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WHAT'S NEW THIS TUESDAY: THREE ON MATERNAL MORBIDITY AND MORTALITY

Sunday, 1st of July 2012

• WHAT'S NEW ON WWW.CHILDSURVIVAL.NET:  THREE ON MATERNAL MORBIDITY AND MORTALITY

CONTENTS

• SPECIAL JOURNAL ISSUE: MATERNAL MORBIDITY, DISABILITY AND THEIR CONSEQUENCES: NEGLECTED AGENDA IN MATERNAL HEALTH 

JOURNAL OF HEALTH, POPULATION AND NUTRITION

Guest Editor: Marge Koblinsky

http://www.jhpn.net/index.php/jhpn/article/view/1211/853

VOLUME 30 NUMBER 2 JUNE 2012

PREAMBLE

121 A New Perspective on Maternal Ill-health and Its Consequences

Mary Ellen Stanton and Neal Brandes

 

EDITORIAL

124 Maternal Morbidity and Disability and Their Consequences: Neglected Agenda in Maternal Health

Marge Koblinsky, Mahbub Elahi Chowdhury, Allisyn Moran, and Carine Ronsmans

 

ORIGINAL PAPERS

131 Profile of Maternal and Foetal Complications during Labour and Delivery among Women Giving Birth in Hospitals in Matlab and Chandpur, Bangladesh

Fauzia Akhter Huda, Anisuddin Ahmed, Sushil Kanta Dasgupta, Musharrat Jahan, Jannatul Ferdous, Marge Koblinsky, Carine Ronsmans, and Mahbub Elahi Chowdhury

143 Occurrence and Determinants of Postpartum Maternal Morbidities and Disabilities among Women in Matlab, Bangladesh

J. Ferdous, A. Ahmed, S.K. Dasgupta, M. Jahan, F.A. Huda, C. Ronsmans, M. Koblinsky, and M.E. Chowdhury

159 An Examination of Women Experiencing Obstetric Complications Requiring Emergency Care: Perceptions and Sociocultural Consequences of Caesarean Sections in Bangladesh

Rasheda Khan, Lauren S. Blum, Marzia Sultana, Sayeda Bilkis, and Marge Koblinsky

172 Obstetric Complications and Psychological Well-being: Experiences of Bangladeshi Women during Pregnancy and Childbirth

K. Gausia, D. Ryder, M. Ali, C. Fisher, A. Moran, and M. Koblinsky

181 Violence against Women with Chronic Maternal Disabilities in Rural Bangladesh

Ruchira T. Naved, Lauren S. Blum, Sadia Chowdhury, Rasheda Khan, Sayeda Bilkis, and Marge Koblinsky

193 Association of Postpartum Maternal Morbidities with Children’s Mental, Psychomotor and Language Development in Rural Bangladesh

J.D. Hamadani, F. Tofail, A. Hilaly, F. Mehrin, S. Shiraji, S. Banu, and S.N. Huda

205 Costs of Maternal Health-related Complications in Bangladesh

Mohammad Enamul Hoque, Timothy Powell-Jackson, Sushil Kanta Dasgupta, Mahbub Elahi Chowdhury, and Marge Koblinsky

213 Early Postpartum Maternal Morbidity among Rural Women of Rajasthan, India: A Community-based Study

Kirti Iyengar

226 Consequences of Maternal Complications in Women’s Lives in the First Postpartum Year: A Prospective Cohort Study

Kirti Iyengar, Ranjana Yadav, and Swapnaleen Sen 

 

Maternal mortality is a good predictor of infant mortality, as these writers document.

• A NEW PERSPECTIVE ON MATERNAL ILL-HEALTH AND ITS CONSEQUENCES

Mary Ellen Stanton and Neal Brandes

United States Agency for International Development, Washington, DC, USA

J HEALTH POPUL NUTR 2012 Jun;30(2):121-123

Full text below; also at http://www.jhpn.net/index.php/jhpn/article/view/1212/854

The purpose of the set of studies published in this issue of the Journal of Health, Population and Nutrition is to examine long- and short-term consequences of maternal complications for mothers and newborns and to document the physical, social, psychological and economic impacts of maternal ill-health and maternal and perinatal death on women and others living in the family unit. This work reflects the spirit of President Obama’s Global Health Initiative that draws special attention to women- and girl-centred approaches as central to the advancement of health and development.

