Survivors’ understanding of vulnerability and resilience to maternal near-miss obstetric events in Uganda

A qualitative study of abortion decision-making trajectories among pregnant women at their first antenatal care visit in Kampala, Uganda

Background

In Uganda, only about half of women who want to avoid pregnancy are using modern contraceptives, leading to high numbers of unintended pregnancies and elevated maternal and neonatal morbidity and mortality. In this study, we aimed to learn more about women's abortion decision-making before continuing to carry a pregnancy.

Methods

We utilised a qualitative study design and interviewed 31 purposively selected single and partnered pregnant women aged ≥18 years at their first antenatal care visit at Kawempe National Referral Hospital in Kampala, Uganda. We conducted the interviews in Luganda or English, transcribed them, and then translated them into English, as needed, for analysis. We analysed the data using thematic analysis. Deductive codes were based on social networks, social support, and health behaviour theories, and inductive codes were derived from interview transcripts.

Results

Almost half of the study participants (n = 13) considered an induced abortion before deciding to continue carrying their pregnancy. The most commonly stated reasons they considered abortion included anticipated interruptions to work and education, exhaustion related to child-rearing, and lack of social support. Other participants (n = 9) reported not considering abortion due to anticipated social support for their pregnancy, concerns about abortion-related morbidity and mortality, late confirmation of pregnancy, and religious beliefs. No participants discussed Uganda's restrictive abortion policies as a reason not to consider abortion.

Conclusions

Our results point to opportunities for continued reproductive health education and improved access to reproductive health services to allow pregnant women to meet their reproductive needs, seek out family planning, antenatal care, and safe abortion services when desired, and create support networks for pregnant women.

Maternal near miss, the voices of health service survivors: a metasynthesis

BACKGROUND

a maternal near miss experience can lead to clinical and psychosocial consequences for the woman and her family.

OBJECTIVES

To synthesize qualitative studies on the perception of women survivors of maternal near miss episodes and their trust in maternal health services.

METHODS

a qualitative systematic review was performed in five electronic databases using the Guidelines for Enhancing Transparency in Reporting the Synthesis of Qualitative Research. The methodological quality of the included studies was assessed using the Critical Appraisal Skills Program. This review contains the International Prospective Register of Systematic Reviews.

RESULTS

a total of 18 studies were chosen based on the eligibility criteria. Three themes emerged from the studies: Factors associated with delays in seeking health care Repercussions of maternal near miss; and Structural and organizational factors of the health care network.

FINAL CONSIDERATIONS

There is a need to create strategies directed not only to improve the quality of care during pregnancy and childbirth, but also to support families after hospital discharge. The development and implementation of support programs for survivors of maternal near miss is recommended, including follow-up visits and psychological support for mothers and families.

Postpartum recovery after severe maternal morbidity in Kilifi, Kenya: a grounded theory of recovery trajectories beyond 42 days

INTRODUCTION

The burden of severe maternal morbidity is highest in sub-Saharan Africa, and its relative contribution to maternal (ill) health may increase as maternal mortality continues to fall. Women's perspective of their long-term recovery following severe morbidity beyond the standard 42-day postpartum period remains largely unexplored.

METHODS

This woman-centred, grounded theory study was nested within the Pregnancy Care Integrating Translational Science Everywhere (PRECISE) study in Kilifi, Kenya. Purposive and theoretical sampling was used to recruit 20 women who experienced either a maternal near-miss event (n=11), potentially life-threatening condition (n=6) or no severe morbidity (n=3). Women were purposively selected between 6 and 36 months post partum at the time of interview to compare recovery trajectories. Using a constant comparative approach of line-by-line open codes, focused codes, super-categories and themes, we developed testable hypotheses of women's postpartum recovery trajectories after severe maternal morbidity.

