Theoretical Framework

The synthesis was guided by the quality of care framework for severe maternal morbidity [12], Andersen behavioral model [13], as well as by findings from articles and team discussions. The quality of care framework for severe maternal morbidity depicts the experience of care received and the experiences of women with severe maternal morbidity. The quality of care received comprised the evaluation of factors such as the provider-client information (communicating the situation and the outcomes to the patient), interpersonal relations (including the attitude of the providers) and human and physical resources. The factors that women discussed in relating their experience of severe maternal morbidity included coping mechanisms, the impact of losing a baby, thoughts and perceptions of death and how the women perceived the care they received, which in turn influenced their satisfaction [12].

The Anderson model explains the health care seeking behavior of individuals, which was categorized into an individual's predisposition to use medical services, enabling or impeding circumstances and the need for health care. Predisposing characteristics related to demographic elements and social structures included age, gender, residence, occupation, education, ethnicity and attitudes regarding one’s health. Enabling elements consisted of community factors that affect the availability and accessibility of health care; and personal factors such as knowing how to take advantage of what is offered. Finally, the needs for health care included the type of illness, perceived health status and the expected treatment outcome [13].

After providing a brief overview on the narratives of women in this review, we describe the experiences of women who experienced severe maternal morbidity and the quality of health care received, organized into the following themes: perception of the provision of care, severe maternal morbidity experience and health care seeking behavior. These elements are interrelated and influence how the women cope with severe maternal morbidity and their perceptions regarding the quality of care.

Design

The design of this review included (a) a comprehensive search, (b) appraisal of reports of qualitative studies, (c) classification of studies, and (d) synthesis of the findings. The meta-ethnographic approach [10] was applied to generate the findings or theoretical insights in exploring the experience of women with severe maternal morbidity. This approach can be applied to a full range of qualitative methods and is not limited to only ethnographic studies. Several findings from one particular paper were identified and compared with the findings from another paper to generate the initial concepts. Similar concepts were then collapsed to create a parsimonious thematic structure in a process termed 'reciprocal translation'. Each author then reviewed the themes independently to ensure that no data were left unexplained or explained differently. This process of searching for disconfirming data is termed 'refutational translation'. The themes were then synthesized into a 'line of argument', which is a phrase or statement that summarizes the main findings of the study.

Search Methods

The search methods included (a) a review of studies that examined the experience of women with severe maternal morbidity (including very severe maternal morbidity), and (b) qualitative and/or mixed methods designs. Studies were limited to (a) those published or available in English, (b) studies in peer-reviewed journals, and (c) those undertaken between January 1980 and August 2013. The literature search was conducted using the following databases: MEDLINE, CINAHL, the Cochrane Library, PubMed, PsycINFO, Scopus, Science Citation Index, EMBASE and BMC. Search terms included the following: near miss morbidity, near miss, severe maternal morbidity, severe acute maternal morbidity, obstetric near miss, maternal near miss and obstetric near miss.

Search Outcome

In total, 276 citations were retrieved, and after reviewing the title and abstract, 265 articles were excluded because they failed to address the initial selection criteria (S1 Fig and S1 PRISMA Checklist). The studies were either quantitative studies or were unrelated to the experience of severe maternal morbidity. The full articles of the remaining 11 citations were obtained and reviewed. Two articles were excluded as they were not published in English; ultimately, nine articles were taken forward for quality appraisal.

Quality Appraisal

The quality of each study included in the review was assessed with a modified version of the Critical Appraisal Skills Programme (CASP) tool [14]. The CASP provides a standardized mechanism for appraising qualitative studies [15]. It consists of 10 questions covering the credibility and relevance of the studies and has been used in previous reviews of qualitative studies [16–18].

The first two questions screened for relevance and appropriateness of the studies and the following eight questions assessed the research design, sampling, data collection and analysis, reflexivity (research partnership relations / recognition of researcher bias), ethics, findings and the value of the research. A scoring system applied by Duggleby et al. (based on a three-point rating system developed by Feder et al.) was used in this review [15, 18]. For each question, a weak score (one point) was assigned to articles that offered little to no justification or explanation for a particular issue (e.g., where, when, or how the data were collected was not mentioned). A moderate score (two points) was given to articles that addressed the issue but did not fully elaborate on it (e.g., the justification for using constant comparisons was presented but the procedure itself was not explained). A strong score (three points) was assigned to articles that extensively justified and explained the issue at hand (e.g., the authors explained that semi-structured interviews were used, transcribed verbatim and modified part way through the study, and then offered some sample interview questions). For each article, a score was calculated for all eight questions and then totaled, with a possible maximum score of 24. For the nine articles included, the CASP score ranged from 11 to 24 with the mean (SD) score being 17.1 (3.66).