In the past, the documentation of the global estimates of reductions in maternal mortality has not been matched by more in-depth efforts to characterize and understand the continuing burden of maternal complications, morbidity, and disability suffered by childbearing women in developing countries. With the exception of recent more in-depth studies in India, Burkina Faso, and Benin, the global understanding of reduction in maternal mortality and morbidity is based upon the estimates of the number and proportion of childbearing women who die (1). By and large, the documentation of morbidities during or after the intrapartum period has lacked specificity and precision to inform the country and the programme managers on the incidence of immediate disabilities and of longer-term consequences for women, their families, and their communities.

The grand syntheses are limited by available evidence—meagre compared to the magnitude and wide array of potential consequences of maternal ill-health on individuals and society (2,3).

This series of papers presents, for the first time in two geographic areas, a comprehensive snapshot of the short- and long-term consequences of acute maternal morbidity. The icddr,b surveillance site in Matlab, Bangladesh, has a unique set of records of the reproductive health of individual women that provide data accumulated for decades. This was selected as an ideal site to draw upon the database to examine retrospectively long-term and prospectively selected short-term consequences of maternal ill-health. This is the first attempt to obtain greater precision on the consequences of maternal ill-health, using a robust methodology and an extensive dataset, with added qualitative studies and postpartum physical examinations of women following childbirth. In addition, we have included a study that provides contrasting and additional information from Action Research and Training for Health in rural Rajasthan, India.

The Bangladesh study found that for every maternal death, there are about 40 severe/less-severe complications and over 160 postpartum morbidities/disabilities.

These numbers are far higher than previous estimates of 20 women with complications and 40 with postpartum morbidities/disabilities for every maternal death (4).

In undertaking this work, it became apparent that even with the provision of free services and the capability to assess and manage the physical conditions of postpartum women, it is extremely hard to ensure that all who need services obtain them.

As a result, it appears from the data that women from higher-income families have a higher burden of morbidity than poorer women. In reality, the poorer women remain outside the available services for various reasons, and their experiences are not reflected in the documentation.

Immediate consequences of maternal complications

In Matlab, about 10% of women have a severe or less-severe maternal complication during the intrapartum period (Huda et al.). While severe dystocia is the most common complication, women are most likely to die of haemorrhage. Most women who died sought care from public or private facilities; about 25% died at home.

The Bangladesh study found that physical complications following delivery are common—over 40% of women, including those with acute maternal complications during the intrapartum period and those with normal vaginal births, suffered from some postpartum morbidity—but most are relatively mild, including first-degree uterine prolapse, haemorrhoids, and hypertension (Ferdous et al.).

‘Consequences of the consequences’

As part of this series of studies, a paper previously published (5) showed a substantial effect of the death of the mother on the survival of her children. “The cumulative probability of survival up to age 10 years was 24% in children whose mothers died before their tenth birthday compared to 89% in those whose mothers remained alive. The greatest effect was noted in children aged 2-5 months, whose mothers had died. The effect of the father’s death on cumulative probability of survival of the child up to 10 years of age was negligible” (5).

An important finding is that infant mortality is approximately eight times higher for those infants whose mothers died than if the mother survived (5). This finding has enormous implications for our care for these infants who are now maternal orphans.

Beyond survival, the studies describe a vast array of sequelae following obstetric complications—some very serious and some less prevalent or more serious than we had anticipated. While there was a small effect of maternal anaemia on young children’s language ability, there were often substantial consequences for women due to different morbidities (Hamadani et al.). Not surprisingly, there is a vast array of quality of life issues. For example, beyond the physical results of fistula, uterine prolapse, and incontinence, there is documentation of profound effects on women’s daily activities. And, in the case of a perinatal death, women may be sequestered for years and be unable to even carry out religious rituals that they consider fundamental to their spiritual well-being (Khan et al.). The consequences of a perinatal death on the mother include postpartum depression as well as emotional violence and controlling behaviour by the family and the community.

