Maternal and newborn health

Maternal and newborn healthMaternal mortality is a well-known quality indicator of obstetric care, and the concept of maternal near miss has gained interest as a complementary indicator, particularly among vulnerable groups with a lack of social networks in situations of general instability or poverty in low-income settings, or after migration to high resource settings. Our current research activities include analyses of maternal and perinatal ill-health in a low income setting. Context related factors affecting utilization of emergency obstetric care (EmOC) are also explored as an influence on birth outcome.

There is a global trend of increasing rates of caesarean delivery due to such reasons as medicalization, economic incitements and parental autonomy, whilst from an equity and priority perspective, safe motherhood is not implied. Hospital caesarean section rates of 24 - 75% are reported from Latin America, Asia and Africa. This project is focused on Iran, Nicaragua and Tanzania.

The study designs are hospital based: audits, demographic health surveillance site, interviews of mothers at hospital delivery and follow-up; maternal and child outcomes, including Robson 10-group classification; and sampling of parents and doctors for anthropological interviews to explore decision making, attitudes, birth experiences and health economic analysis.

Ongoing projects

Maternal mortality and severe obstetric morbidity in a globalised world

Our previous studies conducted in Somaliland, identified potential sub-optimal factors contributing to maternal near miss, mortality and adverse perinatal outcomes. Factors identified included, weak referral systems; bypassing of primary maternal and child health centres and accessing tertiary level hospitals late in critical condition; and the husband and/or father of the near miss mother gave consent for cesarean section and not the mother herself, and this was perceived to delay provision of emergency obstetric care.  Current studies are investigating the influence of consent delay for cesarean section including the role of female circumcision on maternal and perinatal outcome in Somaliland.

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

Earlier projects

”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?

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.

LocationBolivia, Iran, Guatemala, Rwanda, Sweden 

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.


Thesis: 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. Full text To DiVA

Thesis: 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. Full text To DiVA

Thesis: 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. Full text To DiVA

Thesis: Mohammadi, Soheila, Beyond ‘Cesarean Overuse’: Hospital-Based Audits of Obstetric Care and Maternal Near Miss in Tehran, Iran Full text To DiVA

Theis: 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 Full text To 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 Full text To 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. To 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. To 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. To 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 Full text Till DiVA