RESULTS

Grounded in women's accounts of their lived experience, we identify three phases of recovery following severe maternal morbidity: 'loss', 'transition' and 'adaptation to a new normal'. These themes are supported by multiple, overlapping super-categories: loss of understanding of own health, functioning and autonomy; transition in women's identity and relationships; and adaptation to a new physical, psychosocial and economic state. This recovery process is multidimensional, potentially cyclical and extends far beyond the standard 42-day postpartum period.

CONCLUSION

Women's complex needs following severe maternal morbidity require a reconceptualisation of postpartum recovery as extending far beyond the standard 42-day postpartum period. Women's accounts expose major deficiencies in the provision of postpartum and mental healthcare. Improved postpartum care provision at the primary healthcare level, with reach extended through community health workers, is essential to identify and treat chronic mental or physical health problems following severe maternal morbidity.

Discrimination and perinatal depressive symptoms: The protective role of social support and resilience

BACKGROUND

Discrimination is an important social determinant of perinatal depression; however, evidence is limited regarding modifiable social and psychological factors that may moderate this association. We examined whether social support and resilience could protect against the adverse effects of discrimination on perinatal depressive symptoms.

METHODS

Pregnant people (N = 589) receiving Expect With Me group prenatal care in Nashville, TN and Detroit, MI completed surveys during third trimester of pregnancy and six months postpartum. Linear regression models tested the association between discrimination and depressive symptoms, and the moderating effects of social support and resilience, during pregnancy and postpartum.

RESULTS

The sample was predominantly Black (60.6 %), Hispanic (15.8 %) and publicly insured (71 %). In multivariable analyses, discrimination was positively associated with depressive symptoms during pregnancy (B = 4.44, SE = 0.37, p ≤0.001) and postpartum (B = 3.78, SE = 0.36, p < 0.001). Higher social support and resilience were associated with less depressive symptoms during pregnancy (B = -0.49, SE = 0.08, p < 0.001 and B = -0.67, SE = 0.10, p < 0.001, respectively) and postpartum (B = -0.32, SE = 0.07, p < 0.001 and B = -0.56, SE = 0.08, p < 0.001, respectively). Social support was protective against discrimination (pregnancy interaction B = -0.23, SE = 0.09, p = 0.011; postpartum interaction B = -0.35, SE = 0.07, p < 0.001). There was no interaction between discrimination and resilience at either time.

LIMITATIONS

The study relied on self-reported measures and only included pregnant people who received group prenatal care in two urban regions, limiting generalizability.

CONCLUSIONS

Social support and resilience may protect against perinatal depressive symptoms. Social support may also buffer the adverse effects of discrimination on perinatal depressive symptoms, particularly during the postpartum period.

Measuring resilience and stress during pregnancy and its relation to vulnerability and pregnancy outcomes in a nulliparous cohort study

BACKGROUND

Resilience reflects coping with pregnancy-specific stress, including physiological adaptations of the maternal organism or factors arising from the socioeconomic context, such as low income, domestic violence, drug and alcohol use, lack of a support network and other vulnerability characteristics. Resilience is a dynamic characteristic that should be comparatively evaluated within a specific context; its association with perceived stress and social vulnerability during pregnancy is still not fully understood. This study aimed at exploring maternal resilience, perceived stress and social vulnerability during pregnancy and its associated factors and outcomes.

METHODS

Prospective multicenter cohort study of nulliparous women in Brazil determining resilience (Resilience Scale; RS) and stress (Perceived Stress Scale; PSS) at 28 weeks of gestation (± 1 week). Resilience and stress scores were compared according to sociodemographic characteristics related to maternal/perinatal outcomes and social vulnerability, defined as having low level of education, being adolescent, without a partner or ethnicity other than white.