The study finds that there is a significant association between Bangladeshi women who report negative experiences with their childbirth and postpartum depression (Gausia et al.). Furthermore, women with conditions of chronic maternal morbidities, such as uterine prolapse, sometimes experience khota (insult) whereby they are ridiculed by neighbours and in-laws for jeopardizing the marriage through not meeting the sexual needs of the husband or not carrying out household responsibilities. Women described physical and sexual violence in response to not meeting husbands’ demands. The subordinate role of women subjects them to an array of hardships and injustices that result from their chronic morbidities and disabilities (Khan et al.).

This research has elicited considerable detail about the economic consequences of maternal morbidity, which are the highest within the six weeks after birth and decline substantially by six months (Hoque et al.). Faced with maternal complications, families take loans and, to a lesser extent, sell assets to pay for healthcare. By interviewing cohorts of families, the study found that, even among the poorest households, there was unexpected resiliency to the economic shock of the cost of paying for obstetric emergencies. Families invest in their women in Bangladesh and will bypass lower-level facilities perceived to have lower quality to seek care for obstetric emergencies. These findings differ from findings in other country settings and point to the need for more robust methodologies and more comparable studies in other settings to increase the understanding of various coping strategies and both economic and non-economic consequences—beyond the actual financial debt.

Evolving context in Bangladesh

We recognize that the environment in Bangladesh is highly dynamic. Maternal mortality declined by 40% to 194/100,000 livebirths between 2001 and 2010 (6). Death from maternal causes now follows cancers and circulatory diseases as the major causes of death of Bangladeshi women of reproductive age. This progress appears to result from improved awareness of the need for care during emergencies and overall increased care-seeking for delivery, higher levels of maternal education, better economic conditions, and reduction in fertility—the total fertility rate has fallen to 2.5 (6). As a result, we are not finding the extent of long-term injury apparently suffered by women in other settings, particularly in settings where maternal mortality is higher. With the lowering of fertility and maternal mortality and the increased use of services, there is the prospect that more complications leading to disabilities can be prevented.

Comparing India and Bangladesh findings

The study in rural Rajasthan, India, published in this special issue, focused on the physical problems of postpartum women (Iyengar). As in Bangladesh (6), delivery-care in Rajasthan is rapidly moving to the health facility. Unlike in Bangladesh, moderate and severe anaemia is the most common maternal morbidity, followed by puerperal infections. Both the studies raise the concern that the postpartum period is one with high risk for women.

Given the variation in the pattern of postpartum maternal morbidities and disabilities in the Bangladesh and India studies, additional research in other country contexts is needed to quantify the changes in the burden of disease and to add to our knowledge concerning the many maternal morbidities and disabilities not now included in the calculationof disability-adjusted life-years.

Recommendations

The results of this wide-ranging set of studies make the case for galvanizing attention in a Call to Action to highlight the importance of postpartum and postnatal care that goes beyond the standard 4-6-week period. This will involve communications to women and their families about the importance of postpartum care and assessing the risk and actual occurrence of complications and responding effectively to them by healthcare providers. It will also mean following up women who have had a normal vaginal delivery, especially those who remained at home. The children of mothers who died and the mothers of perinates who died require very special attention because of their increased vulnerability.

Screening is called for several times following the birth, whether inside or outside a healthcare facility since problems may emerge or be recognized at different times in the postpartum period. All women need to be screened for physical postpartum problems, including anaemia, infection, incontinence, uterine prolapse, and obstetric fistula, and be managed, along with the provision of family planning and counselling for taking care of themselves and their babies. Women also need to be screened for postpartum depression and experience of emotional, physical and sexual violence. There are obvious possibilities for making this happen—first, at the time of hospital discharge and at the ‘usual’ 4-6-week postpartum check-up, and perhaps at immunization points for the child. We need to assess and re-assess. The findings of this study in Matlab, Bangladesh, point to the need for follow-up, including outreach to the community, especially when the birth has occurred at home, and particularly to follow-up on the survivors of a maternal or perinatal death. These mothers and babies are highly vulnerable and require special attention.  

Second, beyond screening, we need improvements in the healthcare system to build individual expertise and organizational capacity to respond to and effectively treat problems ranging from severe uterine prolapse and fistula, requiring specialized surgery, to depression and violence, requiring specialized counselling and intervention.

