 38739618 PMCID: PMC11090357 DOI: 10.1371/journal.pone.0299663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 02/14/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND In the past few decades, several studies on the determinants and risk factors of severe maternal outcome (SMO) have been conducted in various developing countries. Even though the rate of maternal mortality in Eritrea is among the highest in the world, little is known regarding the determinants of SMO in the country. Thus, the aim of this study was to identify determinants of SMO among women admitted to Keren Provincial Referral Hospital. METHODS A facility based unmatched case-control study was conducted in Keren Hospital. Women who encountered SMO event from January 2018 to December 2020 were identified retrospectively from medical records using the sub-Saharan Africa maternal near miss (MNM) data abstraction tool. For each case of SMO, two women with obstetric complication who failed to meet the sub-Saharan MNM criteria were included as controls. Bivariate and multivariate logistic regression analyses were employed using SPSS version-22 to identify factors associated with SMO. RESULTS In this study, 701 cases of SMO and 1,402 controls were included. The following factors were independently associated with SMO: not attending ANC follow up (AOR: 4.53; CI: 3.15-6.53), caesarean section in the current pregnancy (AOR: 3.75; CI: 2.69-5.24), referral from lower level facilities (AOR: 11.8; CI: 9.1-15.32), residing more than 30 kilometers away from the hospital (AOR: 2.97; CI: 2.29-3.85), history of anemia (AOR: 2.36; CI: 1.83-3.03), and previous caesarean section (AOR: 3.49; CI: 2.17-5.62). CONCLUSION In this study, lack of ANC follow up, caesarean section in the current pregnancy, referral from lower facilities, distance from nearest health facility, history of anaemia and previous caesarean section were associated with SMO. Thus, improved transportation facilities, robust referral protocol and equitable distribution of emergency facilities can play vital role in reducing SMO in the hospital.
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Affiliation(s)
- Henos Kiflom Zewde
- Departement of Family and Community Health, Ministry of Health Anseba Province, Keren, Anseba, Eritrea
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Habte A, Bizuayehu HM, Lemma L, Sisay Y. Road to maternal death: the pooled estimate of maternal near-miss, its primary causes and determinants in Africa: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2024; 24:144. [PMID: 38368373 PMCID: PMC10874058 DOI: 10.1186/s12884-024-06325-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 02/06/2024] [Indexed: 02/19/2024] Open
Abstract
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.
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Affiliation(s)
- Aklilu Habte
- School of Public Health, College of Medicine and Health Sciences, Wachemo University, Hosanna, Ethiopia.
| | | | - Lire Lemma
- Department of Health Informatics, School of Public Health, College of Medicine and Health Sciences, Wachemo University, Hosanna, Ethiopia
| | - Yordanos Sisay
- Department of Epidemiology, College of Health Science and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia
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Vasconcelos A, Sousa S, Bandeira N, Alves M, Papoila AL, Pereira F, Machado MC. Factors associated with perinatal and neonatal deaths in Sao Tome & Principe: a prospective cohort study. Front Pediatr 2024; 12:1335926. [PMID: 38434731 PMCID: PMC10904650 DOI: 10.3389/fped.2024.1335926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/02/2024] [Indexed: 03/05/2024] Open
Abstract
Background Neonatal mortality reduction is a global goal, but its factors are seldom studied in most resource-constrained settings. This is the first study conducted to identify the factors affecting perinatal and neonatal deaths in Sao Tome & Principe (STP), the smallest Central Africa country. Methods Institution-based prospective cohort study conducted at Hospital Dr. Ayres Menezes. Maternal-neonate dyads enrolled were followed up after the 28th day of life (n = 194) for identification of neonatal death-outcome (n = 22) and alive-outcome groups (n = 172). Data were collected from pregnancy cards, hospital records and face-to-face interviews. After the 28th day of birth, a phone call was made to evaluate the newborn's health status. Crude odds ratios and corresponding 95% confidence intervals were obtained. A p value <0.05 was considered statistically significant. Results The mean gestational age of the death-outcome and alive-outcome groups was 36 (SD = 4.8) and 39 (SD = 1.4) weeks, respectively. Death-outcome group (n = 22) included sixteen stillbirths, four early and two late neonatal deaths. High-risk pregnancy score [cOR 2.91, 95% CI: 1.18-7.22], meconium-stained fluid [cOR 4.38, 95% CI: 1.74-10.98], prolonged rupture of membranes [cOR 4.84, 95% CI: 1.47-15.93], transfer from another unit [cOR 6.08, 95% CI:1.95-18.90], and instrumental vaginal delivery [cOR 8.90, 95% CI: 1.68-47.21], were factors significantly associated with deaths. The odds of experiencing death were higher for newborns with infectious risk, IUGR, resuscitation maneuvers, fetal distress at birth, birth asphyxia, and unit care admission. Female newborn [cOR 0.37, 95% CI: 0.14-1.00] and birth weight of more than 2,500 g [cOR 0.017, 95% CI: 0.002-0.162] were found to be protective factors. Conclusion Factors such as having a high-risk pregnancy score, meconium-stained amniotic fluid, prolonged rupture of membranes, being transferred from another unit, and an instrumental-assisted vaginal delivery increased 4- to 9-fold the risk of stillbirth and neonatal deaths. Thus, avoiding delays in prompt intrapartum care is a key strategy to implement in Sao Tome & Principe.
