Abstract
This thesis concerns maternal morbidity at the time of childbirth and postpartum. The aims are to better understand the phenomenon by measuring the magnitude of maternal morbidity and to identify the determinants and consequences of severe maternal morbidity (near miss) around childbirth and in the postpartum period to help to improve care for the mother and newborn.
Our analytical framework is mainly based on two complementary conceptual models. The first, based on the work of Geller et al (2002), shows the progress of women’s health throughout the continuum of pregnancy, including the degree of development of complications. The second model, developed by Graham et al (2006), shows the importance of describing the various factors inherent in the woman’s environment and factors related to the health system, influencing the development of women’s health during pregnancy, childbirth and the postpartum period. Our results are organized into three studies.
The first study revealed the magnitude and categories of morbidity in the postpartum period and compared the perception of these morbidities by women to the diagnosis of these morbidities by doctors. For this purpose, we conducted a cross-sectional descriptive study in the Al Massira district of Marrakech for a year. We coupled a clinical examination and a laboratory examination (hemogram) with a questionnaire administered at day 42 after birth. Analysis of the results was performed for 1210 women who gave birth and completed a postpartum consultation. During this consultation, 44% of women expressed at least one complaint. These complaints were related to gynecological problems (20%) and mental health problems (10%), followed by complaints about hemorrhoids and breast problems, affecting 6% and 5% of women, respectively. During the same visit, 60% of women had a health problem diagnosed by the doctor. The most frequent diagnoses were related to gynecological problems (22%), followed by laboratory-confirmed anemia (19%), whereas problems related to mental health were diagnosed in only 5% of women. The comparative analysis of the perceived and diagnosed morbidities highlights a divergence between the complaints of women during the postpartum consultation and the clinical morbidity established by the physician.
In the second study, aimed to determine the incidence, characteristics, and determinants of maternal near misses. We conducted a case-control study with mixed methods in two districts (Marrakech Al Haouz) from 1 February to 31 July 2012. We included all cases of maternal near misses detected during the study period in our sample. For the controls, we selected women who had the same types of complications as the near misses but who did not reach the stage of near miss. For the qualitative analysis, we analyzed a sample of 30 women with near misses and 30 controls by conducting extensive interviews about their care pathways.
The incidence of maternal near misses was 12‰ hospital births. Hypertensive disorders (45%) and severe bleeding (39%) were the categories that most frequently directly caused the near misses. The risk factors occurring in the near miss episodes were a low level of education, a lack of monitoring during pregnancy and having experienced complications during pregnancy. Regarding delays in support, women who waited for more than 24 hours before reporting to their care provider had an eight times higher risk of experiencing a near-miss episode. Similarly, women who waited for more than 60 minutes at the top-level structures showed four times greater risk. The main reasons for a near miss occurring at home were the women’s lack of decision-making power, lack of money and fear of health facilities. For the delay at the first-level structures, the majority of women with near misses reported many successive referrals without explanation and occasionally less-than-welcoming attitudes among care providers.
The third study aimed to assess the physical and mental health consequences of near-miss episodes on Moroccan women 8 months after childbirth. We conducted a prospective cohort of 80 women with near misses and 188 unexposed women with normal deliveries who were recruited at the three referral hospitals in Marrakech Al Haouz during the second study. A subsample of 20 women with near misses and 20 unexposed women were deeply interviewed. At a consultation 8 months postpartum, 76 of near misses and 169 unexposed women had medical consultation. Women with near misses were poorer and less educated than women who had uncomplicated deliveries. The proportion of serious complications was higher in the women with near misses (22%) than in the women who gave birth without complications (6%) (p = 0.001). The risk of depression was significantly higher among the near-misses with perinatal death [OR=7.16; 95% CI: (2.85-17.98)] than among those who had uncomplicated delivery. Interviews revealed that the economic burden of near-miss care contributed to social equilibrium disturbances among the women and their households.
Regarding the in-depth interviews, these focused on the fact that the economic burden of obstetric complications contributes to adverse and lasting consequences on women’s health status and their relationship with their spouses and families in law.
Based on the results of our research, we noted three essential points:
i) Better listening to and understanding of the complaints of women is de facto one of the key elements needed to ensure quality in care for women and their newborns. In particular, fostering awareness among clinicians and reviewing the training of doctors, especially concerning mental health issues in obstetrics, are important to encourage patient-centered care, which is an essential component of better-quality maternal and neonatal care.
ii) Improvement of the quality of care for women and their newborns is also dependent on clearly defining a referral system based on the profiles and characteristics of women, allowing quick orientation at a competent level and increased respect for the care sector and less delays.
iii) In fact, it has become essential to develop maternal and newborn health care mechanisms that focus not only on the birthing episode and obstetric interventions but also on women and newborns in the postpartum period. More resources are specifically needed to ensure that these women receive appropriate care before and after hospital discharge. Awareness and involvement of families and spouses are also essential to the well-being of women and their newborns.
