Rajbanshi, Sushma
(2021)
Severe maternal and neonatal morbidity status and qualitative exploration of high-risk, referral refusals and quality of care in Morang district, Nepal.
PhD thesis, Universiti Sains Malaysia.
Abstract
Early identification of pregnant women at risk of developing complications at birth, is fundamental to antenatal care (ANC) and an important strategy to prevent maternal death. The availability of services does not always increase their use. The quality of care should be monitored based on patients’ perceptions. This study aims to determine the magnitude of risk stratification, severe maternal morbidity (SMM), and a neonatal near miss (NNM). It further explored association between risk stratification and SMM and the associated factors of SMM and NNM. This study explored the meaning of high-risk pregnancy, the barriers to non-adherence to referral services and the perceptions of good-quality antenatal and birthing services among women with high-risk factors. This was a concurrent mixed-method study where hospital-based prospective cohort study, a cross-sectional study and a phenomenological study was applied. A total of 346 pregnant women, 1000 newborns and 14 participants with high-risk factors were enrolled. The quantitative study was conducted at Koshi Hospital and qualitative study within Morang district in Nepal. Multiple logistic regression analyses and thematic analysis were performed. The prevalence of high-risk pregnancy was 14.4%, SMM 6.6%, and NNM 7.9%. Risk stratification and SMM were significantly associated. Maternal education was significantly associated with SMM. Illiteracy, multiparity, SMM, and caesarean section were associated with NNM. Nine themes emerged in the qualitative study: (i) knowledge and understanding of risk, (ii) normalizing and non-acceptance of risk, (iii) preference of
homebirth, (iv) women’s diminished autonomy and financial dependence, (v) conditional factors, (vi) sociocultural factors, (vii) women’s opinions and satisfactory factors of health services, (viii) expectations of the health facility and staff, (ix) a lack of suggestions to improve the quality of care.Women with high-risk factors were four times more likely to develop SMM conditions than low-risk women. Routine ANC follow-up could identify and prevent high-risk factors related complications in pregnancy and is recommended to be used. Healthcare providers should be aware that risk perception is a subjective matter. Although risk in pregnancy or childbirth is communicated, women may not be fully convinced or deny that they are at risk. Adherence to a referral for hospital birth among high-risk pregnant women was poor among the poorest segments. They lack knowledge of their basic reproductive rights. Women judge the quality of care in terms of staff interpersonal behavior, free drug supply, personal experiences, or based on their relative’s recommendations.
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