 Third, social protection is vital for the most vulnerable. Although this study suggests innovative coping and care-seeking strategies by Bangladeshi families, an effective health system is needed to provide accessible preventive and lifesaving care, particularly for the most economically- and socially-vulnerable populations.

 Finally, since societal customs and expectations set the stage for perpetrating and condoning the devastating emotional, physical and sexual abuse that women experience as a result of chronic morbidities and disabilities, these problems will not all be solved by healthcare providers or health services improvement alone. We must spotlight the fundamental issues of status and human rights of women for which the answers will be found in education, employment, and empowerment of women, in partnership with men, to improve the well-being of families.

 ACKNOWLEDGEMENTS

The opinions expressed in this paper are those of the authors and not necessarily of the United States Agency for International Development where they work.

REFERENCES

1. Filippi V, Ganaba R, Baggaley RF, Marshall T, Storeng KT, Sombié I et al. Health of women after severe obstetric complications in Burkina Faso: a longitudinal study. Lancet 2007;370:1329-37.

 2. National Research Council. The consequences of maternal morbidity and maternal mortality: report of a workshop. Committee on Population. In: Reid HE, Koblinsky MA, Mosley WH, editors. Commission on behavioral and social sciences and education. Washington, DC: National Academy Press, 2000.

 3. Better off dead? A report on maternal morbidity from the UK All Party Parliamentary Group on Population, Development and Reproductive Health. London: UK All Party Parliamentary Group on Population, Development and Reproductive Health, 2009.

 4. Filippi V, Ronsmans C, Campbell OM, Graham WJ, Mills A, Borghi J et al. Maternal health in poor countries: the broader context and a call for action. Lancet 2006;368:1535-41. 

 5. Ronsmans C, Chowdhury ME, Dasgupta SK, Ahmed A, Koblinsky M. Effect of parent’s death on child survival in rural Bangladesh: a cohort study. Lancet 2010;375:2024-31. 

 6. Bangladesh maternal mortality and health care survey 2010: summary of key findings and implications. Dhaka: National Institute of Population Research and Training, 2010. 11 p.

 

• MATERNAL MORBIDITY AND DISABILITY AND THEIR CONSEQUENCES: NEGLECTED AGENDA IN MATERNAL HEALTH

Marge Koblinsky1,2, Mahbub Elahi Chowdhury1, Allisyn Moran1,3, and Carine Ronsmans4

1icddr,b, GPO Box 128, Dhaka 1000, Bangladesh, 2John Snow Inc., Arlington, Virginia, USA, 3Saving Newborn Lives, Save the Children Federation, Washington, DC, USA, and 4London School of Hygiene & Tropical Medicine, London, UK

J HEALTH POPUL NUTR 2012 Jun;30(2):124-130

Complete text, with figures, is at http://www.jhpn.net/index.php/jhpn/article/view/1213/855

INTRODUCTION

Women’s ill-health and its consequences are poorly defined. Despite women living longer than men, their lives are not necessarily healthy, according to the 2009 Women and Health Report of the World Health Organization (WHO) (1). One condition that impacts only women and may contribute to continued ill-health is pregnancy and childbirth.

Whereas the appropriate use of skilled birth attendance with supportive emergency obstetric care can reduce health risks during pregnancy and childbirth, there are negative consequences of maternal ill-health that reach far beyond the health of the mother at the time of pregnancy and childbirth.

These consequences can lead to her death, further morbidities or disability in the extended postpartum period (up to one year) and can negatively impact the health of her baby, the health of her other children, and the social and economic standing of her family. Except outcomes of the newborns, such consequences are poorly understood both in quality and magnitude and remain, to a large extent, without any programmatic response in lowincome countries. With limited and patchy data, maternal deaths and disabilities are considered a leading contributor to the burden of disease among women. Maternal conditions were second only to HIV/AIDS in terms of women’s deaths worldwide and third in terms of disability-adjusted life-years (DALYs) for women aged 15-44 years, based on the 2005 global burden of disease estimates. More specifically, maternal conditions contributed to 2.7% of deaths among women worldwide and 12% of deaths among women aged 15-44 years. In the South-East Asian region, maternal conditions are the leading cause of women’s death and responsible for 14% of deaths among women aged 15-44 years (2). As the impact of maternal deaths and disabilities is additive, it is anticipated that, with more complete data, there would be an even greater impact of the burden of maternal ill-health with concomitant economic impact on the country.

