Maternal near miss, the voices of health service survivors: a metasynthesis

Abstract

Background

a maternal near miss experience can lead to clinical and psychosocial consequences for the woman and her family.

Objectives

To synthesize qualitative studies on the perception of women survivors of maternal near miss episodes and their trust in maternal health services.

Methods

a qualitative systematic review was performed in five electronic databases using the Guidelines for Enhancing Transparency in Reporting the Synthesis of Qualitative Research. The methodological quality of the included studies was assessed using the Critical Appraisal Skills Program. This review contains the International Prospective Register of Systematic Reviews.

Results

a total of 18 studies were chosen based on the eligibility criteria. Three themes emerged from the studies: Factors associated with delays in seeking health care Repercussions of maternal near miss; and Structural and organizational factors of the health care network.

Final considerations

There is a need to create strategies directed not only to improve the quality of care during pregnancy and childbirth, but also to support families after hospital discharge. The development and implementation of support programs for survivors of maternal near miss is recommended, including follow-up visits and psychological support for mothers and families.

Introduction

The concept of Maternal Near Miss (MNM) comprises the survival of women after a serious complication occurred during pregnancy, childbirth or the first 42 days postpartum [1]. Women who survive MNM have many aspects in common with those who died from such complications [2, 3]. Cases of MNM are important indicators for understanding the evolution of a pregnancy that ends in maternal death [4]. Due to the fact that the number of women who survive MNM is greater than the number of maternal deaths and because they are survivors, these women constitute a source of information for identifying problems and obstacles in the care provided during the pregnancy-puerperal cycle [4].

A systematic review found that the worldwide prevalence of MNM was 18.67 per 1000 live births [5], however, these rates may vary. When comparing continents, the prevalence of MNM ranged from 3.10 per 1000 live births in Europe to 31.88 per 1000 live births in Africa [5]. A systematic review carried out in African countries showed a prevalence of 73.77 per 1000 live births on the continent, with postpartum hemorrhage being the leading cause of MNM, followed by severe hypertension [6]. A study conducted in Suriname found that the stillbirth rate among women who experienced MNM was 193 per 1,000 live births, with a chance of occurrence six times higher than women who did not experience MNM [7].

Among the clinical criteria for identifying MNM are: acute cyanosis gasping, respiratory rate > 40 or < 6 breaths per minute, shock, oliguria unresponsive to fluids/diuretics, coagulation disorders, total paralysis, loss of consciousness for more than 12 h, absence of heartbeat, and jaundice in the presence of pre-eclampsia [1]. Management criteria include continuous use of vasoactive drugs, hysterectomy, transfusion > 5 units of packed red blood cells, dialysis for acute renal failure, intubation and ventilatory support for more than one hour, and cardiopulmonary resuscitation. There can also be changes in laboratory criteria [1].

Sometimes surviving a critical condition can lead to more complications and further negative consequences for the woman and her family [8]. A woman may suffer from acute or chronic clinical conditions as a consequence of the underlying disease or life-saving interventions, these include contracting an infectious disease, such as hepatitis through blood transfusions or surgery, or from continuous obstetric problems [8].

Women who survived MNM and their families can experience clinical and psychosocial consequences in their lives [9, 10]. The literature points out that, in some cases, women who survive these events continue to experience intense psychological suffering in mourning for the loss of the fetus or her reproductive capacity [11]. Additionally the women can experience changes in family dynamics [11], emotional overload, post-traumatic stress disorder [12], anxiety, depression [13], gender violence [14], and obstetric violence [15, 16]. Reports from the women themselves corroborate the fact that there are psychological scars [15].

The impacts also include disruption of the family economy through high spending, incurred debt, and loss of productive capacity, all of which can cause psychological and social problems [17]. The partners of these women seem to experience feelings of loss of dreams, dilemmas, alienation, seclusion, self-isolation and dependence on social networks. Men also report that family livelihoods may be disrupted [18].

The repercussions for near miss mothers who survived have not been fully explored and more studies are needed [8]. Health policies must include the prevention of maternal death and psychological support for women who survived maternal near miss and for their families [17]. So, obtaining qualitative information from women who have survived episodes of MNM is important to improve maternal health care [19].

