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

International Journal of Women's Health, Volume 14, Year 2022

Interprétation

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. The study was conducted in three selected hospitals in the Southern Nations, Nationalities and Peoples’ Region (SNNPR). The region is located in the south of Ethiopia. Hawassa, which is 285 kilometres from Addis Ababa, is the capital city of the region. According to the Central Statistical Agency (CSA) report, the region has a total population of 15 million, of whom half (50.3%) are women.22 The hospitals selected for the study were Hawassa University Comprehensive Specialized Hospital (HUCSH), Nigist Eleni Mohammed General Hospital (NEMGH) and Durame General Hospital (DGH). HUCSH is a teaching referral hospital ranked in the top level of the three-tier Ethiopian health care system. HUCSH provides services to a catchment population from the SNNPR and other neighbouring catchments of the Oromia region. NEMGH is a general hospital located in Hosanna city that provides services to a catchment population of 1,506,733. The DGH is located in Durame city and serves as a referral hospital for Kembata Tembaro zone. This was a prospective cohort study involving pregnant women who were admitted for delivery or pregnancy-related complications between 12 July and 26 November 2018. The sample size calculation for the current study has been indicated elsewhere.23 The study population consisted of all women admitted to the selected hospitals during pregnancy, childbirth or within 42 days of pregnancy termination during the study period. Eligibility for the study was not restricted by gestational age. Women who experienced complications more than 42 days after delivery were not eligible. The data collection tool was based on the WHO near-miss approach.7 The tool was prepared using an online survey application (Survey Gizmo) and downloaded on iPads for offline data collection. Three trained data collectors were recruited to collect the data, which were collected on a daily basis. The data collectors were health care providers who were not staff of the hospitals. Participants’ medical records and charts were reviewed until participants were discharged from the hospital. The data collectors made day-to-day visits to delivery rooms, obstetric wards, maternity waiting rooms, gynaecology wards and ICUs to obtain pertinent data related to pregnancy complications and pregnancy outcomes. In uncertain cases or cases of missing data on medical records, the data collectors contacted attending health care providers to obtain more information. Data were collected regarding morbidities, contributory or associated conditions, and treatment and management of complications. Morbidities were defined according to potentially life-threatening conditions such as sepsis, severe postpartum haemorrhage, uterine rupture, severe pre-eclampsia, eclampsia and abortion. Key clinical, laboratory and management criteria were used to identify women who developed life-threatening conditions (see Table 1). WHO Near-Miss Criteria and Modifications for South Ethiopia, 2018 Notes: *Transfusion of ≥ 2 units of blood. WHO near-miss criteria data from: World Health Organization. Evaluating the quality of care for severe pregnancy complications: the WHO near-miss approach for maternal health; 2011. Available from: https://apps.who.int/iris/bitstream/handle/10665/44692/9789241502221_eng.pdf?sequence=1&isAllowed=y.7 Data were collected on obstetric care interventions used for the prevention and management of the causes of complications. Further, associated or contributory conditions related to SMO were extracted from the medical records. Access to hospital and intrahospital care was evaluated according to the proportion of women with SMO presenting within the first 12 hours of hospital stay or after 12 hours of hospital stay. Based on WHO criteria, the latter indicated the quality of care provided within the hospital.7 The quality was assessed based on the actual use and optimal use of effective lifesaving interventions in the prevention and management of severe complications after the women arrived in hospital. Information about referral status was also collected. Referred cases signified women coming from other health facilities and was a good indicator of the hospital referral system. The supervisors were health care providers who were employed by study team to oversee the data collection process by checking the collected data and providing feedback. The supervisors were not staff of the hospitals. The data were exported from the Survey Gizmo application into SPSS Statistics 20 for analysis. Descriptive statistics of indicators of MNM and process indicators were calculated. Severe maternal outcome ratio, maternal near-miss ratio (MNMR), MI and MMR were calculated (see Table 2). The results were presented in accordance with the WHO MNM approach, using clinical, laboratory and management criteria.7 The definitions for MNM terminology and indicators were taken from the WHO near-miss approach and published research.7,12 Maternal Near-Miss Definitions and Indicators This study was conducted in accordance with the Declaration of Helsinki. Ethical approval was granted from the Human Research Ethics Committee (HREC) of the University of Newcastle, Australia (reference no. H-2017-0253; date: 15-Jun-2018) and Institutional Review Board located in SNNPR Health Bureau, Ethiopia (reference no.pm 37-186/24015). Informed verbal consent was obtained from each participant before conducting the interviews. The ethics committees had approved the verbal consent procedure.

