Trop Doct 2008;38:204-208
doi:10.1258/td.2008.070417
© 2008 Royal Society of Medicine Press
Maternal morbidity during postpartum period in a village of north India: a prospective study
Somdatta Patra MD
Bir Singh MD
V P Reddaiah MD
Centre for Community Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Correspondence to: Somdatta Patra, Centre for Community Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India Email: somdattap{at}gmail.com
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SUMMARY
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This prospective community-based study was conducted in the
village of Chhainsa, Haryana, India, in order to discover the
incidence and types of postpartum morbidity and the factors
associated with the morbidities. The subjects were followed
up to 42 days of postpartum with a minimum of three visits;
the first visit was within 14 days of delivery and subsequent
visits were every 14 days. A first visit was made to 211 women
and 174 (82.46%) completed the study. Seventy-four percent reported
at least one morbidity and there were 1.75 reported morbidities
per woman per postpartum period. Common problems reported were:
weakness, lower abdominal pain, perineal pain, abnormal vaginal
discharge, high fever, breast problems, excessive vaginal bleeding,
etc. There was greater morbidity among women of lower socioeconomic
status, parity >4, birth interval >36 months, having a
breech or caesarean delivery or a delivery assisted by relatives/neighbours.
A significant positive association was found between age and
non-maintenance of the ‘five cleans’ during delivery.
Seventy-five percent of those who had reported morbidity had
taken some action, but only 20% sought help from a qualified
doctor and 14% from other health workers.
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Introduction
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Around half a million (529,000) maternal deaths occur worldwide
every year
1 and a quarter (136,000)
2 of them from India. There
are numerous episodes of maternal morbidities for every maternal
death. The range varies from 15 permanent disabilities to 100
acute episodes of morbidities for each death.
3–5 Sixty
percent of all maternal deaths occur after delivery, yet less
than 17% of women in India receive any postpartum care.
6,7 Morbidity
is also more common in the postpartum period than the antepartum
period.
8–11 Though these are crude estimates, they highlight
the magnitude of the problem. There are many medical and behavioural
aspects, which are unrecognized and, hence, are poorly managed.
12 These conditions may not be life threatening but they have long-term
consequences for the mother's health.
The absence of clear research and a paucity of data in India and many other developing countries on postpartum morbidity motivated the authors to discover the incidence and types of postpartum morbidities and the health-care seeking behaviour of the women who suffered the morbidities. Such a study should help us to find out if we do need to focus our attention on the postpartum period, currently not an area of focus in the maternity cycle.
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Method
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The study was carried out in Chhainsa village, under the Comprehensive
Rural Health Services Project Ballabgarh, Haryana State in northern
India. It is the rural field practice area of the Centre for
Community Medicine, All India Institute of Medical Sciences,
New Delhi. The village of Chhainsa is 17 km from Ballabgarh
where a secondary care level hospital (which is also a First
Referral Unit under Child Survival and Safe motherhood Programme)
is located.
The data was collected between August 2002 and July 2003. This study was planned as an exploratory study to measure the incidence of postpartum morbidity. Hence, a sample size of 200 women was used, taking into consideration Chhainsa's population (8000) and the birth rate (30/1000 live births). Verbal informed consent was taken from all the study subjects and medical care was provided as and when required. The subjects comprised all women who experienced childbirth during the study period in the village of Chhainsa. The women were followed up to six weeks postpartum by paying a minimum of three home visits at approximately two week intervals. Recruitment was done after 28 weeks of pregnancy. The first visit was paid within 14 days of delivery and an in-depth semi-structured interview was conducted. For information on some part of the intrapartum events, the person with the woman at the time of delivery was interviewed. The study subject was asked if there was any morbidity at the time of visit and also to recall if there had been any episode of ill health since delivery or since the time of last visit.
The five cleans were said to be present if the delivery was conducted using clean hands, clean surfaces, clean cuts, clean cord and clean ties. In the case of institutional deliveries it was assumed that all five cleans were maintained. For home deliveries further probing was done:
- Clean hands: The person conducting the delivery used sterile gloves or washed their gloves in boiling water or cleaned their hands with soap and water;
- Clean surface: The material spread over the delivery surface was washed and dried;
- Clean blade: A new blade was used which had been purchased from the market (and not used before) or a blade that was not rusted and had been boiled in water;
- Clean tie: The material used to tie the cord had been boiled in water;
- Clean cord: Nothing had been applied to the cord.
