Abstract
BackgroundAs maternal deaths have decreased worldwide, increasing attention has been placed on the study of severe obstetric complications, such as hemorrhage, eclampsia, and obstructed labor, to identify where improvements can be made in maternal health. Though access to medical care is considered to be life-saving during obstetric emergencies, data on the factors associated with health care decision-making during obstetric emergencies are lacking. We aim to describe the health care decision-making process during severe acute obstetric complications among women and their families in rural Bangladesh.MethodsUsing the pregnancy surveillance infrastructure from a large community trial in northwest rural Bangladesh, we nested a qualitative study to document barriers to timely receipt of medical care for severe obstetric complications. We conducted 40 semi-structured, in-depth interviews with women reporting severe acute obstetric complications and purposively selected for conditions representing the top five most common obstetric complications. The interviews were transcribed and coded to highlight common themes and to develop an overall conceptual model.ResultsWomen attributed their life-threatening experiences to societal and socioeconomic factors that led to delays in seeking timely medical care by decision makers, usually husbands or other male relatives. Despite the dominance of male relatives and husbands in the decision-making process, women who underwent induced abortions made their own decisions about their health care and relied on female relatives for advice. The study shows that non-certified providers such as village doctors and untrained birth attendants were the first-line providers for women in all categories of severe complications. Coordination of transportation and finances was often arranged through mobile phones, and referrals were likely to be provided by village doctors.ConclusionsStrategies to increase timely and appropriate care seeking for severe obstetric complications may consider targeting of non-certified providers for strengthening of referral linkages between patients and certified facility-based providers. Future research may characterize the treatments and appropriateness of emergency care provided by ubiquitous village doctors and other non-certified treatment providers in rural South Asian settings. In addition, future studies may explore the use of mobile phones in decreasing delays to certified medical care during obstetric emergencies.
Highlights
As maternal deaths have decreased worldwide, increasing attention has been placed on the study of severe obstetric complications, such as hemorrhage, eclampsia, and obstructed labor, to identify where improvements can be made in maternal health
Since our study is based on self-report and not on clinically confirmed events, we refer to lifethreatening pregnancy-related complications as severe acute obstetric complications rather than near misses
Women cited their inability to convince family members or to obtain permission from their husbands as major obstacles to seeking timely medical care. Though families in these cases were able to access emergency care in time to save women’s lives, the women complained of the tremendous pain they had to endure before their male relatives decided it was necessary to seek medical care
Summary
As maternal deaths have decreased worldwide, increasing attention has been placed on the study of severe obstetric complications, such as hemorrhage, eclampsia, and obstructed labor, to identify where improvements can be made in maternal health. We aim to describe the health care decision-making process during severe acute obstetric complications among women and their families in rural Bangladesh. An obstetric complication is defined as an acute condition arising from a direct cause of maternal death, such as antepartum or postpartum hemorrhage, obstructed labor, postpartum sepsis, complications of abortion, pre-eclampsia or eclampsia, ectopic pregnancy, and ruptured uterus, or indirect causes such as anemia, malaria, and tuberculosis [7]. The World Health Organization (WHO) has recently standardized the definition of life-threatening, severe acute obstetric complications under the concept of near miss, which is “a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy” [10]. Among women with severe obstetric complications, near misses are considered to have the most serious conditions, nearly resulting in maternal death
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