Study Factors Involved in Maternal Deaths Attributed to COVID-19 in a Disadvantaged Area in Southeast of Iran
,
Abstract
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.
1. Murphy R, Calugi S, Cooper Z, Dalle Grave R. Challenges and opportunities for enhanced cognitive behaviour therapy (CBT-E) in light of COVID-19. Cogn Behav Therap 2020; 13: e14.
2. Cucinotta D, Vanelli M. WHO Declares COVID-19 a Pandemic. Acta Biomed 2020; 91: 157-60.
3. Rassouli M, Ashrafizadeh H, Shirinabadi Farahani A, Akbari ME. COVID-19 Management in Iran as One of the Most Affected Countries in the World: Advantages and Weaknesses. Front Public Health 2020; 8:510.
4. Wei SQ, Bilodeau-Bertrand M, Liu S, Auger N. The impact of COVID-19 on pregnancy outcomes: a systematic review and meta-analysis. CMAJ 2021; 193: E540-E8.
5. Wastnedge EAN, Reynolds RM, van Boeckel SR, Stock SJ, Denison FC, Maybin JA, et al. Pregnancy and COVID-19. Physiol Rev2021; 101: 303-18.
6. Takemoto MLS, Menezes MO, Andreucci CB, Nakamura-Pereira M, Amorim MMR, Katz L, et al. The tragedy of COVID-19 in Brazil: 124 maternal deaths and counting. Int J Gynaecol Obstet. 2020; 151: 154-6.
7. Takemoto MLS, Menezes MO, Andreucci CB, Knobel R, Sousa LAR, Katz L, et al. Maternal mortality and COVID-19. J Matern Fetal Neonatal Med 2022; 35: 2355-2361.
8. Hantoushzadeh S, Shamshirsaz AA, Aleyasin A, Seferovic MD, Aski SK, Arian SE, et al. Maternal death due to COVID-19. Am J Obstet Gynecol 2020; 223: 109 e1- 109.e16.
9. Souza ASR, Amorim MMR. Maternal mortality by COVID-19 in Brazil. Rev Bras Saude MaternInfant 2021; 21: S253-S6.
10. Chmielewska B, Barratt I, Townsend R, Kalafat E, van der Meulen J, Gurol-Urganci I, et al. Effects of the COVID-19 pandemic on maternal and perinatal outcomes: a systematic review and meta-analysis. Lancet Glob Health 2021; 9: e759-e72.
11. Kingsley JP, Vijay PK, Kumaresan J, Sathiakumar N. The Changing Aspects of Motherhood in Face of the COVID19 Pandemic in Low and Middle Income Countries. Matern Child Health J 2021; 25 : 15-21.
12. Roberton T, Carter ED, Chou VB, Stegmuller AR, Jackson BD, Tam Y, et al. Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study. Lancet Glob Health 2020; 8: e901-e8.
13. Metz TD, Collier C, Hollier LM. Maternal Mortality From Coronavirus Disease 2019 (COVID-19) in the United States. Obstet Gynecol 2020; 136: 313-6.
14. Cahyanti RD, Widyawati W, Hakimi M. The reliability of maternal audit instruments to assign cause of death in maternal deaths review process: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2021; 21: 380.
15. Heher YK. A brief guide to root cause analysis. Cancer Cytopathol 2017; 125: 79-82.
16. Kinney MV, Walugembe DR, Wanduru P, Waiswa P, George AS. Implementation of maternal and perinatal death reviews: a scoping review protocol. BMJ Open 2019; 9: e031328.
17. Rahmanzade R, Rahmanzadeh R, Hashemian S M, Tabarsi P. Iran's Approach to COVID-19: Evolving Treatment Protocols and Ongoing Clinical Trials. Front Public Health 2020; 8: 551889.
18. Ghanbari M K, Behzadifar M, Bakhtiari A , Behzadifar M, Azari S, Gorji H A, et al. Assessing Iran's health system according to the COVID-19 strategic preparedness and response plan of the World Health Organization: health policy and historical implications. J Prev Med Hyg 2021; 61: E508-19.
19. Kalafat E, O’Brien P, Heath P T, Le Doare K, von Dadelszen P, Magee L, et al. Benefits and potential harms of COVID-19 vaccination during pregnancy: evidence summary for patient counseling. Ultrasound Obstet Gynecol 2021; 57: 681–6.
20. Afghah SM, Ahangari A, Askarei Pour Lahiji H. Estimating human development index of Iranian provinces and investigating its impact on economic growth using fuzzy logic. Quarterly Journal of Quantitative Economics 2020; 17: 89-121.