 This special issue of JHPN aims to address this information vacuum about maternal morbidities and disabilities and their consequences based on findings of research from rural areas in Bangladesh and Rajasthan in India.

THE INFORMATION VACUUM

The existing maternal health literature focuses primarily on maternal death: more than 275,000 women are estimated to die each year in pregnancy and childbirth worldwide (3-5). One known consequence of maternal death is increased mortality of the baby—stillbirth or death of the newborn (6).

 While the estimates of maternal mortality and its consequences are built on relatively limited data, women who suffer from direct obstetric complications that kill—obstructed or prolonged labour, puerperal sepsis, septic abortion, severe pre-eclampsia and eclampsia, and postpartum haemorrhage—are estimated to be far higher in number yet less well-documented. The global estimates range from 15% of pregnant women suffering from complications—about 20 million women annually (7,8)—to 1-2% in resource-poor settings when the definition is restricted to the most severe morbidities (9,10).

 Even less is known about the numbers and description of the consequences women may suffer as a result of pregnancy and childbirth and the life threatening obstetric complications (11-13). These consequences—maternal morbidities or disabilities—are estimated to affect 15-20 million women worldwide each year (14). Assumed to be directly or indirectly related to difficult obstetric events, these morbidities/disabilities include conditions, such as uterine prolapse, stress incontinence, hypertension, haemorrhoids, perineal tears, urinary tract infections, severe anaemia, depression, fistula, and ectopic pregnancy.

 Beyond the acute obstetric complications and potential for consequent morbidities and disabilities—either physical or mental or both—it is assumed that the health of women during pregnancy or childbirth further impacts the health and development of the next generation and the well-being of the family—both economically and socially—through impoverishment, violence, stigmatization, isolation, divorce, and remarriage. Reports from Burkina Faso tell of secondary consequences for women and their families up to a year following a severe obstetric complication, including excess mortality and mental health problems of the women (15) plus loss of physical strength, family stability, community status, and impoverishment.

 Such reports extend the meaning of loss beyond that quantified in measures, such as the maternal mortality ratio or DALYs (16). As with the health of girls and women across andwithin countries more generally, the health of women during pregnancy and childbirth is highly affected by the social and economic factors, including education, household wealth, and the place of residence. Typically, those living in wealthier households, having higher education, or living in urban areas, have lower levels of mortality and higher use of healthcare services than their poorer, less-educated, or rural counterparts (1,17-19).

What is less understood is whether these same determinantsdrive action and better health when a woman faces other consequences of pregnancy or childbirth—the short-term morbidities or chronic disabilities, such as postpartum depression or social consequences, such as violence.

FUELLING THE INFORMATION VACUUM

Two major factors contribute to the information vacuum surrounding maternal ill-health—(a) the inconsistent use of terminologies to describe maternal morbidities and disabilities, and their consequences and (b) the methods used for ascertaining these quantitatively.

Inconsistent Terminology

The inconsistent use of terminologies to describe various maternal morbidities and disabilities is a major source of confusion in interpreting the available literature. In this series, the obstetric complications that can kill are part of a wider group of morbidities suffered during the antenatal, natal or postpartum periods that we call acute maternal morbidities.

Those that affect women and their families in the longer-term are called postpartum maternal morbidities and disabilities. The following section provides a general review of terms used in the literature on various conditions of maternal morbidity.

 

Defining Maternal Morbidity

Maternal morbidity is an overarching term that refers to any physical or mental illness or disability directly related to pregnancy and/or childbirth. These are not necessarily life-threatening but can have a significant impact on the quality of life.

Acute maternal morbidities include various terms, such as ‘obstetric complications’, ‘maternal complications’, ‘absolute maternal indications’ (AMIs), ‘severe acute maternal morbidities’ (SAMMs), and ‘near-miss’ and typically refers to acute problems suffered during pregnancy through the standard postpartum period of 42 days.