RESULTS

We included 383 women who completed the RS and PSS instruments. Most women showed low resilience scores (median: 124.0; IQR 98-143). Women with a low resilience score (RS < 125) were more likely from the Northeast region, adolescents, other than whites, did not study or work, had a low level of education, low family income and received public antenatal care. Higher scores of perceived stress were shown in the Northeast, other than whites, at low levels of education, low annual family income and public antenatal care. Pregnant women with low resilience scores (n = 198) had higher perceived stress scores (median = 28) and at least one vulnerability criterion (n = 181; 91.4%).

CONCLUSION

Our results reinforce the role of resilience in protecting women from vulnerability and perceived stress. It may prevent complications and build a positive experience during pregnancy.

Examining vulnerability and resilience in maternal, newborn and child health through a gender lens in low-income and middle-income countries: a scoping review

INTRODUCTION

Gender lens application is pertinent in addressing inequities that underlie morbidity and mortality in vulnerable populations, including mothers and children. While gender inequities may result in greater vulnerabilities for mothers and children, synthesising evidence on the constraints and opportunities is a step in accelerating reduction in poor outcomes and building resilience in individuals and across communities and health systems.

METHODS

We conducted a scoping review that examined vulnerability and resilience in maternal, newborn and child health (MNCH) through a gender lens to characterise gender roles, relationships and differences in maternal and child health. We conducted a comprehensive search of peer-reviewed and grey literature in popular scholarly databases, including PubMed, ScienceDirect, EBSCOhost and Google Scholar. We identified and analysed 17 published studies that met the inclusion criteria for key gendered themes in maternal and child health vulnerability and resilience in low-income and middle-income countries.

RESULTS

Six key gendered dimensions of vulnerability and resilience emerged from our analysis: (1) restricted maternal access to financial and economic resources; (2) limited economic contribution of women as a result of motherhood; (3) social norms, ideologies, beliefs and perceptions inhibiting women's access to maternal healthcare services; (4) restricted maternal agency and contribution to reproductive decisions; (5) power dynamics and experience of intimate partner violence contributing to adverse health for women, children and their families; (6) partner emotional or affective support being crucial for maternal health and well-being prenatal and postnatal.

CONCLUSION

This review highlights six domains that merit attention in addressing maternal and child health vulnerabilities. Recognising and understanding the gendered dynamics of vulnerability and resilience can help develop meaningful strategies that will guide the design and implementation of MNCH programmes in low-income and middle-income countries.

The Journey towards resilience following a traumatic birth: A grounded theory

Statistics have shown that up to 30% of women experience birth as traumatising. However, most women do not go on to develop post-traumatic stress disorder (PTSD), and instead appear to be resilient. Research is still sparse in the field of traumatic birth and resilience, and it is not known how women develop resilience after a traumatic birth.

OBJECTIVES

The aim of this study was to understand the process of fostering resilience after a traumatic birth.

METHOD

Semi-structured interviews were conducted with eight female participants aged 30 to 50 years who experienced a traumatic birth. A constructivist grounded theory was used to analyse interviews.

RESULTS

Two main themes were identified which were developed into an emergent model: 1) the feeling of powerlessness during a traumatic birth; and 2) the journey towards resilience. The powerlessness of a traumatic birth was related to a perceived lack of voice and abandonment by healthcare professionals. The model revealed that women's journey towards resilience was aided by both internal and external resources that included healing self-care and ownership of the role of mother; and drawing upon faith, spirituality and supportive relationships.

DISCUSSION

The findings suggest resilience is a process whereby women draw upon internal and external resources or both at different points in their journey. The implications of the findings include training healthcare professionals in communication to avoid trauma during labour; and prompting women to identify and utilise both internal and external resources to help them to overcome any trauma.

Surviving mothers and lost babies - burden of stillbirths and neonatal deaths among women with maternal near miss in eastern Ethiopia: a prospective cohort study

Background

Although maternal near miss (MNM) is often considered a ‘great save’ because the woman survived life-threatening complications, these complications may have resulted in loss of a child or severe neonatal morbidity. The objective of this study was to assess proportion of perinatal mortality (stillbirths and early neonatal deaths) in a cohort of women with MNM in eastern Ethiopia. In addition, we compared perinatal outcomes among women who fulfilled the World Health Organization (WHO) and the sub-Saharan African (SSA) MNM criteria.

