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Prevalence of Maternal Near Miss and Community-Based Risk Factors in Central Uganda

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Prevalence of Maternal Near Miss and Community-Based Risk Factors in Central Uganda International Journal of Gynecology and Obstetrics 135 (2016) 214–220 Contents lists available at ScienceDirect International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo CLINICAL ARTICLE Prevalence of maternal near miss and community-based risk factors in Central Uganda Elizabeth Nansubuga a,b,c,⁎,NatalAyigaa,CherylA.Moyerd a Population Research and Training Unit, North West University, Mafikeng, South Africa b Department of Population Studies, Makerere University, Kampala, Uganda c African Studies Center, University of Michigan, Ann Arbor, Michigan, USA d Departments of Learning Health Sciences and Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA article info abstract Article history: Objective: To examine the prevalence of maternal near-miss (MNM) and its associated risk factors in a community Received 4 November 2015 setting in Central Uganda. Methods: A cross-sectional research design employing multi-stage sampling collected Received in revised form 19 May 2016 data from women aged 15–49 years in Rakai, Uganda, who had been pregnant in the 3 years preceding the survey, Accepted 26 July 2016 conducted between August 10 and December 31, 2013. Additionally, in-depth interviews were conducted. WHO-based disease and management criteria were used to identify MNM. Binary logistic regression was used to Keywords: predict MNM risk factors. Content analysis was performed for qualitative data. Results: Survey data were collected Maternal near-miss from 1557 women and 40 in-depth interviews were conducted. The MNM prevalence was 287.7 per 1000 pregnan- Pregnancy complications Prevalence cies; the majority of MNMs resulted from hemorrhage. Unwanted pregnancies, a history of MNM, primipara, Risk factors pregnancy danger signs, Banyakore ethnicity, and a partner who had completed primary education only were asso- Uganda ciated with increased odds of MNM (all P b 0.05). Conclusions: MNM morbidity is a significant burden in Central Uganda. The present study demonstrated higher MNM rates compared with studies employing organ-failure MNM-diagnostic criteria. These findings illustrate the need to look beyond mortality statistics when assessing ma- ternal health outcomes. Concerted efforts to increase supervised deliveries, access to emergency obstetric care, and access to contraceptives are warranted. © 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. 1. Introduction Second, women not using healthcare facilities during pregnancy were not included in these study designs. Over half of all pregnant women Every year, at least 15% of women who become pregnant experience in Uganda do not attend four prenatal care visits, 43% deliver at home, life-threatening complications, the majority of these occurrences are in 66% do not receive post-natal care, and 89% have no access to obstetrics low-resource settings [1]. These complications can result in either death services [7,8]. With such limitations, new study approaches are or maternal near-miss (MNM). MNM refers to a woman who nearly warranted. Community-based studies take into account all women who died but ultimately survived life-threatening pregnancy complications have had a pregnancy, regardless of where delivery occurs. Additionally, [2]. In Sub-Saharan Africa, the incidence of MNM ranges from 1.1% to disease and management criteria for identifying MNM events take into 33.4% of all deliveries [3]. In Uganda, the incidence of MNM and its account MNM complications that do not necessarily result in organ risk factors remain unclear. MNM events are associated with high dysfunction [9]. An approach combining community-based studies and healthcare costs, poor maternal and infant outcomes, lost productivity, WHO near-miss criteria is likely to result in better MNM-prevalence increased burden on healthcare systems, and increased risk of maternal estimations and associated risk factors in the general population. The death [4]. However, relatively little attention has been paid to MNM, aim of the present study was to examine the prevalence of MNM, as particularly its prevalence and associated risk factors. well as risk factors associated with MNM, in one district in rural Uganda. Previous hospital-based studies in Uganda have reported MNM rates of 10.1% [5] and 33.4% [6]. However, these rates are likely under- 2. Materials and methods estimates for two reasons. First, these studies employed an organ- dysfunction classification system for identifying MNMs; this system is A cross-sectional study design was used to collect survey data in difficult to implement in settings with limited