Burden of physical, psychological and social ill-health during and after pregnancy among women in India, Pakistan, Kenya and Malawi

Abstract

IntroductionFor every woman who dies during pregnancy and childbirth, many more suffer ill-health, the burden of which is highest in low-resource settings. We sought to assess the extent and types of maternal morbidity.MethodsDescriptive observational cross-sectional study at primary-level and secondary-level healthcare facilities in India, Pakistan, Kenya and Malawi to assess physical, psychological and social morbidity during and after pregnancy. Sociodemographic factors, education, socioeconomic status (SES), quality of life, satisfaction with health, reported symptoms, clinical examination and laboratory investigations were assessed. Relationships between morbidity and maternal characteristics were investigated using multivariable logistic regression analysis.Results11 454 women were assessed in India (2099), Malawi (2923), Kenya (3145), and Pakistan (3287). Almost 3 out of 4 women had ≥1 symptoms (73.5%), abnormalities on clinical examination (71.3%) or laboratory investigation (73.5%). In total, 36% of women had infectious morbidity of which 9.0% had an identified infectious disease (HIV, malaria, syphilis, chest infection or tuberculosis) and an additional 32.5% had signs of early infection. HIV-positive status was highest in Malawi (14.5%) as was malaria (10.4%). Overall, 47.9% of women were anaemic, 11.5% had other medical or obstetric conditions, 25.1% reported psychological morbidity and 36.6% reported social morbidity (domestic violence and/or substance misuse). Infectious morbidity was highest in Malawi (56.5%) and Kenya (40.4%), psychological and social morbidity was highest in Pakistan (47.3%, 60.2%). Maternal morbidity was not limited to a core at-risk group; only 1.2% had all four morbidities. The likelihood of medical or obstetric, psychological or social morbidity decreased with increased education; adjusted OR (95% CI) for each additional level of education ranged from 0.79 (0.75 to 0.83) for psychological morbidity to 0.91 (0.87 to 0.95) for infectious morbidity. Each additional level of SES was associated with increased psychological morbidity (OR 1.15 (95% CI 1.10 to 1.21)) and social morbidity (OR 1.05 (95% CI 1.01 to 1.10)), but there was no difference regarding medical or obstetric morbidity. However, for each morbidity association was heterogeneous between countries.ConclusionWomen suffer significant ill-health which is still largely unrecognised. Current antenatal and postnatal care packages require adaptation if they are to meet the identified health needs of women.

Continence, quality of life and depression following surgical repair of obstetric vesicovaginal fistula: a cohort study

“…Our findings may reflect the low rate of depressive disorders observed among Malawian women in the general population (3-15%). 17,[33][34][35] Further research is needed in this field, including further validation of survey instruments among women with VVF.…”

Priorities in health care for women in India

“…1 The maternal mortality ratio is estimated to be 174 per 100 000 live births, and similarly the neonatal mortality rate remains high, with the most recent estimate at 25.4 per 1000 live births. 3 There is large variation in coverage and health outcome indicators across the various states, and generally, urban populations and those in the higher wealth quintiles are better served than are those who have low incomes and live in rural areas. This is despite strong government support and several innovative initiatives that have been introduced in India to improve maternal and newborn health outcomes, including dedicated strategic funding through the National Rural Health Mission and the introduction of accredited social health activists, auxiliary nursemidwives and Anganwari workers.…”

“…2 Given India's increasing socioeconomic status, these indicators are still comparatively high. 3 A re-emphasis on the content and quality of care that women receive is now considered a more important priority than is increasing access to care. With improved access to, and availability of, health services for most people, there remain significant challenges to the health system to be able to identify and meet the health needs of women and babies during and after pregnancy.…”

“…Against the background of an increase in maternal morbidity due to pre-existing disease that has a detrimental impact on the maternal health and wellbeing during and after pregnancy, 3 Nagraj et al (pages 34-42) conducted key informant interviews and focus group discussions to explore women's own views as well as those of healthcare providers. Key themes that emerged were that anaemia remains a key concern during pregnancy, blood pressure is not routinely measured after childbirth, gestational diabetes mellitus is not considered a problem per se and there are significant challenges to ensure screening for gestational diabetes mellitus is offered to women who access care.…”

“…3 Although with time they observed an annual 1% reduction in stillbirth rates, the three most commonly documented causes of stillbirth remained the same: hypertensive disorders of pregnancy, antepartum haemorrhage and congenital anomalies. 3 Although with time they observed an annual 1% reduction in stillbirth rates, the three most commonly documented causes of stillbirth remained the same: hypertensive disorders of pregnancy, antepartum haemorrhage and congenital anomalies.…”