21. Zamankhani F, Abachizadeh K, Omidnia S, Abadi A, Hiedarnia MA. Composite social health index: Development and assessment in provinces of Iran. Medical Journal of the Islamic Republic of Iran 2019; 33: 78.
22. Patwardhan M, Eckert LO, Spiegel H, Pourmalek F, Cutland C, Kochhar S, et al. Maternal death: Case definition and guidelines for data collection, analysis, and presentation of immunization safety data. Vaccine 2016; 34: 6077-6083.
23. Shaqdan K, Aran S, Daftari Besheli L, Abujudeh H. Root-cause analysis and health failure mode and effect analysis: two leading techniques in health care quality assessmen. J Am Coll Radiol 2014; 11: 572-9.
24. Takemoto M, Menezes MO, Andreucci CB, Knobel R, Sousa L, Katz L, et al. Clinical characteristics and risk factors for mortality in obstetric patients with severe COVID-19 in Brazil: a surveillance database analysis. BJOG 2020; 127: 1618-26.
25. Tadesse E. Antenatal Care Service Utilization of Pregnant Women Attending Antenatal Care in Public Hospitals During the COVID-19 Pandemic Period. Int J Womens Health 2020; 12: 1181-8.
26. Abdelhafiz AS, Mohammed Z, Ibrahim ME, Ziady HH, Alorabi M, Ayyad M, et al. Knowledge, Perceptions, and Attitude of Egyptians Towards the Novel Coronavirus Disease (COVID-19). J Community Health 2020; 45: 881-90.
27. Shahin MAH, Hussien RM. Risk perception regarding the COVID-19 outbreak among the general population: a comparative Middle East survey. Middle East Current Psychiatry 2020; 27: 71.
28. Eyanoer PC, Farhat F, Daulay ER, Zaluchu F. Perception against COVID-19 threat affecting the behavior of Indonesia people three months after the outbreak. Open Access Macedonian Journal of Medical Sciences 2020; 07: 459-64.
29. Goyal M, Singh P, Singh K, Shekhar S, Agrawal N, Misra S. The effect of the COVID-19 pandemic on maternal health due to delay in seeking health care: Experience from a tertiary center. Int J Gynaecol Obstet 2021; 152: 231-5.
30. Mahmood MA, Mufidah I, Scroggs S, Siddiqui AR, Raheel H, Wibdarminto K, et al. Root-Cause Analysis of Persistently High Maternal Mortality in a Rural District of Indonesia: Role of Clinical Care Quality and Health Services Organizational Factors. Biomed Res Int 2018; 2018: 3673265.
31. Hacker K, Choi YS, Trebino L, Hicks L, Friedman E, Blanchfield B, et al. Exploring the impact of language services on utilization and clinical outcomes for diabetics. PLoS One 2012; 7: e38507.
32. Murphy A, Abdi Z, Harirchi I, McKee M, Ahmadnezhad E. Economic sanctions and Iran's capacity to respond to COVID-19. Lancet Public Health 2020; 5: e254.
33. Malik S, Ullah I, Irfan M, Ahorsu DK, Lin CY, Pakpour AH, et al. Fear of COVID-19 and workplace phobia among Pakistani doctors: A survey study. BMC Public Health 2021; 21: 833.
34. Raoofi A, Takian A, Akbari Sari A, Olyaeemanesh A, Haghighi H, Aarabi M. COVID-19 Pandemic and Comparative Health Policy Learning in Iran. Arch Iran Med 2020; 23: 220-34.
35. Galle A, Semaan A, Huysmans E, Audet C, Asefa A, Delvaux T, et al. A double-edged sword-telemedicine for maternal care during COVID-19: findings from a global mixed-methods study of healthcare providers. BMJ Glob Health2021; 6: e004575.
36. Houghton C, Meskell P, Delaney H, Smalle M, Glenton C, Booth A, et al. Barriers and facilitators to healthcare workers’ adherence with infection prevention and control (IPC) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis (Review). Cochrane Database Syst Rev 2020; 4: CD013582.
37. Madzimbamuto FD, Ray SC, Mogobe KD, Ramogola-Masire D, Phillips R, Haverkamp M, et al. A root-cause analysis of maternal deaths in Botswana: towards developing a culture of patient safety and quality improvement. BMC Pregnancy Childbirth 2014; 14: 231.
38. Busse R, Klazinga N, Panteli D, Quentin W. Improving healthcare quality in Europe: Characteristics, effectiveness and implementation of different strategies. Copenhagen (Denmark): European Observatory on Health Systems and Policies; 2019.
