Development and Validation of a Program Logic Model (PLM) to Support "Near Miss Mother"(NMM): A Nominal Group Technique (NGT)

Background: Mothers who have experienced a near miss event, their normal life is affected by physical, psychological, emotional, social and economic adverse effects. The aim of this study is to develop a supportive program for near miss mothers (NMM), based on a program logical model (PLM) that has been validated using the nominal group technique (NGT). Methods: After conducting qualitative and systematic reviews studies to assess the needs, components of PLM were extracted that provided the framework for the utilization of activities, outputs, outcomes and impact. A Nominal Group Technique method done in a one-day workshop with the participation of 12 professionals was held in November 2020. Results: Eight strategies used in draft support programs based on the logical model, included the following: "psychological", "fertility / childbearing", "information", "care quality improvement", "socio-cultural", "nancial", "breastfeeding" and "nutritional". The validation of the program was done based on the ve steps of the NGT during the steps of creating ideas, silent generation of ideas, round robin, clarication of ideas, Prioritization. Finally, a nal program was presented to support NMM. Conclusions: Simultaneous integration in the PLM and NGT method allowed the rst program developed to support NMM to be comprehensive and complete. Using this evidence-based program can help reduce the burden of maternal morbidities in millions of women around the world and prevent long-term complications and shorten their rehabilitation phase.


Background
Mothers who due to childbirth morbidities have gone close to death, but have had a narrow escape, experience near-miss conditions [1,2] and experience long-term negative psychological and emotional effects [3,4,5,6,7], and along with organ dysfunction and physical problems, they experience anxiety, isolation, depression, and trauma childbirth [8,9]. Other family members and the infant will not be immune to these negative effects, either [7,10]. It has been shown that psychological interventions can signi cantly reduce postnatal depression among at-risk women [11]. These interventions include programs and policies such as home visits by a health professional, peer support provided over the telephone, interpersonal psychotherapy, and counseling [11]. In a study conducted in 2016 in the United Kingdom, to support "near-miss" mothers(NMM), Knighte recommended routine application of counseling and other methods that are helpful for the prevention of post-traumatic stress disorder and postpartum depression [12]. Following a delay in resuming sexual activity, there is a higher prevalence of sexual problems among such mothers, too [13]. Sometimes after a baby loss, the mother should be followed up for a shorter or longer time for a subsequent pregnancy [14]. Implementing integrated care, including physical, psychological, social, and spiritual aspects of women, can help reduce the burden of pregnancy complications on millions of women around the world [15]. Standard Six of the World Health Organization's standards for maternal and neonatal care also states that every woman and her family and companions should be emotionally supported and empowered [16]. To prevent depression, this standard also recommends that trained personnel provide high-risk women with psychological support during postpartum care [17].
Due to the physical, psychological, economic, and socio-cultural problems that these mothers tackle, many sources focus on special care and support for them [15,18,19]. Unfortunately, there is currently no coherent plan to support such mothers, and the current irregular follow-up may not re ect a complete image of their primary care after discharge from the hospital [20]. A study conducted by Furniss in New Zealand in 2018 recommends that speci c programs should be planned, implemented, and evaluated to reduce the burden of mental and physical problems of these mothers [21] and prior to hospital discharge and based on their biography, the information should be elicited from such mothers to make social-psychological support and regular and periodic follow-up possible [21] so that their concerns are mitigated as they know they are cared for [22]. Because these mothers are discharged from the hospital in di cult conditions, they struggle with the problems faced by themselves or their families, a fact which highlights the need for a plan. To this aim, this study used the Program Logic Model (PLM) to provide support for "near-miss" mothers. This use of this model is justi ed on the account that it is a practical and easily-implemented program which takes all required aspects for goal achievement into account and, furthermore, there is a logical relationship between program resources, activities, outputs, audience, and immediate, intermediate and long-term outcomes of a particular problem or situation [23]. This model has also been used in reproductive health planning [24,25] and has gained special popularity in the eld of midwifery [26,27]. Therefore, the purpose of this study is to develop a supportive program for near miss mothers, based on a logical model that has been validated using the nominal group technique.