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Affiliation(s)
- Alexandra Vasconcelos
- Unidade de Clínica Tropical-Global Health and Tropical Medicine (GHTM), Instituto de Higiene e Medicina Tropical (IHMT), Universidade NOVA de Lisboa, Lisboa, Portugal
| | - Swasilanne Sousa
- Department of Pediatrics, Hospital Dr. Ayres de Menezes, São Tomé, Sao Tome and Principe
| | - Nelson Bandeira
- Department of Obstetrics & Gynecology, Hospital Dr. Ayres de Menezes, São Tomé, Sao Tome and Principe
| | - Marta Alves
- CEAUL, NOVA Medical School/Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, Lisboa, Portugal
| | - Ana Luísa Papoila
- CEAUL, NOVA Medical School/Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, Lisboa, Portugal
| | - Filomena Pereira
- Unidade de Clínica Tropical-Global Health and Tropical Medicine (GHTM), Instituto de Higiene e Medicina Tropical (IHMT), Universidade NOVA de Lisboa, Lisboa, Portugal
| | - Maria Céu Machado
- Faculdade de Medicina de Lisboa, Universidade de Lisboa, Lisboa, Portugal
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Kamangira B, Ayele G, Dube P, Melaku K, Vushoma E. Maternal near miss hospitalizations in the Borana Zone, Ethiopia: A facility-based longitudinal cross-sectional study. J Public Health Res 2024; 13:22799036241238665. [PMID: 38525053 PMCID: PMC10960350 DOI: 10.1177/22799036241238665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 02/25/2024] [Indexed: 03/26/2024] Open
Abstract
Background Maternal near miss refers to a woman who nearly died but survived a complication that occurred during pregnancy, childbirth, or within 42 days of pregnancy termination. While there has been considerable progress in reducing maternal mortality rates, maternal near miss cases can provide valuable insights into the quality of maternal healthcare and help identify areas for improvement. However, there is limited evidence on the factors contributing to maternal near miss cases, including health system failures, delays in care, and provider-related factors. Therefore, this study aimed to assess the incidence, causes, and factors associated with maternal near misses in public Hospitals of Borena Zone. Methods A facility-based longitudinal cross-sectional study design was employed at four Public Hospitals in Borena Zone from August 15, 2022, to November 15, 2022, using the WHO criteria for maternal near miss event. In total, 117 participants were included in the study. Eligibility was determined using key clinical, organ dysfunction, laboratory, and management criteria, as per the WHO guidelines for near-miss events. Underlying and contributing causes of maternal near misses were documented from each participant's records. Result There were 1421 deliveries during the study period and 117 eligible women developed potentially life-threatening conditions. Only 61 women experienced severe maternal outcomes (55 near misses and six maternal deaths). The maternal near miss incidence ratio was 38.7 per 1000 live births, with a mortality index of 9.8%. Hypertensive disorders and obstetric hemorrhage are the leading underlying causes of maternal near misses. Conclusion The incidence of maternal near miss was remarkably high when compared to previous studies. Giving special emphasis to life-saving interventions, critical care, reducing delays and improving the referral system are critical to improve quality of care.
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Affiliation(s)
- Boboh Kamangira
- Catholic Organization for Relief and Development Aid (CORDAID), Ethiopian Country Office, Addis Ababa, Ethiopia
| | - Gudeta Ayele
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Polite Dube
- Catholic Organization for Relief and Development Aid (CORDAID), Ethiopian Country Office, Addis Ababa, Ethiopia
| | - Kaleb Melaku
- Catholic Organization for Relief and Development Aid (CORDAID), Ethiopian Country Office, Addis Ababa, Ethiopia
| | - Eubert Vushoma
- Catholic Organization for Relief and Development Aid (CORDAID), Ethiopian Country Office, Addis Ababa, Ethiopia
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Negash A, Sertsu A, Mengistu DA, Tamire A, Birhanu Weldesenbet A, Dechasa M, Nigussie K, Bete T, Yadeta E, Balcha T, Debele GR, Dechasa DB, Fekredin H, Geremew H, Dereje J, Tolesa F, Lami M. Prevalence and determinants of maternal near miss in Ethiopia: a systematic review and meta-analysis, 2015-2023. BMC Womens Health 2023; 23:380. [PMID: 37468876 PMCID: PMC10357694 DOI: 10.1186/s12905-023-02523-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 07/01/2023] [Indexed: 07/21/2023] Open
Abstract
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.
