Effect of antenatal care and severe maternal complications on neonatal near miss in south Ethiopia

Introduction: The health of mothers and the development of babies are very closely related and require the same services, such as antenatal care(ANC), the presence of a skilled birth attendant, availability of emergency obstetric and newborn care, postnatal care, and family planning. Such services improve the lives of both the mother and the newborn. Recently, there has been progress in the reduction of maternal deaths in Ethiopia, which is 412 maternal deaths per 100,000 live births. For every mother who dies due to pregnancy-related causes, many other experience severe maternal complications that affect the well being of the mothers and their neonates. In Ethiopia, neonatal deaths account for 44% of under-five deaths. For every neonate who dies, many others experience a ‘near miss’ event that could result in death but does not. Neonatal near miss (NNM) refers to a neonate who nearly died but survived a severe complication that occurred during the neonatal period. Assessing near miss events provides health workers with a learning opportunity to use specific evidence-based interventions to prevent and treat maternal and newborn morbidities. This thesis fills a gap in the current literature by investigating the effect of ANC and severe maternal complications on NNM in south Ethiopia, using a systematic review with meta-analysis and a facility-based prospective study. Method: In order to determine the factors affecting utilization of ANC and its impact on neonatal mortality, systematic review and meta-analysis were conducted. To investigate the magnitude of severe maternal outcomes (SMO), quality of maternal health care, incidence and determinants of NNM, a facility based prospective study was conducted. A prospective study was conducted in three hospitals among women who presented while pregnant, during childbirth and within 42 days after delivery between 12 July and 26 November 2018. A sample of 3006 women and their neonates, who were identified from the three hospitals were included in the study. The mothers and their neonates were followed from the time of admission until the hospital discharge. The World Health Organization (WHO) maternal near miss (MNM) approach was used to assess SMO indicators and quality of maternal health care. Pragmatic, clinical and management criteria were used to determine the incidence of NNM. The data were collected through an interviewer-administered questionnaire and a medical record review. Multiple logistic regression analysis was employed to identify the distant, intermediate and proximal factors associated with NNM. The independent variables were analysed in three hierarchical levels. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were used to determine the strength of the associations. Result: The systematic review and meta-analysis show that pooled prevalence of utilization of ANC in Ethiopia was 63.8%. Further, utilization of at least one ANC visit by a skilled provider during pregnancy reduces the risk of neonatal mortality by 39% in sub-Saharan African (SSA) countries. The prospective study findings demonstrate that SMO incidence ratio and NNM incidence rate were 37.5 (95 % CI = 30.6 – 44.4) and 45.1 (95% CI = 37.7–53.8) per 1000 live births, respectively. The most common cause of SMO was eclampsia (37%) followed by severe postpartum haemorrhage (33.3%). The majority of SMO cases were referred from other health facilities. The intensive care unit (ICU) admission rate was 13% for women with SMO. The hospital maternal mortality ratio (MMR) and neonatal mortality rate (NMR) were 625 per 100,000 live births and 17.4 (95% CI = 13.0–23.3) per 1000 live births, respectively. Of those newborns who experienced NNM, more than half (59.8%) the mothers were referred from other health facilities. After adjusting for potential confounders, the odds of NNM were significantly higher among neonates born to a mother with severe complications. Additionally, low family income (< USD 79 monthly) and a birth interval of less than 24 months were independently associated with NNM. ANC did not show a statistically significant association with NNM. Conclusion and recommendation: The occurrence of SMO and NNM are lower compared to other studies which used similar criteria. Efforts are required to enable early identification and prevention of severe maternal complications, reduce inequalities by increasing women’s income and promote an optimal birth interval of 24 months or above through postpartum family planning to improve newborn survival and achieve the Sustainable Development Goals (SDGs) relevant to reducing maternal and infant mortality and morbidity (3.1 and 3.2). The findings also suggest that policymakers should design and implement different strategies such as reducing delays in seeking or reaching care, use of lifesaving interventions, improving the referral system in lower health facilities which may reduce severe maternal complications from occurring in hospitals and this in turn may improve the neonatal survival. Further research is also needed to measure the burden NNM in the whole neonatal period.