Data abstraction and synthesis

Table 1 presents a summary of included studies and their purpose, methods and quality appraisals. The stated methodological approaches employed were: (a) thematic analysis [12, 19–25] and (b) discourse analysis [26]. The findings from the studies were managed using NVIVO 10 software. It is software that allows users to classify, sort and arrange information by coding and generating the list of code categories. The code categories formed were based on the analytic expertise of the users. Code categories were refined as subsequent data were gathered. The initial concepts identified the experiences of women with severe maternal morbidity and their perceptions toward the quality of health care as reported in the studies. Following the interpretations or conclusions of the primary studies, emerging themes were formed. Interpretations or conclusions of the metasynthesis formed the final themes. The constructs were also assessed in relation to the quality of the included studies.

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Table 1. Summary of articles in the metasynthesis.

https://doi.org/10.1371/journal.pone.0130452.t001

Validity

The validity of this metasynthesis was maintained by (a) a comprehensive literature search, (b) team discussions and decisions on search terms and inclusion criteria, and (c) an assessment of the appraisal and assignment of CASP scores. Two reviewers (NMN and SS) independently appraised each study, and presence of any differences was resolved by discussion or adjudication by a third reviewer (NHNH). The team also discussed the findings of the studies and themes until agreement was reached through consensus.

Theme One: Perception Regarding Provision of Care

This theme incorporates three emerging themes, which include the quality of medical care, provider-client information and relationship, and human and physical resources within the health care setting.

Theme Two: Severe Maternal Morbidity Experience

Theme Three: Health Care Seeking Behavior

Theme One: Perception on Provision of Care

An important aspect that was revealed and needs to be considered regarding the pregnancy, delivery and puerperium periods is the quality of medical care and provider-client relationship. The patients' evaluation of the occurrences in severe maternal morbidity cases may or may not be the same as that of the providers. As such, this metasynthesis provides additional elements in the evaluation of the quality of maternity care [24]. Delays that include the woman or her family waiting to seek care, delays in reaching appropriate health care facilities and delays in receiving adequate care have long been recognized in overall patient management and were frequently observed in previous studies [12, 19, 24, 27]. In these studies, the documented reasons for the delays included the requirement to disinfect the operating theater following an infective surgery and the lack of theater space and staff [19].

Inadequate or inappropriate diagnosis or recognition of high risk and inappropriate treatment and inadequate documentation were the most common preventable events. This situation represents a potential causal chain where poor diagnosis may lead to inappropriate, inadequate or even the absence of treatment. Additionally, inadequate charting may reflect indecision in both diagnosis and treatment options [28]. Based on a 5-factor scoring system for classification of maternal morbidity, women with near-miss morbidity were four times more likely to have these provider-related preventability factors, compared to women with other severe but non-life-threatening morbidity. This finding indicates that changes in health care providers' behavior may have a significant impact on the women [29].

Women's perception of good quality of care includes adequate provision of information, good communication and the attitude of health staff. Women require information about their condition and treatment protocols and need to be given the opportunity to ask questions and receive clear answers. Although in certain circumstances this was not possible as the women were unconscious, it is important to highlight the fact that having access to such information calms their worries and makes them feel safer. Positive doctor-patient interactions may also improve their coping mechanisms and self-confidence, leading to improved future health care seeking [12, 24]. Gratitude for the care received may reflect either optimal care or, on the contrary, the women's low expectations [19].

Theme Two: Severe Maternal Morbidity Experience

The occurrence of disagreeable physical experiences triggered by a severe pregnancy complication leads to the feeling of impending death and fear. Women may then be involved in a complex process of reviewing their life history and future expectations. Those dealing with loss or sick babies were at risk of experiencing adverse psychological consequences [12, 22, 26]. This situation has been described as 'maternal near-miss syndrome' [22].

'Failure' of the normal pregnancy damages the woman’s self-perception and hampers the fulfillment of some of her social roles [22]. Appropriate doctor-patient interactions involving the provision of adequate information and care for both physical and emotional aspects should be ensured for the mothers. Considering maternal needs, respecting their expectations and individuality, and including them in the child’s recovery, could provide more security, higher self-esteem and trust for the women [26].

