title: A mixed-methods study of maternal near miss and death after emergency cesarean delivery at a referral hospital in Somaliland.
abstract: OBJECTIVE
  To explore maternal near miss and death after emergency cesarean delivery in Somaliland, including the impact of the prerequisite for family consent.
  
  
  METHODS
  A facility-based, mixed-methods study was conducted to assess all maternal near misses and deaths recorded at a referral hospital that provided services to women from all regions of Somaliland. The data sources comprised a quantitative prospective cross-sectional study using the WHO near-miss tool (performed from August 1 to December 31, 2015) and qualitative interviews with 17 healthcare providers working at the referral hospital who were in direct contact with the women in labor (performed from January 15 to March 15, 2015).
  
  
  RESULTS
  Of the 138 maternal near misses and deaths recorded, 50 (36%) were associated with emergency cesarean delivery. The most frequent maternal complication was severe pre-eclampsia (n=17; 34%), and the most frequent underlying causes were hypertensive disorders (n=31; 62%) and obstetric hemorrhage (n=15; 30%). Healthcare providers were often prevented from performing emergency cesarean delivery until the required consent had been received from the woman's extended family.
  
  
  CONCLUSIONS
  Maternity care in Somaliland must be improved, and the issue of legal authority for consent examined, to ensure both safe and timely provision of emergency cesarean delivery.
authors.affiliation: College of Health Science and Medicine, Faculty of Nursing and Midwifery, Hargeisa University, Hargeisa, Somaliland.
authors.forename: Hamda A
authors.initials: HA
authors.lastname: Abdillahi
authors.affiliation: College of Health Science and Medicine, Faculty of Nursing and Midwifery, Hargeisa University, Hargeisa, Somaliland.
authors.forename: Khadra A
authors.initials: KA
authors.lastname: Hassan
authors.affiliation: College of Health Science and Medicine, Faculty of Nursing and Midwifery, Hargeisa University, Hargeisa, Somaliland.
authors.forename: Jonah
authors.initials: J
authors.lastname: Kiruja
authors.affiliation: School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.
authors.forename: Fatumo
authors.initials: F
authors.lastname: Osman
authors.affiliation: College of Health Science and Medicine, Faculty of Nursing and Midwifery, Hargeisa University, Hargeisa, Somaliland.
authors.forename: Jama A
authors.initials: JA
authors.lastname: Egal
authors.affiliation: School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.
authors.forename: Marie
authors.initials: M
authors.lastname: Klingberg-Allvin
authors.affiliation: School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.
authors.forename: Kerstin
authors.initials: K
authors.lastname: Erlandsson
mesh_terms: D000328:Adult; D002585:Cesarean Section / Q000706:statistics & numerical data*; D015730:Djibouti / Q000453:epidemiology; D004630:Emergencies / Q000453:epidemiology; D005260:Female; D006771:Hospitals, Maternity / Q000706:statistics & numerical data*; D006801:Humans; D007258:Informed Consent; D008428:Maternal Mortality; D000067491:Near Miss, Healthcare / Q000706:statistics & numerical data*; D011247:Pregnancy; D011248:Pregnancy Complications / Q000453:epidemiology / Q000601:surgery*; D012017:Referral and Consultation; D020458:Third-Party Consent; D055815:Young Adult
keywords: Cesarean delivery; Consent; Maternal death; Near miss; Somaliland