Thus, this research aims to synthesize qualitative studies on the perception of women survivors of MNM episodes and their trust in maternal health services.

Methods

Type of study

This is a metasynthesis of literature, developed to synthesize and analyze primary qualitative studies to allow for the construction and presentation of a new interpretation of the phenomenon of MNM from the perspective of users of maternal health services.

The following steps were adopted: elaboration of the guiding question, systematic search in the literature and selection from references for analysis, evaluation of selected studies, and extraction and preparation of qualitative synthesis data [20]. ENTREQ (Enhancing Transparency in Reporting the Synthesis of Qualitative Research) recommendations were followed to ensure transparency and consistency of the synthesis [21]. This synthesis has a study protocol registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the number CRD42023487727.

Inclusion and exclusion criteria of articles

We included primary studies which used qualitative methods of collection and analysis focusing on the perspectives of women survivors of MNM on the repercussions of the event in their lives and their trust in maternal health services.

We chose to include articles published from 2010 onwards due to the fact that the definition of severe maternal morbidity and its clinical criteria were established in 2009 [1]. Studies with mixed methods, literature reviews, secondary analyses and grey literature (book chapters, theses, dissertations, editorials, abstracts and technical reports, articles that were not peer-reviewed) were excluded.

Search strategy and study selection

The search was carried out in five databases: Web of Science; Scopus; Cumulative Index to Nursing & Allied Health Literature (CINAHL); Latin American and Caribbean Health Sciences Literature (LILACS); and Medical Literature Analysis and Retrieval System Online (MEDLINE-PubMed). To identify other eligible relevant studies, we examined the reference lists of selected studies.

The SPIDER tool was used to structure the search strategy and guiding question [22]: What is the qualitative evidence on the perspectives of women who survived episodes of MNM, its impact on their lives and their trust in maternal health services? A librarian was consulted to ensure accuracy in the search process and in the definition of the combinations of descriptors (DECS), keywords (MeSH) and boolean operators (OR, AND) (Table 1).

Table 1 Search strategy. Ribeirão Preto - SP, Brazil, 2024. ^§

(“Near Miss” OR “Near Misses” OR “Close Call” OR “Close Calls”) AND (Maternal* OR mother* OR woman OR women) AND (pregnant* OR Postpartum OR Puerperium OR Labor OR Obstetric OR birth OR Peripartum OR delivery) AND (“Qualitative Research” OR “Qualitative studies” OR “Qualitative”) AND (Experience OR Experiences OR Meaning OR Meanings OR Perspective OR Perspectives OR Sense OR Senses OR Subjectivities OR Behavior OR Behaviors) AND (“Focus Groups” OR “Focus Group” OR “Medical Anthropology” OR “Grounded Theory” OR “Thematic Analysis” OR Hermeneutics OR Hermeneutic OR Ethnographic OR Phenomenology OR Narrative OR “Qualitative Interview” OR “Content Analysis” OR “Semantic Analysis” OR “Discourse Analysis” OR “Social representation”).

Selection of articles and evaluation of quality

The selection of the studies was performed independently by two reviewers, through the Rayyan selection platform. Initially the articles were selected after reading the title and abstract. Those that met the eligibility criteria and obtained consensus between the two reviewers were read in full for inclusion or exclusion of the synthesis (Fig. 1). Cases of disagreement were evaluated by a third reviewer.

The selected studies were evaluated independently by two reviewers in terms of quality and internal validity, according to the list of 10 questions of the Critical Appraisal Skills Program (CASP). A third reviewer was consulted in cases of disagreement. The established criteria included domains related to the adequacy of the study design, objective, research question, recruitment strategy, data collection techniques, data analysis methods, ethical issues, and results. The exclusion of any study, at any stage of the research, was described and justified.

Fig. 1

Source: Prisma flowchart of the literature search process, 2021 [23].

PRISMA flowchart of the literature search process. Ribeirão Preto - São Paulo, Brazil, 2022.

