Lived experiences of women who developed uterine rupture following severe obstructed labor in Mulago hospital, Uganda

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Study Justification:
– Maternal mortality is a major public health challenge in Uganda.
– Uterine rupture is a major cause of maternal morbidity and mortality.
– Limited research exists on the experiences of women who survive severe obstetric complications.
– Understanding these experiences can inform strategies to support survivors.
Highlights:
– Barriers to accessing healthcare for women with uterine rupture include failure to recognize danger signs, late decision making, geographical barriers, and late or failed diagnosis.
– Women who develop uterine rupture experience multiple losses, including loss of lives, fertility, body image, quality of life, and disrupted marital relationships.
– Uterine rupture has grim economic consequences, including financial loss and loss of income.
– Poor quality of care contributes to uterine rupture and its consequences.
Recommendations:
– Improve access to and provision of emergency obstetric care to prevent uterine rupture from obstructed labor.
– Provide counseling and support to survivors to help them cope with physical, social, psychological, and economic consequences.
Key Role Players:
– Healthcare providers
– Obstetricians and gynecologists
– Nurses and midwives
– Community health workers
– Policy makers
– Government agencies
– Non-governmental organizations (NGOs)
– Community leaders
Cost Items:
– Training and capacity building for healthcare providers
– Infrastructure improvement for healthcare facilities
– Medical equipment and supplies
– Outreach and awareness campaigns
– Counseling and support services for survivors
– Research and data collection
– Monitoring and evaluation

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it presents the findings of a qualitative study that used a phenomenological approach to explore the lived experiences of women who developed uterine rupture following obstructed labor. The study conducted in-depth interviews initially during hospitalization and repeated them 3-6 months after childbirth to explore the health and meanings attached to the traumatic events and their outcomes. Thematic analysis was used to analyze the data, resulting in themes related to barriers to access healthcare, multiple losses, and enduring consequences. The abstract provides a clear overview of the study design, methods, and key findings. To improve the evidence, the abstract could include more specific details about the sample size, demographics of the participants, and the specific themes identified in the analysis.

Background: Maternal mortality is a major public health challenge in Uganda. Whereas uterine rupture remains a major cause of maternal morbidity and mortality, there is limited research into what happens to women who survive such severe obstetric complications. Understanding their experiences might delineate strategies to support survivors. Methods. This qualitative study used a phenomenological approach to explore lived experiences of women who developed uterine rupture following obstructed labor. In-depth interviews initially conducted during their hospitalization were repeated 3-6 months after the childbirth event to explore their health and meanings they attached to the traumatic events and their outcomes. Data were analyzed using thematic analysis. Results: The resultant themes included barriers to access healthcare, multiple “losses” and enduring physical, psychosocial and economic consequences. Many women who develop uterine rupture fail to access critical care needed due to failure to recognise danger signs of obstructed labor, late decision making for accessing care, geographical barriers to health facilities, late or failure to diagnose obstructed labor at health facilities, and failure to promptly perform caesarean section. Secondly, the sequel of uterine rupture includes several losses (loss of lives, loss of fertility, loss of body image, poor quality of life and disrupted marital relationships). Thirdly, uterine rupture has grim economic consequences for the survivors (with financial loss and loss of income during and after the calamitous events). Conclusion: Uterine rupture is associated with poor quality of care due to factors that operate at personal, household, family, community and society levels, and results in dire physical, psychosocial and financial consequences for survivors. There is need to improve access to and provision of emergency obstetric care in order to prevent uterine rupture consequent to obstructed labor. There is also critical need to provide counselling and support to survivors to enable them cope with physical, social, psychological and economic consequences. © 2014 Kaye et al.; licensee BioMed Central Ltd.

