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Priorities in emergency obstetric care in Bolivia: maternal mortality and near-miss morbidity in metropolitan La Paz
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health. (Internationell kvinno- & mödrahälsovård/Essén)
La Paz Hospital, La Paz, Bolivia.
Division of Social Medicine and Global Health, Lund University, Malmö, Sweden.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health. (Internationell kvinno- & mödrahälsovård/ Essén)
2009 (English)In: BJOG : An International Journal of Obstetrics and Gynaecology, ISSN 1471-0528, Vol. 116, no 9, 1210-1217 p.Article in journal (Refereed) 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.

Place, publisher, year, edition, pages
2009. Vol. 116, no 9, 1210-1217 p.
Keyword [en]
Bolivia, maternal mortality, near-miss, severe maternal morbidity
National Category
Medical and Health Sciences
URN: urn:nbn:se:uu:diva-107814DOI: 10.1111/j.1471-0528.2009.02209.xISI: 000267879700010PubMedID: 19459864OAI: oai:DiVA.org:uu-107814DiVA: diva2:233228
Available from: 2009-08-31 Created: 2009-08-31 Last updated: 2010-07-19Bibliographically approved
In thesis
1. Pre-hospital Barriers to Emergency Obstetric Care: Studies of Maternal Mortality and Near-miss in Bolivia and Guatemala
Open this publication in new window or tab >>Pre-hospital Barriers to Emergency Obstetric Care: Studies of Maternal Mortality and Near-miss in Bolivia and Guatemala
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Alternative title[es]
Barreras pre-hospitalarias para la atención obstétrica de emergencia : Estudios de mortalidad materna y morbilidad obstétrica severa en Bolivia y Guatemala
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.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2010. 74 p.
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 515
pre-hospital barriers, maternal mortality, near-miss, traditional birth attendants, social marginalization, Bolivia, Guatemala, barreras pre-hospitalarias, mortalidad materna, morbilidad obstétrica severa, parteras tradicionales, marginalización social, Bolivia, Guatemala
National Category
Medical and Health Sciences
Research subject
International Health
urn:nbn:se:uu:diva-112481 (URN)978-91-554-7709-7 (ISBN)
Public defence
2010-03-12, Auditorium Minus, Museum Gustavianum, Akademigatan 3, Uppsala, 09:15 (English)
Available from: 2010-02-19 Created: 2010-01-13 Last updated: 2010-02-19Bibliographically approved

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