Data extraction, analysis and treatment

In the process of data extraction and synthesis, the reviewers independently performed successive readings of the articles in full. Data were organized in a standardized form, prepared by the authors, which includes: authors, year of publication, objective, method, and participants (Table 2). Simultaneously with the extraction of the data, there was the codification and the elaboration of the categories related to the perspectives on the maternal health services of the surviving women of MNM on the maternal health services. The process of coding the results of the articles was guided by thematic analysis, consisting of 6 phases: (i) becoming familiar with the data, (ii) generating the initial codes, (iii) seeking the themes, (iv) reviewing the themes obtained, (v) defining and naming the themes, and (vi) producing the final report. The coding was carried out inductively through comparison. The codes were independently organized by the reviewers into descriptive themes and, then, jointly, interpreted critically. In the chart below it is possible to verify the codes that emerged from the works analyzed in this synthesis.

Table 2 Synthesis of knowledge and thematic coding. Ribeirão Preto - São Paulo, Brazil, 2024

Results

The synthesis demonstrated that the works were carried out in countries of high, medium and low income. The country that presented the most studies on the subject was Iran [24,25,26,27]. The number of study participants ranged from less than five to almost 50 women. The most used data collection technique was the semi-structured interview [24–26, 28–33], but participant observation and the focus group were also used as data collection methods. The main theoretical reference used for data analysis was phenomenology [26–36]. Table 3 presents a summary of the studies.

Table 3 Characteristics of the included studies. Ribeirão Preto – São Paulo, Brazil, 2024

Factors associated with delay in seeking health care

Women’s lack of trust in health services and their low perception of symptoms during pregnancy, signs of risk and the severity of the clinical condition meant that they delayed seeking services [34, 37]. They chose to seek support where they had the most confidence, including family members, people in the community, or traditional healers [34, 37].

The division of responsibilities for paid work and motherhood was identified as a barrier to health care, as many women were unable to interrupt domestic tasks, hire helpers or take adequate periods of rest, even during pregnancy, worsening conditions of vulnerability [24, 36, 38], causing concerns and stress for women and their families [24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39]. The long-term impact of high diagnostic and treatment costs is evident, leading to absenteeism and incapacity for work, both for women and their spouses [24, 25, 39].

Many women reported that economic restrictions were also one of the reasons for delays in seeking health services, especially for those who did not have access to health insurance [24, 25, 34, 37]. The lack of financial resources impacted access to means of transport to travel between home and health services, the continuity of treatment, the performance of surgical procedures, the acquisition of medications and food [25, 34, 37, 39, 40]. Women work during pregnancy or return to work after an episode of NMM, even without having fully recovered their health [35, 36, 39]. Work overload, as a strategy to obtain greater financial resources, caused social isolation and distancing from friends and family [39]. It is reported that health professionals, family members and community members mobilized in solidarity actions to contribute to the financial costs [36, 37, 39]. This scarcity of resources also favored the use of alternative routes, such as medicinal plants, informal treatments, spiritual medicine [37, 39].

Religiosity and/or spirituality also played an important role for some women, who believed in divine protection and the resolution of health conditions without medical intervention [38, 40]. Many accepted obstetric complications with resignation, interpreting them as part of God’s plan [24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39]. At the same time, cultural concepts, such as belief in witchcraft also influenced delays, as some women considered complications to be the result of envy or hatred, choosing not to disclose their pregnancy or not resort to biomedical care [37, 38].

Another factor identified was the historical normalization of suffering during pregnancy, childbirth and motherhood, a historical context in which these are processes that women suffer because they were created for this, whether religiously or socially [37, 40].

Low education was a limiting factor in understanding medical guidelines, and consequently favoring delays in seeking health care [25, 26, 40].

Marital status also had a significant influence, especially when a pregnancy was terminated. It was observed that single women who chose to terminate their pregnancies hid pain and bleeding and received assistance in critical condition when they were found by family members or neighbors. In contrast, married women delayed seeking care less, feeling protected from suspicion and stigma related to spontaneous termination of pregnancy [37].

