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

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 me