A Qualitative Critical Incident Analysis of the 'Third Delay' in Postconflict

Open access Original research BMJ Open: first published as 10.1136/bmjopen-2020-042909 on 22 March 2021. Downloaded from Why women die after reaching the hospital: a qualitative critical incident analysis of the ‘third delay’ in postconflict northern Uganda Gasthony Alobo ,1,2 Emmanuel Ochola,3,4 Pontius Bayo,5 Alex Muhereza,6 Violah Nahurira,7 Josaphat Byamugisha 8,9 To cite: Alobo G, Ochola E, ABSTRACT Strengths and limitations of this study Bayo P, et al. Why women Objectives To critically explore and describe the die after reaching the pathways that women who require emergency obstetrics ► This qualitative study used two methods of data hospital: a qualitative critical and newborn care (EmONC) go through and to understand incident analysis of the collection for diagrammatic and thematic analyses: the delays in accessing EmONC after reaching a health ‘third delay’ in postconflict critical incident technique (CIT) and key informant facility in a conflict-affected setting. northern Uganda. BMJ Open interview, which are complementary and yield richer Design This was a qualitative study with two units of 2021;11:e042909. doi:10.1136/ data for realist enquiry. bmjopen-2020-042909 analysis: (1) critical incident technique (CIT) and (2) key ► CIT comprehensively mapped the pathways typically informant interviews with health workers, patients and Prepublication history and followed by cases of maternal deaths and mater- ► attendants. additional materials for this nal near- misses in similar settings based on critical Thirteen primary healthcare centres, one general paper is available online. To Setting case purposive sampling. private-not- for -profit hospital, one regional referral hospital view these files, please visit ► We conducted all interviews within health facilities, the journal online (http:// dx. doi. and one teaching hospital in northern Uganda. which might have influenced some responses. org/ 10. 1136/ bmjopen- 2020- Participants Forty- nine purposively selected health ► Part of this study focused on the referral system; 042909). workers, patients and attendants participated in key however, the addition of two tertiary facilities in Lira informant interviews. CIT mapped the pathways for Received 18 July 2020 without additional stepdown health centres might maternal deaths and near-misses selected based on limit data saturation and not fully present the prima- Revised 18 February 2021 critical case purposive sampling. Accepted 25 February 2021 ry healthcare centre experience. http://bmjopen.bmj.com/ Results After reaching the health facility, a pregnant ► Critical case sampling could be biased by research- woman goes through a complex pathway that leads to ers’ selection interests; however, the researchers delays in receiving EmONC. Five reasons were identified used independent maternal and perinatal death for these delays: shortage of medicines and supplies, surveillance and response teams at the tertiary hos- lack of blood and functionality of operating theatres, pitals to identify cases based on the principles of gaps in staff coverage, gaps in staff skills, and delays in analytical generalisation. the interfacility referral system. Shortage of medicines and supplies was central in most of the pathways, characterised by three patterns: delay to treat, back- on September 26, 2021 by guest. Protected copyright. and-forth movements to buy medicines or supplies, and Asia.1 2 These regions include fragile, human- multiple referrals across facilities. Some women also itarian and postconflict areas.3 bypassed facilities they deemed to be non-functional. In Uganda, maternal mortality ratio Conclusion Our findings show that the pathway to declined modestly between 2011 and 2016 EmONC is precarious and takes too long even after making early contact with the health facility. Improvement of skills, from 438 to 336, but with regional differ- better management of the meagre human resource and ences due to variations in social determi- 4 5 availing essential medical supplies in health facilities may nants of health. For example, northern © Author(s) (or their help to reduce the gaps in a facility’s emergency readiness Uganda is a postconflict area and is currently employer(s)) 2021. Re- use and thus improve maternal and neonatal outcomes. host to refugees from South Sudan; these permitted under CC BY-NC. No circumstances have exacerbated food inse- commercial re- use. See rights and permissions. Published by curity and constrained health resources, with BMJ. BACKGROUND possible suboptimal maternal healthcare in 6 7 For numbered affiliations see Globally, maternal mortality is still unaccept- the region. The leading causes of maternal end of article. ably high. By 2017, about 295 000 women death (MD) are