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

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Study Justification:
This study aimed to address the lack of information on the circumstances surrounding maternal near misses in Morocco. By determining the incidence, characteristics, and determinants of maternal near misses, the study provides valuable insights into the factors contributing to these complications. This information is crucial for improving maternal healthcare and reducing maternal mortality rates in Morocco.
Highlights:
– The study found that the incidence of near misses in Morocco was 12 per 1000 births.
– The most frequent direct causes of near misses were hypertensive disorders during pregnancy and severe hemorrhage.
– Risk factors for near misses included illiteracy, lack of antenatal care, complications during pregnancy, and delays in seeking care.
– The study highlighted the importance of information, good communication, and attitude in providing quality care to women with obstetric complications.
– The findings emphasize the need for immediate referral to functioning hospitals and responsive healthcare providers for women and newborns with serious obstetric complications.
Recommendations:
– Improve access to healthcare facilities, particularly in rural areas, to reduce delays in seeking care.
– Enhance antenatal care services to ensure early detection and management of complications during pregnancy.
– Strengthen health education programs to address illiteracy and improve women’s knowledge about pregnancy and childbirth.
– Enhance communication and information-sharing between healthcare providers and patients to improve the quality of care.
– Invest in obstetric intensive care units and referral hospitals to provide timely and appropriate care for women with severe obstetric complications.
Key Role Players:
– Ministry of Health: Responsible for implementing policies and strategies to improve maternal healthcare in Morocco.
– Healthcare Providers: Including doctors, nurses, and midwives who play a crucial role in providing quality care to women with obstetric complications.
– Community Health Workers: Involved in health education and outreach programs to improve awareness and access to healthcare services.
– Non-Governmental Organizations (NGOs): Collaborate with the government and healthcare providers to support maternal health initiatives and advocacy efforts.
Cost Items for Planning Recommendations:
– Infrastructure Development: Budget for building and upgrading healthcare facilities, including obstetric intensive care units and referral hospitals.
– Training and Capacity Building: Allocate funds for training healthcare providers on obstetric care, communication skills, and emergency management.
– Health Education Programs: Budget for developing and implementing health education campaigns targeting pregnant women and their families.
– Equipment and Supplies: Allocate funds for procuring medical equipment and supplies necessary for providing quality obstetric care.
– Monitoring and Evaluation: Set aside funds for monitoring and evaluating the implementation and impact of the recommendations.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a prospective case-control study conducted at 3 referral maternity hospitals in Morocco. The study provides incidence, characteristics, and determinants of maternal near misses. The sample size of 30 near misses and 30 non-near misses is relatively small, which may limit the generalizability of the findings. To improve the strength of the evidence, a larger sample size could be used to increase statistical power and enhance the representativeness of the study population. Additionally, conducting a multicenter study involving more hospitals and regions in Morocco could provide a more comprehensive understanding of the determinants of maternal near misses in the country.

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.

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

1. Telemedicine: Implementing telemedicine services can help overcome geographical barriers and provide access to healthcare professionals for remote areas. This would allow pregnant women in rural areas to consult with healthcare providers and receive necessary care without having to travel long distances.

2. Mobile clinics: Setting up mobile clinics that travel to remote areas can provide essential prenatal care, including screenings, check-ups, and education. This would ensure that pregnant women in hard-to-reach areas have access to basic healthcare services.

3. Community health workers: Training and deploying community health workers can help bridge the gap between healthcare facilities and pregnant women in underserved communities. These workers can provide education, support, and basic healthcare services, as well as facilitate referrals to higher-level facilities when necessary.

4. Improving transportation infrastructure: Investing in better transportation infrastructure, such as roads and ambulances, can reduce delays in reaching healthcare facilities during emergencies. This would ensure that pregnant women can access timely and appropriate care when needed.

5. Health education and awareness programs: Implementing comprehensive health education programs can increase awareness about the importance of antenatal care, early recognition of complications, and timely seeking of healthcare services. This would empower pregnant women to make informed decisions and seek care when necessary.

6. Strengthening referral systems: Enhancing the coordination and communication between different levels of healthcare facilities can improve the timely transfer of pregnant women with complications to appropriate facilities. This would ensure that women receive the necessary care without unnecessary delays.