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Affiliation(s)
- Abraham Negash
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia.
| | - Addisu Sertsu
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Dechasa Adare Mengistu
- School of Environmental Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Aklilu Tamire
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Adisu Birhanu Weldesenbet
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Mesay Dechasa
- School of Pharmacy, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Kabtamu Nigussie
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Tilahun Bete
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Elias Yadeta
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Taganu Balcha
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | | | - Deribe Bekele Dechasa
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Hamdi Fekredin
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Habtamu Geremew
- College of Health Sciences, Oda Bultum University, Chiro, Ethiopia
| | - Jerman Dereje
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Fikadu Tolesa
- College of Health Sciences, Salale University, Fitche, Ethiopia
| | - Magarsa Lami
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
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Berihun A, Abebo TA, Aseffa BM, Simachew Y, Jisso M, Shiferaw Y. Third delay and associated factors among women who gave birth at public health facilities of Gurage zone, southern Ethiopia. BMC Womens Health 2023; 23:369. [PMID: 37438692 DOI: 10.1186/s12905-023-02526-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 07/04/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND The third delay is a delay in accessing emergency obstetric care timely and appropriately once a woman reaches a health facility. The third delay plays a crucial role as an indicator to assess the quality of obstetrics services and is often the leading contributing factor to maternal mortality in developing countries. Although considerable research has been conducted on pre-facility delays in healthcare access, there is a lack of focus on delays experienced upon arrival at health facilities, particularly in Ethiopia and the specific study areas of Gurage zone. This study aimed to assess the magnitude of the third delay and associated factors among women who gave birth at Public Health Facilities of Gurage Zone, Southern Ethiopia. METHOD A facility-based cross-sectional study was conducted with 558 women who gave birth at public health facilities of Gurage Zone from January 01/2020 to March 30/2020. Multi-stage stratified sampling technique was used to select the nine facilities. The data was collected using a structured interviewer administer questionnaire and an observational checklist. Women who waited more than an hour to receive delivery services after arriving at the health facility were classified as experiencing the third delay. The data were entered and analyzed using Epi Data version 3.1 and SPSS version 20.0 software, respectively. Binary logistic regression was employed to identify the determinant factors for the third delay. Variables having a P-value < 0.25 in the binary analysis were a candidate for multivariable analysis. Variables with P < 0.05 were considered statistically significant. RESULT The magnitude of the third delay was 193 [(34.8%; 95% CI; (30.8%, 38.8%)]. Complication during labor [AOR = 2.0; 95% CI, (1.4, 3.0)], Presence of functional generator in a health facility [AOR = 2.8; 95% CI, (1.3, 6.3)], level of health institution [AOR = 2.8; 95% CI, (1.04, 7.8)] and BEMONC training in the last two years [AOR = 1.6; 95% CI, (2.0, 6.5)] were significantly associated with third delay. CONCLUSION The magnitude of third delay was high compared to some low income countries, which shows most of mothers were not getting the service timely after they arrived at the health facility. Equipping health facilities with trained manpower and with necessary materials and infrastructure will contribute to hastening the provision of obstetric care.
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Affiliation(s)
| | - Teshome Abuka Abebo
- School of Public Health, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia
| | - Bethelhem Mezgebe Aseffa
- School of Public Health, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia
| | - Yilkal Simachew
- School of Public Health, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia.
| | - Meskerem Jisso
- School of Public Health, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia
| | - Yemisrach Shiferaw
- School of Public Health, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia
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Vasconcelos A, Sousa S, Bandeira N, Alves M, Papoila AL, Pereira F, Machado MC. Adverse birth outcomes and associated factors among newborns delivered in Sao Tome & Principe: A case‒control study. PLoS One 2023; 18:e0276348. [PMID: 37418369 PMCID: PMC10328319 DOI: 10.1371/journal.pone.0276348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 06/16/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND Newborns with one-or-more adverse birth outcomes (ABOs) are at greater risk of mortality or long-term morbidity with health impacts into adulthood. Hence, identifying ABO-associated factors is crucial for devising relevant interventions. For this study, ABOs were defined as prematurity (PTB) for gestational age <37 weeks, low birth weight (LBW) <2.5 kg, macrosomia >4 kg, asphyxia for a 5-minute Apgar score <7, congenital anomalies, and neonatal sepsis. This study aimed to assess factors associated with ABOs among babies delivered at the only hospital of Sao Tome & Principe (STP), a resource-constrained sub-Saharan-Central African country. METHODS A hospital-based unmatched case‒control study was conducted among newborns from randomly selected mothers. Newborns with one-or-more ABO were the cases (ABO group), while healthy newborns were the controls (no-ABO group). Data were collected by a face-to-face interview and abstracted from antenatal care (ANC) pregnancy cards and medical records. Multivariable logistic regression analysis was performed to identify ABO-associated factors considering a level of significance of α = 0.05. RESULTS A total of 519 newborns (176 with ABO and 343 no-ABO) were enrolled. The mean gestational age and birthweight of cases and controls were 36 (SD = 3.7) weeks with 2659 (SD = 881.44) g and 39.6 (SD = 1.0) weeks with 3256 (SD = 345.83) g, respectively. In the multivariable analysis, twin pregnancy [aOR 4.92, 95% CI 2.25-10.74], prolonged rupture of membranes [aOR 3.43, 95% CI 1.69-6.95], and meconium- fluid [aOR 1.59, 95% CI 0.97-2.62] were significantly associated with ABOs. Eight or more ANC contacts were found to be protective [aOR 0.33, 95% CI 0.18-0.60, p<0.001]. CONCLUSION Modifiable factors were associated with ABOs in this study and should be considered in cost-effective interventions. The provision of high-quality ANC should be a priority. Twin pregnancies and intrapartum factors such as prolonged rupture of membranes and meconium-stained amniotic fluid are red flags for ABOs that should receive prompt intervention and follow-up.
