Facility-based maternal deaths: Their prevalence, causes and underlying circumstances. A mixed method study from the national referral hospital of Somaliland.

OBJECTIVE: Somaliland has one of the highest rates of maternal deaths in the world. An estimated 732 women die for every 100,000 live births. This study aims to identify the prevalence of facility-based maternal deaths, the causes and their underlying circumstances by interviewing relatives and health care providers at the main referral hospital. METHOD: A hospital-based mixed method study. The prospective cross-sectional design of the WHO Maternal Near Miss tool was combined with narrative interviews with 28 relatives and 28 health care providers in direct contact with maternal deaths. The quantitative data was analysed with descriptive statistics using SPSS and the qualitative part of the study was analysed with content analysis using NVivo. RESULTS: From the 6658 women included 28 women died. The highest direct cause of maternal death was severe obstetric haemorrhage (46.4%), followed by hypertensive disorders (25%) and severe sepsis (10.7%). An indirect obstetric cause of death was medical complications (17.9%). Twenty-five per cent of these cases were admitted to ICU and 89% had referred themselves to the hospital for treatment. The qualitative data identifies two categories of missed opportunities that could have prevented these maternal mortalities: poor risk awareness in the community and inadequate interprofessional collaboration at the hospital. CONCLUSION: The referral system needs to be strengthened utilizing Traditional Birth Attendants as community resource supporting the community facilities. The communication skills and interprofessional collaboration of the health care providers at the hospital needs to be addressed and a national maternal death surveillance system needs to be commenced.

Qualitative study of the roles of midwives in the provision of sexual and reproductive healthcare services in the Somaliland health system.

OBJECTIVES: To explore midwives' perspectives in providing sexual reproductive healthcare services in the Somaliland health system. METHODS: An exploratory qualitative design using focus group discussions (n=6) was used. The study was conducted in the capital of Somaliland, Hargeisa, at six maternal and child healthcare centres that provide sexual and reproductive healthcare (SRH) services. Qualified midwives (n=44) who had been working in the maternal and child health centres for a minimum of 1 year were recruited to participate, and only one did not participate due to illness. RESULTS: The results showed that Somaliland midwives face multiple challenges from a lack of formal arrangements, primarily written guidelines and policies, that explicitly define their role as healthcare professionals, which impact the quality of care they provide. They also reported feeling unsafe when practising according to their professional scope of practice due to challenging cultural norms, customary traditions and Somaliland's legal system. Finally, the midwives called for support, including training, institutional protection and psychological support, to enhance their ability and fulfil their role in SRH services in Somaliland. CONCLUSION: Midwives are essential to the provision of equitable SRH services to women and girls, yet are not fully supported by policies, laws or institutions, often living in fear of the consequences of their behaviours. Our research highlights the importance of understanding the context of Somaliland midwifery in order to better support the development of the midwifery workforce, stronger governance structures and midwifery leadership. Appropriately addressing these challenges faced by midwives can better sustain the profession and help to improve the quality of care provided to women and girls and ultimately enhance their reproductive health outcomes.

A lack of reproductive agency in facility-based births makes home births a first choice regardless of potential risks and medical needs-a qualitative study among multiparous women in Somaliland.

BACKGROUND: Around 20% of births in Somaliland take place at health facilities staffed by trained healthcare professionals; 80% take place at home assisted by Traditional Birth Attendants (TBAs) with no formal training. There has been no research into women's choice of place of birth. OBJECTIVE: In this study, we explore multipara women's needs and preferences when choosing the place of birth. METHOD: An explorative qualitative study using individual in-depth interviews analysed inductively using content analysis. The interviews were conducted in Somaliland with 25 multiparous women who had experience of giving birth both at home and at a health facility within the past three years. RESULTS: The results provide a description of how, for women in Somaliland, a lack of reproductive agency in facility-based births makes home births a first choice regardless of potential risks and medical need. The women in this study desired intentionality in their role as mothers and sought some measure of control over the environment where they planned to give birth, depending on the circumstances of that particular birth. The results describe what quality care means for multipara women in Somaliland and how women choose birthplace based on previous experiences of care. The expectation of respectful care was a vital part for women when choosing a place of birth. CONCLUSION: To meet women's needs and preferences in Somaliland, further investments are needed to strengthen the midwifery profession and to define and test a context specific midwife-led continuity of care model to be scaled up. A dialogue to create new roles and responsibilities for the TBAs who attend most home births is further needed to link them to the formal healthcare system and assure timely healthcare seeking during pregnancy and birth.

