Maternal postpartum morbidity in Marrakech: what women feel what doctors diagnose?

In light of trends in the worldwide maternal mortality, it is commonly acknowledged that the fifth Millennium Development Goal is not likely to be achieved by 2015 [1]. Nevertheless, maternal mortality represents only the tip of the iceberg of the much larger issue of maternal morbidity [2]. Estimates suggest that among the 136 million women who give birth every year, about 1.4 million experience life-threatening medical emergencies, 9.5 million experience other complications, and 20 million have long-term disabilities [3‐6]. These morbidities have different etiologies; some are related to the quality of care during pregnancy and delivery, and others are related to a broader set of social and personal factors.

Depending on the definition, we have different estimates for maternal morbidity. If we take severe acute maternal morbidity as defined by the World Health Organization (WHO) in 2010 as “a woman who nearly died but survived a complication during pregnancy, childbirth, or within 42 days of pregnancy termination through care in health facilities,” [7], prevalence rates of life-threatening medical emergencies in many countries varies from 0.6% to 14.98% using disease-specific criteria, 0.04% to 4.54% using management-based criteria, and 0.14% to 0.92% using organ-based dysfunction based on Mantel criteria [8]. Rates are higher in the low- and middle-income countries of Asia and Africa (eg, Benin, Cote d’Ivoire, Morocco, Indonesia) [9, 10]. These variations might be due to real epidemiological differences in different populations or to differences in the definitions and approaches of maternal morbidity.

The lack of harmonization of these criteria makes it difficult to establish priorities in terms of assistance and treatment in maternal and infant health, especially in countries with limited resources. Morbidity data are vital for policymakers and health care planners who need to know how many women require essential obstetric care [11, 12]. Studies on postpartum morbidity have been scarce in Morocco. Only one study, conducted in 2001, measured the proportion of hospital admissions for acute maternal morbidity during pregnancy, childbirth, and postpartum [13]. Usually, many reproductive disorders go unnoticed, because they cause no symptoms or only nonspecific symptoms. Because of a lack of or incomplete information due to poor documentation, we measured self-described postpartum morbidity in a group of postpartum women living in Marrakech, along with their sociodemographic factors, to compare women’s postpartum complaints with medical diagnoses.

Of the 1,530 women recruited, 1,210 women attended a postpartum consultation. One death was reported following a hemorrhagic episode during delivery complicated by the Hemolysis Elevated Liver enzymes Low Platelet count (HELLP) syndrome. Regarding the sociodemographic characteristics of the 1,210 participants, 6% were younger than 20 years, and 44% were older than 30. Mean age was 29 years. Only 13 were single, and 23% had not received any formal education (Table 1).

Three hundred-twenty (21%) women did not attend the postpartum consultation. In general, these women had a lower level of education (p = 0.0001), a lower socioeconomic score (p < 0.001), and higher parity (p = 0.0001). Among the 1,210 women who attended a postpartum consultation, 893 (74%) did not have medical insurance, and 91% were unemployed. Most women (87%) had fewer than three children, and 32% were primigravidae. Nineteen percent of women had had at least one abortion (data not shown). The vast majority (94%) of women had delivered in a health facility; more than two-thirds (71%) had delivered in a delivery house, 10% in a private hospital, 7% at the university hospital, and 6% at the regional hospital. In 79% of deliveries, women decided on their own where to deliver their baby. More than one-third (35%) had at least one complication during delivery. Life-threatening emergencies represented 6% of the hospital’s deliveries in our study.

Information on postpartum morbidity in developing countries is limited and, when available, usually describes the type of medical condition diagnosed at the hospital level. This is the first study conducted in Morocco comparing postpartum morbidity diagnosed by a physician vs. self-reported morbidity among women. In this study, 44% of women reported postpartum problems. This prevalence is high, and the morbidities were a mixture of benign and severe. The most common type of problem was psychological (10%) and reveals that mental distress that should be addressed because it is an indicator of postpartum depression [21].

