Determinants of maternal near-miss in morocco: Too late, too far, too sloppy?

Background In Morocco, there is little information on the circumstances surrounding maternal near misses. This study aimed to determine the incidence, characteristics, and determinants of maternal near misses in Morocco. Method A prospective case-control study was conducted at 3 referral maternity hospitals in the Marrakech region of Morocco between February and July 2012. Near-miss cases included severe hemorrhage, hypertensive disorders, and prolonged obstructed labor. Three unmatched controls were selected for each near-miss case. Three categories of risk factors (sociodemographics, reproductive history, and delays), as well as perinatal outcomes, were assessed, and bivariate and multivariate analyses of the determinants were performed. A sample of 30 near misses and 30 non-near misses was interviewed. Results The incidence of near misses was 12‰ of births. Hypertensive disorders during pregnancy (45%) and severe hemorrhage (39%) were the most frequent direct causes of near miss. The main risk factors were illiteracy [OR = 2.35; 95% CI: (1.07 -5.15)], lack of antenatal care [OR = 3.97; 95% CI: (1.42-11.09)], complications during pregnancy [OR = 2.81; 95% CI: (1.26-6.29)], and having experienced a first phase delay [OR = 8.71; 95% CI: (3.97- 19.12)] and a first phase of third delay [OR = 4.03; 95% CI: (1.75-9.25)]. The main reasons for the first delay were lack of a family authority figure who could make a decision, lack of sufficient financial resources, lack of a vehicle, and fear of health facilities. The majority of near misses demonstrated a third delay with many referrals. The women’s perceptions of the quality of their care highlighted the importance of information, good communication, and attitude. Conclusion Women and newborns with serious obstetric complications have a greater chance of successful outcomes if they are immediately directed to a functioning referral hospital and if the providers are responsive. We conducted a case-control study in the districts of Al Haouz and Marrakech from 1 February to 31 July, 2012. These2 districts combined have a population of 1,714,000 inhabitants, and Marrakech is predominantly urban (84%) whereas Al Haouz is predominantly rural (89%). Al Haouz is located approximately 30 km from Marrakech and has an area of 6612 km². This district is characterized by difficult access to healthcare facilities (75% of the area is mountainous), with 83% of the population living 10 km or more from healthcare facilities. These2 study districts contain 20 delivery houses, 3 referral hospitals, and 22 private clinics. The study was conducted simultaneously in the 3 referral maternity hospitals: Mohammed VI Hospital at Al Haouz, the regional Ibn Zohr Hospital in Marrakech, and the University Hospital in Marrakech. Only the University Hospital in Marrakech includes an obstetric intensive care unit (ICU). We identified all women who were between the ages of 18 and 49 years, who originated from Marrakech or Al Haouz, who had severe obstetric complications (near misses), and who delivered their children in the 3 study hospitals between 1 February and 31 July, 2012. We applied the definition used by Sahel et al. [11] for screening near miss cases (see S1 Appendix). Sahel et al. [11] combined different criteria, including those based on clinical signs specific for a disease, organ dysfunction, and case management (e.g., admission to an ICU) [12–14]. The controls included women who had the same types of complications as the near misses but who did not reach the stage of near miss. We included complications during pregnancy and childbirth or those within 42 days after delivery. Complications comprised hemorrhage, hypertensive disorders, dystocia, and infection. For inclusion in the study, the controls must have been admitted to the hospital no longer than 48 h after a near miss was identified. We aimed to reduce bias as a result of changes in the care team, and we opted for a ratio of 3 controls per near miss to increase the detection of differences in predictive factors between the cases and controls. All complicated cases were identified at the end of each week by trained investigators (nurses or midwives) at the 3 hospitals. These cases were reviewed and approved by the principal investigator and the intensive care specialist or the gynecologist. All of the women who were recruited were interviewed in the hospital using a questionnaire administered by the investigators, who collected baseline data on the women’s sociodemographic variables and antenatal, delivery, and postpartum care. Delays in obtaining care were collected according to the 3-delay model [15], which was adapted as follows. (1) Delay at home before deciding to go to a health facility was defined as the number of hours between the onset of labor and the decision to go to a health facility. The source of information was the women, and labor was defined as a set of intensified contractions. (2) Delay in reaching the first health facility was defined as the number of hours between leaving home and reaching the health facility. The source of information was the reference sheet, if it existed, or the woman, her husband, or her family. (3) Delay between the first place of care and the final place of care was divided into 2 phases. The first phase corresponded to the period between arrival at the first facility and arrival at the final one (some women were referred several times). The second phase corresponded to the time spent between arrival at the final facility (last location where the woman was recruited) and the first examination by a midwife or a doctor. The sources of information were the obstetric register and the husband. We collected information from the respondents regarding the newborns, including gestational age at birth, perinatal mortality or live birth, Apgar scores at 5 and 10 min, and birth weight. The results for the newborns will be published in another article. Information on the women’s history from pregnancy to the postpartum period and on their perceptions of the quality of care was collected from a sample of cases and controls. Each week, we randomly selected 4 women, 2 in the near-miss group and 2 in the control group, to obtain a final sample of 60 women (30 near misses and 30 control women). A specifically trained investigator conducted semi-structured individual interviews with the women at home in Arabic or Berber according to each woman’s preference. The interview mainly consisted of open-ended questions that focused on the women’s perceptions of complications, their experiences with the processes of transfer and care, their opinions and views on the care they received, their contacts with staff, and their suggestions for improving health services. Each interview lasted between 30 and 45 min. We did not include private clinics in our study because there were none in the Al Haouz district (rural), and the socioeconomic status of the majority of pregnant women did not allow them to attend private clinics [16]. Private clinics in Marrakech are only used by a small number of wealthy women, who are referred to public hospitals in case of severe complications. The study protocol and consent procedure were approved by the ethics committees of the Institute of Tropical Medicine Antwerp (Belgium), the University of Antwerp, and the University Mohammed V Souissi Rabat (Morocco). The women who participated in the study were informed of the study objectives, and written consents were obtained, documented, and classified. No minor was enrolled in this study. Statistical analysis was performed using IBM SPSS statistical software, version 20 (New York, USA). The sociodemographic characteristics and descriptions of the near-miss cases and controls were analyzed in 2 stages. First, we compared the proportions of each variable. We then used the chi-square and Fisher’s tests to compare the variations in the proportions among the near misses and controls. Multivariate analysis by logistic regression was used to estimate the association between near miss, low education level, and first and third delays. A p value of 0.05 was considered significant. Concerning the qualitative component, we analyzed the experiences of women in both groups based on information obtained from the interviews. All of the interviews were transcribed in Arabic and translated into French. The transcripts were analyzed and coded into themes, using the “coding up” method of induction [17], by 2 researchers (the principal investigator and a sociologist) and were analyzed according to thematic content. All of the developed themes were discussed and reported.