diagnostic equipment. Central Uganda between August 10 and December 31, 2013 from women aged 15–49 years who had been pregnant in the 3 years preceding the survey. Ethical approval for the study was provided by ⁎ Corresponding author at: North West University, Mafikeng, Private Bag X2046, Mmabatho, 2745, South Africa. Tel.: +256 772 382 377; fax: +256 414 530 756. North West University, Mafikeng,SouthAfrica,andRakaidistrictleader- E-mail address: [email protected] (E. Nansubuga). ship granted permission to conduct the study. Informed consent was http://dx.doi.org/10.1016/j.ijgo.2016.05.009 0020-7292/© 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. E. Nansubuga et al. / International Journal of Gynecology and Obstetrics 135 (2016) 214–220 215 obtained from all participants verbally, and strict confidentiality was demographics of the study cohort are detailed in Table 2; the majority maintained throughout data collection and analysis. of the respondents were married, resided in rural areas, had completed A multi-stage sampling process was used to select women to be no further than primary education, were employed in the agricultural invited to complete the survey. First, as the district in Uganda with the sector, were of Baganda ethnicity, and were Catholic. The bivariate worst performance in terms of maternal health indicators from the analysis demonstrated associations between MNM and marital status District League Table [10], Rakai district was selected for the survey. (P = 0.029), residing in a rural area (P b 0.001), employment status Second, the rural and urban sub-counties with the highest number of (P = 0.012), religion (P = 0.024), ethnicity (P = 0.001), wealth status pregnancies were selected; thereafter, a sampling frame of women (P = 0.029), partner’s occupation (P =0.039),andpartner’s education aged 15–49 years who had been pregnant in the 3 years preceding the (P =0.001)(Table 2). survey was generated from a complete household listing. Third, a random Of the 1557 women who had been pregnant in the 3 years preceding sampling of 19 out of 58 enumeration areas, stratified by place of resi- the study period, 434 had experienced MNM events, a prevalence of dence, was performed; all women who met the inclusion criteria in the 278.7 MNM events per 1000 pregnancies (95% confidence interval selected enumeration areas were contacted for interview. Individuals 256.612–301.228). The clinical causes of MNM were analyzed and who agreed to participate were interviewed in their homes by trained in- hemorrhage was identified as accounting for more than half of the terviewers. Following the interviews, 40 participants who had experi- MNM events reported in the study (Fig. 1). enced MNMs identified from the quantitative sample were purposively The odds ratios of the MNM risk factors investigated are detailed in selected to participate in in-depth interviews to gather qualitative data. Table 3. Increased odds of experiencing a MNM were demonstrated Rakai district is a predominantly rural district with similar reproduc- among women with unwanted pregnancies, with a greater increase tive health indicators to other parts of Central Uganda. Only a third of observed when participants’ partners’ characteristics (education and women in the district undergoing delivery do so under supervision, and employment status) were included in the model. the ratio of midwives to pregnant women is 1:360 [11]. This region in- This increase in the odds of an MNM occurring was supported by the cludes one of Uganda’s largest ethnic groups–the Baganda. Data were col- qualitative data, as illustrated by an excerpt from an in-depth interview lected from Kalisizo town council and Lwamaggwa sub-county. Kalisizo with a 27-year-old mother, “Itoldmyhusbandbuthedidn’t care as we town council is serviced by a government hospital, private health facili- had fought a week back. The pains got stronger and the bleeding ties, and a relatively good transport network. By contrast, Lwamaggwa persisted… By then, I had become very weak. At the clinic, the health sub-county is rural, with a poor road network, and no access to electricity; worker put a cannula on my hand, but I refused the drip [intravenous it is serviced by a health center III–a facility offering basic maternal health drip] because I had no money. Since my husband didn’t care, I also services–and health center IIs, which operate at a parish level. decided to let the pregnancy go.” The dependent variable in the present study was a binary outcome of Experiencing pregnancy danger signs was demonstrated to increase MNM; this was determined by the research team’s review of participant the risk of MNM complications (Table 3). Pregnancy danger signs responses to questions focused on MNM disease and management included swelling
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