The way women were embraced and received information from health professionals affected the decision of when to seek care. Those who received information focused on the negative results of health complications and available treatments reported more anxiety and fear when faced with the need to seek professional help. It is observed that professionals’ attitudes negatively affect trust in the health service, being an important barrier [40]. It is noteworthy that many women reported that, when they went to primary care services, there was a delay in care, and the fragility of professionals’ knowledge, especially when diagnosing a woman’s clinical condition and underestimating the symptoms reported by her [34, 40].

The distance of the health service from the women’s home, geographical obstacles especially in rural and remote areas, climatic conditions, also represented barriers to access to health services [38, 40].

Repercussions of maternal near miss

The experience of the episode of MNM has led to high dependency of critical care, complications during hospitalization and postoperative surgical procedures [30, 34, 37], permanent infertility [27, 29, 37−39, 41], as well as pain reports [30,31,32,33,34,35,36,37,38,39,40,41], physical limitations [31, 34], weakness [30,31,32,33,34,35,36,37,38,39,40,41], lethargy [34], sleep disorders [39, 41] and residual illness [41], long term injuries [27] which generated loss of functionality [34]. In addition, the feeling of being defective, loss of the feminine ability and body image made the subjects extremely concerned [24, 27, 29, 36].

The mothers who experienced MNM referred to tolerating significant pain for many reasons, psychological pains added more discomfort to labor pain, postoperative pain and infection, re-surgery, intensive care procedures, lack of proper support and other imposed stresses [24, 32].

Women also reported that, a loss of consciousness, seizure or being under sedation, they missed the critical events and reported not knowing what had happened during their childbirth. They had no knowledge of what happened to their babies or procedures had been done, including hysterectomies [32, 34].

The women declared that they escaped death or experienced actual death. According to these individuals, they felt death after several procedures by physicians or their reactions/comments based on their physical sensations at that moment [24, 27, 34, 39].

MNM’s experience was a traumatic event and impacted psychological wellbeing women and spouses [26, 27, 30,31,32, 34, 39, 41]. The repercussions varied in shape and amplitude [24, 30, 39], for some women, the situation affected their mental health [24, 30], the reactions varied from insecurity, fear, stress, irritability, guilty, shocking, alarm, anxiety, incomplete self, panic attacks, flashbacks, altered consciousness, postpartum depression and post-traumatic stress disorder (PTSD) [24, 26, 27, 29–30, 31, 34, 36, 41]. Hospitalization in Intensive Care Units (ICU) caused some women to feel frightened [29]. There were still reports of hopelessness [24], hallucinations, nightmares and vivid dreams [30, 39]. Furthermore, stigma is evident, causing some women to choose not to share their condition with other people [38].

Women who experienced traumatic childbirth and perinatal death, had high levels of anxiety and concern with potential or actual harm to the newborns [32, 34, 36, 41]. The need for interventions and hospitalization of the woman or baby due to complications, resulted in the separation of the mother and the child [29, 32, 35, 41], which represented a stressful, uncomfortable and difficult event for mothers [33, 35, 41]. The breach of expectation of the idealized pregnancy, natural delivery and a feeling of failure to fulfill the maternal role [29, 31, 35, 36, 41], were deprived of initial contact, taking care of the newborn, as well as difficulties in breastfeeding [29, 33, 35, 41]. This situation caused emotional repercussions, including frustration, sadness, guilt, regret, suffering and ennui [29, 30, 35, 41].

The experience of mourning is highlighted by the death of the newborn causing heightened levels of anxiety, sadness, and worry [24, 27, 35, 41], many women had no opportunity to see the dead newborn [41]. The experience of grief for a prolonged period was evident, with significant impacts on the woman’s life [24].

Although most women made a good recovery, it often took weeks or months. frightening and emotionally upsetting, it could also result in ongoing physical problems. Several women were dismayed as they realised they were going to be less fit for the rest of their lives [30].

The lack of information or knowledge of the consequences of complications resulted in fear and insecurity about their sexual and reproductive capacity [24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39, 41]. Furthermore, the lack of guidance from professionals is highlighted [39]. Some women experienced fear, trauma and insecurity of becoming pregnant in the future and experiencing complications again [24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39, 41], in addition to having an abortion in unsafe conditions [37]. The choice of irreversible contraceptive methods was considered by some women [41]. However, unmet need for contraception and unintended pregnancies are a reality for these women [37]. In certain situations, the episode of MNM led to permanent infertility, which caused suffering, guilt and was devastating for women, especially those who wanted to get pregnant again [24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39, 41] and for those who lost their babies [41].