A postpartum visit was said to have occurred if during
the visit to the health facility or during a home visit by the
health worker the following aspects were covered (excluding
the visit by the investigator):
- A physical examination had taken place in order to identify and manage the woman's health problems;
- Counselling and information on family planning, breastfeeding and nutrition had been given.
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Analysis
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Analysis was carried out using both Epi Info 2002 (AIIMS, New
Delhi, India) and SPSS version 10.0 (AIIMS, New Delhi, India).
An independent
t-test was used to compare two groups. The association
between variables was computed by using
2 test and
2 test for
linear trends. Fishers' exact test was applied when appropriate.
Results were expressed as follows: (1) percentage of problems
reported during the postpartum period and (2) Incidence density,
i.e. morbidity/100 women postpartum periods (total number of
reported morbidities/person weeks followed).
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Results
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A first visit was made to 211 women; 174 (82.46%) completed
all follow up visits during the study period. Baseline socio-demographic,
obstetric, antenatal care (ANC) service utilization and delivery
characteristics of study participants are presented in Table
1.
Seventy-four percent (156) delivered at home; 65% (138) of the
deliveries were conducted by traditional birth attendants and
relatives/neighbours conducted another 8% (17). A history of
prolonged labour (more than 18 hours) was reported by 13% (27).
In only 67% (128) of deliveries, were all the recommended ‘five
cleans’ maintained. One hundred and ten women (63.27%)
did not have any postpartum visits. The characteristics of the
37 women who were lost to follow up were compared with the 174
women who were present throughout the study. Both the groups
were comparable except in their receiving of iron folic acid
(IFA) and ANC visits. Those who were lost to follow up had statistically
significant lower levels (received IFA
90: 36 versus 19% and
three ANC visits 80 versus 63%,
P = 0.04 and 0.01).
Morbidity during postpartum period
Table 2 presents the distribution of women reporting health problems at different times of their postpartum period and also the number of episodes of morbidity reported by them. The overall number of morbidities reported declined over time. Of 211 women contacted during first visit, 67% complained of some health problem. During the second visit 194 were contacted and 46% complained some health problem. At the last visit, 174 women were contacted and 32% complained of some health problem. At least one morbidity was reported by 157 (74.4%) women at any time during their postpartum period (Table 3).
The incidence density was 175 morbidities per 100 women per
postpartum period, or 1.75 morbidities per woman per postpartum
period. We compared the number of reported morbidities of the
211 women with the 174 women who remained in the study during
the entire study period and there was not much difference between
the patterns of reporting morbidity. Table
3 shows the
health problems reported.
Types of morbidity
Perceived weakness (43%) was the most common problem. Other common and serious problems reported were lower abdominal pain (31%), pain perineum (25%), abnormal vaginal discharge (VD) (23%), fever (21%), and breast problems (14%), bleeding after childbirth (7%) (Table 3).
Characteristics of participants who did not report any problems
Twenty-six percent of study participants who did not report any morbidity were compared with those who reported at least one problem. Those who did not report morbidity were younger (mean age 23.9 ± 4.3 years versus mean age 26 ± 5.2 years, P =–0.003) and of a lower parity (mean parity –2.6 versus mean parity –3.1, P = –0.04). There was no other significant difference.
Factors associated with reported morbidity in the postpartum period
A statistically significant association was found between the age of the women and the maintenance of cleanliness. With increased age there was an increase in number of morbidities reported. Analysis revealed that reported morbidities decreased when all the five cleans were maintained. No statistically significant association was found between the morbidities reported and other factors (P > 0.05). However, the group categorized as being lower in socio-economic status reported more morbidities and there was increasing trend of morbidity with an increase in parity as well as birth interval. Women are more likely to report health problems after a caesarean, breech, induced vaginal delivery, a history of prolonged labour or when the delivery was assisted by relatives/others (Table 4).
Health seeking behaviour for problems reported during the postpartum period
Women were asked during each visit if they had sought consultation
or treatment for the morbidities they reported. Forty-three
women (33%) had sought advices from family elders or from neighbourhood
elders. Only 20% had gone to a primary health centre or a hospital
for treatment. Another 14% had sought treatment from a health
worker. Twelve percent had consulted a local unqualified village
doctor. It was found that at the time of the second visit more
respondents had been to a doctor/primary health centre for treatment
than at the first visit.