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Affiliation(s)
- Alexandra Vasconcelos
- Instituto de Higiene e Medicina Tropical (IHMT), Unidade de Clínica Tropical—Global Health and Tropical Medicine (GHTM), Universidade NOVA de Lisboa, Lisboa, Portugal
| | - Swasilanne Sousa
- Department of Pediatrics, Hospital Dr. Ayres de Menezes, São Tomé, República Democrática de São Tomé e Príncipe
| | - Nelson Bandeira
- Department of Obstetrics & Gynecology, Hospital Dr. Ayres de Menezes, São Tomé, República Democrática de São Tomé e Príncipe
| | - Marta Alves
- NOVA Medical School/Faculdade de Ciências Médicas, CEAUL, Universidade NOVA de Lisboa, Lisboa, Portugal
| | - Ana Luísa Papoila
- NOVA Medical School/Faculdade de Ciências Médicas, CEAUL, Universidade NOVA de Lisboa, Lisboa, Portugal
| | - Filomena Pereira
- Instituto de Higiene e Medicina Tropical (IHMT), Unidade de Clínica Tropical—Global Health and Tropical Medicine (GHTM), Universidade NOVA de Lisboa, Lisboa, Portugal
| | - Maria Céu Machado
- Faculdade de Medicina de Lisboa, Universidade de Lisboa, Lisboa, Portugal
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Klemann D, Rijkx M, Mertens H, van Merode F, Klein D. Causes for Medical Errors in Obstetrics and Gynaecology. Healthcare (Basel) 2023; 11:healthcare11111636. [PMID: 37297775 DOI: 10.3390/healthcare11111636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 05/29/2023] [Accepted: 05/31/2023] [Indexed: 06/12/2023] Open
Abstract
Background: Quality strategies, interventions, and frameworks have been developed to facilitate a better understanding of healthcare systems. Reporting adverse events is one of these strategies. Gynaecology and obstetrics are one of the specialties with many adverse events. To understand the main causes of medical errors in gynaecology and obstetrics and how they could be prevented, we conducted this systematic review. Methods: This systematic review was performed in compliance with the Prisma 2020 guidelines. We searched several databases for relevant studies (Jan 2010-May 2023). Studies were included if they indicated the presence of any potential risk factor at the hospital level for medical errors or adverse events in gynaecology or obstetrics. Results: We included 26 articles in the quantitative analysis of this review. Most of these (n = 12) are cross-sectional studies; eight are case-control studies, and six are cohort studies. One of the most frequently reported contributing factors is delay in healthcare. In addition, the availability of products and trained staff, team training, and communication are often reported to contribute to near-misses/maternal deaths. Conclusions: All risk factors that were found in our review imply several categories of contributing factors regarding: (1) delay of care, (2) coordination and management of care, and (3) scarcity of supply, personnel, and knowledge.
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Affiliation(s)
- Désirée Klemann
- Department of Gynaecology and Obstetrics, Maastricht University Medical Centre+, 6229 HX Maastricht, The Netherlands
- Care and Public Health Research Institute, Maastricht University, 6200 MD Maastricht, The Netherlands
| | - Maud Rijkx
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Centre+, Maastricht University, 6229 HX Maastricht, The Netherlands
| | - Helen Mertens
- Executive Board, Maastricht University Medical Centre+, Maastricht University, 6229 HX Maastricht, The Netherlands
| | - Frits van Merode
- Care and Public Health Research Institute, Maastricht University, 6200 MD Maastricht, The Netherlands
- Maastricht University Medical Centre+, Maastricht University, 6229 HX Maastricht, The Netherlands
| | - Dorthe Klein
- Care and Public Health Research Institute, Maastricht University, 6200 MD Maastricht, The Netherlands
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre+, 6228 HX Maastricht, The Netherlands
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Habte A, Tamene A, Woldeyohannes D. The uptake of WHO-recommended birth preparedness and complication readiness messages during pregnancy and its determinants among Ethiopian women: A multilevel mixed-effect analyses of 2016 demographic health survey. PLoS One 2023; 18:e0282792. [PMID: 36952431 PMCID: PMC10035894 DOI: 10.1371/journal.pone.0282792] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 02/22/2023] [Indexed: 03/25/2023] Open
Abstract