Obstetric or maternal complications are acute conditions that may directly cause maternal deaths. According to the United Nations Children’s Fund/WHO/United Nations Population Fund (1997) ‘complicated cases’ include antepartum or postpartum haemorrhage, prolonged or obstructed labour, postpartum sepsis, complications of abortion, preeclampsia/eclampsia, ectopic pregnancy, and ruptured uterus (8). Anaemia, malaria, tuberculosis, and other pre-existing conditions that may complicate delivery are considered indirect obstetric complications. Rarely are the definitions for these terms for obstetric complications—direct or indirect—more specified.

Severe obstetric complications have been defined variously based on the criteria of disease, management and/or organ failure/dysfunction as follows:

Absolute maternal indications (AMIs) are lifethreatening or severe obstetric complications requiring a specific major obstetric intervention which can be verified through records of health services. AMIs reflect conditions that, without intervention, have a high probability of causing maternal death during childbirth or sequelae includingthe following (20):

 

a. Severe antepartum haemorrhage

b. Placenta praevia and abruptio placentae

c. Severe postpartum haemorrhage requiring surgical intervention

d. Foetopelvic disproportion (pre-rupture and uterine rupture)

e. Shoulder or transverse lie

 Severe acute maternal morbidities (SAMMs) include complications that are ‘absolutely’ lifethreatening using concepts of organ failure and lifesaving surgery—such that women who experience these problems are unlikely to survive if they do not receive care in a hospital (9).

Near-miss is defined by the WHO as “a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy” (21), or to put more simply, “… women are considered near-miss cases when they survive life-threatening conditions (i.e. organ dysfunction)” (22). The criteria to determine a near miss condition are based on organ-system dysfunction or failure versus disease-specific or intervention-specific criteria as the organ-based criteria are found to be more specific in identifying real severe acute maternal morbidity cases (10). The organ-system-based criteria include cardiovascular, respiratory, renal, coagulation/haematological, hepatic, neurological and uterine dysfunction (22).

Postpartum maternal morbidities and disabilities are the long-term physical or mental consequences resulting from pregnancy, childbirth, acute maternal morbidities, or the management thereof, and most often referred to as long-term chronic morbidities and other problems experienced postpartum (23).

Chronic morbidities are conditions caused by the birthing process and are not life-threatening but greatly impair the quality of life, such as fistula, uterine prolapse, and dyspareunia.

Milder disabilities are also called postpartum maternal morbidities and include urinary incontinence, hernias, haemorrhoids, breast problems,and postpartum depression

Methodological Loopholes and the Way Out

What Is Valid Reporting of Morbidities and Disabilities?

Capturing maternal morbidity and its consequences where women do not usually use skilled care providers or facilities for delivery has been difficult. Under such circumstances, women’s self-report in response to survey questionnaire or interviews by community-based health workers has been the primary means to obtain data.

Limitation in using self-reported complications:

Results of studies conducted in the mid-1990s demonstrate that the reliability of self-reported complications based on a woman’s recall is poor compared to medical records, even if the woman suffered from a life-threatening complication (24-27).

Assessment by community-based healthcare providers:

Many studies have worked with community-based healthcare providers to assess acute maternal morbidities (28-35). These community-based care providers most likely had differing levels of training, supervision, and equipment to diagnose maternal complications. The reliability and validity of these assessments and, obviously, comparability, are unclear. Even with the assessment by community workers followed up by skilled care providers

in the community, the type of measurement, done by whom, and timing of the assessment and of the complications, can vary widely. For example, in a review of maternal morbidity in India and Bangladesh, puerperal sepsis identified by community workers was defined as fever lasting for three or more days, up to two weeks or up to six weeks postpartum

in different studies (28,30,34).

Assessment of gold standard—skilled providers in facility: The ‘gold’ standard for the diagnosis of morbidity remains assessment by skilled care providers at a health facility. Ronsmans argues that, using facility-based diagnoses by skilled care providers based on organ failure and lifesaving surgery to determine SAMMs, one can estimate the population

levels of severe maternal morbidity—as women with such problems will die if not managed in such facilities (9). She acknowledges that the management criteria continue to be only partially reliable across settings because of the human element but that the criteria for lifesaving surgery are more standardized, and comparable population-based data are becoming increasingly available.

