Determinants of maternal near-miss in private hospitals in eastern Ethiopia: A nested case–control study

Prevalence and determinants of maternal near miss in Ethiopia: a systematic review and meta-analysis, 2023

BACKGROUND

Ethiopia's progress in maternal health is commendable, but the persistence of life-threatening complications during pregnancy and childbirth highlights the need for further research and action. While individual studies on maternal near-misses (MNM) exist, a comprehensive understanding of their prevalence and underlying factors remains elusive. This systematic review and meta-analysis aimed to bridge that gap by consolidating available evidence, paving the way for targeted interventions to improve maternal health outcomes.

METHODS

A search for relevant studies was performed using the databases of PubMed, Scopus, the Cochrane Library, and Google Scholar, from years November 26 to 30, 2023, encompassed studies conducted in Ethiopia and published in English that reported the prevalence of maternal near miss and/or identified at least one determinant. Duplicate studies were removed using Endnote X8, resulting in a total of 13 studies included for analysis. The methodological quality of the included studies was assessed using the Joanna Briggs Institute's (JBI) quality appraisal checklist. The data synthesis and statistical analysis were performed using STATA Version 17 software. The pooled prevalence was presented using forest plots based on the random effects model.

RESULT

The nationwide combined prevalence of maternal near misses (MNM) in Ethiopia was an adjusted odds ratio (AOR) of 12.9 and a 95% confidence interval (CI) of 6.30 to 19.49. Several factors were identified as determinants of maternal near-misses based on the pooled estimate. These factors included the absence of formal education (AOR = 2.48, 95% CI: 1.59-3.36), pre-existing chronic conditions (AOR = 4.70, 95% CI: 2.97-6.42), lack of antenatal care (AOR = 3.09, 95% CI: 2.12, 4.05), previous cesarean section (AOR = 4.40, 95% CI: 3.51, 5.28), and a history of referral (AOR = 2.67, 95% CI: 1.36-3.98); thus, factors were found to contribute significantly.

CONCLUSION

Maternal near-misses are prevalent in Ethiopia, with determinates including chronic conditions, lack of education, referral history, inadequate antenatal care, and previous cesarean sections. Addressing this requires improving women's education access, enhancing antenatal care services for early complication management, and proactive chronic condition care during pregnancy. Promoting safe delivery practices, reducing unnecessary cesarean sections, and enhancing referral systems are crucial steps. Effective implementation necessitates collaboration among healthcare providers, policymakers, the Ethiopian Ministry of Health, and hospitals to reduce maternal near-misses in Ethiopia. The cross-sectional design hinders drawing causal conclusions, and the relevance of the findings may be limited to countries with specific socio-economic and cultural contexts, considering that the research was conducted exclusively in Ethiopia.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023485844.

Prevalence, underlying causes, and determinants of maternal near miss in Ethiopia: a systematic review and meta-analysis

Background

Maternal near miss (MNM) is one of the newly adopted assessment parameters to gauge the quality of maternity care. In Ethiopia, several studies have been conducted to investigate the incidence, underlying causes, and determinants of MNM. However, the findings from those studies vary greatly and are largely inconsistent. Thus, this review aims to more robustly estimate the pooled prevalence, identify underlying causes, and single out determinants of MNM in Ethiopia.

Methods

Studies were searched from international databases (PubMed/ Medline, Cochrane Library, and Embase databases) and other potential sites. All observational studies were included. Heterogeneity between studies was checked using Cochrane Q test statistics and I2 test statistics and small study effects were checked using Egger's statistical test at a 5% significance level. Outcome measures were overall and specific underlying causes (obstetrics hemorrhage, hypertensive disorder pregnancy, pregnancy-related infection) rates of MNMs per 10,000 live births.