Background Birth preparedness and complication readiness (BPCR) is a package of interventions recommended by the World Health Organization to improve maternal and newborn health and it is provided and implemented through a focused antenatal care program. This study aimed at assessing the uptake of birth preparedness and complication readiness messages, and compliance with each key message, among Ethiopian women during their recent pregnancies using the 2016 demographic health survey report. Methods The data for this study was taken from the Ethiopian Demographic and Health Survey, which was conducted from January to June 2016 and covered all administrative regions. STATA version 16 was used to analyze a total of 4,712 (with a weighted frequency of 4,771.49) women. A multilevel mixed-effects logistic, and multilevel mixed-effect negative binomial regressions were fitted, respectively. Adjusted odds ratio (AOR) and Incidence rate ratio (IRR) with their corresponding 95% confidence interval (CI) were used to report significant determinants. Results More than half, 56.02% [95% CI: 54.58, 57.41] of women received at least one birth preparedness and complication readiness message. Being in the richest wealth quintiles (AOR = 2.33; 95% CI: 1.43, 3.73), having two birth/s in the last five years (AOR = 1.54; 95% CI: 1.13, 2.10), receiving four or more antenatal visits(AOR = 3.33; 95% CI: 2.49, 4.45), and reading a newspaper at least once a week (AOR = 1.27; 95% CI: 1.07, 1.65) were the individual‑level factors, whereas regions and residence(AOR = 1.54; 95% CI: 1.11, 1.96) were the community-level factors associated with the uptake of at least one BPCR message. On the other hand, receiving four or more antenatal visits (IRR = 2.78; 95% CI: 2.09, 3.71), getting permission to go to a health facility (IRR = 1.29; 95% CI: 1.028, 1.38), and not covered by health insurance schemes (IRR = 0.76; 95% CI: 0.68, 0.95) were identified as significant predictors of receiving key birth preparedness and complication readiness messages. Conclusion The overall uptake of the WHO-recommended birth readiness and complication readiness message and compliance with each message in Ethiopia was found to be low. Managers and healthcare providers in the health sector must work to increase the number of antenatal visits. Policymakers should prioritize the implementation of activities and interventions that increase women’s autonomy in decision-making, job opportunity, and economic capability to enhance their health-seeking behavior. The local administrative bodies should also work to enhance household enrollment in health insurance schemes.
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Affiliation(s)
- Aklilu Habte
- School of Public Health, College of Medicine and Health Sciences, Wachemo University, Hosanna, Ethiopia
- * E-mail:
| | - Aiggan Tamene
- School of Public Health, College of Medicine and Health Sciences, Wachemo University, Hosanna, Ethiopia
| | - Demelash Woldeyohannes
- School of Public Health, College of Medicine and Health Sciences, Wachemo University, Hosanna, Ethiopia
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Podder D, Paul B, Biswas SC, Dasgupta A, Roy S, Pal A. Predictors and Pathway of Maternal Near Miss: A Case-Control Study in a Tertiary Care Facility in Kolkata. Indian J Community Med 2022; 47:555-561. [PMID: 36742971 PMCID: PMC9891049 DOI: 10.4103/ijcm.ijcm_183_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 08/23/2022] [Indexed: 02/07/2023] Open
Abstract
Background Use of maternal near-miss (MNM) cases as an adjunct has been advocated to understand the processes of obstetric care because they share similar pathways as maternal deaths. Identifying the predictors and care pathway is crucial to improve the quality of care and end preventable maternal deaths. Materials and Methods This case-control study was conducted at a tertiary care facility in Kolkata from May 2019 to March 2020. Women admitted with complications during pregnancy, childbirth, or within 42 days of postpartum, who met the World Health Organization (WHO) near-miss criteria, were identified as cases, and equivalent age-group matched controls were recruited. Sample size of 60 cases and 60 controls was estimated, assuming a power of 80%, level of significance 0.05, and case-control ratio of 1. After obtaining approval from the institutional ethics committee and informed written consent from the participants, data was collected through face-to-face interview and review of records. Statistical analysis including care pathway analysis (using three-delay model) was performed using Statistical Package for Social Sciences version 16. Results Joint family type (adjusted odds ratio [AOR] [CI] = 5.06 [1.48, 7.28]), lack of antenatal checkups (AOR [CI] = 7.85 [1.47, 12.09]), previous history of cesarean section (AOR [CI] = 3.94 [1.09, 14.33]), first delay in seeking care (AOR [CI] = 13.84 [3.62, 32.83]), and preexisting medical disorders (AOR [CI] = 11.03 [4.62, 22.80]) were identified as significant predictors of MNM in the adjusted model. Significant difference in the proportion of first and second delays in the care pathway was observed between cases and controls. Conclusions Identification of risk factors of MNM and pattern of delays in the care pathway will help improving quality of obstetric care.
