Materials and methods
The case study was conducted in one of general hospitals in the Somali regional state of Ethiopia. The hospital was established approximately 50 years ago. The study was conducted from February 1 to March 1, 2017; using an explorative qualitative case study design. The tools used to collect data were in-depth interviews (IDIs), key informant interviews (KIIs), and facility abstraction using World Health Organization (WHO) near-miss assessment tools [
8]. Participants of this study were the mother herself, her sister, her male partner, maternal and child health (MCH) coordinators at the health facilities she has visited, the head of the health center/hospital, and the health service providers who assisted her both at first contact and at the referral hospital, such as the gynecologist, midwife, and general practitioner (GP). Purposive sampling was used to select the case as well the participants. A near-miss case was identified from among women with pregnancy-related complications whose diagnosis met the WHO near-miss criteria [
8] and who were admitted to the obstetric unit of the hospital. Investigations were conducted for abnormalities, septicemia, anemia, and other organ dysfunction/failure. Data were collected for determining the nature of the obstetric complication, presence of organ system dysfunction/failure, and timing of near-miss events with respect to admission. Fetal outcome and Intensive Care Unit (ICU) admissions were also noted. Detailed information on maternal complication for the underlying cause and time period was obtained. The information was documented using the narrative qualitative method. For this, multiple interviews were carried out. The data collectors had many years of experience with qualitative case study data collection, verbatim transcription, and translation. The data collectors in the field transcribed audio-digital recordings into the local language and then translated the data into English. The data collectors also kept notes and kept records of field reports, field notes, completed questionnaires, and interview recordings. The inductive qualitative data analysis method was used to analyze the data collected. The data were entered, coded, categorized, and analyzed using NVIVO version 11 software. Consent for data collection:
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◈ Ethical clearance for study was obtained from SPHMMC IRRB and local IRRB Ethio-Somali Regional Health Bureau (ESRHB).
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◈ Official letters were taken to zonal health departments, Woreda Health Offices, health centers, and health post/kebele (neighborhood) administrators.
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◈ The study participants were informed about the purpose of the study and written and informed verbal consent was taken.
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◈ All participants’ right to self-determination was respected.
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◈ The confidentiality and the privacy of the respondents were maintained.
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◈ Written informed consent was obtained from the patient for publication of this case report and any accompanying images.
The case was a 25-year-old married, multigravida, black woman. She was gravida 7 and para 6, all surviving. She lived in a rural pastoral area. She had no formal education and her livelihood was pastoralist. She was categorized into a low socioeconomic class. She had no history of abortion, stillbirth, cesarean section (C-section), or any obstetric complications.
History of current pregnancy
The current pregnancy was her seventh with a gestational age of approximately 37 weeks at presentation. The mother explained as her gestational age increased she started to develop generalized body swelling that started from her eyes, then face, and eventually migrated to her legs. She had history of blurred vision and headache. After two to three episodes of seizure, she was unconscious, and then she was taken to a nearby health facility (Health center) by her husband and mother.
“I was unconscious when my husband and my mother took me to the nearby health center.”
The mother
At the first contact health center her axial temperature was 36.5 °C and her BP was 170/105 mmHg in supine position; she had three episodes of seizure and other clinical findings and no tests were found on the patient's chart.
After this episode, there was no altered state of consciousness and no seizure. She did not have, headache, nausea, visual disturbances, or fever; she had no history of head injury, central nervous infection, no history of alcohol intake, no history of seizure or epilepsy, and she was negative for stigmata of neurocutaneous syndrome.
Because of shortage of supply and instruments, except urine analysis (protein 3+), no other laboratory or other investigative tests were done at the health center. The health care providers at the primary health facility diagnosed her as having preeclampsia and referred her to the nearby general hospital with an ambulance.
Maternal condition on arrival at the general hospital
The hospital is named as a general hospital but is serving as a referral hospital in the region, providing a wide range of services including approximately 25 deliveries per day.
“It is serving beyond its capacity. If you look around the maternity area, many women were in labor there; since there is no place we can refer to, we don’t have a limit on admission, and we accept everyone. When you provide service beyond capacity, there will be quality problems. The delivery rate is extremely high in our situation. Sometimes there are up to 25 deliveries per day.”
