Description of participants
Participant characteristics are shown in table 2 below. In summary, nine women with obstetric near miss participated in interviews. Ages ranged from 22 to over 30. Four experienced eclampsia, three had severe postpartum haemorrhage, one had both, and one had severe pre-eclampsia and postpartum psychosis. Eight delivered by caesarean section and were multiparous. All were married, with varying education levels. Healthcare professionals from two level 3 facilities participated in focus groups. HC-A (high near-miss burden) included six nurse-midwives and one clinical officer, while HC-B (low near-miss burden) had five nurse-midwives and one clinical officer.
Table 2
Participant characteristics
| Characteristic | # of Participants | Percentage |
|---|
| Age | | |
|---|
| > 30 years | 5 | 55.6% |
| 25–30 years | 3 | 33.3% |
| 22 years | 1 | 11.1% |
| Obstetric condition | | |
| Eclampsia | 4 | 44.4% |
| Severe Postpartum Haemorrhage | 3 | 33.3% |
| Both Eclampsia & Postpartum Haemorrhage | 1 | 11.1% |
| Severe Pre-eclampsia & Postpartum Psychosis | 1 | 11.1% |
| Delivery Method | | |
| Caesarean Section | 8 | 88.9% |
| Parity | | |
| Multiparous | 8 | 88.9% |
| Relationship Status | | |
| Married and Living with Partner | 9 | 100% |
| Education | | |
| Secondary School | 4 | 44.4% |
| College-level | 4 | 44.4% |
| Postgraduate (Masters) | 1 | 11.1% |
| Health Care Providers (Focus Groups) | | |
| (high near-miss burden facility) 6 Nurse-midwives, 1 Clinical officer HC-B (low near-miss burden facility) 5 Nurse-midwives, 1 Clinical officer |
Thematic overview
We deductively identified four themes based on the WHO framework, activity theory and phase one study outcomes. The most discussed theme was collaboration of health care providers and health teams across facilities, and we labelled this sequential coordination. The second theme related to relationships between health care teams and women across the continuum of care, and we marked this continuity. The third theme was collaboration between healthcare professionals and teams in primary healthcare settings, and we called this parallel coordination. Finally, other factors that did not fall into one of the categories of continuity and coordination but contributed to the overall outcomes were classified as access. Table 3 below shows emergent themes and subthemes.
Table 3
Emergent themes and subthemes
| THEMES | SUB-THEMES |
|---|
| Sequential coordination | − Antagonistic professional relationships − Specialist consultation − Emergency services and transport − Information transfer |
| Parallel coordination | − Community-based follow up − Task shifting |
| Continuity | − Communication of diagnostic and clinical information − Woman centeredness |
| Access to services | − Telephone hotline as an accommodation strategy − Birth planning and companionship − Alternative referral pathways |
Theme one: Sequential coordination
Sequential coordination emerged in this study as an outcome of the network of activities within the referral drainage. The activities within the primary health care setting include collective actions of the midwife, clinical officer and the community health volunteer, the means of communication, rules of engagement and the division of work. We categorized the subthemes that emerged from this theme as professional relationships (collective team actions), specialist consultation (individual action), emergency services and transport (tools of work), and information transfer (means of communication).
Subtheme one: Antagonistic professional relationships
Collaboration between facilities and collective team actions during an emergency emerged necessary for effective sequential coordination. Disagreements between professionals, specifically between midwives in referral and referring facilities, were evident. Consequently, near-miss survivors felt that these disagreements delayed their care and management, as disclosed by the quotation below.
“…. In fact, the people at (facility X) really blamed (facility Y), saying that you should have brought this patient earlier, why did you wait until she worsened for you to make a phone call? You should have called early. Although when they realized things are tough, they [facility Y] switched off the phone, they "no longer received phone calls…” [woman 05]
Perceived power imbalances lead to mistrust between professionals, causing staff at lower levels to fear seeking guidance. Disagreements arise from suspicion about technical competence in managing emergencies and fear of blame for adverse events or maternal deaths. These issues are more common among women referred to multiple facilities before reaching the main referral hospital.
“At times attitude causes delay, that’s a fifth delay, attitude is a fifth delay, because you are from (PH-1), you have called, you reach there you are told this patient, now, is not even that serious., I had also a client with a cord presentation, I am being challenged is this a cord presentation or a cord prolapse? so the person had to do VE (Vaginal examination), in the process cord the cord ruptured, so you find that clients are not dying along the way, they are dying at (RH-B) and then the blame becomes political, the MCA (Member of county Assembly) calls the CEC (chief executive officer)…. the buck stops kwa ground …the buck stops with us in the referring facility [Midwife 01]
The attitude of the health care professionals emerged as a delay for care as it influenced the mistrust and caused barriers in communication between the midwives in referring and referral facilities. Although the midwife from the referring facility was sure regarding her assessment of the client, the midwife at the referral hospital doubted the assessment. The mistrust caused the emergency to complicate the situation further.