Result

The meta-analysis included 43 studies consisting of 77240 MNM cases. The pooled prevalence MNM per 1000 live births in Ethiopia was 54.33 (95% CI: 33.93 to 85.89). Between-study heterogeneity was high (I2 = 100%, P < 0.0001), with the highest rate observed in Amhara region (384.54 per 1000). The prevalence of obstetrics hemorrhage (14.56 per 1000) was higher than that of hypertensive disorder pregnancy (12.67 per 1000) and pregnancy-related infections (3.55 per 1000) were identified as underlying causes. Various factors, including socio demographic characteristics, previous medical and obstetrics history as well as access to and quality of care obtained, were associated with MNM.

Conclusion

Almost six women encounter near miss among a hundred live births in Ethiopia. Obstetric hemorrhage and hypertensive disorder pregnancy were the most common underlying causes of MNM. Both individual and facility level determinants were found to be associated with MNM. Considering the magnitude and identified factors, tailored measures should be taken at every stage of the continuum of care.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42023395259.

Maternal near-miss prediction model development among pregnant women in Bahir Dar City administration, northwest Ethiopia: a study protocol

INTRODUCTION

Maternal near-miss is a condition when a woman nearly died but survived from complications that happened during pregnancy, childbirth or within 42 days after delivery. Maternal near-miss is more prevalent among women in developing nations. Previous studies have identified the impact of different predictor variables on maternal near-miss but shared prognostic predictors are not adequately explored in Ethiopia. It is therefore necessary to build a clinical prediction model for maternal near-misses in Ethiopia. Hence, the aim of this study is to develop and validate a prognostic prediction model, and generate a risk score for maternal near-miss among pregnant women in Bahir Dar City Administration.

METHODS AND ANALYSIS

A prospective follow-up study design will be employed among 2110 selected pregnant women in the Bahir Dar City administration from 1 May 2023 to 1 April 2024. At the initial antenatal visit, pregnant women will be systematically selected. Then, they will be followed until 42 days following birth. Data will be collected using structured questionnaires and data extraction sheet. The model will be created using Cox proportional hazard regression analysis. The performance of the model will be assessed based on its capacity for discrimination using c-index and calibration using calibration plot, intercept and slope. The model's internal validity will be evaluated through the bootstrapping method. Ultimately, the model will be illustrated through a nomogram and decision tree, which will be made available to prospective users.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Institutional Review Board of the College of Medicine and Health Sciences, Bahir Dar University (protocol number 704/2023). Findings will be published in peer-reviewed journals and local and international seminars, conferences, symposiums and workshops. Manuscripts will be prepared and published in scientifically reputable journals. In addition, policy briefs will be prepared.

Prevalence and determinants of maternal near miss in Ethiopia: a systematic review and meta-analysis, 2015-2023

BACKGROUND

One of the most challenging problems in developing countries including Ethiopia is improving maternal health. About 303,000 mothers die globally, and one in every 180 is at risk from maternal causes. Developing regions account for 99% of maternal deaths. Maternal near miss (MNM) resulted in long-term consequences. A systematic review and meta-analysis was performed to assess the prevalence and predictors of maternal near miss in Ethiopia from January 2015 to March 2023.

METHODS

A systematic review and meta-analysis cover both published and unpublished studies from different databases (PubMed, CINHAL, Scopus, Science Direct, and the Cochrane Library) to search for published studies whilst searches for unpublished studies were conducted using Google Scholar and Google searches. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. Duplicated studies were removed using Endnote X8. The paper quality was also assessed based on the JBI checklist. Finally, 21 studies were included in the study. Data synthesis and statistical analysis were conducted using STATA Version 17 software. Forest plots were used to present the pooled prevalence using the random effect model. Heterogeneity and publication bias was evaluated using Cochran's Q test, (Q) and I squared test (I²). Subgroup analysis based on study region and year of publication was performed.

RESULT

From a total of 705 obtained studies, twenty-one studies involving 701,997 pregnant or postpartum mothers were included in the final analysis. The national pooled prevalence of MNM in Ethiopia was 140/1000 [95% CI: 80, 190]. Lack of formal education [AOR = 2.10, 95% CI: 1.09, 3.10], Lack of antenatal care [AOR = 2.18, 95% CI: 1.33, 3.03], history of cesarean section [AOR = 4.07, 95% CI: 2.91, 5.24], anemia [AOR = 4.86, 95% CI: 3.24, 6.47], and having chronic medical disorder [AOR = 2.41, 95% CI: 1.53, 3.29] were among the predictors of maternal near misses from the pooled estimate.