2. Cucinotta D, Vanelli M. WHO Declares COVID-19 a Pandemic. Acta Biomed 2020; 91: 157-60.
3. Rassouli M, Ashrafizadeh H, Shirinabadi Farahani A, Akbari ME. COVID-19 Management in Iran as One of the Most Affected Countries in the World: Advantages and Weaknesses. Front Public Health 2020; 8:510.
4. Wei SQ, Bilodeau-Bertrand M, Liu S, Auger N. The impact of COVID-19 on pregnancy outcomes: a systematic review and meta-analysis. CMAJ 2021; 193: E540-E8.
5. Wastnedge EAN, Reynolds RM, van Boeckel SR, Stock SJ, Denison FC, Maybin JA, et al. Pregnancy and COVID-19. Physiol Rev2021; 101: 303-18.
6. Takemoto MLS, Menezes MO, Andreucci CB, Nakamura-Pereira M, Amorim MMR, Katz L, et al. The tragedy of COVID-19 in Brazil: 124 maternal deaths and counting. Int J Gynaecol Obstet. 2020; 151: 154-6.
7. Takemoto MLS, Menezes MO, Andreucci CB, Knobel R, Sousa LAR, Katz L, et al. Maternal mortality and COVID-19. J Matern Fetal Neonatal Med 2022; 35: 2355-2361.
8. Hantoushzadeh S, Shamshirsaz AA, Aleyasin A, Seferovic MD, Aski SK, Arian SE, et al. Maternal death due to COVID-19. Am J Obstet Gynecol 2020; 223: 109 e1- 109.e16.
9. Souza ASR, Amorim MMR. Maternal mortality by COVID-19 in Brazil. Rev Bras Saude MaternInfant 2021; 21: S253-S6.
10. Chmielewska B, Barratt I, Townsend R, Kalafat E, van der Meulen J, Gurol-Urganci I, et al. Effects of the COVID-19 pandemic on maternal and perinatal outcomes: a systematic review and meta-analysis. Lancet Glob Health 2021; 9: e759-e72.
11. Kingsley JP, Vijay PK, Kumaresan J, Sathiakumar N. The Changing Aspects of Motherhood in Face of the COVID19 Pandemic in Low and Middle Income Countries. Matern Child Health J 2021; 25 : 15-21.
12. Roberton T, Carter ED, Chou VB, Stegmuller AR, Jackson BD, Tam Y, et al. Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study. Lancet Glob Health 2020; 8: e901-e8.
13. Metz TD, Collier C, Hollier LM. Maternal Mortality From Coronavirus Disease 2019 (COVID-19) in the United States. Obstet Gynecol 2020; 136: 313-6.
14. Cahyanti RD, Widyawati W, Hakimi M. The reliability of maternal audit instruments to assign cause of death in maternal deaths review process: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2021; 21: 380.
15. Heher YK. A brief guide to root cause analysis. Cancer Cytopathol 2017; 125: 79-82.
16. Kinney MV, Walugembe DR, Wanduru P, Waiswa P, George AS. Implementation of maternal and perinatal death reviews: a scoping review protocol. BMJ Open 2019; 9: e031328.
17. Rahmanzade R, Rahmanzadeh R, Hashemian S M, Tabarsi P. Iran's Approach to COVID-19: Evolving Treatment Protocols and Ongoing Clinical Trials. Front Public Health 2020; 8: 551889.
18. Ghanbari M K, Behzadifar M, Bakhtiari A , Behzadifar M, Azari S, Gorji H A, et al. Assessing Iran's health system according to the COVID-19 strategic preparedness and response plan of the World Health Organization: health policy and historical implications. J Prev Med Hyg 2021; 61: E508-19.
19. Kalafat E, O’Brien P, Heath P T, Le Doare K, von Dadelszen P, Magee L, et al. Benefits and potential harms of COVID-19 vaccination during pregnancy: evidence summary for patient counseling. Ultrasound Obstet Gynecol 2021; 57: 681–6.
20. Afghah SM, Ahangari A, Askarei Pour Lahiji H. Estimating human development index of Iranian provinces and investigating its impact on economic growth using fuzzy logic. Quarterly Journal of Quantitative Economics 2020; 17: 89-121.
21. Zamankhani F, Abachizadeh K, Omidnia S, Abadi A, Hiedarnia MA. Composite social health index: Development and assessment in provinces of Iran. Medical Journal of the Islamic Republic of Iran 2019; 33: 78.
22. Patwardhan M, Eckert LO, Spiegel H, Pourmalek F, Cutland C, Kochhar S, et al. Maternal death: Case definition and guidelines for data collection, analysis, and presentation of immunization safety data. Vaccine 2016; 34: 6077-6083.