Résumé de l’IA

Study Justification:

– The study aimed to assess the incidence of severe maternal outcomes (SMO) and the quality of maternal health care in south Ethiopia.
– This study is important because it provides valuable information on the current state of maternal health care in the region and identifies areas for improvement.
– By understanding the incidence of SMO and the quality of care, policymakers and healthcare providers can develop targeted interventions to reduce maternal morbidity and mortality.

Study Highlights:

– The study was conducted in three hospitals in the Southern Nations, Nationalities and Peoples’ Region (SNNPR) of Ethiopia.
– Of the 2880 live births included in the study, 108 had severe maternal outcomes, including 90 near-miss cases and 18 maternal deaths.
– The incidence ratio of severe maternal outcomes was 37.5 per 1000 live births, and the near-miss incidence ratio was 31.3 per 1000 live births.
– The most common causes of severe maternal outcomes were eclampsia and postpartum hemorrhage.
– The study found that most women with severe maternal outcomes were referred from other health facilities, indicating delays in seeking and reaching care.
– The study suggests that effectively using intensive care units, reducing delays, and improving the referral system can help reduce severe maternal outcomes and improve the quality of care in the hospitals.

Recommendations for Lay Readers:

– Improve access to quality maternal health care services in the study area.
– Strengthen the referral system to ensure timely and appropriate care for women with complications.
– Enhance the use of intensive care units for women with severe maternal outcomes.
– Continuously review and monitor severe maternal outcomes to identify areas for improvement in treatment and management.

Recommendations for Policy Makers:

– Allocate resources to improve maternal health care services in the study area.
– Develop and implement strategies to reduce delays in seeking and reaching care.
– Enhance the capacity of healthcare facilities to provide effective care for women with complications.
– Strengthen the referral system to ensure seamless transfer of patients between health facilities.
– Establish mechanisms for continuous monitoring and evaluation of severe maternal outcomes to inform policy and practice.

Key Role Players:

– Ministry of Health: Responsible for policy development and resource allocation.
– Regional Health Bureau: Oversees the implementation of maternal health programs in the region.
– Hospital Administrators: Responsible for ensuring the availability of resources and infrastructure for maternal health care.
– Healthcare Providers: Provide direct care to pregnant women and play a crucial role in improving the quality of care.

Cost Items for Planning Recommendations:

– Infrastructure development: Upgrading facilities, including intensive care units and maternity wards.
– Training and capacity building: Providing training for healthcare providers on managing severe maternal outcomes.
– Equipment and supplies: Procuring necessary medical equipment and supplies for maternal health care.
– Referral system improvement: Investing in transportation and communication systems to facilitate timely referrals.
– Monitoring and evaluation: Allocating resources for continuous monitoring and evaluation of maternal health outcomes.
Please note that the cost items provided are general categories and not actual cost estimates. Actual costs may vary depending on the specific context and requirements of the study area.