Methods
The following are the components that the PLM illustrates: assumptions, inputs, activities, outputs, outcomes and impact. The outcomes include three situations immediate, intermediate, and long-term. Resources include personnel, educational facilities, equipment, funding or nancial incentives. Activities encompass all activities that cover the extracted needs assessments. Outputs include products resulting from the program, such as the number of participant served in the activities or intervention. Immediate outcomes are changes in the target groups' knowledge. Attitudes or skills are changes in intermediate outcomes. Long-term outcomes relate to behavior. Impact relates to larger scale of overall effects or vision of program. Based on this model, at the outset, a needs assessment should be done to assess the situation. Therefore, in this study, data sources were performed based on a phenomenological study[28] and a systematic review study [29] so that the resulting program includes the experiences and views of mothers and service providers and the published papers comprehensively re ect the concerns of the target population. We also interviewed 37 experts in the eld of NMM to assess the needs of these mothers and then use them in the structural components of the program. After the approval of the university ethics committee, receiving informed consent and adherence to con dentiality, the assumptions of the program were determined. After the needs were extracted, the relationship between the program inputs and outputs was accounted for using a logical pattern within the "if-then" framework. i.e., "if" resources or inputs are provided, then what activities can be implemented, or "If" the program activities are implemented successfully, "then" what are the outputs and consequences. Then, after a few sessions of brainstorming by the research team, the initial draft of program near-miss mothers' support program was prepared.
Then, the Nominal Group Technique (NGT) was used to validate the program. This technique has repeatedly been used to facilitate decision-making processes in health care and has shown good results [30].The decision-making process using the nominal group technique consists of ve steps [31].
After the approval of the ethics committee of University of Medical Sciences, 12 experts and key people in the eld of near-miss mothers were invited to participate in the meeting through o cial correspondence in accordance with the opinions of professors and members of the research team. The selection of experts was purposeful. This expert panel was formed in October 2020 at the university meeting hall. All methods were carried out in accordance with relevant guidelines and regulations. Also written consents were obtained from those present at the meeting to publish their views.

Results
The results of developing a support program for near-miss mothers based on a rational model included eight strategies. These strategies are designed based on "psychological", "fertility / childbearing", "information", "care quality improvement", "socio-cultural", " nancial", "breastfeeding" and "nutritional" needs. Based on this, the inputs and activities of the program were listed and the results and consequences of these activities were identi ed. Table 1 summarizes the strategies of the Near-Miss Mothers Support Program. In the next step, the initial draft program was validated through the nominal group technique. For this purpose, 12 experts in the eld of near-miss mothers participated in a one-day workshop that lasted about 3 hours. Then the meeting was led based on the following steps: Step 1: Creating Ideas: At this stage, as a facilitator, the researcher introduced the purpose and general topic of the meeting. Then she explained the steps of the nominal group technique and how to announce the results. At this stage, the initial draft program was given to the people at the outset of their attendance.
Step 2: The silent generation of ideas: At this stage, the researcher asked the participants to provide clear and straightforward responses to the written questions individually, while maintaining silence in the meeting and without consulting other people. They were asked to generate ideas. In this study, the participants were given half an hour to generate ideas. The questions raised in this meeting were: "What are the shortcomings in the draft program that need to be corrected?" and "What suggestions do you have for upgrading the "Near-miss" mothers support program?". At the end of the idea generation period, the researcher collected the written ideas.
Step 3: Recording Ideas or Round robin: In this step, the researcher wrote all the ideas written on the paper on the board. The researcher listed the ideas regardless of their content and evaluation. Sometimes ideas were either for or against each other. In this study, this step lasted for 30 minutes. At this stage, the researcher asked two of her colleagues to help her write ideas so that she would spend less time on this stage.
Step 4: Clari cation of ideas: This step aims to let all participants have a full understanding of the generated ideas. Therefore, in case there were any ambiguities or questions by any person, they were clari ed and the ideas were elucidated. Similar or duplicate ideas were then merged so that clari cation could be done with a fewer number of ideas. Some of the ideas were removed after clari cation with the permission of the owners of the ideas because they were not properly connected with the purpose of the program. After the owners of the ideas provided su cient explanations on the remaining ideas, clari cation, and speci cation was done. In this study, this step lasted about 50 minutes.
Step 5: Voting and Prioritization: The last step in the nominal group technique is to prioritize the remaining ideas. This step has two parts. First, each person selected ve ideas she thought were the most important. Second, the selected ideas were scored and ranked. In this method, the number one meant the lowest score and the number ve meant the highest score for each idea. After the participants scored the ideas, the scores of ideas were listed and the ten ideas that received the top scores were selected to be used in the near-miss mothers' support program. The nal list of top ideas for the nearmiss mothers' support program is displayed in Table 2. After the initial draft of the near-miss mothers support program was edited to include the top ideas, the nal program was prepared and based on the logic model shown in Table 3.