"Change-makers in midwifery care": Exploring the differences between expectations and outcomes-A qualitative study of a midwifery net-based education programme in the Somali region.

OBJECTIVE: The aim of this study is to explore midwifery educators' expected outcomes in the net-based master's programme, the programmes' realised outcomes and the reported difference regarding the increased choices for the graduates and the effect on their agency. DESIGN: In this case study, we focused on a net-based master's programme in sexual and reproductive health in Somalia. Somalia suffers from a shortage of skilled birth attendants and there is a need for building up the capacity of midwifery educators. SETTING AND PARTICIPANTS: Data was collected in focus group discussions at the start of the programme and eight months after the students graduated. The data were analysed through the lens of the choice framework, which is based on the capability approach. FINDINGS: Findings show that many of the graduates' expectations were met, while some were more difficult to fulfil. While the midwives' choices and resource portfolios had improved because of their role as educators, the social structure prevented them from acting on their agency, specifically in regards to making changes at the social level. Several of the positive developments can be attributed to the pedagogy and structure of the programme. CONCLUSION: The flexibility of net-based education gave the midwifery educators a new educational opportunity that they previously did not have. Students gained increased power and influence on some levels. However, they still lack power in government organisations where, in addition to their role as educators, they could use their skills and knowledge to change policies at the social level.

Evaluation of an online master's programme in Somaliland. A phenomenographic study on the experience of professional and personal development among midwifery faculty.

To record the variation of perceptions of midwifery faculty in terms of the possibilities and challenges related to the completion of their first online master's level programme in Sexual and Reproductive Health and Rights in Somaliland. The informants included in this phenomenongraphical focus group study were those well-educated professional women and men who completed the master's program. The informant perceived that this first online master's level programme provided tools for independent use of the Internet and independent searching for evidence-based information, enhanced professional development, was challenge-driven and evoked curiosity, challenged professional development, enhanced personal development and challenged context-bound career paths. Online education makes it possible for well-educated professional women to continue higher education. It furthermore increased the informants' confidence in their use of Internet, software and databases and in the use of evidence in both their teaching and their clinical practice. Programmes such as the one described in this paper could counter the difficulties ensuring best practice by having a critical mass of midwives who will be able to continually gather contemporary midwifery evidence and use it to ensure best practice. An increase of online education is suggested in South-central Somalia and in similar settings globally.

Maternal near-miss and death incidences - Frequencies, causes and the referral chain in Somaliland: A pilot study using the WHO near-miss approach.

Background Somaliland is a self-declared country with a population of 3.5 million. Most of its population reside in rural areas. The objective of this pilot near-miss study was to monitor the frequency and causes of maternal near-miss and deaths and the referral chain for women to access Skilled Birth Attendants (SBA). METHOD: A facility-based study of all maternal near-miss and mortality cases over 5months using the WHO near-miss tool in a main referral hospital. Reasons for bypassing the Antenatal Care facility (ANC) and late arrival to the referral hospital were investigated through verbal autopsy. RESULTS: One hundred and thirty-eight (138) women with severe maternal complications were identified: 120 maternal near-miss, 18 maternal deaths. There were more near-miss cases on arrival (74.2%) compared with events that developed inside the hospital (25.8%). Likewise, there were more maternal deaths (77.8%) on arrival than was the case during hospitalization (22.2%). The most common mode of referral among maternal near-miss events was family referrals (66.7%). Of 18 maternal deaths, 15 were family referrals. Reasons for bypassing ANC were as follows: lack of confidence in the service provided; lack of financial resources; and lack of time to visit ANC. Reasons for late arrival to the referral hospital were as follows: lack of knowledge and transportation; and poor communication. Conclusion and clinical implication: To increase the utilization of ANC might indirectly lower the number of near-miss and death events. Collaboration between ANC staff and referral hospital staff and a more comprehensive near-miss project are proposed.