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Discussion
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Perceived morbidity is important for policy planners for at
least two reasons. First, women's health behaviour, particularly
in seeking health care, is governed by what is perceived as
ill-health, irrespective of whether this perception is consistent
with medical symptoms or not. Secondly, attention is drawn to
what worries women about their health based on a criteria of
seriousness such as discomfort, interference with their daily
routine or with their feelings of dignity.
13
In this study 74% reported at least one morbidity. The percentage of the population reporting postpartum morbidity from other studies varied from 23–87%.8,14–18
For weakness or fatigue, symptoms were classified as mild, moderate or severe. Mild symptoms did not significantly hamper household activities and were considered normal after childbirth by the women in the study area and these reports have been excluded from the analysis. Moderate or severe symptoms confined the mother to bed or made her unable to perform household duties and were not considered to be normal by the women in this study.
In the present study, 43% of women reported weakness, which is comparable with a Bangladesh study which reported 47%,15 but lower than a Grampian study18 which reported 59%.
Lower abdominal pain did not include pain in the lower abdomen within the first week of childbirth, as this was considered normal by the women. In the present study, 31% women complained of lower abdominal pain which continued after the first week. In other studies it varied from 11.68 to 39%.15
Information was sought from women who reported VD so that we could distinguish abnormal VD from physiological or normal discharge. They were asked about the colour, quantity, odour and other factors associated with the symptoms. Abnormal VD was reported by 26%. Reported prevalence from other studies varied from 1.4 to 16%.17–19
Urinary problems included incontinence, increased frequency of urination, and a burning sensation during micturition. Urinary problems were reported by 7%. Other studies reported from 2.4–22%.15,18–20 In the present study 27% complained of perineal pain compared with 22% of women in other studies.18,20 Fourteen percent reported breast problems, which included sore nipple, cracked nipple, breast engorgement and mastitis, in the present study 14% compared with other studies which reported 15–33%.17,18,20
Perineal tear/injury was reported by 7% in our study compared with 20% from Bangladesh.15 Excessive vaginal bleeding was reported by 9% compared with other reports of 7–13.9%.17,18,21
There is a wide range of variation of the percentage of women reporting postpartum problems between studies. This might be due to methodological differences caused by different definitions, misclassifications of illnesses or the use of non-representative sample. This study is the first prospective study from India and has focused only on the postpartum period and which tried to discover the associated factors. The incidence density was 1.75 morbidities per woman per postpartum period. Though there are a few studies on postpartum morbidities, to the best of our knowledge only one study, by Glazener et al.,18 reported the incidence density as health problems/hospitalized woman as 2.13 to 13 days and 2.5 in the first eight weeks at home.
Though some studies8,10 have reported that women with a lower educational status report more morbidity, our study showed no such association. We found: a higher number of morbidities with increased age, a higher parity and greater number with a history of prolonged labour in the lower socioeconomic strata. This is in agreement with those reported in other studies.3,8,15 We found no other study which compared the maintenance of cleanliness, but we did find that this was significantly associated with reported morbidities.
Seventy-five percent of women had taken some action. In the study conducted in Bangladesh15 it was reported that 71% women reporting some complaints during the postpartum period had sought treatment from western or traditional care providers. Bhatia and Cleland8 found that, although a high percentage of women sought treatment, the prevalence of seeking care for postnatal problems was lower than for antenatal problems. This might be due to the fact that many of the problems which occur commonly in the postnatal period, e.g. painful perineum, urinary incontinence and haemorrhoids, are not easy subjects for women to disclose.20
In our present study, follow up visits were paid only during the conventional postpartum period although it is well known that morbidity will occur beyond that period. The outcome was self-reported morbidity. There is a chance of under-reporting as well as over-reporting. Under-reporting might be due women's perception as well as limitations in recall. Women might also have considered morbidities as normal following delivery. Over-reporting might be due to the fact that, this being an active follow up study, subject's perception or behaviour may have been modified and they might have felt obliged to report something.
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Conclusion
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This study revealed high morbidity levels during the postpartum
period. Routine postpartum visits by health workers, as well
as visits to professional health-care personnel, were low. There
is a need for a greater emphasis on postpartum care by health
workers and education and information about the need for postpartum
care.
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References
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SUMMARY
Introduction