Some women reported difficulties in returning to their routines [27]. The MNM episode influenced family dynamics, with a greater need for social support and support in self-care, childcare and domestic tasks, however, many women reported that they did not have a support network [27, 30, 34, 35, 37,38,39], occurrence of divorce after the occurrence of the traumatic event and impact on sexual life [25, 27]. Furthermore, the experience of social isolation stands out [27, 30, 39]. Women were afraid and worried about mothers dying and their children being alone [24] and their husbands getting married again to have other children [24, 25].

Structural and organizational factors of the health care network

It was evident that communication between women and professionals was not effective [2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26, 28, 34, 38,39,40,41], with misleading and lacking information about the severity of health condition, on warning signs and symptoms, potential complications and procedures [25, 26, 30,31,32,33,34,35,36,37,38,39,40,41]. The professionals were busy or had no time for careful interaction [25, 28], in addition to a form of communication that was harsh and judgmental [34]. This difficulty in communication between professionals and women was even more difficult by the use of medical jargon [24, 26], represented a factor of stress and anxiety during hospitalization [39] and, many times the women and their family were excluded in the decision-making process about care [26, 34, 36]. These difficulties in communicating with professionals also occurred with families and companions [28].

The fear of being judged or ignored by the healthcare team negatively influenced women’s confidence in communicating their complaints [40], who often did not have the opportunity to ask questions or did not have enough time to question professionals about their concerns [28]. Some women felt frustrated with the way professionals communicated and wanted to leave the health service and go home for care [28]. Lack of communication can lead to negative attitudes toward accessing care [38, 40], frustration [28], deficiency of understanding of information and misconceptions [34].

Beyond the difficulty of communication, women had the perception that the obstetric professionals were inexperience, poorly skilled to diagnose the illness timely, performed misdiagnoses, inappropriate treatment, incomplete care, neglect [24,25,26, 29, 34, 37], delay in healthcare service [33, 34] and early hospital discharge [37,38,39,40]. Women also reported that obstetric professionals did not pay enough attention to complaints, with consequent delayed treating disorders, which caused worsening of the clinical condition [25, 26, 33, 37]. In addition, limitations were noted by medical professionals in identifying risk and manifestations of severe maternal morbidity in women with a history of previous complications [40]. As a result, women reported neglect of the medical team [24], low confidence in their guidance, and consequently refusing to undergo treatment [25, 26, 37, 40]. Women felt that their voices were not heard [26].

Infrastructure deficiency in health services, congested wards, lack or malfunction of equipment, lack of supplies, poor organization of services, transportation problems, therapeutic itinerary, staffing issues, harmful protocols, and inconsistent processes were highlighted [25, 26, 33,34,35,36,37,38, 40]. The turnover of professionals who care for women leads to fragmented care and the breakdown of bonds [26, 34].

Furthermore the carrying out of different interventions, without the women’s consent, about the care that they received or the procedures performed [26, 28, 33,34,35,36, 38, 39], confidential information transmitted to other people [38]. This situation promoted the woman’s feeling of clear disruption of feelings of bodily integrity [39] and disrespect [37]. It was reported that some professionals presented an authoritarian stance, verbally attacking the women and failing to provide physical and mental support [24, 25, 33], and did not inform the woman about her health condition [25, 26]. In addition to the violation of rights and carrying out interventions without scientific evidence, the women studied also reported undesirable behaviors by professionals, such as: disrespectful treatment, physical and gender abuse, disregard, lack of compassion and lack of privacy, not taking the patient seriously and intolerance [26, 33]. Also reported were episodes of discrimination due to: origin, ethnicity, social status, gender, insurance, racial, and stereotyping [25, 26, 33].

Discussion

This meta-synthesis enabled a rigorous review of the qualitative literature and analyzed the experience of women in the puerperal pregnancy cycle who survived an episode of MNM, as well as their perception of maternal health services. Factors that characterize this experience and the intertwined perceptions about the services can have repercussions on the negative and positive outcomes of these women’s pregnancies.