Discussion
In this study, the near-miss mothers support program developed based on the logical model was validated using the nominal group technique. In 2011, the World Health Organization published a guide entitled 'Evaluating the quality of care for severe pregnancy complications: The WHO near-miss approach for maternal health' so that the executive teams of the Ministry of Health of each country can collect the required information on a current situation and based on the type and characteristics of the required facilities and resources be able to have a complete and sound plan [32]. In this regard, the manual of the World Health Organization's Regional O ce for Europe suggests meetings with the presence of all stakeholders of the health care system to prevent errors. Along these lines, a facilitator who has already reviewed the entire case summary from the beginning of the mother's arrival until her discharge using the door-to-door approach conducts the meeting [33]. Another interesting program running in the UK for near-miss mothers is the UK Obstetrics Surveillance System (UKOSS), which by asking questions assesses the sepsis, identi es avoidable factors, and xes current problems while revising existing guidelines [34].
A comprehensive review of near-miss mothers' programs in Iran and other countries leads us to conclude that all these programs identi ed and collected quantitative data of near-miss mothers or evaluated errors based on the patient records. These programs have focused only on the situation and prevalence of these mothers and have ignored their psychological, social, economic, cultural, and nutritional conditions. However, the program designed in this study, aiming at providing near-miss mothers with comprehensive support, emphasizes emotional support and counseling in eight strategies and is fully comprehensive. People involved in the implementation program include gynecologists, hospital midwives, midwives of healthcare centers, health care providers, primary healthcare providers, nurses, university professors, and students and other staff working in healthcare centers such as hospital committee o cials, supervisors, hospital managers, senior nursing o cers of the obstetrics and gynecology wards and the intensive care units, maternal health experts, etc.

Strengths and Limitations
This program is the rst accredited support program in the world, which was based on the aggregation of views of service providers and policymakers in the eld of maternal health, and prior to this study there was no comprehensive program focusing on maternal morbidities and especially near-miss mothers in Iran and other countries. Examining the reliability of the program and con rmation of its validity by health experts were other strengths of the study. A further strength of this study was needs of participants such as mothers, spouses, service providers, and policymakers were extensively assessed through qualitative studies that included maximum diversity from all groups in the eld of health care who had valuable experiences. This made it possible to assess the needs of mothers from different perspectives and angles, and no points were ignored in the program.

Conclusion
Due to the nominal group technique with maximum diversity of experts and authorities in the eld of near-miss mothers and the generalizability of the model, applying the results of the validated program to maternal health policy-making can be very bene cial and signi cant, and in line with the millennium development goals, these ndings can be used not only in Iran but also in most countries and will be a turning point in advancing the goals of maternal health. Informing service providers and families about the support procedure taking the needs of near-miss mothers into account, in addition to empowering and rehabilitating mothers and reducing the burden of childbirth complications for mothers, makes children and spouses enjoy the bene ts of the mother's higher quality of life, and prevents from lifelong prevention of women. This program increases the mental readiness of healthcare personnel to provide the support required by near-miss mothers and convinces them not to be negligent for a moment of the thoughts and feelings of someone who has been on the verge of death and undergone conditions different from a low-risk mother. It is recommended that the effects of program implementation be investigated through interventional studies on reducing the burden of morbidities, such as physical, psychosocial.