A recent Maternal Mortality and Morbidity Classifications Working Group of the WHO outlined criteria to determine severe obstetric morbidity (near-miss) that is more limited than SAMMs, i.e. women presenting with features of organ dysfunction. They have also developed tools and outlined a process of gathering data to improve comparability

across studies (22).

STUDIES OF MATERNAL MORBIDITIES AND DISABILITIES IN THIS SPECIAL ISSUE OF JHPN

This special issue of the Journal aims to respond to the major gaps in knowledge with studies on acute and postpartum maternal morbidities and disabilities from Matlab in Bangladesh and Rajasthan in India. A conceptual framework for this work is depicted in Figure 1. The studies specifically report the following:

 

• • The level of severe and less-severe acute maternal morbidities during pregnancy, childbirth,

and postpartum (42 days) in rural Bangladesh and Rajasthan in India

 

Fig. 1. Conceptual framework for the study of maternal morbidity and its consequences

Child

Growth/developmental

Low education

Survival

Family/household

Social

• Less social support

• Change in relationship

• Child-caring problem

• Change in family structure

• Violence

Economic

• Productivity loss

• Impoverishment

• Incontinence

• Obstetric fistula

• Uterine prolapse

• Dyspareunia

• Haemorrhoids

• Haemorrhage

• Infection

• Hypertension

• Maternal nutrition

Woman

Physical consequences

Psychological consequences

Survival

Consequences/Disabilities (short- and long-term)

Maternal morbidity (haemorrhage, pre-eclampsia, prolonged/obstructed labour, sepsis)

• • The consequences of maternal morbidity (postpartum morbidities and disabilities experienced up to nine weeks in Bangladesh or 12 months in India, including depression (for the women), and death or developmental delays(for her newborn)
• • The longer-term impact on women and families— mentally, socially, and economically (Bangladesh) and deaths of children or mothers up to one year postpartum (India).

Hypotheses

The hypotheses underlying the studies of maternal morbidities, disabilities, and consequences include the following:

o Women who suffer from severe acute maternal morbidities are at risk of suffering from longterm consequences (e.g. physical, social and mental consequences) or death compared to those with vaginal deliveries with no complications.

o Women who suffer from moderate and severe acute maternal morbidities and those who die are at higher risk of suffering poor pregnancy outcomes (e.g. stillbirths, neonatal death, and infant death) compared to those with vaginal deliveries with no complications.

o A child of a mother suffering from long-term consequences of severe acute maternal morbidities is at higher risk of death and poorer development than those of women without such consequences.

o Families of women who have suffered from severe acute maternal morbidities (and/or poor pregnancy outcomes) are at higher risk of dissolution, violence, and/or impoverishment.

Studies and the resulting papers

Driven by the above hypotheses, three types of studies were conducted, each with qualitative and quantitative components. The papers detailing the findings of each study type are listed below.

1. Examination of the incidence of short- and long-term morbidities and physical disabilities of women with severe and less-severe acute maternal morbidities (obstetric complications) and those with normal vaginal deliveries in rural Bangladesh and India:

• • Profile of maternal and foetal complications during labour and delivery among women giving birth in hospitals in Matlab and Chandpur,Bangladesh (Huda et al.)

 

• • Occurrence and determinants of maternal postpartum morbidities and disabilities among women in Matlab, Bangladesh (Ferdous et al.)

 • Early postpartum maternal morbidity among rural women of Rajasthan, India: a communitybased study (Iyengar)

 

• • Consequences of maternal complications onwomen’s lives in the first postpartum year: a prospective cohort study (Iyengar et al.).

 

Findings regarding morbidity or disability relating to abortion or complications of abortion are not included in the studies reported in this special issue of the Journal. 

2. Determination of the outcomes of the newborn (death and developmental delays) as related to maternal morbidity/mortality:

• • Consequences of maternal complications on women’s lives in the first postpartum year: a prospective cohort study (Iyengar et al.)

 • Profile of maternal and foetal complications during labour and delivery among women giving birth in hospitals in Matlab and Chandpur, Bangladesh (Huda et al.)