Subtheme 2: Failure to follow up on specialist referral
In both high and low near-miss burden facilities, the failure of mothers to follow through on their referrals to specialist consultation emerged as a potential determinant of the occurrence of near misses. Although the HCPs in the referring facility do their due diligence in referring the high-risk women for specialist care, the individual action of the woman influenced the outcome.
“Actually most of the clients even the pre-eclampsia clients, and the pregnancy induced clients, most of them we usually advise them to go to (RH-B), even the multiple pregnancy, even the breech but you find the situation whereby you are at night, the same client who, even if you check on the ANC book, the same client was referred to high risk clinic, but the same client comes during labour comes with complications”[ midwife 01, high near-miss burden facility]
Health care providers suggest that several factors contribute to women not attending specialist consultations at the main referral hospital. These factors include out-of-pocket fees for accessing specialists, travel costs due to the distance (e.g., 50 Kilometers from the high near-miss facility), and long waiting times for an obstetrician/gynaecologist on designated days. There is no mechanism in place to monitor whether these women have attended their referral appointments, which may exacerbate the issue. These findings are connected to the results discussed in the “community follow-up” section.
Subtheme 3: Lack of emergency services/transport
A stark difference between high and low near-miss burden facilities was the availability of an ambulance. In the high near-miss facility, an ambulance was shared between several facilities and therefore was not readily available in an emergency. The lack of ambulance services points to the scarcity of investment in resources for this facility. Also, from the same FGD, we learned that HCPs have learned to manage the situation through improvisation (see the quote below). Although most facilities with ambulance problems tend to devise ingenious workarounds, they tend to be counterproductive because they seem to “normalize” delays.
[High near-miss facility] ….after informing them is when we look for means of transport, we have a good referral system although we don’t have a vehicle here, we have one at Moi’s bridge health centre most of the time when we call them we are able to reach the ambulance and if it’s not available, we have a call centre at UGDH where they look for an ambulance from anywhere, any corner so long as they send an ambulance to us”[midwife 04].
“...there is one nurse at CWC who tells me she must rush to the maternity in case there is an emergency. I cannot see an ambulance; on inquiry I am told the facility does not have one – they call in case of an emergency [Observation field notes from high near-miss facility]
Therefore, emergency services were a barrier to swift care. The health care professionals would have required timely responses when referring a woman.
Theme two: Continuity
This theme was broadly related to how women perceived their relationships with HCPs, and how this relationship influenced their probability of returning to the same facility for subsequent consultations. The subthemes that emerged under this theme were woman-centeredness, miscommunication, and poor follow-up.
Subtheme one: Woman centeredness
Women-centred care was highlighted as important to near-miss survivors in their relationships with health care providers, particularly midwives providing antenatal services. Satisfaction increased when women received care from familiar health care providers, either from antenatal care or community connections. Women expected sensitive treatment even from unfamiliar health care providers, with perceived insensitivity causing them to change facilities. Sensitive care included proper palpation and attentive listening to concerns. Women valued health care providers who addressed their concerns, leading to increased trust and a willingness to return to the same provider. This factor contributed to how women assessed health care provider competency.
“For that facility, you lie on the bed, immediately they place that thing for listening, after they listen, they tell you that you are ok, please climb down. You see, maybe you have come with some issues, the way am telling you I was in so much pain and my legs, I wasn’t able to walk well. So, you want them to touch you, so that you know why the pain is there. So they didn’t do that …..so I went to facility (name), also they were not good. So, I went to another one, I can’t remember the name, it’s in the bush, the doctor was not bad, he was touching me…unfortunately they transferred him from there…so I stopped going there, I went to this one here (name). Here it was the same, they just listen, they just listen, they don’t palpate well. So, I said, let me go to this one (name), at least they seem to manoeuvre the baby, in fact they are the ones who told me how the baby was positioned, so I even preferred to deliver from there…” [woman 03]
This woman changed facilities because she felt ‘not listened to’. The lack of follow-up care from one facility to the next caused the woman to have inadequate assessment and management during pregnancy and birth. Further, interpersonal care was necessary for the woman to feel confident in the care provided.