Methods

In a prospective cohort design, women with potentially life-threatening conditions (PLTC) (severe postpartum hemorrhage, severe pre-(eclampsia), sepsis/severe systemic infection, and ruptured uterus) were identified every day from January 1st, 2016, to April 30th, 2017, and followed until discharge in the two main hospitals in Harar, Ethiopia. Maternal and perinatal outcomes were collected using both sets of criteria. Numbers and proportions of stillbirths and early neonatal deaths were computed and compared.

Results

Of 1054 women admitted with PTLC during the study period, 594 women fulfilled any of the MNM criteria. After excluding near misses related to abortion, ectopic pregnancy or among undelivered women, 465 women were included, in whom 149 (32%) perinatal deaths occurred: 132 (88.6%) stillbirths and 17 (11.4%) early neonatal deaths. In absolute numbers, the SSA criteria picked up more perinatal deaths compared to the WHO criteria, but the proportion of perinatal deaths was lower in SSA group compared to the WHO (149/465, 32% vs 62/100, 62%). Perinatal mortality was more likely among near misses with antepartum hemorrhage (adjusted odds ratio (aOR) = 4.81; 95% CI = 1.76-13.20), grand multiparous women (aOR = 4.31; 95% confidence interval CI = 1.23-15.25), and women fulfilling any of the WHO near miss criteria (aOR = 4.89; 95% CI = 2.17-10.99).

Conclusion

WHO MNM criteria pick up fewer perinatal deaths, although perinatal mortality occurred in a larger proportion of women fulfilling the WHO MNM criteria compared to the SSA MNM criteria. As women with MNM have increased risk of perinatal deaths (in both definitions), a holistic care addressing the needs of the mother and baby should be considered in management of women with MNM.

Hindering resilience in the transition to parenthood: a thematic analysis of parents' perspectives

OBJECTIVE

Investigate parents' recollections of resilience hindering experiences in the first year of parenthood.

BACKGROUND

The transition to parenthood is a significant period of change in the lifespan. Understanding the factors which undermine resilience during this process will help illuminate resilience theory and provision of perinatal support.

METHODS

We conducted a thematic analysis of in-depth interviews with 10 parents (including four fathers) and examined factors hindering resilience as a global theme within a broader thematic network.

RESULTS

We identified two organising themes; context which related to external experiences and relationships and appraisals which related to parents' internal attributions and experiences. We refined these organising themes into 24 specific resilience hindering factors including ambivalence about parenthood, fear of judgement, compromised self-care and relationship change. We also collated parents' suggested changes to structural supports such as providing a comprehensive overview of services available to new parents, having credible resources online, engaging fathers directly in perinatal care and a greater focus on postnatal support such as prioritising continuity of care and making longer hospital stays available.

CONCLUSION

Our work illuminates parents' own thoughts about factors hindering resilience in the transition to parenthood and provides direct recommendations from consumers about improvements to provision of support throughout this critical period.

What maternal morbidities are and what they mean for women: A thematic analysis of twenty years of qualitative research in low and lower-middle income countries

Background

With an estimated 27 million annual incidents of maternal morbidity globally, how they are manifested or experienced is diverse and shaped by societal, cultural and personal influences. Using qualitative research to examine a woman's perception of her pregnancy, its complications, and potential long-term impact on her life can inform public health approaches and complement and inform biomedical classifications of maternal morbidities, historically considered a neglected dimension of safe motherhood. As part of the WHO’s Maternal Morbidity Working Group’s efforts to define and measure maternal morbidity, we carried out a thematic analysis of the qualitative literature published between 1998 and 2017 on how women experience maternal morbidity in low and lower-middle income countries.