The prevalence is lower than the prevalence of postnatal depression (18.6%), anxiety (13.1%), and stress (8.7%) found in a representative sample of Qatari women who attended a primary health care postpartum consultation within 6 months after delivery [22]. Other studies in Australia [23] and Zimbabwe [24] showed similarly high levels of postnatal depression (17.4% and 16%, respectively). The WHO and the United Nations Population Fund reported 10%–15% postnatal depression in industrialized countries [25]. However, in our study, we did not specifically look for this type of health outcome. Certainly, our findings suggest the need to further explore postpartum mental disorders using appropriate tools. We hope that, given that mental distress ranked first among all self-reported postpartum health problems, postpartum depression in Morocco will receive more attention and bring postnatal depression ‘out of the shadows’ [26]. The second most common complaint was symptoms of genital infections (8%). It should be noted that 91% of women did not seek care.

The reasons given for not seeking care were distance from home to the maternity hospital, no pain, a bad experience during childbirth (for those who delivered at the regional maternity hospital), and fear of having a serious illness. These factors should be further studied so that interventions can be defined and implemented to increase the number of women who seek medical care for postpartum health problems. Subnotification of pathologies compared with observed measurements was demonstrated to be influenced first by age, education, and socioeconomic level and, second, by asymptomatic or vague signs of genital infection [27].

Our study also shows that a high proportion of women (60%) were given a diagnosis of a postnatal problem 6 to 8 weeks after delivery. Similar levels of prevalence, or higher (72%), were reported in other studies [16, 28]. As with the prevalence of self-reported complaints, these medical diagnoses are a mixture of severe and benign. Only 12 women (1%) who attended the 42-day postpartum consultation had a severe condition such as an infected perineal tear, infected caesarean section or episiotomy wound, third-degree uterine prolapse, cervical cancer, or severe anemia. These women, who apparently were not aware of the severity of their problem, were immediately referred to the university hospital.

Of interest, only 85% of diagnoses were aligned with women’s self-reported complaints. Two health problems, in particular, account for this difference: psychological complaints and diagnoses of anemia. The physician recognized psychological complaints in only 5% of women, only half of the women who voiced such a complaint. Informal discussions with physicians indicate that they often did not take this type of complaint seriously, implying that anxiety, stress, tiredness, or crying were ‘normal’ in postpartum women and not important enough to be diagnosed or treated. Moreover, in Moroccan physicians’ training, significantly more attention is devoted to physical health than to mental health. Anemia was diagnosed in 19% of women, but only a small proportion of them complained of symptoms that could be attributed to anemia, and none were from women with hemoglobin >10 g Hb/dL. Physicians were able to diagnose anemia in this instance because the women were invited to take the laboratory test for free. Under normal circumstances, women would have to pay to get the test, and most would be unable to pay. The question remains as to whether a more specific test (eg, ferritin to measure iron stock) is required before treating anemia with iron.

Estimates of self-assessed morbidity prevalence are generally more specific than sensitive [29]. Underestimation or overestimation by women tends to be influenced by age, level of education, and specificity of clinical symptoms [27]. In industrialized countries, greater value is given to women’s self-reports of complaints, and responding to these complaints is considered more important than measuring the prevalence of true postpartum morbidity [2, 30, 31].

Today in Morocco, the proportion of women who attend a postnatal consultation at 6 weeks is 22% [14]. We believe that our study has brought clear advocacy arguments to increase this percentage. In our study, we were able to reach 80% of potential subjects by recruiting women at delivery and inviting them to return 6 weeks later for a health consultation by providing a voucher to get a free blood test and calling the small proportion of women who did not show up for their appointment.

This analysis of the magnitude of postpartum morbidity revealed a possible hidden burden among Moroccan women. The comparison of women’s perceptions with their medical diagnoses highlighted the need to train physicians to listen to their patients and recognize the signs of psychological distress. Indeed, postpartum consultation should take into account women’s complaints, which are often not acknowledged or expressed. This study showed the importance of late (6 weeks) postpartum consultations. We were able to reach 80% of women in this study because women were invited at hospital discharge after delivery to attend the consultation and were actively followed by phone to remind them of their appointments. Making postpartum maternal morbidity a priority on the national agenda will help the fight against obstetric complications, which is cri tical to the wellbeing of women and their infants.