7. Quality improvement initiatives: Implementing quality improvement initiatives in healthcare facilities can enhance the overall quality of care provided to pregnant women. This includes improving communication, ensuring respectful and compassionate care, and addressing any gaps in the healthcare system that may contribute to delays or inadequate care.

It is important to note that the specific context and needs of the community should be considered when implementing these innovations. Additionally, a multidisciplinary approach involving collaboration between healthcare providers, policymakers, and community members is crucial for the successful implementation of these innovations.
AI Innovations Description
Based on the information provided, here is a recommendation that can be developed into an innovation to improve access to maternal health:

Develop a comprehensive community-based maternal health program that focuses on addressing the determinants of maternal near misses in Morocco. This program should include the following components:

1. Education and awareness: Implement initiatives to improve literacy rates among women, particularly in rural areas, to address the risk factor of illiteracy. This can be done through adult literacy programs and community awareness campaigns.

2. Antenatal care: Strengthen the availability and accessibility of antenatal care services, ensuring that all pregnant women have access to regular check-ups and screenings. This can be achieved by increasing the number of healthcare facilities in remote areas and providing transportation services for women who live far from healthcare facilities.

3. Timely identification and management of complications: Train healthcare providers to recognize and manage complications during pregnancy and childbirth promptly. This includes providing them with the necessary skills and resources to handle severe hemorrhage, hypertensive disorders, and prolonged obstructed labor.

4. Reducing delays in seeking care: Address the delays in seeking care by addressing the barriers identified in the study, such as lack of a family authority figure who can make a decision, lack of financial resources, lack of transportation, and fear of health facilities. This can be done through community engagement and empowerment programs that educate women and their families about the importance of seeking timely care.

5. Strengthening referral systems: Improve the referral systems to ensure that women with serious obstetric complications are immediately directed to functioning referral hospitals. This includes improving communication and coordination between healthcare facilities and providing transportation services for referrals.

6. Quality of care: Enhance the quality of care provided to women and newborns by focusing on information sharing, good communication, and positive attitudes of healthcare providers. This can be achieved through training programs for healthcare providers that emphasize patient-centered care and respectful maternity care.

By implementing this comprehensive community-based maternal health program, it is expected that access to maternal health services will be improved, leading to a reduction in maternal near misses and improved outcomes for women and newborns in Morocco.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Strengthening Antenatal Care: Increase awareness and access to antenatal care services, including regular check-ups, screenings, and education on pregnancy complications and danger signs.

2. Improving Transportation: Address the lack of vehicles and difficult access to healthcare facilities by implementing transportation solutions such as mobile clinics, ambulances, or transportation vouchers for pregnant women.

3. Enhancing Health Facility Infrastructure: Invest in improving the quality and capacity of healthcare facilities, especially in rural areas, by providing necessary equipment, supplies, and trained healthcare professionals.

4. Community Engagement and Education: Conduct community outreach programs to educate women and their families about the importance of maternal health, encourage early healthcare seeking behavior, and address cultural and social barriers.

5. Strengthening Referral Systems: Establish effective referral systems between primary healthcare centers and referral hospitals to ensure timely and appropriate care for women with obstetric complications.

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

1. Baseline Data Collection: Gather data on the current state of maternal health access, including the number of maternal near misses, delays in seeking care, availability of healthcare facilities, and other relevant indicators.

2. Define Key Metrics: Identify specific metrics to measure the impact of the recommendations, such as the reduction in delays in seeking care, increase in antenatal care utilization, improvement in transportation availability, and changes in maternal health outcomes.

3. Modeling and Simulation: Use mathematical modeling techniques to simulate the potential impact of the recommendations on the identified metrics. This could involve creating a simulation model that incorporates various factors such as population demographics, healthcare facility capacity, transportation infrastructure, and behavior change.

4. Sensitivity Analysis: Conduct sensitivity analysis to assess the robustness of the simulation model and explore different scenarios and assumptions. This could help understand the potential variations in outcomes based on different implementation strategies or external factors.

5. Evaluation and Monitoring: Continuously monitor and evaluate the implementation of the recommendations and compare the simulated outcomes with real-world data. This iterative process can help refine the recommendations and improve the accuracy of the simulation model over time.

It is important to note that the methodology for simulating the impact of recommendations may vary depending on the specific context and available data. Collaboration with experts in public health, epidemiology, and data analysis would be beneficial in designing and implementing an effective simulation study.

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