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Affiliation(s)
- Debayan Podder
- Department of Community Medicine, Raiganj Government Medical College Hospital, Raiganj, West Bengal, India
| | - Bobby Paul
- Department of Preventive and Social Medicine, All India Institute of Hygiene and Public Health, Kolkata, West Bengal, India
| | - Subhas C. Biswas
- Department of Gynaecology and Obstetrics, IPGMER-SSKM Hospital, Kolkata, West Bengal, India
| | - Aparajita Dasgupta
- Department of Preventive and Social Medicine, All India Institute of Hygiene and Public Health, Kolkata, West Bengal, India
| | - Soumit Roy
- Department of Community Medicine, IQ City Medical College, Durgapur, West Bengal, India
| | - Arkaprovo Pal
- Department of Community Medicine, ESI-PGIMSR and ESIC MCH, Joka, Kolkata, West Bengal, India
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Teshome HN, Ayele ET, Hailemeskel S, Yimer O, Mulu GB, Tadese M. Determinants of maternal near-miss among women admitted to public hospitals in North Shewa Zone, Ethiopia: A case-control study. Front Public Health 2022; 10:996885. [PMID: 36091552 PMCID: PMC9452817 DOI: 10.3389/fpubh.2022.996885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 08/10/2022] [Indexed: 01/26/2023] Open
Abstract
Background A maternal near-miss (MNM) refers to a woman who presents with life-threatening complications during pregnancy, childbirth, or within 42 days of termination of pregnancy but survived by chance or due to the standard care she received. It is recognized as a valuable indicator to examine the quality of obstetrics care as it follows similar predictors with maternal death. Ethiopia is one of the sub-Saharan African countries with the highest rate of maternal mortality and morbidity. Thus, studying the cause and predictors of maternal near-miss is vital to improving the quality of obstetric care, particularly in low-income countries. Objective To identify determinants of maternal near-miss among women admitted to public hospitals in North Shewa Zone, Ethiopia, 2020. Methods A facility-based unmatched case-control study was conducted on 264 women (88 cases and 176 controls) from February to April 2020. Data were collected using pretested interviewer-administered questionnaires and a review of medical records. Data were entered into Epi-data version 4.2.2 and exported to SPSS version 25 for analysis. Variables with a p-value <0.25 in the bivariable analysis were further analyzed using multivariable logistic regression analysis. Finally, variables with a p-value <0.05 were considered statistically significant. Result Severe pre-eclampsia (49.5%) and postpartum hemorrhage (28.3%) were the main reasons for admission of cases. Educational level of women (AOR = 4.80, 95% CI: 1.78-12.90), education level of husbands (AOR = 5.26; 95% CI: 1.46-18.90), being referred from other health facilities (AOR = 4.73, 95% CI: 1.78-12.55), antenatal care visit (AOR = 2.75, 95% CI: 1.13-6.72), cesarean section (AOR = 3.70, 95% CI: 1.42-9.60), and medical disorder during pregnancy (AOR = 12.06, 95% CI: 2.82-51.55) were found to significantly increase the risk of maternal near-miss. Whereas, the younger age of women significantly decreased the risk of maternal near miss (AOR = 0.26, 95% CI: 0.09-0.75). Conclusion Age, educational level, antenatal care follow-ups, medical disorder during pregnancy, mode of admission, and mode of delivery were significant predictors of maternal near-miss. Socio-demographic development, use of ANC services, early detection and management of medical diseases, reducing cesarean section, and improving the referral systems are crucial to minimizing the maternal near-miss.
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Affiliation(s)
- Hana Nigussie Teshome
- Department of Nursing, College of Health Sciences, Debre Berhan University, Debre Berhan, Ethiopia
| | - Esubalew Tesfahun Ayele
- Department of Public Health, College of Health Sciences, Debre Berhan University, Debre Berhan, Ethiopia
| | - Solomon Hailemeskel
- Department of Midwifery, College of Health Sciences, Debre Berhan University, Debre Berhan, Ethiopia
| | - Osman Yimer
- Department of Midwifery, College of Health Sciences, Debre Berhan University, Debre Berhan, Ethiopia
| | - Getaneh Baye Mulu
- Department of Nursing, College of Health Sciences, Debre Berhan University, Debre Berhan, Ethiopia
| | - Mesfin Tadese
- Department of Midwifery, College of Health Sciences, Debre Berhan University, Debre Berhan, Ethiopia,*Correspondence: Mesfin Tadese
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Dahie HA. Determinants of maternal near miss events among women admitted to tertiary hospitals in Mogadishu, Somalia: a facility-based case-control study. BMC Pregnancy Childbirth 2022; 22:658. [PMID: 35996082 PMCID: PMC9396757 DOI: 10.1186/s12884-022-04987-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/18/2022] [Indexed: 01/22/2023] Open
Abstract
Background A maternal near-miss is a situation in which a woman was on the verge of death but survived a life-threatening obstetric complication that happened during pregnancy, childbirth, or within 42 days after the pregnancy's termination. Survivors of near-miss events share several features with mothers who have died and identifying determinants of maternal near miss will aid in improving the capacity of the health system to reduce severe maternal morbidity and mortality. Therefore, this study was designed to identify determinants of maternal near miss incidents among women hospitalized to tertiary hospitals in Mogadishu, Somalia. Methods A facility-based unmatched case–control study was conducted in four tertiary hospitals in Mogadishu from May 1 to July 31, 2021. A total of five hundred thirty-three (178 cases and 355 controls) study participants were involved in the study. The discharge period, cases were recruited consecutively as they emerged, whereas