Subtheme two: Miscommunication
How HCPS communicated examination findings and other clinical information seemed to influence women’s perception of the health care providers. Women interpreted terms such as “bad obstetric history” as stigmatization of their fertility. The perceived judgmental attitudes by HCPs seemed to erode informational, relational, and longitudinal continuity because women were unwilling to visit the clinic subsequently, as illustrated by the quote below.
“Normally when I went to hospital, when I give my history about like I am para 0 plus 4, they say eeh that’s interesting point. They will say what happened, until you are para 0 plus 4? So, they normally categorize me to be part of bad obstetric history.… Sometimes it is not good because my prayer is that my fertility will be good....” [woman 02]
The inadequate or inappropriate communication with women becomes a catalyst to disempowerment. The women do not necessarily understand what to expect, especially with previous poor experiences. The women felt desperate for positive outcomes, although the communication from midwives made them sad.
Theme two: Parallel Coordination
This theme emerged as the collective activities within the primary health care setting that influenced care coordination. This involved how the midwives, clinical officers and community health volunteers acted as a cooperative team, enabling desired or undesired outcomes. The themes that emerged included (1) inappropriate task shifting and (2) poor community follow-up.
Subtheme one: Inappropriate task shifting
Heavy workloads, staff shortages and inappropriate task-shifting emerged as the main detriment to parallel coordination. Improper task-shifting emerged as scenarios where, due to staff shortages, unqualified workers such as cleaning assistants performed monitoring of women in labour even when they had arrived in the facility early enough for good management, as described below. The staffing norms for clinical staff in level 3 facilities are expected to be at least three nurses and one clinical officer at any given time. In the high near-miss facility, there were two nurses and one clinical officer. The situation worsened during night shifts as nurses perform both nursing and clinical duties, which may be burdensome.
[Near miss survivors – PPH] “The person I blame is the nurse that I found there, instead of attending to me he left me saying that he has some other business. He left me with the person who cleans the ward. So, reaching 9 am another nurse came. He is the one who should have taken responsibility to say, “we can’t manage this patient, lets refer…” (woman 05).
[High near-miss facility] “The challenges we have is shortage, many times we have only one person like a weekend, so imagine once the clinician has gone the nurse remains alone on the whole facility and am imagining now, suppose she gets an eclampsia or pre-eclampsia?…” [midwife 02]
While the women felt neglected, the midwives felt overworked due to staff shortages. The women viewed task-shifting to unqualified personnel such as cleaners as irresponsible and the reason for delayed referrals.
Subtheme 2: Poor community follow up
Failure to follow up on high-risk women within the community and household levels emerged as detrimental to parallel coordination. In Kenya, community health volunteers and extension workers are mandated to conduct household visits for preventive and promotive care, which includes checking on any identified high-risk woman and reporting back to the facility. Near miss survivors consistently said that although some were known to have pre-eclampsia, they were neither followed up nor contacted by the facility. This may point to poor coordination between the health facility and community-based teams. Specifically, the health centre clinical team leader supervises community-based extension workers and volunteers.
Ok you know what is happening, what we normally do is when we find a client who has an issue we normally take their number but we have never done any follow up to be frank, maybe we can start on that but we normally do is that when we see a situation that requires attention we exchange the numbers in case of anything we just call that is what we normally do…” [midwife 05]
Some participants perceive this to have contributed to them experiencing a near miss. Nurses and midwives blamed the failure to follow up with women in the community on their job description, which does not include household visits. Thus, it seems unclear how household visits are organized and whether they are carried out.
Theme four: Access to services
This theme emerged as the need for service relationships that connect people to the activities within the health care setting. However, the access was enabled or hampered through communication, health literacy, companionship, and alternate referral pathways.
Subtheme one: Telephone hotline as an accommodation strategy
Accommodation emerged as a critical strategy for continuity of care. In this context, accommodation is defined as health systems interventions for increasing access through special consultation hours and other arrangements. We observed that in the low near-miss facility, there was a telephone hotline for pregnant women to call the facility (free of charge) in case of an emergency or at the onset of labour pains. In contrast, there was none in the high near-miss facility.
It is now one hour since the emergency unfolded, and apparently the patient is stable…each of the rooms has a nurse. there is a toll-free number for pregnant mothers to call in case of an emergency [Observation notes, Chepkigen Health Centre, Low Near miss burden facility]
Subtheme two: Health literacy [ individual action-women]
This subtheme emerged as the near-miss survivors’ own capacity to make decisions and act during pregnancy or around childbirth. These included empowering women with the appropriate sexual and reproductive health information for self-management and creating positive practice environments. The ability for women to identify potentially serious signs and symptoms during pregnancy emerged as a necessary measure to prevent near-miss events. Women’s empowerment before and during pregnancy emerged as an enabler to birth preparedness. Participants reported engaging in downplaying or minimizing the significance of symptoms – particularly for pre-eclampsia and eclampsia. Part of the reason appeared to be driven by popular beliefs about specific symptoms considered “normal” during pregnancy.