This project involved research on women who ‘nearly died’ of pregnancy-related complications, but somehow survived, hence called near-miss morbidity. The study was conducted in Mukono, Wakiso and Mpigi districts of Central Uganda, from June 1, 2013 to August 30, 2013. The theoretical framework used to explore the meanings attached by survivors to this experience was adapted from Souza et al. [22], which was developed from the definition of a maternal near miss[23,24]. Conceptually, maternal near misses represent a point on a continuum between extremes of good health and death, where mothers develop severe obstetric morbidity and somehow survive, either due to luck or the health care they receive. Such individuals may eventually recover, become temporarily or permanently disabled or die [22-24]. The World Health Organization has developed tools [24] which could be used to identify maternal near misses. These tools utilize a combination of clinical signs/symptoms, management practices or presence of organ dysfunction. The analysis was informed by the concept of health (a state of complete physical, social, psychological and spiritual well-being, and not merely the absence of disease or infirmity). A qualitative study design was chosen to investigate the lived experiences of women with history of uterine rupture during childbirth. This paper analyses findings these intermittent in-depth interviews with 16 women who survived a clinically defined ‘near-miss’. These interviews were conducted as part of a prospective longitudinal study, which was a post-doctoral research project of the first author (DKK) entitled: Evaluation and surveillance of the impact of maternal and neonatal near-miss morbidity on the health of mothers and infants in Jinja and Mulago hospitals. The goal of the project of this mixed-methods study is to assess preventable factors associated with maternal and neonatal near miss morbidity, from the perspective of patients and healthcare providers. Purposive sampling was used to select 16 participants who had uterine rupture during childbirth. Potential research participants were recruited from Mulago hospital at the time of childbirth, at which time they were requested to participate in an ongoing study. Telephone contacts and residential addresses were obtained from them during their hospital stay. Using contact addresses and directions obtained from the participants during this initial contact, the participants were traced to their individual villages and communities, where a second in-depth interview was conducted at a venue chosen by the participant, 3–6 months after the initial interview. Unstructured interviews were employed in order to enable the participants to express their views freely and the meanings they attached to their experiences. To clarify the questions, an interview guide (Table 1) was used. There was some flexibility in the order of questions and in the prompts employed to enhance understanding of the unique experiences of the participants. With the permission of the participants, the interviews were audiotaped in the local dialect (Luganda) and later translated into English. A journal was kept for recording detailed field notes about the cultural and contextual incidents that were heard, seen, experienced, and thought about during the process of data collection, in order to better comprehend and interpret the content of the interviews. Interview guide on lived experiences of women with uterine rupture Thematic analysis was employed. This entailed reading and rereading transcribed interviews to gain insight and deeper meaning in order to identify themes and categories. The analysis was done concurrently with data gathering, which helped to know what to ask in the next interview and to cross check information from each interview with subsequent participants. This process made it possible to recognize the saturation point at which no new information emerged from the data. Ethical approval to conduct the study was obtained from the Ethics and research committees of Mulago hospital (REC 310–2012), the School of Medicine, Makerere University College of Health Sciences (REC 2012–172) and Uganda National Council for Science and Technology. Permission to conduct the study was obtained from the Department of Obstetrics and Gynaecology, Makerere University. All participants gave written informed consent to be interviewed and to have follow-up assessment for a period of six months after the initial hospitalization. They were also provided with counselling and treatment during this period, which was a follow up of the initial evaluation during their hospitalization (the time during which they had developed uterine rupture).

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

1. Mobile health clinics: Implementing mobile health clinics that can travel to remote areas, where geographical barriers to health facilities are a challenge, can provide access to maternal health services for women who may not be able to easily reach a hospital or clinic.

2. Community health workers: Training and deploying community health workers who can educate women about the danger signs of obstructed labor and the importance of seeking timely care can help improve recognition and early decision making for accessing care.

3. Telemedicine: Introducing telemedicine services that allow healthcare providers to remotely diagnose and consult on cases of obstructed labor can help overcome the challenge of late or failure to diagnose obstructed labor at health facilities.

4. Emergency obstetric care centers: Establishing well-equipped emergency obstetric care centers in areas with high rates of uterine rupture can ensure that women have access to critical care when needed, reducing delays in performing caesarean sections.

5. Maternal health counseling and support programs: Providing counseling and support services to survivors of uterine rupture can help them cope with the physical, social, psychological, and economic consequences of their experience.

6. Strengthening health systems: Investing in the overall strengthening of health systems, including improving infrastructure, training healthcare providers, and ensuring the availability of essential supplies and medications, can contribute to better access to maternal health services and improved outcomes for women with obstetric complications.