controls were chosen using systematic sampling approach based on every fifth interval of those delivered through normal spontaneous vaginal delivery. Women who were hospitalized during pregnancy, delivery, or within 42 days of termination of pregnancy and met at least one of the maternal near-miss disease specific criteria were classified as cases, while women who were admitted and gave birth by normal vaginal delivery and resealed from the hospital without experiencing severe obstetric complications were considered controls. Participants were interviewed by well-trained research assistants using pre-tested structured questionnaire and the medical records were reviewed to identify maternal near-miss cases. Data were entered into and analyzed with SPSS 25.0. Logistic regression was used, and the significance level was set at p value ≤ 0.05. Results The most common maternal near-miss morbidities identified were severe anemia (32%), severe pre-eclampsia (19.6%), severe ante partum haemorrhage (15.0%), abortion complications (8.4%), eclampsia (6.1%), ICU admission (5.6%), severe PPH (2.8%) and severe systemic infections (2.8%). The main factors associated with maternal near-miss were rural residency [OR = 2.685, 95%CI: (1.702–4.235)], age below 20 years [OR = 2.728, 95%CI: (1.604–4.5640)], unmarried [OR = 2.18, 2.18, 95%CI (1.247–3.81)], lack of formal education [OR = 2.829, 95%CI: (1.262–6.341)], husband’s unemployment [OR = 2.992, 95%CI: (1.886–4.745)], low family income [OR = 3.333, 95%CI (1.055–10.530)], first pregnancy before 18 years of age [OR = 3.091, 95% CI: (2.044–4.674)], short birth interval [OR = 5.922, 95%CI: (3.891–9.014)], previous history of obstetric complication [OR = 6.568, 95%CI: (4.286–10.066)], never attended ANC services [OR = 2.687, 95%CI: (1.802–4.006)], lack of autonomy in seeking medical help [OR = 3.538, 95%CI: (1.468–8.524)], delivery at non-health facility setting [OR = 4.672, 95%CI: (3.105–7.029)], experiencing the second delay [OR = 1.773, 95% CI: (1.212–2.595)] and stillbirth of the last pregnancy [OR = 5.543, 95%CI: (2.880–10.668)]. Conclusion and recommendation. Lack of maternal education, lack of antenatal care, lack of autonomy to seek medical assistance, short birth interval, rural residence and delay in accessing obstetric services were identified as factors associated with maternal near-miss morbidity. As a result, the study suggests that those modifiable characteristics must be improved in order to avoid severe maternal complications and consequent maternal death.
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Affiliation(s)
- Hassan Abdullahi Dahie
- Department of Nursing and Midwifery, Faculty of Medicine and Health Sciences, SIMAD University, Mogadishu, Somalia. .,SOS Children's Villages, Mogadishu, Somalia.
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Habte A, Lukas K, Melis T, Tamene A, Sahle T, Hailu M, Gizachew A. Determinants of neonatal near miss among neonates admitted to public hospitals in Southern Ethiopia, 2021: A case-control study. PLoS One 2022; 17:e0268041. [PMID: 35522663 PMCID: PMC9075625 DOI: 10.1371/journal.pone.0268041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 04/15/2022] [Indexed: 11/30/2022] Open
Abstract
Background Neonatal near-miss (NNM) cases refer to situations in which babies are on the verge of dying between the ages of 0 and 28 days due to severe morbidity that occurs during pregnancy, delivery, or extra-uterine life, but survive either by luck or due to high-quality health care. Identifying NNM cases and addressing their determinants is crucial for devising comprehensive and relevant interventions to tackle neonatal morbidity and mortality. Hence, this study aimed at finding out the determinants of NNM in neonates admitted to public hospitals in Hadiya zone, southern Ethiopia. Methods A hospital-based unmatched case-control study was conducted in three selected hospitals in southern Ethiopia from May 1 to June 30, 2021. A total of 484 participants took part in the study (121 cases and 363 controls). Controls were chosen using systematic sampling approaches, whereas cases were recruited consecutively at the time of discharge. Cases were selected based on the Latin American Centre for Perinatology (CLAP) criteria of an NNM. A structured interviewer-administered questionnaire and a data extraction checklist were used for data collection. The Data were entered into Epi-Data version 3.1 and exported to SPSS version 23 for analysis. A multivariable logistic regression analysis with a p-value of <0.05 was used to determine the determinants of NNM. Results Ninety-seven (80.1%) and 56 (46.2%) near-miss cases encountered at least one pragmatic and management criteria, respectively. The most common pragmatic and management criteria were gestational age less than 33 weeks (44.6%) and intravenous antibiotic usage up to 7 days and before 28 days of life (27.3%), respectively. A short birth interval [AOR = 2.15, 95% CI: 1.29, 3.57], lack of ANC [AOR = 3.37; 95%CI: 1.35, 6.39], Caesarean mode of delivery [AOR = 2.24; 95%CI: 1.20, 4.16], the occurrence of a third maternal delay [AOR = 3.47; 95% CI: 2.11, 5.75], and poor birth preparedness and complication readiness (BPCR) plan[AOR = 2.50; 95% CI: 1.49,4.13] were identified as a significant determinants of NNM. Conclusion and recommendation The provision of adequate ANC should be a priority for health care providers at service delivery points. To avoid serious neonatal problems, mothers who deliver by Cesarean section should receive more attention from their families and health care providers. Health care providers in the ANC unit should encourage pregnant women to implement the WHO-recommended elements of the BPCR plan. To achieve optimal birth spacing, healthcare providers should focus on the contraceptive provision. Unnecessary delays in health facilities during childbirth should be avoided at all costs.