direct obstetric causes and 1 Correspondence to were still dying every year. More than half include haemorrhage, infection, hyperten- Dr Gasthony Alobo; of the global maternal mortality occurs in sive disorders, uterine rupture and abortion gasthonya@ gmail. com Sub- Sahara Africa and about a third in South complications.8 9 Malaria and HIV/AIDS Alobo G, et al. BMJ Open 2021;11:e042909. doi:10.1136/bmjopen-2020-042909 1 Open access BMJ Open: first published as 10.1136/bmjopen-2020-042909 on 22 March 2021. Downloaded from contribute significantly to the indirect causes of MDs in (CEmONC) services and also serves as a referral site for Uganda.10 the greater northern Uganda. It has three satellite level Several delays also exist along the pathway to care. The 3 health centres (H/C) within an average distance of 70 ‘three delays’ model has been widely used to understand km, Pabbo, Opit and Amuru, which offer basic EmONC the factors that underlie MDs.11 The first delay is delay in (BEmONC) services. The main means of transport is deciding to seek clinical care during an obstetric emer- motorcycle due to poor road networks. The second part gency, the second delay is delay in reaching the health of the study was carried out at Lira Regional Referral facility, and the third delay is delay in receiving appro- Hospital and Lira University Teaching Hospital in the priate care while at the health facility. Compared with the Lango subregion, east of northern Uganda. The addi- first and second delays, the third delay has been underdoc- tion of these two tertiary facilities aimed to increase the umented and under- researched, with only a few indepth number of participants to achieve saturation. The popula- and critical analyses of the pathways followed by women tion used in CIT and KII included patients’ relatives and with obstetric complications.12 13 Moreover, the met need attendants, facility- based key informants, and the patients for emergency obstetrics and newborn care (EmONC) in themselves for MNM. some postconflict regions, and in low- income and middle- income countries (LMICs) generally, is still very low.14–17 Sampling and participants In the context of Uganda, a low-income country which Key informants is conflict- affected and with fragile health and referral We used a purposive sampling technique to identify and systems, it is possible to hypothesise significant delays in recruit the first few key informants, who were health- receiving EmONC even after arriving at a health facility. care workers as well as unit in-charges and attendants Such delays could lead to poor maternal and newborn with knowledge of critical incidents or members of the outcomes. Therefore, the purposes of this study were to maternal and perinatal death surveillance and response (1) explore and describe the pathways that women who (MPDSR) teams at Lacor Hospital, Lira Regional Referral require EmONC go through after deciding to seek care Hospital and Lira University Teaching Hospital. This and (2) understand the delays in accessing EmONC after was followed by a snowball technique to identify further reaching a health facility. key informants, including ambulance drivers, midwives, patients and relatives who also participated in care during critical incidents. During data collection, we also identi- METHODS fied other key informants in the above categories who Study design agreed to participate in this study. A total of 49 key infor- This qualitative study used an embedded study design mants took part in this study (table 1). with two units of analysis: (1) critical incident analysis of http://bmjopen.bmj.com/ maternal deaths (MD) and maternal near- misses (MNM) Critical incidents and (2) key informant interviews (KII) with persons We used critical case purposive sampling to identify cases. who were perceived to know about maternal healthcare We restricted ourselves to MD and MNM as critical inci- by their roles as health workers or experience with the dents. Critical case sampling has been described as ‘a health system. The critical incident technique (CIT) was method where selected important or critical cases are first described by Flanagan18 in 1954 as a way of collecting examined based on the following: ‘If it happens there, specific and significant behavioural facts, thus giving will it happen anywhere?’ or ‘if that group is having prob- a solid basis for making inferences. It has been used as lems, then can we be sure all the groups are having prob- 22 on September 26, 2021 by guest. Protected copyright. a qualitative methodology in health systems research lems?’’ The MPDSR teams of the hospitals identified a and is useful in exploring barriers to quality care or to total of 50 cases that had complete records and met the achieving satisfaction with

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