 • Association of postpartum maternal morbidities with children’s mental, psychomotor andlanguage development in rural Bangladesh (Hamadani et al.).

3. Documentation of the psychological, social and economic impacts of maternal ill-health and death (maternal and perinatal) on women and other members living in the family unit: 

• • Obstetric complications and psychological well-being: Bangladeshi women’s experiences with pregnancy and childbirth (Gausia et al.)

 

• • An examination of women experiencing obstetric complications requiring emergency care: perceptions and sociocultural consequences of caesarean sections in Bangladesh (Khan et al.)

 • Violence against women with chronic maternaldisabilities in rural Bangladesh (Naved et al.)

 

• • Costs of maternal health complications in Bangladesh (Hoque et al.)

 

• • Early postpartum maternal morbidity among rural women of Rajasthan, India: a community-based study (Iyengar).

 

Study sites

In Bangladesh, the icddr,b’s community data from the Matlab intervention area with its population of 110,000 plus facility data from Matlab and Chandpur district town provide a unique opportunity to capture the levels of maternal mortality, morbidities, and disabilities while tracing women and families who have suffered and linking them to changes in familial, social and economic status over time. This is done through secondary analysis of the existing data dating back 30 years plus prospective data collected over 24 months starting in 2007. In the prospective study, only those women who had a care provider’s diagnosis of morbidity were included (Fig. 2 for study design). Ninety-two percent of women who had a hospital admission, a live- or stillbirth outcome, and who had records of diagnosis by care provider, were traced representing 36% of all pregnancies in the Matlab area with icddr,b interventions over the life of the project. All other women delivered at home, in subcentres (health centres), in sites beyond Matlab/Chandpur, or their records could not be traced. We assume that women with a hospital delivery were those with the most serious acute morbidities; those who died during this period (12 maternal deaths) were also known and are reported in the paper of Huda et al.

 

Fig. 2. Matlab prospective study

Women who had acute maternal morbidities

Physical consequence

Psychological consequence

Social consequence

Economic consequence

Child development

Normal birth(control)

Women who hadperinatal deaths

 

In India, Action Research and Training for Health(ARTH), a non-profit organization based in

Udaipur, provides data on maternal morbidities and their consequences from a 36-month prospective study (starting in 2007) on a rural tribal population of 58,000 in southern Rajasthan. Given that few women in the area used facilities for deliveries, morbidity data on all women with a birth in the area were collected by midwives within 2-3 days of birth during home-visits, using a checklist developed to question women on pregnancy or intrapartum complications and their consequences; they also carried out a physical examination, including measurement of haemoglobin. Follow-up visits of these women continued for 12 months postpartum.

 Recently-delivering women were identified by the family members or community workers [accredited social health activists (ASHAs) and village health volunteers] who were paid by ARTH for providing information on births.

 

Burden of disease for maternal deaths and disabilities

Finally, we contemplated the recalculation of the burden of disease for maternal death and disabilities for Bangladesh, using the methodology of the Global Burden of Disease Study (36) with the maternal mortality, morbidity and disability data from Matlab. This exercise made clear that most maternal morbidities and disabilities were not assigned any weight in the methodology of the 2004 Updated Burden of Disease (Box), and calculations of the burden of disease for maternal conditions were and remain highly underestimated.

 

Calculation of DALY for Maternal Conditions— What Is Missing?   Global burden of disease morbidities for which there are DALYs include anaemia, cardiovascular conditions, obstructed labour, haemorrhage, hypertensive disorders, reproductive tract infections, and sepsis.   Unaccounted disabilities in the global burden of disease calculation (as of 2008) include dyspareunia, genital prolapse, haemorrhoids, mastitis, stillbirths, perineal tears, postpartum depression, urinary tract infections, and vulvar disruption.

 

Such an undervaluation is only secondary to the underestimation of the incidence of maternal morbidities and disabilities and to the undervaluation of women’s health more generally.

 

ACKNOWLEDGEMENTS

The authors are grateful to Evelyn Ford (Intern), Sushil Dasgupta (icddr,b), and Sandee Minovi (John Snow Inc.) for their assistance with this document. They also thank the United States Agency for International Development for funding this effort and for stimulating them to think beyond the conventional boundaries of the topic.

 

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