Study Factors Involved in Maternal Deaths Attributed to COVID-19 in a Disadvantaged Area in Southeast of Iran.

Objective: It is a fact that coronavirus disease of 2019 (COVID-19) infection mortality rate is high, but the question is "what is the role of other factors in maternal death with COVID-19?" The present study aimed to understand the factors that prevent women from timely use of healthcare services and also the potential weaknesses of the healthcare system that cause the lack of quality healthcare services for women. Materials and methods: This case-series study was performed in the southeast of Iran. In total, 12 cases of maternal deaths attributed to COVID-19 were identified through the Iranian Maternal Mortality Surveillance System. The required information was collected through existing verbal autopsy data sets. In some cases, the family members had to be re-contacted and healthcare workers were asked to supply the missing information. The root cause analysis method was employed for data analysis. Results: From March 2020 to March 2021, the deaths of 12 women were attributed to COVID-19. The majority of these women lived in rural areas (58%) and had a secondary school education level or less (83.3%). The contributing factors were divided into three categories: barriers at the community level (no prenatal care, lack of trust, lack of recognition of the severity of disease, and attribution of symptoms to something else), at the primary health system level, and at the hospital level (fear of staff of being infected, non-compliance with guidelines, lack of team working, and problem with telehealth). Conclusion: The socio-cultural context and unmet healthcare needs hinder the utilization of available services. Moreover, factors at the level of the healthcare system prevent the timely detection and referral of women with COVID-19 to receive quality healthcare services. Using telehealth also did not help to appropriately triage pregnant women.

Empowering midwives to manage postpartum haemorrhage in rural areas of Islamic Republic of Iran: lessons learnt from cases of maternal death.

BACKGROUND: Postpartum haemorrhage is the main cause of maternal mortality in rural areas of low-income countries. AIMS: This study investigated the causes of maternal death from postpartum haemorrhage in rural areas of Sistan and Baluchestan, Islamic Republic of Iran, and determined the effect of three interventions on midwives' management of haemorrhage. METHODS: Maternal deaths in women with postpartum haemorrhage between 9 April 2012 and 9 April 2013 were reviewed to determine what contributed to the death. Following the review, prostaglandin was permitted for use in rural maternity units. A flowchart on managing haemorrhagic shock and a training workshop on management of postpartum haemorrhage were also developed for midwives working in rural areas. After the interventions, all cases of postpartum haemorrhage (n = 81) that occurred during 23 September 2014-23 February 2015 in rural maternity facilities were reviewed based on 19 indicators. A control group (n = 81) was selected from women with postpartum haemorrhage who had been admitted to the same maternity units before the interventions. RESULTS: After the training interventions, more midwives used more than one method to estimate blood loss and higher doses of oxytocin to control haemorrhage. They showed improvements in the use of intravenous fluid therapy, pulse and blood pressure checks, external uterine massage, and uterotonic drugs. Following training, more women were admitted to hospital in a stable condition and recovered and were discharged (P = 0.002), and fewer had surgical interventions (P = 0.007). CONCLUSION: Midwives' management of postpartum haemorrhage improved after the interventions. Training programmes should be based on study of the local situation to identify shortcomings. Regular monitoring of outcomes is needed to detect and resolve failures.

Hospitalized Pregnant Women Who Leave Against Medical Advice: Attributes and Reasons.

OBJECTIVES: To identify the contributing factors for discharge against medical advice (DAMA) among pregnant women in Sistan and Balouchestan Province, southeastern Iran. METHODS: This hospital-based case-control study included a total of 168 DAMA pregnant women and 191 pregnant women who left hospital with medical approval. The participants were recruited between August 2012 and August 2013. Logistic regression models were used for data analysis. RESULTS: Factors that increased the chance of DAMA in pregnant women included older age, younger spouse age, low level of education, low income level and having a health insurance. History of DAMA in previous hospitalizations, referral from other clinics, emergency admission and admission advice from non-physician individuals for hospitalization, and giving birth at home during previous pregnancies, were associated with an increase in the risk of DAMA. The most common hospital-related reason for DAMA was the teaching environment of the hospital (26.2%) followed by hospital staff misconduct (23.8%) and overcrowding in the hospital wards (23.2%). The most frequent patient-related factors for DAMA were willingness of the patients to continue treatment at home (58.9%) and feeling relative improvement (58.3%). CONCLUSIONS FOR PRACTICE: We found that both hospital and patient related factors contribute to DAMA among pregnant women. Early identification of women at risk of DAMA and improvement of medical staff communication skills may decrease the occurrence of DAMA and improve health outcomes of pregnant women.