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Pre-hospital Barriers to Emergency Obstetric Care: Studies of Maternal Mortality and Near-miss in Bolivia and Guatemala
Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
2010 (engelsk)Doktoravhandling, med artikler (Annet vitenskapelig)Alternativ tittel
Barreras pre-hospitalarias para la atención obstétrica de emergencia : Estudios de mortalidad materna y morbilidad obstétrica severa en Bolivia y Guatemala (spansk)
Abstract [en]

Maternal mortality is a global health concern but inequalities in utilization of maternal health care are not clearly understood. Severe morbidity (near-miss) is receiving increased attention due to methodological difficulties in maternal mortality studies.

The present thesis seeks to increase understanding of factors that impede utilization of emergency obstetric care (EmOC) in Bolivia and Guatemala. Studies I and IV employed qualitative interviews to explore the role of traditional birth attendants (TBAs) and the care-seeking behaviour of women who arrived at hospital with a near-miss complication. Studies II–III documented maternal mortality and near-miss morbidity at the hospital level and investigated the influence of socio-demographic factors and antenatal care (ANC) on near-miss upon arrival.

The studies identified unfamiliarity with EmOC among TBAs and a lack of collaboration with formal care providers. A perception of being dissociated from the health care system and a mistrust of health care providers was common among near-miss women from disadvantaged social backgrounds. In the Bolivian setting, 187 maternal deaths per 100,000 live births and 50 cases of near-miss per 1000 were recorded. Causes of near-miss differed from those of maternal deaths. Most women with near-miss arrived at hospital in critical condition: severe preeclampsia, complications after childbirth at home and abortions were mostly encountered among them. Lack of ANC, low education, and rural residence were interactively associated with near-miss. ANC reduced socio-demographic differentials for near-miss.

Complementing maternal mortality reviews with data on near-miss morbidity increases the understanding of priority needs and quality of maternal health care. Additionally, focusing on near-miss upon arrival was found useful in exploring pre-hospital barriers to EmOC. The findings identified subgroups of women who seemed especially vulnerable to pre-hospital barriers. They also underscored the need for initiatives to reduce the effect of social marginalization and to acknowledge the influential role of formal and informal care providers on the utilization of EmOC.

Abstract [es]

La mortalidad materna es un tema de inquietud global, sin embargo la comprensión de las desigualdades en la utilización de los servicios de salud materna es limitada. La morbilidad obstétrica severa (near-miss) está recibiendo creciente atención, producto de problemas metodológicos en los estudios de mortalidad materna.

El objetivo de la presente tesis es aumentar la comprensión de factores que impiden la utilización de la atención obstétrica de emergencia en Bolivia y Guatemala. Los estudios I y IV usaron metodologías cualitativas en un esfuerzo por explorar el rol de las parteras tradicionales y las estrategias de las mujeres que arriban a los hospitales con una morbilidad obstétrica severa. Los estudios II–III documentaron la mortalidad materna y la morbilidad obstétrica severa en el marco hospitalario e investigaron el impacto de los factores socio-demográficos y el control prenatal en la llegada a los establecimientos de salud con complicaciones severas.

Los estudios identificaron la falta de familiaridad con atención obstétrica de emergencia entre las parteras tradicionales y la falta de cooperación con los profesionales de salud formales. La sensación de estar distanciadas del sistema de salud y la desconfianza hacia los profesionales de la salud eran aspectos comunes entre las mujeres de sectores marginales con experiencias de complicaciones severas. En el contexto boliviano, 187 muertes maternas por cada 100,000 nacidos vivos y 50 casos de morbilidad obstétrica severa por cada 1000 fueron registradas. Las causas de la morbilidad obstétrica severa y las muertes maternas se distinguieron. La major parte de las mujeres con morbilidad obstétrica severa llegaron al hospital en condiciones críticas: preeclampsia severa, complicaciones después de partos domiciliarios y abortos eran causas más frecuentes en esta categoría. Combinaciones del bajo nivel de educación con la falta de controles prenatales o la residencia en zonas rurales fueron asociadas con la morbilidad obstétrica severa. El control prenatal redujo diferencias socio-demográficas en lo concerniente a la morbilidad obstétrica severa.

La complementación de estudios de mortalidad materna con datos sobre morbilidad obstétrica severa aumenta la comprensión de las prioridades y de la calidad en la atención de la salud materna. Además, centrándose en la morbilidad obstétrica severa a la llegada al establicimiento de salud, ha sido útil para investigar las barreras pre-hospitalarias en relación a la atención de emergencia obstétrica. Los resultados permiten identificar categorías específicas de mujeres que parecen ser especialmente vulnerables a las barreras pre-hospitalarias. Los resultados, también subrayan la necesidad de iniciativas que reduzcan los efectos de la marginalización social, y que reconozcan el importante rol que tanto el personal de salud formal como informal cumplen en la utilización de los servicios de atención obstétrica de emergencia.

