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Beyond ‘Cesarean Overuse’: Hospital-Based Audits of Obstetric Care and Maternal Near Miss in Tehran, Iran
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

With one in two women delivering surgically, Iran has one of the highest rates of cesarean section (CS) worldwide. CS overuse in low-risk pregnancies potentially exposes women to Maternal Near-Miss (MNM) morbidity with minimal health benefits. This thesis studied obstetric care quality and MNM at hospitals with high rates of CS in Tehran, Iran.

In Study I, we investigated whether audits of CS indications and feedback influenced CS rates at a general hospital. Subsequent to the audit, a 27% reduction in the risk of primary CS was found.

In Study II, characteristics of MNM were investigated at university hospitals between 2012 and 2014. During a 26-month period, 82 MNM cases were identified using the WHO MNM approach. Severe postpartum hemorrhage (35%), severe preeclampsia (32%), and placenta previa including abnormally invasive placenta (10%) were the main three causes of MNM. Iran has a huge influx of migrants from Afghanistan. Women with antepartum CS and those who lacked health insurance, almost all Afghans, had increased risk of MNM.

In Study III, audits examined whether MNM care quality differed between 54 Iranians and 22 Afghans and whether near-miss events were preventable. A majority of MNM cases (62%) arrived at hospital in a moribund state and obstetric care was more suboptimal for Afghans than Iranians (adjusted odds ratio 5.1, 95% confidence interval 1.2–22.6). Moreover, MNM was commonly (71%) potentially preventable and professionals with suboptimal practice were involved in 85% of preventable cases.

In Study IV, a qualitative interview study was conducted to explore care experiences of Afghan MNM survivors. Discrimination, insufficient medical attention, and ineffective counseling were the main experiences. To a lesser extent, poverty and low education were perceived as contributing factors to delays in accessing care.

This thesis emphasizes the importance of high-quality care for preventing undesirable maternal outcomes. The audit method along with interviews was useful to determine quality and equity gaps in care provision. Policymakers and professionals should consider these gaps when structuring programs to reduce adverse maternal outcomes.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2016. , p. 95
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1280
Keyword [en]
Caesarean section, maternal near miss, clinical audit, care quality, care experience, Afghan migrants, Iran
National Category
Health Care Service and Management, Health Policy and Services and Health Economy Obstetrics, Gynecology and Reproductive Medicine Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Medical Science
Identifiers
URN: urn:nbn:se:uu:diva-308081ISBN: 978-91-554-9757-6 (print)OAI: oai:DiVA.org:uu-308081DiVA, id: diva2:1049158
Public defence
2017-01-18, Rosénsalen, Kvinnokliniken, Ing 95-96, Akademiska Sjukhuset, Uppsala, 13:00 (English)
Opponent
Supervisors
Available from: 2016-12-22 Created: 2016-11-23 Last updated: 2016-12-28
List of papers
1. Clinical Audits: A pratical strategy for reducing cesarean section rates in a general hospital in Tehran, Iran
Open this publication in new window or tab >>Clinical Audits: A pratical strategy for reducing cesarean section rates in a general hospital in Tehran, Iran
2012 (English)In: Journal of reproductive medicine, ISSN 0024-7758, E-ISSN 1943-3565, The Journal of Reproductive Medicine, Vol. 57, no 1-2, p. 43-48Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: To investigate whether the introduction of clinical audits by the Safe Motherhood Committee of a general hospital in Tehran, Iran, influenced cesarean section (CS) rates. STUDY DESIGN: A retrospective study was performed. The number of deliveries before and after the institution of clinical audits (May to December 2005) were tabulated in the audited hospital and analyzed by c2 test. Additionally, CS rates were measured in 3 other general hospitals during the same time period for comparison. RESULTS: A total of 3,494 deliveries were recorded during the study periods in 2004 and 2005 at the audited hospital. Subsequent to the audit, the overall CS rate decreased from 40% to 33% (p<0.001) and the primary CS rate from 29% to 21% (p<0.001), accounting for a 27% reduction in the risk of primary CS. In 2006 CS rates reverted to 42%. None of the other 3 general hospitals indicated a decline in CS rates in 2005. CONCLUSION: Our findings show a preventive association between the clinical audits and CS rates in a general hospital. The implementation of a clinical audit process can be an effective way to track care pathways and reduce unnecessary CS deliveries.

Keyword
cesarean section, clinical audit, Iran
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-307484 (URN)22324267 (PubMedID)
Available from: 2016-11-16 Created: 2016-11-16 Last updated: 2017-08-16Bibliographically approved
2. Maternal near-miss at university hospitals with cesarean overuse: an incident case-control study
Open this publication in new window or tab >>Maternal near-miss at university hospitals with cesarean overuse: an incident case-control study
Show others...
2016 (English)In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 95, no 7, p. 777-786Article in journal (Refereed) Published
Abstract [en]

INTRODUCTION: Cesarean section (CS) carries a substantial risk of maternal near-miss (MNM) morbidity. This study aimed at determining the frequency, causes, risk factors, and perinatal outcomes of MNM at three university hospitals with a high rate of CS in Tehran, Iran.