Declarations
Declarations heading: This program is the rst accredited support program which was based on the aggregation of views of service providers and policymakers in the eld of maternal health that focusing on maternal morbidities and especially near-miss mothers.
Using this evidence-based program can help reduce the burden of maternal morbidities in millions of women around the world and prevent long-term complications and shorten their rehabilitation phase.

Ethical considerations
The study was approved by the Ethics Committee of Mashhad University of Medical Sciences (IR.MUMS.NURSE.REC.1398.009). All participants were given oral information about the goal of study, and informed consent was obtained from all of the participants. Anonymity were secured, and participants were informed that they could withdraw from the study at any time.

Consent for publication
Consent for Publication-NA/Not Applicable.

Availability of data and material
Data could be available upon a reasonable request and with the permission of Mashhad University of Medical Science ethical committee. The interviews used in this study are taken from a part of the doctoral dissertation work.

Competing statement
The authors declare that they have no con icts of interest. Program Vision: The main commitment of this program is to support near-miss mothers, which is possible through the promotion of physical, mental, fertility/childbearing, social, cultural, nancial, breastfeeding, and nutritional health. Improving the quality of care in hospital care and post-discharge health care is the main prerequisite for the implementation of the program.
Strategy 1: Psychological counseling: Psychological support of the mother at the time of the incident, psychological counseling of the mother in the hospital, psychological counseling of the mother at the time of discharge, psychological counseling of the mother in post-discharge health care, psychological counseling of the spouse, psychological counseling of previous offsprings of the family Strategy 2: Fertility / childbearing counseling: Counseling in cases of loss of fertility, childbearing counseling in high-risk pregnancies, childbearing counseling for future pregnancies Strategy 3: Information Support: Ful lling information needs about the current problem, ful lling the information needs of family members, sexual counseling, and marital education Strategy 4: Socio-cultural support: Counseling to reduce social isolation by a mental health expert, maternal support by peers, correspondence with the Welfare Organization for referring mothers before hospital discharge, risk assessment of mothers in terms of socio-cultural dimensions Strategy 5: Improving nancial/geographical access: Assigning a monthly budget for near-miss mothers, insurance coverage for childbirth complications of near-miss mothers stated in the promotion package of the health system reform plan, nancial accountability for legal negligence in the health system, charity support, scheduling a pre-arranged visit to the clinic at the time of the mother's discharge, identifying mothers with poor nancial status Strategy 6: Breastfeeding counseling: Facilitating mother-infant communication to start breastfeeding, facilitating the process of using formula/milk bank Strategy 7: Nutritional counseling: Performing nutritional counseling at the time of hospitalization/health care Strategy 8: Promoting the care quality in near-miss mothers: Empowering staff/managers in terms of legal accountability, empowering staff in terms of ethics and professional behavior, empowering staff in terms of clinical skills, reviewing educational curricula, providing intensive care for near-miss mothers in health care, reviewing existing programs to prevent or physically rehabilitate mothers, establishing a coherent relationship between health care and treatment, forming a focus working group of mothers' follow-up team, and improving processes Socio-economic and cultural assessments of mothers from the beginning of pregnancy to implement preventive support 52 5 Forming centralized special working groups for near-miss mothers and registering of mothers in this working group for long-term follow-up 60 6 Supervision of maternal treatment processes by an experienced midwife in the eld of near-miss mothers who is not assigned by the hospital for accurate and direct monitoring 58 7 Using a 24-hour hospital IVR as an information source to answer questions from mothers and their families 48 8 Forming organizational associations for near-miss mothers 53 9 Using standard back-breaking cost tools in nancial access strategy 50 10 Using the word childbearing alongside a fertility counseling strategy 49