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Afghan Migrants Face more Suboptimal Care than Natives: a Maternal Near-Miss Audit Study at University Hospitals in Tehran, Iran
Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell kvinno- och mödrahälsovård och migration. Shahid Beheshti Univ Med Sci, Infertil & Reprod Hlth Res Ctr, Tehran, Iran..
Shahid Beheshti Univ Med Sci, Infertil & Reprod Hlth Res Ctr, Tehran, Iran..
Shahid Beheshti Univ Med Sci, Infertil & Reprod Hlth Res Ctr, Tehran, Iran..
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2017 (Engelska)Ingår i: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 17, artikel-id 64Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Background: Women from low-income settings have higher risk of maternal near miss (MNM) and suboptimal care than natives in high-income countries. Iran is the second largest host country for Afghan refugees in the world. Our aim was to investigate whether care quality for MNM differed between Iranians and Afghans and identify potential preventable attributes of MNM. Methods: An MNM audit study was conducted from 2012 to 2014 at three university hospitals in Tehran. Auditors evaluated the quality of care by reviewing the hospital records of 76 MNM cases (54 Iranians, 22 Afghans) and considering additional input from interviews with patients and professionals. Main outcomes were frequency of suboptimal care and the preventable attributes of MNM. Crude and adjusted odds ratios with confidence intervals for the independent predictors were examined. Results: Afghan MNM faced suboptimal care more frequently than Iranians after adjusting for educational level, family income, and insurance status. Above two-thirds (71%, 54/76) of MNM cases were potentially avoidable. Preventable factors were mostly provider-related (85%, 46/54), but patient-(31%, 17/54) and health system-related factors (26%, 14/54) were also important. Delayed recognition, misdiagnosis, inappropriate care plan, delays in care-seeking, and costly care services were the main potentially preventable attributes of MNM. Conclusions: Afghan mothers faced inequality in obstetric care. Suboptimal care was provided in a majority of preventable near-miss events. Improving obstetric practice and targeting migrants' specific needs during pregnancy may avert near-miss outcomes.

Ort, förlag, år, upplaga, sidor
2017. Vol. 17, artikel-id 64
Nyckelord [en]
Maternal near miss, Audit, Quality of care, Afghan migrants, Preventability, Iran
Nationell ämneskategori
Hälso- och sjukvårdsorganisation, hälsopolitik och hälsoekonomi Klinisk medicin
Identifikatorer
URN: urn:nbn:se:uu:diva-308075DOI: 10.1186/s12884-017-1239-2ISI: 000394469000003PubMedID: 28193186OAI: oai:DiVA.org:uu-308075DiVA, id: diva2:1049133
Anmärkning

The manuscript of this paper is part of the thesis Beyond ‘Cesarean Overuse’: Hospital-Based Audits of Obstetric Care and Maternal Near Miss in Tehran, Iran http://uu.diva-portal.org/smash/record.jsf?pid=diva2:1049158

Tillgänglig från: 2016-11-23 Skapad: 2016-11-23 Senast uppdaterad: 2018-02-27Bibliografiskt granskad
Ingår i avhandling
1. Beyond ‘Cesarean Overuse’: Hospital-Based Audits of Obstetric Care and Maternal Near Miss in Tehran, Iran
Öppna denna publikation i ny flik eller fönster >>Beyond ‘Cesarean Overuse’: Hospital-Based Audits of Obstetric Care and Maternal Near Miss in Tehran, Iran
2016 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
Abstract [en]

With one in two women delivering surgically, Iran has one of the highest rates of cesarean section (CS) worldwide. CS overuse in low-risk pregnancies potentially exposes women to Maternal Near-Miss (MNM) morbidity with minimal health benefits. This thesis studied obstetric care quality and MNM at hospitals with high rates of CS in Tehran, Iran.

In Study I, we investigated whether audits of CS indications and feedback influenced CS rates at a general hospital. Subsequent to the audit, a 27% reduction in the risk of primary CS was found.

In Study II, characteristics of MNM were investigated at university hospitals between 2012 and 2014. During a 26-month period, 82 MNM cases were identified using the WHO MNM approach. Severe postpartum hemorrhage (35%), severe preeclampsia (32%), and placenta previa including abnormally invasive placenta (10%) were the main three causes of MNM. Iran has a huge influx of migrants from Afghanistan. Women with antepartum CS and those who lacked health insurance, almost all Afghans, had increased risk of MNM.

In Study III, audits examined whether MNM care quality differed between 54 Iranians and 22 Afghans and whether near-miss events were preventable. A majority of MNM cases (62%) arrived at hospital in a moribund state and obstetric care was more suboptimal for Afghans than Iranians (adjusted odds ratio 5.1, 95% confidence interval 1.2–22.6). Moreover, MNM was commonly (71%) potentially preventable and professionals with suboptimal practice were involved in 85% of preventable cases.

In Study IV, a qualitative interview study was conducted to explore care experiences of Afghan MNM survivors. Discrimination, insufficient medical attention, and ineffective counseling were the main experiences. To a lesser extent, poverty and low education were perceived as contributing factors to delays in accessing care.

This thesis emphasizes the importance of high-quality care for preventing undesirable maternal outcomes. The audit method along with interviews was useful to determine quality and equity gaps in care provision. Policymakers and professionals should consider these gaps when structuring programs to reduce adverse maternal outcomes.

Ort, förlag, år, upplaga, sidor
Uppsala: Acta Universitatis Upsaliensis, 2016. s. 95
Serie
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1280
Nyckelord
Caesarean section, maternal near miss, clinical audit, care quality, care experience, Afghan migrants, Iran
Nationell ämneskategori
Hälso- och sjukvårdsorganisation, hälsopolitik och hälsoekonomi Reproduktionsmedicin och gynekologi Folkhälsovetenskap, global hälsa, socialmedicin och epidemiologi
Forskningsämne
Medicinsk vetenskap
Identifikatorer
urn:nbn:se:uu:diva-308081 (URN)978-91-554-9757-6 (ISBN)
Disputation
2017-01-18, Rosénsalen, Kvinnokliniken, Ing 95-96, Akademiska Sjukhuset, Uppsala, 13:00 (Engelska)
Opponent
Handledare
Tillgänglig från: 2016-12-22 Skapad: 2016-11-23 Senast uppdaterad: 2016-12-28

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Mohammadi, SoheilaKällestål, CarinaZiaei, ShirinEssén, Birgitta

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