“…that day I had gone to work morning hours, but my body was swollen, the whole body including the face ok, I didn’t think it’s a big deal, at that particular time, I thought its normal because people say when a woman is pregnant her legs usually swell…” [woman 06]
Most participants reported attempts to manage their conditions at home based on cultural practices or family advice. These ranged from purchasing over-the-counter medications without prescriptions to using herbal medicines. This practice was more common among women who experienced pregnancy-induced hypertension.
“I just wake up, try my best, when they find that its high, I just take drugs…sometimes I take drugs and it refuses, so when it goes high, I take garlic so that it goes down. That is how life had become until now, in-fact I don’t take medicines anymore, I have ever gone to take medicines, when it goes high, I take garlic ” [woman 02]
Subtheme three: Birth planning and companionship
Birth planning and anticipation of steps to take emerged as necessary in supporting women through pregnancy, birth and postpartum, especially when they needed to make swift decisions. A common subtheme among participants was the lack of anticipation or preparedness for their day of delivery. This was the case even among mothers with a previous near-miss situation. For example, a mother who experienced severe postpartum haemorrhage said.
“The labour pains started at three in the morning, at that time it was not very painful, but I knew now my time for delivery has reached…because sometimes the abdomen has some other pain, I thought I should go to hospital because for my second child, I ignored the pain and ended up delivering by the roadside…” [woman 01]
Further partner support was vital for swift responses in cases of emergency. Sometimes, actions to be taken on the delivery day were entirely based on whether the husband was available to support the mother or if there was another form of support at home. The woman quoted below waited through her labour pains for her husband to return home before he took her to the hospital. She later experienced retained placenta and severe postpartum haemorrhage. She was briefly admitted to ICU in the main referral hospital and made a complete recovery.
“It started around midnight, so I persevered because my husband had not slept home that day, so around three in the morning is when I called him to come and take me to hospital, that’s when he came immediately and used a motorcycle to take me to (Facility name )..” [woman 03]
Although this woman started bleeding at midnight, she could only be transported to the emergency unit three hours later with transportation that could worsen her bleeding.
Subtheme four: Alternative referral pathways
Referral networks based on social capital were effective ways to find appropriate emergency services. Participants reported that sometimes referral was facilitated by a friend, spouse or someone in the community who “knew” a doctor or other health provider. Often these referrals appeared to lead to a faster consultation, admission, or treatment process.
“First, when I developed that bleeding when the bleeding started, my husband called (Doctors’ name), the gynaecologist doctor at (facility name), and he asked him that we rush to hospital and when we reached there, he just managed (my bleeding) …[woman 02].
Access to immediate consultation in case of an emergency was necessary for women. It emerged that it could be the reason this woman survived mortality, although she ended up with a near miss.
Subtheme five: Cost / financial barriers
Creating enabling environments emerged as necessary for the women to access the care they need. Managing socio-economic issues featured among near-miss survivors as a cause and consequence of their near-miss experience. Failure to return for check-ups or follow referral instructions was all attributed to a lack of money for bus fare or the need to do household chores as the sole breadwinner.
So when I reached here, I knew there is trouble, bus fare for going and coming back... I just went once for check-up but the second time the problem was bus fare. Another problem is that I have young children, I did not have anyone to leave the children with so I gave up, I have never gone back for check-ups … [woman 01]
Within the Kenyan health care system, maternal care at lower-level facilities is entirely free of charge (subsidized). However, should a mother be referred to one of the major referral hospitals (RHA or RHB), they are expected to pay an out-of-pocket fee to access specialized care. This fee also seems to dissuade mothers from seeking care after being referred from lower-level facilities. The quote below is from a nurse-midwife in a high near miss facility.
… we had a patient with epilepsy, she was epileptic and they needed to, they (RHB) say you don’t bring that client unless you have money for CT scan, and sometimes the clients we are handling sometimes they don’t have money at that time, so it delays the referrals that’s one of the challenges, they come with money so that when they reach there they go directly for CT scan… [midwife 05]
A client with epilepsy requiring an urgent CT scan could not receive it unless she had money to pay on arrival at the referral hospital. The delay in the investigation caused a delay in the care provided to the woman.