Force de la preuve

N/A

Abstrait

The study was conducted in three selected hospitals in the Southern Nations, Nationalities and Peoples’ Region (SNNPR). The region is located in the south of Ethiopia. Hawassa, which is 285 kilometres from Addis Ababa, is the capital city of the region. According to the Central Statistical Agency (CSA) report, the region has a total population of 15 million, of whom half (50.3%) are women.22 The hospitals selected for the study were Hawassa University Comprehensive Specialized Hospital (HUCSH), Nigist Eleni Mohammed General Hospital (NEMGH) and Durame General Hospital (DGH). HUCSH is a teaching referral hospital ranked in the top level of the three-tier Ethiopian health care system. HUCSH provides services to a catchment population from the SNNPR and other neighbouring catchments of the Oromia region. NEMGH is a general hospital located in Hosanna city that provides services to a catchment population of 1,506,733. The DGH is located in Durame city and serves as a referral hospital for Kembata Tembaro zone. This was a prospective cohort study involving pregnant women who were admitted for delivery or pregnancy-related complications between 12 July and 26 November 2018. The sample size calculation for the current study has been indicated elsewhere.23 The study population consisted of all women admitted to the selected hospitals during pregnancy, childbirth or within 42 days of pregnancy termination during the study period. Eligibility for the study was not restricted by gestational age. Women who experienced complications more than 42 days after delivery were not eligible. The data collection tool was based on the WHO near-miss approach.7 The tool was prepared using an online survey application (Survey Gizmo) and downloaded on iPads for offline data collection. Three trained data collectors were recruited to collect the data, which were collected on a daily basis. The data collectors were health care providers who were not staff of the hospitals. Participants’ medical records and charts were reviewed until participants were discharged from the hospital. The data collectors made day-to-day visits to delivery rooms, obstetric wards, maternity waiting rooms, gynaecology wards and ICUs to obtain pertinent data related to pregnancy complications and pregnancy outcomes. In uncertain cases or cases of missing data on medical records, the data collectors contacted attending health care providers to obtain more information. Data were collected regarding morbidities, contributory or associated conditions, and treatment and management of complications. Morbidities were defined according to potentially life-threatening conditions such as sepsis, severe postpartum haemorrhage, uterine rupture, severe pre-eclampsia, eclampsia and abortion. Key clinical, laboratory and management criteria were used to identify women who developed life-threatening conditions (see Table 1). WHO Near-Miss Criteria and Modifications for South Ethiopia, 2018 Notes: *Transfusion of ≥ 2 units of blood. WHO near-miss criteria data from: World Health Organization. Evaluating the quality of care for severe pregnancy complications: the WHO near-miss approach for maternal health; 2011. Available from: https://apps.who.int/iris/bitstream/handle/10665/44692/9789241502221_eng.pdf?sequence=1&isAllowed=y.7 Data were collected on obstetric care interventions used for the prevention and management of the causes of complications. Further, associated or contributory conditions related to SMO were extracted from the medical records. Access to hospital and intrahospital care was evaluated according to the proportion of women with SMO presenting within the first 12 hours of hospital stay or after 12 hours of hospital stay. Based on WHO criteria, the latter indicated the quality of care provided within the hospital.7 The quality was assessed based on the actual use and optimal use of effective lifesaving interventions in the prevention and management of severe complications after the women arrived in hospital. Information about referral status was also collected. Referred cases signified women coming from other health facilities and was a good indicator of the hospital referral system. The supervisors were health care providers who were employed by study team to oversee the data collection process by checking the collected data and providing feedback. The supervisors were not staff of the hospitals. The data were exported from the Survey Gizmo application into SPSS Statistics 20 for analysis. Descriptive statistics of indicators of MNM and process indicators were calculated. Severe maternal outcome ratio, maternal near-miss ratio (MNMR), MI and MMR were calculated (see Table 2). The results were presented in accordance with the WHO MNM approach, using clinical, laboratory and management criteria.7 The definitions for MNM terminology and indicators were taken from the WHO near-miss approach and published research.7,12 Maternal Near-Miss Definitions and Indicators This study was conducted in accordance with the Declaration of Helsinki. Ethical approval was granted from the Human Research Ethics Committee (HREC) of the University of Newcastle, Australia (reference no. H-2017-0253; date: 15-Jun-2018) and Institutional Review Board located in SNNPR Health Bureau, Ethiopia (reference no.pm 37-186/24015). Informed verbal consent was obtained from each participant before conducting the interviews. The ethics committees had approved the verbal consent procedure.

Matériaux

N/A

Innovations

Based on the information provided, here are some potential innovations that could be used to improve access to maternal health:

1. Telemedicine: Implementing telemedicine services can improve access to maternal health care, especially in remote areas. This technology allows pregnant women to consult with healthcare providers remotely, reducing the need for travel and increasing access to medical advice and support.

2. Mobile clinics: Setting up mobile clinics that travel to rural and underserved areas can ensure that pregnant women have access to prenatal care, screenings, and essential maternal health services. This approach brings healthcare services closer to the community, reducing barriers to access.

3. Community health workers: Training and deploying community health workers who can provide basic maternal health services, education, and referrals can improve access to care. These workers can reach women in their own communities, providing culturally sensitive and personalized care.

4. Strengthening referral systems: Improving the referral system between health facilities can ensure that pregnant women with complications receive timely and appropriate care. This can involve establishing clear protocols, communication channels, and transportation arrangements to facilitate the transfer of patients.

5. Maternal waiting homes: Creating maternal waiting homes near health facilities can provide a safe and comfortable place for pregnant women to stay as they await delivery or receive prenatal care. This can be particularly beneficial for women who live far from health facilities and need to travel long distances to access care.

6. Task-shifting: Training and empowering non-specialist healthcare providers, such as nurses and midwives, to perform certain tasks traditionally done by doctors can help alleviate the shortage of skilled healthcare professionals. This can increase the availability of maternal health services and improve access for women in need.