The studies showed that trust in maternal health services was associated with individual, social and organizational factors of the network, which may be related to the delay of women in seeking health care. Among these representations were the high financial costs on maternal health services, in which economic constraints and financial costs to pay for procedures and consultations [34, 37], as well as the absence of health insurance [25], were present in the discourse of women, and may be related to the delay in seeking services.

Access to health services includes direct and indirect costs, such as travel, costs of staying at the health service location, procedures and obtaining medicines [42]. It is already well defined in the literature that accessibility to health services is characterized by the relationship between the location of supply and users, distance between them, the form of displacement and the financial costs to acquire care. In this way, any attempt to reduce avoidable deaths of mothers should take into account how costly it is for women to travel to receive professional care [42].

Women’s self-attitude to seek professional care [34], women’s perception of health services [34], women’s low education levels [37], impaired self-evaluation of MNM symptoms [34, 36, 37], as well as problems understanding the guidance of health professionals [28] were referred to as barriers to search for health services at the right time. On the other hand, women reported that when they were well informed, engaged, encouraged and involved by health professionals, this seemed to increase confidence in the health system, as well as the search for the same [28].

The religious belief that something supernatural could solve the clinical picture of women [40] was also listed as a barrier to the rapid search for services. Behaviors resulting from an exaggerated positivism based on the belief that a Superior Being will protect them from any evil, behaviors that may neglect symptoms or not adhere to preventive practices or proposed treatment, or even beliefs in which the disease is seen as punishment are considered harmful with regard to religious coping [43].

It is important to highlight that spirituality and religiosity can also act positively, such as providing relevant resources in coping with a long period of hospitalization. Moreover, to recognize the well-being that these aspects provide to patients is to provide humanized care, through the relevance that patients attribute to religion. Many patients find in faith optimism, hope and the motivation to engage with the treatment, being considered extremely relevant aspects for recovery [43].

Among the structural and organizational factors of the health care network and services associated with the worsening of women’s health conditions the following were reported: absence of professionals [24, 25], lack of professional training [24, 38], lack of ability to recognize episodes of MNM [24,25,26,27, 29,30,31,32,33, 35, 36, 38, 40, 41], difficulties of primary health care workforce in identifying symptoms of MNM [25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40], inadequate obstetric triage [40], failures in prenatal care [24,25,26, 38], deregulation of means of transport [38, 40], not believing women’s reports of discomfort [38, 40], discrimination [25, 26], and occurrence of obstetric violence [25, 26]. Due to inappropriate communication and treatment, women are forced to seek repeated care [25, 37], emphasizing the need to improve communication and continuity of care.

Women recognized the protective role of community health agents [38]. Community health agents (CHA) are singular professionals with general attributions in the prevention, promotion and protection of health, and with a role of social mediation through being a political agent in the territory. The CHA have a fundamental role in articulating actions among families, users and health services, strengthening bonds, helping communication, and developing a broad scope of health actions [44]. In remote rural locations, in general, they are the only accessible health resource and have a broader scope of practices than those of the cities’ clinics, including individual procedures [44]. Thus, CHA can act as a powerful mediator between the population as a whole and the network of maternal health services, acting as a catalyst for communication between users and health professionals.

Among the repercussions of the MNM were the feeling of imminent death [35], suffering due to being separated from the baby, anguish and anxiety generated by not knowing what had happened [28, 41], psychological stress [24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39, 41], physical injuries [24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39], fear of becoming pregnant again [24, 41], post-traumatic stress [27,28,29,30,31,32,33,34,35,36,37,38,39,40,41], mood changes [27], psychological disorder of the spouse [27], and depression [27, 41], in which the risk of postpartum depression in MNM mothers is twice as likely as in women without MNM [44].

Thus, more attention should be paid to psychological symptoms, such as depression in MNM, in order to reduce the burden of maternal morbidity in the long term [45]. More emphasis should be placed on informing women who became unconscious during the hospitalization period, because not being aware of what occurred can cause even more anguish and anxiety [28].