Hospital officer
The mother was visited by GPs, who were assigned to the emergency room at the hospital, as soon as she arrived. The family reported that they brought her to the health facility because she was sick due to an evil spirit and they had unsuccessfully tried spiritual treatment at their locality. Her vital signs on arrival at the general hospital were: BP 180/110 mmHg, temperature 37.6 °C, respiratory rate (RR) 22/minute, and her pulse rate (PR) was 82/minute. The health care providers counseled her family that they can use both modern and spiritual treatments in the hospital and then her family gave consent for admission. Then after the health care providers gave lifesaving emergency treatment using antihypertensive and anti-seizure medications, she was admitted to the obstetrics ward and she underwent full investigations including an ultrasound and laboratory investigations: urine analysis, complete blood count (CBC), and organ function tests like liver function test (LFT) and renal function test (RFT). The laboratory results showed 3+ protein for urine analysis dipstick test which is equivalent to 3 gm/l protein [
14] and CBC was in normal range except for hemoglobin and platelets of 7 mg/dl and 100,000/mm
3, respectively. Her aspartate aminotransferase (AST) result was raised (85 mg/dl) but the RFT result showed no increment in creatinine (1.5 mg/dl). She was finally diagnosed as having severe preeclampsia and full-term pregnancy (even though the diagnosis seemed eclampsia). The pregnancy type was singleton and in the cephalic position as reported by the radiologist. She was started on magnesium sulfate and an antihypertensive treatment (methyldopa). After her BP was controlled and she looked well, she was counseled for induction of labor due to the indication of (preeclamsia/) eclampsia. However, she refused the induction and went home; unfortunately, 2 days later she returned to the hospital soon after labor had started spontaneously at home. She was again admitted to the hospital for delivery. During this time she had no history of loss of consciousness, no history of seizure, no history of blurred vision, and no abnormal findings were detected. Because of abscence of cardiotocography (CTG) fetal heart monitoring was not done. The mother’s BP was 135/95 mmHg, PR was 80 beats/minute, and respiratory rate (RR) was 25/minute. She had pedal and periorbital edema. After 6 hours follow-up at labor and delivery ward, she gave birth to a live male baby with an Apgar score of 6/10 at 5 minutes after delivery and a weight of 1900 mg. The baby was admitted to the under-5 ward due to having a low birth weight (1.9Kg). She went home with orally administered methyldopa 250 mg to be taken twice a day.
“After referral to this facility, she was clerked at emergency ward by a general practitioner and then she was admitted and seen by the gynecologist. Then she had full investigations including an ultrasound and she was counseled for induction of delivery. However, she refused induction and preferred to go back home. Then she delivered spontaneously... The fetal outcome was a live but underweight male child... Now it is 24 hours since she delivered and the maternal status is good. ....We will transfer her to her baby in the ICU after we control her blood pressure.”
MCH focal person of the hospital
The mother and her family described her condition during the pregnancy as very risky and she thinks she would have been died if she had not gone to the health facility and received treatment.
“…this was a very risky pregnancy, she was near to death, if she had no intervention here, and she was near to death...”
The mother’s sister
“...after this pregnancy I decided to go to the health facility”
The mother
She gave birth to all her six previous babies at home without any problems and was supported by a non-trained traditional birth attendant (n-TBA) because she believed visiting a health facility while healthy was not important during pregnancy. She had no history of ANC attendance for the current pregnancy as she felt well and had no previous complications.
“Truly speaking I did not attended any ANC for the benefit of my health and that of the fetus but if I get sick I will go to the health facility to get treatment…I had all my previous deliveries in my home without any complication, I think it is ok to deliver in my home when I have no health problems.”
The mother
She believed that giving birth at a health institution is only necessary when there are problems during pregnancy that is why she presented to this health facility after her family perceived she had developed some complications.
“…it is very good to deliver in a health facility when you have a health concern. In my last delivery I went to the health center, all my body was swollen, to get treatment I went there.”
The mother
The mother perceived that culture and religion are supportive of seeking health services when needed and religion does not prohibit her from seeking any health services except being attended to by male health care providers and “strange individuals,” meaning individuals who do not know her local language; she perceived the patriarchal system in her community affected her use of the health services she needed as men were the source of finance and were the decision makers.