sted, utgiver, år, opplag, sider
Uppsala: Acta Universitatis Upsaliensis , 2010. , s. 74
Serie
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 515
Emneord [en]
pre-hospital barriers, maternal mortality, near-miss, traditional birth attendants, social marginalization, Bolivia, Guatemala
Emneord [es]
barreras pre-hospitalarias, mortalidad materna, morbilidad obstétrica severa, parteras tradicionales, marginalización social, Bolivia, Guatemala
HSV kategori
Forskningsprogram
Internationell hälsa
Identifikatorer
URN: urn:nbn:se:uu:diva-112481ISBN: 978-91-554-7709-7 (tryckt)OAI: oai:DiVA.org:uu-112481DiVA, id: diva2:287151
Disputas
2010-03-12, Auditorium Minus, Museum Gustavianum, Akademigatan 3, Uppsala, 09:15 (engelsk)
Opponent
Veileder
Tilgjengelig fra: 2010-02-19 Laget: 2010-01-13 Sist oppdatert: 2010-02-19bibliografisk kontrollert
Delarbeid
1. A qualitative study of conceptions and attitudes regarding maternal mortality among traditional birth attendants in rural Guatemala
Åpne denne publikasjonen i ny fane eller vindu >>A qualitative study of conceptions and attitudes regarding maternal mortality among traditional birth attendants in rural Guatemala
2004 (engelsk)Inngår i: British Journal of Obstetrics and Gynaecology, ISSN 0306-5456, E-ISSN 1365-215X, Vol. 111, nr 12, s. 1372-1377Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

OBJECTIVE: To explore conceptions of obstetric emergency care among traditional birth attendants in rural Guatemala, elucidating social and cultural factors. STUDY: design Qualitative in-depth interview study. SETTING: Rural Guatemala. SAMPLE: Thirteen traditional birth attendants from 11 villages around San Miguel Ixtahuacán, Guatemala. METHOD: Interviews with semi-structured, thematic, open-ended questions. Interview topics were: traditional birth attendants' experiences and conceptions as to the causes of complications, attitudes towards hospital care and referral of obstetric complications. MAIN OUTCOME MEASURES: Conceptions of obstetric complications, hospital referrals and maternal mortality among traditional birth attendants. RESULTS: Pregnant women rather than traditional birth attendants appear to make the decision on how to handle a complication, based on moralistically and fatalistically influenced thoughts about the nature of complications, in combination with a fear of caesarean section, maltreatment and discrimination at a hospital level. There is a discrepancy between what traditional birth attendants consider appropriate in cases of complications, and the actions they implement to handle them. CONCLUSION: Parameters in the referral system, such as logistics and socio-economic factors, are sometimes subordinated to cultural values by the target group. To have an impact on maternal mortality, bilateral culture-sensitive education should be included in maternal health programs.

HSV kategori
Identifikatorer
urn:nbn:se:uu:diva-112474 (URN)10.1111/j.1471-0528.2004.00270.x (DOI)15663121 (PubMedID)
Tilgjengelig fra: 2010-01-13 Laget: 2010-01-13 Sist oppdatert: 2017-12-12bibliografisk kontrollert
2. Priorities in emergency obstetric care in Bolivia: maternal mortality and near-miss morbidity in metropolitan La Paz
Åpne denne publikasjonen i ny fane eller vindu >>Priorities in emergency obstetric care in Bolivia: maternal mortality and near-miss morbidity in metropolitan La Paz
2009 (engelsk)Inngår i: BJOG : An International Journal of Obstetrics and Gynaecology, ISSN 1471-0528, Vol. 116, nr 9, s. 1210-1217Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

OBJECTIVE: To document the frequency and causes of maternal mortality and severe (near-miss) morbidity in metropolitan La Paz, Bolivia. DESIGN: Facility-based cross-sectional study. SETTING: Four maternity hospitals in La Paz and El Alto, Bolivia, where free maternal health care is provided through a government-subsidised programme. POPULATION: All maternal deaths and women with near-miss morbidity. METHODS: Inclusion of near-miss using clinical and management-based criteria. MAIN OUTCOME MEASURES: Maternal mortality ratio (MMR), severe morbidity ratio (SMR), mortality indices and proportion of near-miss cases at hospital admission. RESULTS: MMR was 187/100,000 live births and SMR was 50/1000 live births, with a relatively low mortality index of 3.6%. Severe haemorrhage and severe hypertensive disorders were the main causes of near-miss, with 26% of severe haemorrhages occurring in early pregnancy. Sepsis was the most common cause of death. The majority of near-miss cases (74%) were in critical condition at hospital admission and differed from those fulfilling the criteria after admission as to diagnostic categories and socio-demographic variables. CONCLUSIONS: Pre-hospital barriers remain to be of great importance in a setting of this type, where there is wide availability of free maternal health care. Such barriers, together with haemorrhage in early pregnancy, pre-eclampsia detection and referral patterns, should be priority areas for future research and interventions to improve maternal health. Near-miss upon arrival and near-miss after arrival at hospital should be analysed separately as that provides additional information about factors that contribute to maternal ill-health.