These innovations, if implemented effectively, have the potential to improve access to maternal health and reduce the incidence of uterine rupture consequent to obstructed labor.
AI Innovations Description
Based on the research findings, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Improve awareness and education: Develop and implement comprehensive educational programs to raise awareness among women and communities about the signs and symptoms of obstructed labor and uterine rupture. This can include community outreach programs, antenatal care sessions, and media campaigns to ensure that women and their families are informed about the importance of seeking timely and appropriate care.

2. Strengthen healthcare infrastructure: Invest in improving the availability and accessibility of emergency obstetric care facilities, especially in rural and remote areas. This can involve upgrading existing health facilities, training healthcare providers in emergency obstetric care, and ensuring the availability of essential medical supplies and equipment.

3. Enhance referral systems: Establish and strengthen referral systems to ensure that women with complications during childbirth can be quickly and safely transferred to higher-level healthcare facilities where they can receive appropriate care. This can involve training healthcare providers at lower-level facilities to recognize and manage obstetric emergencies, as well as establishing clear communication channels between different levels of healthcare facilities.

4. Provide psychosocial support: Develop and implement programs to provide counseling and support to women who have experienced uterine rupture and other severe obstetric complications. This can include individual and group counseling sessions, peer support networks, and mental health services to help women cope with the physical, emotional, and economic consequences of their experiences.

5. Strengthen healthcare financing: Explore innovative financing mechanisms to ensure that the cost of emergency obstetric care is not a barrier for women seeking care. This can involve implementing health insurance schemes, providing financial assistance to women from low-income backgrounds, and advocating for increased government funding for maternal health services.

By implementing these recommendations, it is possible to improve access to maternal health and reduce the incidence of uterine rupture consequent to obstructed labor. This will ultimately contribute to reducing maternal morbidity and mortality in Uganda.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Increase awareness and education: Implement programs to educate women and communities about the signs and symptoms of obstructed labor and the importance of seeking timely medical care. This can be done through community health workers, radio campaigns, and community outreach programs.

2. Strengthen healthcare infrastructure: Improve access to emergency obstetric care by ensuring that health facilities are adequately equipped and staffed to handle obstetric emergencies. This includes having skilled healthcare providers, necessary medical supplies, and functioning referral systems.

3. Improve transportation: Address geographical barriers by providing reliable and affordable transportation options for pregnant women to reach healthcare facilities. This can include ambulances, community transport services, or partnerships with transportation providers.

4. Enhance diagnostic capabilities: Train healthcare providers to accurately diagnose obstructed labor and uterine rupture, and ensure that necessary diagnostic tools and equipment are available at health facilities.

5. Provide comprehensive postpartum care: Develop programs to provide counseling and support to women who have experienced uterine rupture, addressing their physical, psychosocial, and economic consequences. This can include mental health services, rehabilitation programs, and income-generating activities.

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

1. Data collection: Gather baseline data on the current state of access to maternal health services, including information on barriers faced by women in accessing care, healthcare infrastructure, transportation options, diagnostic capabilities, and postpartum support services.

2. Modeling: Use mathematical modeling techniques to simulate the potential impact of the recommendations. This can involve creating a simulation model that incorporates various factors such as population demographics, healthcare facility distribution, transportation networks, and healthcare utilization patterns.

3. Scenario analysis: Test different scenarios by adjusting the variables in the simulation model. For example, simulate the impact of increasing awareness and education programs, improving healthcare infrastructure, or enhancing transportation options. Compare the outcomes of each scenario to assess the potential impact on access to maternal health.

4. Data validation: Validate the simulation results by comparing them with real-world data and existing studies on the effectiveness of similar interventions. This can help ensure the accuracy and reliability of the simulation model.

5. Policy recommendations: Based on the simulation results, provide policymakers with evidence-based recommendations on the most effective interventions to improve access to maternal health. This can inform the development of targeted interventions and policies to address the identified barriers and improve maternal health outcomes.

It is important to note that the specific methodology for simulating the impact of these recommendations may vary depending on the available data, resources, and expertise.

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