7. Quality improvement initiatives: Implementing quality improvement initiatives in healthcare facilities can enhance the overall quality of maternal health care. This can involve regular monitoring and evaluation, training programs for healthcare providers, and the use of evidence-based guidelines and protocols.

It’s important to note that these are just potential recommendations based on the information provided. The feasibility and effectiveness of these innovations would need to be assessed in the specific context of South Ethiopia and its healthcare system.

AI Innovations Description

Based on the study conducted in South Ethiopia, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Strengthen the referral system: Since a significant number of severe maternal outcomes (SMOs) were referred from other health facilities, it is crucial to improve the referral system. This can be done by establishing clear communication channels between health facilities, ensuring timely and efficient transfer of patients, and providing training to healthcare providers on recognizing and managing maternal complications.

2. Enhance the use of intensive care units (ICUs): The study found that a high percentage of maternal deaths occurred without ICU admission. To improve access to maternal health, it is important to effectively utilize ICUs in hospitals. This can be achieved by increasing the availability of ICU beds, ensuring adequate staffing and equipment, and providing training to healthcare providers on managing critically ill pregnant women.

3. Reduce delays in seeking and reaching care: The study identified the presence of delays in seeking and reaching care, which contributed to SMOs. To address this, efforts should be made to raise awareness about the importance of early antenatal care, promote community-based education on recognizing danger signs during pregnancy, and improve transportation systems to facilitate timely access to healthcare facilities.

4. Continuous monitoring and review of SMO cases: It is essential to continuously review SMO cases to identify gaps in treatment and management. This can help in learning from past experiences and implementing necessary improvements in the quality of care provided to pregnant women. Regular audits and feedback mechanisms should be established to ensure ongoing monitoring and evaluation of maternal health services.

By implementing these recommendations, it is possible to develop innovative strategies that can improve access to maternal health and reduce severe maternal outcomes in South Ethiopia.

AI Innovations Methodology

Based on the information provided, here are some potential recommendations to improve access to maternal health:

1. Strengthen the referral system: Since a significant number of severe maternal outcomes (SMOs) were referred from other health facilities, improving the referral system can help ensure timely access to appropriate care. This can be achieved by establishing clear protocols and communication channels between health facilities, training healthcare providers on referral procedures, and providing necessary resources for transportation.

2. Enhance the use of intensive care units (ICUs): The study found that a high percentage of maternal deaths occurred without ICU admission. Increasing the availability and accessibility of ICUs in hospitals can improve the chances of survival for women with severe complications. This can involve investing in ICU infrastructure, equipment, and training healthcare providers on critical care management.

3. Reduce delays in seeking and reaching care: The study identified the presence of delays in seeking and reaching care, which contributed to SMOs. Implementing strategies to reduce these delays, such as community education on recognizing danger signs during pregnancy and childbirth, improving transportation infrastructure, and ensuring availability of skilled birth attendants in remote areas, can help improve access to maternal health services.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define indicators: Identify key indicators that reflect access to maternal health, such as the number of referrals, the percentage of women with SMOs admitted to ICUs, and the time taken to reach a healthcare facility after the onset of complications.

2. Collect baseline data: Gather data on the identified indicators before implementing the recommendations. This can involve reviewing medical records, conducting interviews or surveys with healthcare providers and patients, and analyzing existing data sources.

3. Implement interventions: Introduce the recommended interventions, such as strengthening the referral system and enhancing ICU services. Ensure proper implementation and monitor the process closely.

4. Collect post-intervention data: After a sufficient period of time, collect data on the same indicators to assess the impact of the interventions. This can involve repeating the data collection methods used in the baseline phase.

5. Analyze and compare data: Compare the baseline and post-intervention data to determine the changes in the identified indicators. This analysis can help evaluate the effectiveness of the recommendations in improving access to maternal health.

6. Draw conclusions and make adjustments: Based on the findings, draw conclusions about the impact of the recommendations. If the interventions have been successful, consider scaling them up or replicating them in other settings. If the desired improvements have not been achieved, identify potential barriers or limitations and make adjustments to the interventions accordingly.

It is important to note that this is a general methodology and may need to be adapted based on the specific context and resources available for the simulation.

Auteurs et co-auteurs

Statistics:

Authors: 4

Identifiers:

DOI: 10.2147/IJWH.S341912

Research Areas:

Community Interventions, Health System and Policy, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Ethiopia

Study Design:

Cohort Study, Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Female

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