The loss of a baby negatively influenced the women's perspectives and coping mechanisms. They were more likely to have poor mental health by three months postpartum compared to women who did not have a complicated delivery [7]. Due to the vulnerability of this group towards postpartum morbidity, they require extra attention, including counseling and postpartum visits from their health care providers [7, 22, 30]. The women often anchored themselves in religious beliefs because they believed that God would give them strength in overcoming their problems [12, 26]. Therefore, it is important for health care providers to acknowledge the religious needs of the women and include this as a strategy to increase women’s ability to overcome difficulties [26].

Theme Three: Health Care Seeking Behavior

Many women criticized health care providers for being inattentive to them, suggesting the occurrence of substandard care. However, a delay in the decision to seek help was also observed [21, 22, 25]. The extent to which the delays were either due to lack of recognition of the seriousness of the condition, difficulties in accessing care or difficulties in undertaking natural roles, remains unclear [22].

Some women understood and recognized the severity of their condition but were unable to translate this knowledge into the prompt action of seeking health care because these decisions were made by others [25]. In this regard, interventions to improve the timely seeking of medical care that are targeted to husbands and family members are needed. Nevertheless, lack of decision-making power due to early age at marriage and low maternal education would require societal improvements in the women's status [7, 31]. Women’s empowerment is essential in health promotion programs if maternal mortality and morbidity are to be reduced [19].

The perceptions of being mistreated in the hospital and deprived of essential information led to a lack of confidence and distrust in the health care system. These factors strongly influence the utilization of maternity care services [21, 32, 33]. Distrust in health care providers leads to fear of Cesarean sections, thus causing women to avoid utilization of the delivery care [34]. Maternal care-seeking behavior is also shaped by social differentiation. The perception of being separated from other social categories due to socially demographic disadvantages suggests that the seeking of care is a socially structured practice rather than a reflective decision-making process carried out by the women [21].

Women’s powerlessness was observed, as they generally do not participate in decision-making and are only informed about any medical decisions that are made. They were led to think and act according to the convenience of the health care system [26]. However, it is important to note that the involvement of women depends on the nature of care, whether it is emergency or elective, acute or chronic, or if the women have the motivation or ability to become involved [24].

Care seeking from non-certified health care providers is still prevalent in certain developing countries. Cultural preferences for traditional birth attendants or village doctors were thought to have a role in preventing or delaying women from seeking health care. However, one study reported that this situation was more likely due to social exclusion related to ethnic background [21]. Give the lack of knowledge and skills among non-certified health care providers [19], training them in identifying serious complications and helping to refer the women to health care centers would greatly assist the health care system.

Cost was another important issue. Barriers related to distance and transportation may impede access to maternal health care, especially for poor women [21]. In the event of severe maternal morbidity, the hospital stay tends to be longer and, thus, the hospital charges escalate rapidly. Other expenses (such as drugs that are not available in the hospital pharmacy) may further add to the total cost and cause distress to the women and their families [12].

Language barriers may be overcome by the presence of professional interpreters. However, focused questioning of complaints (which may be vague) and attention to individual circumstances may help in the early diagnosis of maternal morbidity. Thus, competent diagnosis and decisive action by health care providers are more important than patient-centered participation [24].

A major strength of this review is that it explores the experience and perceptions of women who survived severe obstetric complications. It provides insight into the risk factors and potential strategies for the prevention of maternal morbidity and mortality as they share similar characteristics with women who have died. We identified qualitative studies that were completed worldwide, and most of the literature was published within the last few years, indicating a new interest in this area.

This review is not without limitations. First, like many other qualitative research, it is not possible to draw conclusion on causality or generalizability. If this review was substantiated by quantitative component, implications for clinical practice can be made. However, it was beyond the scope of this review. We contend, however, on the credibility of the information, and the transferability of the theoretical knowledge that is applicable to other similar group of women.

Second, although one study included in the review may not met the criteria of high quality research, the expressions of experience offer an insight into important research concepts and questions and contribute to the richness of information. Third, although we have searched multiple databases and the grey literature, we did not include qualitative data in national and regional confidential inquiry reports, unpublished data presented at smaller conferences, or studies published in foreign language and non-indexed journals. Fourth, the majority of the studies were conducted in developing countries, and this review therefore does not represent the complete global view of women with severe maternal morbidity. Finally, more studies are needed to develop further understanding of the differences experienced by the women in various health care systems and communities.