Results and conclusions

Analysis of the 71 papers included in this study shows that women’s status, their marital relationships, cultural attitudes towards fertility and social responses to infertility and pregnancy trauma are fundamental to determining how they will experience morbidity in the pregnancy and postpartum periods. We explore the physical, economic, psychological and social repercussions pregnancy can produce for women, and how resource disadvantage (systemic, financial and contextual) can exacerbate these problems. In addition to an analysis of ten themes that emerged across the different contexts, this paper presents which morbidities have received attention in different regions and the trends in researching morbidities over time. We observed an increase in qualitative research on this topic, generally undertaken through interviews and focus groups. Our analysis calls for the pursuit of high quality qualitative research that includes repeat interviews, participant observation and triangulation of sources to inform and fuel critical advocacy and programmatic work on maternal morbidities that addresses their prevention and management, as well as the underlying systemic problems for women’s status in society.

Application of resilience theories in the transition to parenthood: a scoping review

OBJECTIVE

Investigate the use of resilience theories in the transition to parenthood literature.

BACKGROUND

The transition to parenthood is a key developmental experience for many adults. Resilience is a unifying theoretical concept which incorporates many of the skills and resources linked with the transition to parenthood, but the uptake of resilience theory in this literature is unknown.

METHODS

We used a scoping review to examine the use of resilience theory in published transition to parenthood research. This included a systematic search of the literature, descriptive analysis of theories and methods used and an assessment of theoretical integration.

RESULTS

We identified 17 studies which met inclusion criteria. Explicit use of theory occurred in six studies and quality of theoretical integration was high for all of these. Resilience was seen as a desirable concept for mapping complex data, taking a holistic approach to psychological health and acknowledging environmental and systemic influences. We also identified 29 resilience supporting factors including positive self-concept, optimism, social support, family relationships, community services and social connectedness.

CONCLUSION

Resilience is a useful concept for synthesising information about the transition to parenthood.

Comparison of Urdu Versions of the Resilience Scale and the Resilience Scale for Adults

BACKGROUND AND PURPOSE

Several methodological challenges are associated with measuring resilience in women. This study compares the 14-item Resilience Scale (RS-14) and the Resilience Scale for Adults (RSA) in a community sample of women.

METHODS

Data were collected from 120 women residing in low socioeconomic areas of Karachi, Pakistan. Construct validity, internal consistency, and responsiveness were calculated.

RESULTS

Both scales demonstrated satisfactory psychometric characteristics. The total RS-14 score was significantly associated with all subscales of the RSA. However, two items of the RS-14 did not show any association with any of the subscales of the RSA. Medium effect size was noted on the "structured style"subscale of the RSA.

CONCLUSION

Differences between the scales concluded that the Urdu version the of RSA yielded improved results in this sample.

Male partners' perceptions of maternal near miss obstetric morbidity experienced by their spouses

BACKGROUND

Severe obstetric complications have potential negative impact on the family and household of the survivors, with potential negative effects during (and in the aftermath of) the traumatic obstetric events. The objective was to gain deeper understanding of how severe obstetric complications are perceived by male partners, and their impact on the livelihoods of the family and community.

METHODS

Data was collected through 25 in-depth narrative interviews with male partners of women with severe obstetric morbidity. The interviews occurred 4-12 months after the traumatic childbirth events. To gain a deeper understanding of the meanings and spouses attach to the experiences, we employed the notions of social capital and resilience.

RESULTS

Male partners' perceptions and experiences were mostly characterized by losses, dreams and dilemmas, disempowerment and alienation, seclusion and self isolation or reliance on the social networks. During the aftermath of the events, there was disruption of the livelihoods of the partners and the whole family.

CONCLUSION

While a maternal near miss obstetric event might appear as a positive outcome for the survivors, partners and caregivers of women who experience severe obstetric morbidity are deeply affected by the experiences of this life-threatening episode.