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Affiliation(s)
- Aklilu Habte
- School of public health, College of Medicine and Health Sciences, Wachemo University, Hosanna, Ethiopia
- * E-mail:
| | - Kaleegziabher Lukas
- School of public health, College of Medicine and Health Sciences, Wachemo University, Hosanna, Ethiopia
| | - Tamirat Melis
- Department of public health, College of Medicine and Health Sciences, Wolkite University, Wolkite, Ethiopia
| | - Aiggan Tamene
- School of public health, College of Medicine and Health Sciences, Wachemo University, Hosanna, Ethiopia
| | - Tadesse Sahle
- Department of Nursing, College of Medicine and Health Sciences, Wolkite University, Wolkite, Ethiopia
| | - Mulugeta Hailu
- School of public health, College of Medicine and Health Sciences, Wachemo University, Hosanna, Ethiopia
| | - Addisalem Gizachew
- School of public health, College of Medicine and Health Sciences, Wachemo University, Hosanna, Ethiopia
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Mlambo C, Sibanda K, Ntshangase B, Mvuyana B. ICT and Women's Health: An Examination of the Impact of ICT on Maternal Health in SADC States. Healthcare (Basel) 2022; 10:802. [PMID: 35627939 PMCID: PMC9141576 DOI: 10.3390/healthcare10050802] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 11/25/2022] Open
Abstract
Attainment of sexual and reproductive health is regarded as a human rights matter. Notwithstanding this, maternal mortality continues to be a major public health concern in low-income countries, especially those in sub-Saharan Africa. Maternal mortality remains high in Africa, yet there are information communication technologies (ICTs) (such as the internet, mobile communication, social media, and community radios) that have the potential to make a difference. Making effective use of all of these ICTs can considerably decrease preventable maternal deaths. ICTs, particularly mobile devices, offer a platform for access to health information and services that can bring change in areas where health infrastructure and resources are often limited. However, for Southern Africa, maternal mortality remains high despite the presence of ICT tools that have transformative potential to improve maternal health. In light of this, this study sought to examine the impact of ICT on maternal health. The study was quantitative in nature, and it used panel data that covered the period from 2000-2018. The Mean Group and Pooled Mean Group cointegration techniques and a generalised method of moments panel technique were used for estimation purposes. Results showed that ICT has a negative effect on maternal health. This shows that ICT tools contribute positively to maternal health. The study gave a number of recommendations. The mobile gender gap should be closed (digital inclusion), mobile network connectivity boosted, and digital platforms must be created in order to enhance the transformative potential of ICT in improving health outcomes.
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Affiliation(s)
- Courage Mlambo
- Public Administration and Economics, Faculty of Management Sciences, Mangosuthu University, Umlazi 4031, South Africa; (B.N.); (B.M.)
| | - Kin Sibanda
- Department of Economics, Faculty of Management Sciences, Walter Sisulu University, Mthatha 5099, South Africa;
| | - Bhekabantu Ntshangase
- Public Administration and Economics, Faculty of Management Sciences, Mangosuthu University, Umlazi 4031, South Africa; (B.N.); (B.M.)
| | - Bongekile Mvuyana
- Public Administration and Economics, Faculty of Management Sciences, Mangosuthu University, Umlazi 4031, South Africa; (B.N.); (B.M.)
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Yaghoubi F, Akbari N, Kashanian M, Lakeh MM, Sheikhansari N. Severe maternal outcome (SMO) in Afghan Immigrant Women; A Study in Tehran, Iran. Int J Gynaecol Obstet 2022; 159:302-312. [DOI: 10.1002/ijgo.14111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 10/26/2021] [Accepted: 01/20/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Fatemeh Yaghoubi
- Iran University of Medical Sciences Faculty of Nursing and Midwifery Tehran Iran
| | - Nahid Akbari
- Iran University of Medical Sciences Faculty of Nursing and Midwifery Tehran Iran
| | - Maryam Kashanian
- Iran University of Medical Sciences Department of Obstetrics & Gynecology, Akbarabadi Teaching Hospital Tehran Iran
| | - Maziar Moradi Lakeh
- Iran University of Medical Sciences Department of community and family medicine Tehran Iran
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