23. Shaqdan K, Aran S, Daftari Besheli L, Abujudeh H. Root-cause analysis and health failure mode and effect analysis: two leading techniques in health care quality assessmen. J Am Coll Radiol 2014; 11: 572-9.
24. Takemoto M, Menezes MO, Andreucci CB, Knobel R, Sousa L, Katz L, et al. Clinical characteristics and risk factors for mortality in obstetric patients with severe COVID-19 in Brazil: a surveillance database analysis. BJOG 2020; 127: 1618-26.
25. Tadesse E. Antenatal Care Service Utilization of Pregnant Women Attending Antenatal Care in Public Hospitals During the COVID-19 Pandemic Period. Int J Womens Health 2020; 12: 1181-8.
26. Abdelhafiz AS, Mohammed Z, Ibrahim ME, Ziady HH, Alorabi M, Ayyad M, et al. Knowledge, Perceptions, and Attitude of Egyptians Towards the Novel Coronavirus Disease (COVID-19). J Community Health 2020; 45: 881-90.
27. Shahin MAH, Hussien RM. Risk perception regarding the COVID-19 outbreak among the general population: a comparative Middle East survey. Middle East Current Psychiatry 2020; 27: 71.
28. Eyanoer PC, Farhat F, Daulay ER, Zaluchu F. Perception against COVID-19 threat affecting the behavior of Indonesia people three months after the outbreak. Open Access Macedonian Journal of Medical Sciences 2020; 07: 459-64.
29. Goyal M, Singh P, Singh K, Shekhar S, Agrawal N, Misra S. The effect of the COVID-19 pandemic on maternal health due to delay in seeking health care: Experience from a tertiary center. Int J Gynaecol Obstet 2021; 152: 231-5.
30. Mahmood MA, Mufidah I, Scroggs S, Siddiqui AR, Raheel H, Wibdarminto K, et al. Root-Cause Analysis of Persistently High Maternal Mortality in a Rural District of Indonesia: Role of Clinical Care Quality and Health Services Organizational Factors. Biomed Res Int 2018; 2018: 3673265.
31. Hacker K, Choi YS, Trebino L, Hicks L, Friedman E, Blanchfield B, et al. Exploring the impact of language services on utilization and clinical outcomes for diabetics. PLoS One 2012; 7: e38507.
32. Murphy A, Abdi Z, Harirchi I, McKee M, Ahmadnezhad E. Economic sanctions and Iran's capacity to respond to COVID-19. Lancet Public Health 2020; 5: e254.
33. Malik S, Ullah I, Irfan M, Ahorsu DK, Lin CY, Pakpour AH, et al. Fear of COVID-19 and workplace phobia among Pakistani doctors: A survey study. BMC Public Health 2021; 21: 833.
34. Raoofi A, Takian A, Akbari Sari A, Olyaeemanesh A, Haghighi H, Aarabi M. COVID-19 Pandemic and Comparative Health Policy Learning in Iran. Arch Iran Med 2020; 23: 220-34.
35. Galle A, Semaan A, Huysmans E, Audet C, Asefa A, Delvaux T, et al. A double-edged sword-telemedicine for maternal care during COVID-19: findings from a global mixed-methods study of healthcare providers. BMJ Glob Health2021; 6: e004575.
36. Houghton C, Meskell P, Delaney H, Smalle M, Glenton C, Booth A, et al. Barriers and facilitators to healthcare workers’ adherence with infection prevention and control (IPC) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis (Review). Cochrane Database Syst Rev 2020; 4: CD013582.
37. Madzimbamuto FD, Ray SC, Mogobe KD, Ramogola-Masire D, Phillips R, Haverkamp M, et al. A root-cause analysis of maternal deaths in Botswana: towards developing a culture of patient safety and quality improvement. BMC Pregnancy Childbirth 2014; 14: 231.
38. Busse R, Klazinga N, Panteli D, Quentin W. Improving healthcare quality in Europe: Characteristics, effectiveness and implementation of different strategies. Copenhagen (Denmark): European Observatory on Health Systems and Policies; 2019.
| Files | ||
| Issue | Vol 16, No 1 (March 2022) | |
| Section | Original Articles | |
| DOI | https://doi.org/10.18502/jfrh.v16i1.8596 | |
| Keywords | ||
| COVID-19 Health Services Maternal Mortality | ||
| Rights and permissions | |
|
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
How to Cite
1.
Moudi zahra, Tabatabaei SM, Share Mollashahi S, Zaboli M. Study Factors Involved in Maternal Deaths Attributed to COVID-19 in a Disadvantaged Area in Southeast of Iran. J Family Reprod Health. 2022;16(1):67-77.