MATERIAL AND METHODS: An incident case-control study was conducted from March 2012 to May 2014. The modified WHO near-miss criteria were used to identify cases. A control sample of 1024 women delivering at the study hospitals was recruited to represent the source population. Near-miss ratio, crude and adjusted odds ratios (aORs) with confidence intervals (CI) were assessed.

RESULTS: Among 12 965 live births, 82 mothers developed near-miss morbidities and 12 died. The MNM ratio was 6.3/1000 live births. Severe postpartum hemorrhage (35%, 29/82), severe pre-eclampsia (32%, 26/82), and placenta previa/abnormally invasive placenta (10%, 8/82) were the most frequent causes of MNM. Women with antepartum CS (aOR 7.4, 95%CI 3.7-15.1) and co-morbidity (aOR 2.3, 95%CI 1.4-3.8), uninsured Iranians (aOR 3.4, 95%CI 1.7-7.1) and uninsured Afghans (aOR 4.7, 95%CI 2.4-9.2) had increased risks of near-miss morbidity. Stillbirth and extremely preterm birth were the most prominent adverse perinatal outcomes associated with MNM.

CONCLUSION: Overutilization of CS clearly influenced the causes of MNM. A lack of health insurance had a measurable impact on near-miss morbidity. Tailored interventions for reducing unnecessary CS and unrestricted insurance cover for emergency obstetric care can potentially improve maternal and perinatal outcomes. This article is protected by copyright. All rights reserved.

Keyword
Maternal near-miss; cesarean section; placenta previa; abnormally invasive placenta; Afghan migrant; health insurance; Iran
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-296830 (URN)10.1111/aogs.12881 (DOI)000380358900008 ()26918866 (PubMedID)
Available from: 2016-06-20 Created: 2016-06-20 Last updated: 2017-11-28
3. Afghan Migrants Face more Suboptimal Care than Natives: a Maternal Near-Miss Audit Study at University Hospitals in Tehran, Iran
Open this publication in new window or tab >>Afghan Migrants Face more Suboptimal Care than Natives: a Maternal Near-Miss Audit Study at University Hospitals in Tehran, Iran
Show others...
2017 (English)In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 17, article id 64Article in journal (Refereed) Published
Abstract [en]

Background: Women from low-income settings have higher risk of maternal near miss (MNM) and suboptimal care than natives in high-income countries. Iran is the second largest host country for Afghan refugees in the world. Our aim was to investigate whether care quality for MNM differed between Iranians and Afghans and identify potential preventable attributes of MNM. Methods: An MNM audit study was conducted from 2012 to 2014 at three university hospitals in Tehran. Auditors evaluated the quality of care by reviewing the hospital records of 76 MNM cases (54 Iranians, 22 Afghans) and considering additional input from interviews with patients and professionals. Main outcomes were frequency of suboptimal care and the preventable attributes of MNM. Crude and adjusted odds ratios with confidence intervals for the independent predictors were examined. Results: Afghan MNM faced suboptimal care more frequently than Iranians after adjusting for educational level, family income, and insurance status. Above two-thirds (71%, 54/76) of MNM cases were potentially avoidable. Preventable factors were mostly provider-related (85%, 46/54), but patient-(31%, 17/54) and health system-related factors (26%, 14/54) were also important. Delayed recognition, misdiagnosis, inappropriate care plan, delays in care-seeking, and costly care services were the main potentially preventable attributes of MNM. Conclusions: Afghan mothers faced inequality in obstetric care. Suboptimal care was provided in a majority of preventable near-miss events. Improving obstetric practice and targeting migrants' specific needs during pregnancy may avert near-miss outcomes.

Keyword
Maternal near miss, Audit, Quality of care, Afghan migrants, Preventability, Iran
National Category
Health Care Service and Management, Health Policy and Services and Health Economy Clinical Medicine
Identifiers
urn:nbn:se:uu:diva-308075 (URN)10.1186/s12884-017-1239-2 (DOI)000394469000003 ()28193186 (PubMedID)
Note

The manuscript of this paper is part of the thesis Beyond ‘Cesarean Overuse’: Hospital-Based Audits of Obstetric Care and Maternal Near Miss in Tehran, Iran http://uu.diva-portal.org/smash/record.jsf?pid=diva2:1049158

Available from: 2016-11-23 Created: 2016-11-23 Last updated: 2018-02-27Bibliographically approved
4. ‘Who cares for Afghanis?’ Care Experiences of Migrant Mothers Surviving Near-Miss Morbidity in Iran
Open this publication in new window or tab >>‘Who cares for Afghanis?’ Care Experiences of Migrant Mothers Surviving Near-Miss Morbidity in Iran
(English)Manuscript (preprint) (Other academic)
National Category
Public Health, Global Health, Social Medicine and Epidemiology Health Care Service and Management, Health Policy and Services and Health Economy Other Health Sciences
Identifiers
urn:nbn:se:uu:diva-308078 (URN)
Available from: 2016-11-23 Created: 2016-11-23 Last updated: 2016-11-28

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