“… but it is difficult to get delivery service from males and strange people.”
The mother
“Husband is the source of income for the health care expenses and the family needs husbands who have a good attitude about modern health care utilization, so it is easy for the mother to use.”
The husband
The MCH focal person stated that cases of eclampsia and preeclampsia were increasing in this region, and as the cause is unknown it needs further research.
“The cause of preeclampsia and eclampsia is unknown but cases are increasing in our region. It may be associated with their eating habits. One doctor is doing research into preeclampsia and eclampsia cases to investigate the cause of these problems.” MCH focal person of the hospital
The mother was asked about her personal feelings toward the health facility she was in and the health care providers caring for her; she was satisfied with the services the health care providers provided her but complained that the hospital had inadequate room for labor and childbirth.
“The health care providers were welcoming and friendly to the patients but in the hospital there are no adequate rooms for the women delivering.”
The mother
The MCH focal person also discussed lack of an ICU for delivery. They also do not have enough space for delivery services and the delivery room is very congested. Women were delivering on the floor outside the room.
“It is known that we don’t have ICU services and this is a critical problem in our set up. I and the gynecologists tried a lot but still there is no solution. There are many problems with this but the main reason is that there is no space for establishing it. As you see the delivery ward is crowded, women are delivering on the floor and there is not even a little space.” MCH focal person
The health care providers complained about the accessibility of ambulances; they reported that most of the ambulances which were provided by the Ministry of Health were assigned for other duties, rather than serving emergency health services or laboring mothers.
“…This may be the most common complaint related to transportation. It is thought that there should be an ambulance service for all mothers and the Ministry of Health distributed ambulances to all districts even though they are used for other purposes.”
MCH focal person
The mother also described the quality of services starting from the kebele (neighborhood) she is living in, to the referral facility where she was treated and gave birth. The health facility near her has a shortage of human resources and supplies including medications, but at the referral health facility, she felt that it had enough human resources and they were serving the admitted patients day and night.
“….in our kebele the health center does not have enough health care providers and drugs. But it was okay in the hospital as health care providers were with us day and night.”
The mother
The MCH focal person reported that the mother preferred the death of her child to a surgical intervention done to save the life of herself and her baby. The intention of the mother was to save her own life rather than saving her child, because it was expected that the mother could give birth to many children if she survived. A lot of time was spent counseling the mother to have a C-section and other interventions. Even the father’s focus was not on the baby but on the life of the mother.
“First, the community in our region doesn’t worry about their children. Even the mothers themselves don’t worry about their beloved child. A mother will prefer the death of her fetus rather than surgical delivery. They fear complications of operations and consider it as if we are going to slaughter them. One doctor is doing research on how long it takes to counsel and get consent for cesarean section. If you ask a woman about an operation, she asks ‘Could I survive without an operation despite the survival of the fetus?’ And if we say yes, she says, the child can die, I can have another child tomorrow and I don’t like to be operated on. So they don’t care about their child. All families, the father and the mother don’t focus on the child.”
MCH focal person
The mother discussed that she had learnt many lessons from her current pregnancy complications, in addition to this, she learnt a lot about the advantages of using a health facility for the benefit of the mother and her baby, including about family planning.
“From this pregnancy I have learnt that going to the health facility is good for the health of the mother and baby….”
The mother
In addition, there was poor interaction among the hospital staff. For example, the senior midwifery nurses do not consult the junior physicians on the assumption that these junior GPs lack experience. Moreover, rather than teaching the junior GPs the senior physicians accept the existing trends of the midwives and as a result there was poor communication between the GPs and other senior staff.
“The main thing is most GPs were new graduates and lack experience, second it is time consuming to make the decision. This system is well accepted by the seniors.”
MCH focal person
The main delay before reaching the hospital was lack of transportation followed by lack of awareness about the disease. For example, if a woman is convulsing, the family believes that she was attacked by an evil spirit rather than disease.
“…Then they bring her to hospital after they failed many other trials. But lack of transportation is still a more severe problem and a mother will not die here if she is admitted early.”
MCH focal person