Our analytical framework is mainly based on two complementary conceptual models. The first, based on the work of Geller et al (2002), shows the progress of women’s health throughout the continuum of pregnancy, including the degree of development of complications. The second model, developed by Graham et al (2006), shows the importance of describing the various factors inherent in the woman’s environment and factors related to the health system, influencing the development of women’s health during pregnancy, childbirth and the postpartum period. Our results are organized into three studies.
The first study revealed the magnitude and categories of morbidity in the postpartum period and compared the perception of these morbidities by women to the diagnosis of these morbidities by doctors. For this purpose, we conducted a cross-sectional descriptive study in the Al Massira district of Marrakech for a year. We coupled a clinical examination and a laboratory examination (hemogram) with a questionnaire administered at day 42 after birth. Analysis of the results was performed for 1210 women who gave birth and completed a postpartum consultation. During this consultation, 44% of women expressed at least one complaint. These complaints were related to gynecological problems (20%) and mental health problems (10%), followed by complaints about hemorrhoids and breast problems, affecting 6% and 5% of women, respectively. During the same visit, 60% of women had a health problem diagnosed by the doctor. The most frequent diagnoses were related to gynecological problems (22%), followed by laboratory-confirmed anemia (19%), whereas problems related to mental health were diagnosed in only 5% of women. The comparative analysis of the perceived and diagnosed morbidities highlights a divergence between the complaints of women during the postpartum consultation and the clinical morbidity established by the physician.
In the second study, aimed to determine the incidence, characteristics, and determinants of maternal near misses. We conducted a case-control study with mixed methods in two districts (Marrakech Al Haouz) from 1 February to 31 July 2012. We included all cases of maternal near misses detected during the study period in our sample. For the controls, we selected women who had the same types of complications as the near misses but who did not reach the stage of near miss. For the qualitative analysis, we analyzed a sample of 30 women with near misses and 30 controls by conducting extensive interviews about their care pathways.
The incidence of maternal near misses was 12‰ hospital births. Hypertensive disorders (45%) and severe bleeding (39%) were the categories that most frequently directly caused the near misses. The risk factors occurring in the near miss episodes were a low level of education, a lack of monitoring during pregnancy and having experienced complications during pregnancy. Regarding delays in support, women who waited for more than 24 hours before reporting to their care provider had an eight times higher risk of experiencing a near-miss episode. Similarly, women who waited for more than 60 minutes at the top-level structures showed four times greater risk. The main reasons for a near miss occurring at home were the women’s lack of decision-making power, lack of money and fear of health facilities. For the delay at the first-level structures, the majority of women with near misses reported many successive referrals without explanation and occasionally less-than-welcoming attitudes among care providers.
The third study aimed to assess the physical and mental health consequences of near-miss episodes on Moroccan women 8 months after childbirth. We conducted a prospective cohort of 80 women with near misses and 188 unexposed women with normal deliveries who were recruited at the three referral hospitals in Marrakech Al Haouz during the second study. A subsample of 20 women with near misses and 20 unexposed women were deeply interviewed. At a consultation 8 months postpartum, 76 of near misses and 169 unexposed women had medical consultation. Women with near misses were poorer and less educated than women who had uncomplicated deliveries. The proportion of serious complications was higher in the women with near misses (22%) than in the women who gave birth without complications (6%) (p = 0.001). The risk of depression was significantly higher among the near-misses with perinatal death [OR=7.16; 95% CI: (2.85-17.98)] than among those who had uncomplicated delivery. Interviews revealed that the economic burden of near-miss care contributed to social equilibrium disturbances among the women and their households.
Regarding the in-depth interviews, these focused on the fact that the economic burden of obstetric complications contributes to adverse and lasting consequences on women’s health status and their relationship with their spouses and families in law.
Based on the results of our research, we noted three essential points:
i) Better listening to and understanding of the complaints of women is de facto one of the key elements needed to ensure quality in care for women and their newborns. In particular, fostering awareness among clinicians and reviewing the training of doctors, especially concerning mental health issues in obstetrics, are important to encourage patient-centered care, which is an essential component of better-quality maternal and neonatal care.
ii) Improvement of the quality of care for women and their newborns is also dependent on clearly defining a referral system based on the profiles and characteristics of women, allowing quick orientation at a competent level and increased respect for the care sector and less delays.
iii) In fact, it has become essential to develop maternal and newborn health care mechanisms that focus not only on the birthing episode and obstetric interventions but also on women and newborns in the postpartum period. More resources are specifically needed to ensure that these women receive appropriate care before and after hospital discharge. Awareness and involvement of families and spouses are also essential to the well-being of women and their newborns.
| Original language | French |
|---|---|
| Place of Publication | Bruxelles |
| Publisher | |
| Publication status | Published - 2015 |