Emneord
Bolivia, maternal mortality, near-miss, severe maternal morbidity
HSV kategori
Identifikatorer
urn:nbn:se:uu:diva-107814 (URN)10.1111/j.1471-0528.2009.02209.x (DOI)000267879700010 ()19459864 (PubMedID)
Tilgjengelig fra: 2009-08-31 Laget: 2009-08-31 Sist oppdatert: 2010-07-19bibliografisk kontrollert
3. Does antenatal care facilitate utilization of emergency obstetric care?: A case-referent study of near-miss morbidity in Bolivia
Åpne denne publikasjonen i ny fane eller vindu >>Does antenatal care facilitate utilization of emergency obstetric care?: A case-referent study of near-miss morbidity in Bolivia
2010 (engelsk)Inngår i: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 89, nr 3, s. 335-42Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

OBJECTIVE: To determine whether lack of routine antenatal care (ANC) is associated with near-miss morbidity upon arrival at hospital. DESIGN: Case-referent study. SETTING: Four maternity hospitals in La Paz and El Alto, Bolivia, where free maternal health care is provided through a government subsidized program. SAMPLE: Women with severe maternal morbidity upon arrival at hospital (n = 297). Facility-matched referents with an uncomplicated childbirth at hospital (n = 297). METHODS: Prospective inclusion of participants over a period of six months, using clinical and management-based criteria for near-miss. Multivariate logistic regression. MAIN OUTCOME MEASURES: Odds ratios (ORs) with 95% confidence intervals (CIs). Individual and joint effects of interacting variables. RESULTS: Lack of ANC, lower education levels, and rural residence were interactively associated with near-miss upon arrival. Lack of ANC among women with limited education resulted in a four-fold greater risk for this condition. Such risk was considerably increased for women who lived in rural areas (OR 12.6; 95% CI 2.8-56.6). In addition, high maternal age and first time pregnancy were associated with near-miss upon arrival. CONCLUSIONS: This study identified subpopulations most likely to benefit from interventions designed to enable timely care-seeking for obstetric complications. ANC appears to facilitate utilization of emergency obstetric care, especially for women with socio-demographic disadvantages. Targeted initiatives to increase routine ANC may reduce severe maternal morbidity and mortality, both in urban and rural areas.

Emneord
Near-miss morbidity, antenatal care, socio-demographic differentials
HSV kategori
Identifikatorer
urn:nbn:se:uu:diva-112480 (URN)10.3109/00016340903511050 (DOI)000275154100008 ()20078393 (PubMedID)
Tilgjengelig fra: 2010-01-13 Laget: 2010-01-13 Sist oppdatert: 2017-12-12bibliografisk kontrollert
4. Social differentiation and embodied dispositions: a qualitative study of maternal care-seeking behaviour for near-miss morbidity in Bolivia
Åpne denne publikasjonen i ny fane eller vindu >>Social differentiation and embodied dispositions: a qualitative study of maternal care-seeking behaviour for near-miss morbidity in Bolivia
2009 (engelsk)Inngår i: Reproductive health, ISSN 1742-4755, Vol. 6, s. 13-Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

ABSTRACT: BACKGROUND: Use of maternal health care in low-income countries has been associated with several socioeconomic and demographic factors, although contextual analyses of the latter have been few. A previous study showed that 75% of women with severe obstetric morbidity (near-miss) identified at hospitals in La Paz, Bolivia were in critical conditions upon arrival, underscoring the significance of pre-hospital barriers also in this setting with free and accessible maternal health care. The present study explores how health care-seeking behaviour for near-miss morbidity is conditioned in La Paz, Bolivia. METHODS: Thematic interviews with 30 women with a near-miss event upon arrival at hospital. Near-miss was defined based on clinical and management criteria. Modified analytic induction was applied in the analysis that was further influenced by theoretical views that care-seeking behaviour is formed by predisposing characteristics, enabling factors, and perceived need, as well as by socially shaped habitual behaviours. RESULTS: The self-perception of being fundamentally separated from "others", meaning those who utilise health care, was typical for women who customarily delivered at home and who delayed seeking medical assistance for obstetric emergencies. Other explanations given by these women were distrust of authority, mistreatment by staff, such as not being kept informed about their condition or the course of their treatment, all of which reinforced their dissociation from the health-care system. CONCLUSION: The findings illustrate health care-seeking behaviour as a practise that is substantially conditioned by social differentiation. Social marginalization and the role health institutions play in shaping care-seeking behaviour have been de-emphasised by focusing solely on endogenous cultural factors in Bolivia.

HSV kategori
Identifikatorer
urn:nbn:se:uu:diva-107815 (URN)10.1186/1742-4755-6-13 (DOI)19640286 (PubMedID)
Tilgjengelig fra: 2009-08-31 Laget: 2009-08-31 Sist oppdatert: 2011-03-28bibliografisk kontrollert

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