CONCLUSION

The national prevalence of maternal near miss was still substantial. Antenatal care is found to be protective against maternal near miss. Emphasizing antenatal care to prevent anemia and modifying other chronic medical conditions is recommended as prevention strategies. Avoiding primary cesarean section is recommended unless a clear indication is present. Finally, the country should place more emphasis on strategies for reducing MNM and its consequences, with the hope of improving women's health.

Determinants of maternal near miss events among women admitted to tertiary hospitals in Mogadishu, Somalia: a facility-based case-control study

BACKGROUND

A maternal near-miss is a situation in which a woman was on the verge of death but survived a life-threatening obstetric complication that happened during pregnancy, childbirth, or within 42 days after the pregnancy's termination. Survivors of near-miss events share several features with mothers who have died and identifying determinants of maternal near miss will aid in improving the capacity of the health system to reduce severe maternal morbidity and mortality. Therefore, this study was designed to identify determinants of maternal near miss incidents among women hospitalized to tertiary hospitals in Mogadishu, Somalia.

METHODS

A facility-based unmatched case-control study was conducted in four tertiary hospitals in Mogadishu from May 1 to July 31, 2021. A total of five hundred thirty-three (178 cases and 355 controls) study participants were involved in the study. The discharge period, cases were recruited consecutively as they emerged, whereas controls were chosen using systematic sampling approach based on every fifth interval of those delivered through normal spontaneous vaginal delivery. Women who were hospitalized during pregnancy, delivery, or within 42 days of termination of pregnancy and met at least one of the maternal near-miss disease specific criteria were classified as cases, while women who were admitted and gave birth by normal vaginal delivery and resealed from the hospital without experiencing severe obstetric complications were considered controls. Participants were interviewed by well-trained research assistants using pre-tested structured questionnaire and the medical records were reviewed to identify maternal near-miss cases. Data were entered into and analyzed with SPSS 25.0. Logistic regression was used, and the significance level was set at p value ≤ 0.05.

RESULTS

The most common maternal near-miss morbidities identified were severe anemia (32%), severe pre-eclampsia (19.6%), severe ante partum haemorrhage (15.0%), abortion complications (8.4%), eclampsia (6.1%), ICU admission (5.6%), severe PPH (2.8%) and severe systemic infections (2.8%). The main factors associated with maternal near-miss were rural residency [OR = 2.685, 95%CI: (1.702-4.235)], age below 20 years [OR = 2.728, 95%CI: (1.604-4.5640)], unmarried [OR = 2.18, 2.18, 95%CI (1.247-3.81)], lack of formal education [OR = 2.829, 95%CI: (1.262-6.341)], husband's unemployment [OR = 2.992, 95%CI: (1.886-4.745)], low family income [OR = 3.333, 95%CI (1.055-10.530)], first pregnancy before 18 years of age [OR = 3.091, 95% CI: (2.044-4.674)], short birth interval [OR = 5.922, 95%CI: (3.891-9.014)], previous history of obstetric complication [OR = 6.568, 95%CI: (4.286-10.066)], never attended ANC services [OR = 2.687, 95%CI: (1.802-4.006)], lack of autonomy in seeking medical help [OR = 3.538, 95%CI: (1.468-8.524)], delivery at non-health facility setting [OR = 4.672, 95%CI: (3.105-7.029)], experiencing the second delay [OR = 1.773, 95% CI: (1.212-2.595)] and stillbirth of the last pregnancy [OR = 5.543, 95%CI: (2.880-10.668)].

CONCLUSION

and recommendation. Lack of maternal education, lack of antenatal care, lack of autonomy to seek medical assistance, short birth interval, rural residence and delay in accessing obstetric services were identified as factors associated with maternal near-miss morbidity. As a result, the study suggests that those modifiable characteristics must be improved in order to avoid severe maternal complications and consequent maternal death.