Mödrars och nyföddas hälsa

Mödrars och nyföddas hälsaMödradödlighet är en välkänd kvalitetsindikator inom obstetrisk vård och nu har även konceptet svår mödrasjuklighet vunnit mark som en kompletterande indikator, särskilt för utsatta grupper som saknar sociala skyddsnät eller som lever i fattigdom i låginkomstländer, eller har migrerat till höginkomstländer. I detta projekt analyserar vi mödra- och perinatal ohälsa i en låginkomstmiljö. Vi studerar även hur kontextrelaterade faktorer påverkar användandet av akut obstetrisk vård (EmOC) och hur dessa påverkar födelseutfallet.

Globalt ses en ökande kejsarsnittsfrekvens som tillskrivs medicinska och ekonomiska incitament eller föräldrars rätt att välja. Kunskap saknas om hur den ökade kejsarsnittsfrekvensen är kopplad till ”Safe Motherhood Initiative” med målsättning att minska mödrasjuklighet genom en säkrare förlossningsvård. Kejsarsnittsfrekvenser mellan 24-75% rapporteras från sjukhus i Latinamerika, Asien och Afrika. Samtidigt brottas dessa regioner med knappa mödravårdsresurser och en osäker och ojämn fördelad förlossningsvård för den kvinnliga befolkningen.

Projekten fokuserar på kejsarsnittsproblematiken i två låginkomstländer; Nicaragua och Tanzania, samt medelinkomstlandet Iran. Vi har en flervetenskaplig ansats; klinisk audit, obstetrik, hälsoekonomi och antropologi med sjukhusbaserade studier inklusive Robsons 10-grupps-klassificering, intervjuer med uppföljning av nyförlösta mödrar och behandlande läkare. Det övergripande syftet är att utforska beslutsprocessen kring kejsarsnitt, analysera förlossningsutfall inkluderat hälsoekonomiska analyser. Resultaten kommer att ligga till grund för interventioner och rättvisare fördelning av säker förlossningsvård i låg- och medelresursområden.

Pågående projekt

Mödradödlighet och svår mödrasjuklighet i en globaliserad värld

Våra tidigare studier i Somaliland identifierade potentiella suboptimala faktorer som bidrar till svår mödrasjuklighet, negativa födelseutfall eller mödradödlighet. De identifierade faktorerna var: undermåliga remitteringssystem; att inte ta del av mödravårdscentraler för att sedan söka sig till sjukhus sent i ett kritiskt läge; att det är mannen och/eller fadern till den svårt sjuka kvinnan som ger samtyckte till kejsarsnitt och inte kvinnan själv, vilket ofta försenar tillhandahållandet av akut obstetrisk vård. Nuvarande studier undersöker hur fördröjning av samtycke för kejsarsnitt, samt, hur/om kvinnlig omskärelse påverkar mödradödlighet, svår mödrasjuklighet och födelseutfall i Somaliland.

Birgitta Essén, Professor
Soheila Mohammadi, PhD
Dalarna University:
Jonah Kiruja, doktorand
Fatumo Osman, PhD
Marie Klingberg, Professor
Kerstin Erlandsson, docent
Jama Ali Egal, doktorand

Tidigare projekt

”Near miss” and maternal mortality in a globalized world

Research questions

  • What are the factors that impedes utilization of emergency obstetric care in Bolivia and Guatemala?
  • What are the factors that impede utilization of emergency obstetric care in Bolivia and Guatemala?
  • What are the characteristics of severe maternal morbidity in a middle income country like Iran with a high influx of refugees from Afghanistan?
  • What are the potential barriers to preventable maternal mortality and partner involvement during pregnancy in a setting like Rwanda, with a strong policy program for achieving gender equity?
  • What are the medical and non-medical factors behind maternal mortality among migrants in Sweden?

LocationBolivia, Iran, Guatemala, Rwanda, Sweden

Major findings

  • In Iran, Afghan mothers face more suboptimal obstetric care than their Iranian counterparts through unequal access to insurance coverage.
  • Traditional birth attendants in Guatemala are unfamiliar with emergency obstetric care and there is a lack of collaboration with formal care providers.
  • In Bolivia, most women with near-miss arrived at hospital in critical condition.
  • Poor patient-provider interaction at care-encounter increases the risk of preventable complications, and decreases trust in facility based maternal care.
  • Even though men wish to participate during antenatal care and labour to ensure quality of care, they feel excluded from the maternal health system in Rwanda.
  • Migrant women born in low-income countries were identified as being at higher risk of maternal mortality due to suboptimal care and miscommunication despite giving birth in a high income country like Sweden.
  • Maternal mortality among immigrants in Sweden were related to broken trust  in relation to the care providers, influencing the women’s late booking or refusal of treatment.
  • Somali-born childbearing women need targeted attention in the maternity healthcare system due to less antenatal care attendance and adverse maternal health.

Too many caesarean deliveries challenging Safe Motherhood?