Among the physical symptoms that affect women after hospital discharge, are loss of stamina, general weakness, residual hypertension, signs and symptoms of anemia, pain, difficulties with sleep, dyspareunia, and permanent infertility [41]. As an example of the clinical conditions that affect these women, dyspareunia is frequently presented [9, 10] and usually women resume sexual activity later when compared to those who did not have MNM [10].

A study conducted in São Paulo-SP, Brazil [46], observed that women, when beginning the process of illness in the pregnancy-puerperal cycle, follow different trajectories, seeking services of low and high complexity, while also looking for support in the neighborhood, and self-medicating. There were barriers related to embarrassment, continuity of care, resolution, and reference in the Health Care Network (HCN). There were also important critical points in relation to obstetric care, which included the journey to health services, the delay of referral, and the reality of institutional violence experienced by women [46]. The tertiary service was also pointed out in the literature as being welcoming and effective in care [46].

The factors that influence women’s perception of the quality of care should be a cause of concern for those seeking to improve services in health units [34]. It is believed that the results of pregnancy would be improved with educational actions on pregnancy complications, CHA training, and the implementation of programs of sustained orientation [38]. Women affected by socioeconomic and humanitarian challenges and with special needs, such as health literacy, should receive additional attention in prenatal consultations to improve maternal outcomes [40].

Conducting educational groups for pregnant women is an important tool in reducing maternal and neonatal mortality among women living in rural areas and should be considered in other contexts [31]. Training in communication and information provision should be an integral part of medical training to improve the quality of care [28]. Such training in communication should consider the special needs of women and families where there was an episode of unconsciousness during morbid events [28].

There is a need to create strategies directed not only to the quality of care during pregnancy and childbirth, but also for support after hospital discharge due to severe obstetric complications [24]. It is recommended to develop and implement support programs for MNM survivors, including additional follow-up visits, psychological support for mothers and other family members, from the moment of hospitalization until long after discharge, counseling on marital relationships, and sexual counseling [27].

It is suggested that communications be improved between health team members and patients in order to prevent MNM [24]. Psychological counseling is also recommended to relieve emotional pain. The provision of health insurance services after discharge is essential to reduce financial expenses [24]. Also, family counseling can also relieve the fear of becoming pregnant again [38].

Another aspect to be highlighted is that women have expressed concern about being penalized for violating laws, however, this does not seem to prevent women from carrying out procedures and practices that go against the legislation in force in their countries. It is recommended that there be an improved, though respectful, understanding of beliefs and sociocultural aspects [37].

Maternal health professionals need to know that it is not enough to focus only on saving the physical life of the mother. Strengthening the role of motherhood and fatherhood should be an essential element to support families that have survived a MNM, and who have undergone difficult physical and psychological conditions [35].

There is also a need to conduct a weekly MNM audit and use data to inform and improve the practice in all health units [46]. The approach to MNM survivors should be guided beyond epidemiological observation, but should also be screened for psychological suffering, which is a marker of vulnerability [27]. The limitation of this study centers on the delimitation of the search period of the articles, and some articles may not have been included outside this period.

Conclusion

To reduce preventable maternal deaths, it is necessary to consider the burden on women of seeking professional care. Barriers such as individual attitudes, perceptions about health services, low education, impaired self-evaluation, and religious beliefs can delay the search for health services. On the other hand, when women are well informed and encouraged by healthcare professionals, their confidence in the healthcare system and seeking care increases. Structural and organizational factors, such as lack of professionals, team errors, lack of training, inadequate communication and the occurrence of obstetric violence, contribute to the worsening of women’s health conditions. Improving communication and continuity of care is essential so as to avoid repeated seeking of health care due to inappropriate treatments.

MNM can have significant repercussions, including feelings of imminent death, separation from the baby, distress, anxiety, psychological stress, physical injuries, fear of becoming pregnant again, post-traumatic stress, mood swings, and depression, with an increased risk of post-partum depression. After hospital discharge, physical symptoms such as loss of stamina, weakness, residual hypertension, anemia, pain, sleeping difficulties, dyspareunia, and permanent infertility may persist. Support strategies, including psychological support programs, follow-up visits, relationship counseling and financial support, are essential to help women after hospital discharge.