Research questions

  • What are the effects and reasons for a high caesarean section rate in a low-resource setting like Tanzania?
  • Can criteria based audit of obstructed labor improve accuracy of the decision of caesarean section and standard of care in a setting with high maternal and perinatal mortality?
  • What are the characteristics of ”near-miss” in a setting with very high rate of caesarean section like Teheran and Dar-es-Salaam?
  • What is the explanation behind the paradox that Somali migrants have the highest rate of caesarean sections but still express a very negative attitude towards a caesarean delivery?

LocationIran, Tanzania, Sweden

Major findings

  • Caesarean section (CS) is being overused also in some low-resource settings.
  • Despite improved safety, CS still entails high risks of severe maternal complications.
  • There is a tendency to justify maternal risks with CS by referring to a need to “secure” the baby.
  • Transparency, auditing, and dysfunctional team-work can contribute to CS overuse.
  • Placenta previa due to earlier CS is associated with maternal near-miss morbidity.
  • Non-medical reasons for unnecessary caesarean section include lack of support for junior clinicians from seniors and pressure from midwives during decision making, and fear of blame from colleagues and management in case of poor perinatal outcome.
  • Medical anthropology is a useful approach to understand adverse obstetric outcome among migrants. Socioeconomic factors seem to be more important than cultural factors per se. Shared language was found to be one of the most important factors for optimal care for migrants.

Publikationer

Avhandling: August, Furaha. Effect of Home Based Life Saving Skills education on knowledge of obstetric danger signs, birth preparedness, utilization of skilled care and male involvement: A Community-based intervention study in rural Tanzania. Fulltext Till DiVA

Avhandling: Litorp, Helena. 'What about the Mother?': Rising Caesarean Section Rates and their Association with Maternal Near-Miss Morbidity and Death in a Low-Resource Setting. Fulltext Till DiVA

Avhandling: Mgaya, Andrew Hans. Improving the quality of caesarean section in a low-resource setting: An intervention by criteria-based audit at a tertiary hospital, Dar es Salaam, Tanzania. Fulltext Till DiVA

Avhandling: Mohammadi, Soheila, Beyond ‘Cesarean Overuse’: Hospital-Based Audits of Obstetric Care and Maternal Near Miss in Tehran, Iran Fulltext Till DiVA

Avhandling: Påfs, Jessica, The Quest for Maternal Survival in Rwanda: Paradoxes in Policy and Practice from the Perspective of Near-Miss Women, Recent Fathers and Healthcare Providers Fulltext Till DiVA

Saleh Gargari S, Essén B, Fallahian M, Mulic-Lutvica A, Mohammadi S. Auditing the appropriateness of cesarean delivery using the Robson classification among women experiencing a maternal near miss. International Journal of Gynecology & Obstetrics [Internet]. 2019;144(1):49–55. Till DiVA

Mohammadi, Soheila; Gargari, S. Saleh; Fallahian, M.; Ziaei, Shirin et al. Afghan mothers with near-miss morbidity face disparity in obstetric care at university hospitals in Tehran, Iran. Ingår i European Journal of Public Health, s. 122-122, 2018. Till DiVA

Mohammadi S., Carlbom A., Taheripanah R., Essén, B. (2017). Experiences of inequitable care among Afghan mothers surviving near-miss morbidity in Tehran, Iran: a qualitative interview study. International Journal for Equity in Health, 2017;16(1):121. Till DiVA

Mohammadi, Soheila; Gargari Saleh, Soraya; Fallahian, Masoumeh; Källestål, Carina et al. Afghan Migrants Face more Suboptimal Care than Natives: a Maternal Near-Miss Audit Study at University Hospitals in Tehran, Iran. Ingår i BMC Pregnancy and Childbirth, 2017. DOI FulltextTill DiVA

Mohammadi S., Essén B., Fallahian M., Taheripanah R., Saleh S., Essén B. (2016). Maternal near-miss at university hospitals with cesarean overuse: an incident case-control study. Acta Obstetricia et Gynecologica Scandinavica, 2016;95(7): 777-786. Till DiVA

Mohammadi S., Essen B., Källestål C. (2012). Clinical audits to reduce cesarean section rates in a general hospital in Tehran, Iran. Ambitious or obtainable goal? Acta Obstetricia et Gynecologica Scandinavica, 91: 114-115. Till DiVA

Mohammadi, S., Källestål, C., Essén, B. (2012). Clinical Audits: A practical strategy for reducing cesarean section rates in a general hospital in Tehran, Iran. Journal of Reproductive Medicine, 2012;57(1-2): 43-48. Till DiVA

Påfs, Jessica; Rulisa, Stephen; Klingberg Allvin, Marie; Binder, Pauline et al. Implementing the liberalized abortion law in Kigali, Rwanda: Ambiguities of rights and responsibilities among health care providers. Ingår i Midwifery, 2020. DOI Fulltext Till DiVA