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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 4  |  Issue : 1  |  Page : 40-46

An assessment of maternal morbidity pattern among reproductive age group women in a district of West Gujarat: A community based cross sectional study


1 Tutor, Department of Community Medicine, Shree M.P.Shah GMC, Jamnagar, India
2 Professor & Head, Department of Community Medicine, Shree M.P.Shah GMC, Jamnagar, India
3 Associate Professor, Department of Community Medicine, Shree M.P.Shah GMC, Jamnagar, India
4 Assistant Professor, Department of Medicine, Shree M.P.Shah GMC, Jamnagar, India
5 Tutor, Department of Community Medicine, GMERS Medical College, Himmatnagar, India

Date of Submission20-May-2018
Date of Acceptance14-Nov-2017
Date of Web Publication1-Feb-2019

Correspondence Address:
Mittal Rathod
Department of Community Medicine, Shree M.P.Shah Medical College, Jamnagar, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2395-2113.251348

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  Abstract 


Introduction: For each maternal mortality, there are number of various morbidities, which directly or indirectly affects health of women. For every woman who dies of pregnancy-related causes, an estimated 20 women experience acute or chronic morbidity, often with tragic consequences. Objectives: To assess maternal morbidity pattern, prevalence of maternal morbidity & its associated factors. Material and Methods: A community based cross- sectional study was conducted among 450 women of reproductive age group women of Jamnagar district. Study subjects were selected by multistage sampling. Data collected in proforma consist of sociodemographic profile, past obstetric profile & any antenatal, Intranatal, & postnatal morbidities. Results: Prevalence of maternal morbidity was about 80% with, highest morbidity found during antenatal period in 36% subjects, followed by 26% in postnatal period. There were also associated medical problems during pregnancy. Conclusion: There is 80% prevalence of morbidity related to pregnancy which adds on to ill health of women. It was also observed that statistical significance between few of the important variables like educational status, parity & place of delivery, which could be independent risk factors & occurrence of maternal morbidity.

Keywords: Morbidity, Reproductive age group, Maternal Health


How to cite this article:
Rathod M, Parmar D, Unadakat S, Kaliya M, Patel N, Goel A. An assessment of maternal morbidity pattern among reproductive age group women in a district of West Gujarat: A community based cross sectional study. Indian J Community Fam Med 2018;4:40-6

How to cite this URL:
Rathod M, Parmar D, Unadakat S, Kaliya M, Patel N, Goel A. An assessment of maternal morbidity pattern among reproductive age group women in a district of West Gujarat: A community based cross sectional study. Indian J Community Fam Med [serial online] 2018 [cited 2019 Dec 6];4:40-6. Available from: http://www.ijcfm.org/text.asp?2018/4/1/40/251348




  Introduction Top


If India intends to accomplish the goal of health for all, far greater attention must be given to women's health and their roles in health and development[1] because maternal health affects the health of whole family, community and thus society. Pregnancies and child births are very special events happening in women and, indeed, in the lives of their families. This can be a time of great hope and joyful anticipation. It can also be a time of fear, suffering and even death. Bunch of programmes are focusing on prevention of the maternal mortality. The RCH services started long back, mainly focus on the Reproductive health profile. The statistics are published regarding the mortality only. While looking at various health programmes related to the reproductive health, majority of them targeted to reduce the mortality. For each mortality, there are number of various morbidities, which directly or indirectly affects health. For every woman who dies of pregnancy-related causes, an estimated 20 women experience acute or chronic morbidity, often with tragic consequences.[2] There is dearth of data available on morbidity pattern of the reproductive age group women & if available then it particularly gives largely hospital based picture, which does not give the actual scenario prevailing in the community. Keeping in view the above stated problems, there is a need of conducting study which can assess morbidity profile of reproductive women.


  Objectives Top


  • To study the prevalence of antenatal, Intranatal and postnatal morbidities amongst women in the study population.
  • To study pattern of antenatal, Intranatal and postnatal morbidities.
  • To study the effect of various determinants on maternal morbidity amongst the study population.



  Material and Methods Top


Study area and population: The present assessment employed quantitative research methodology in rural areas of Jamnagar district of Gujarat.

Type of study: A cross sectional study.

Period of study: 1 year (July 2013- June 2014)

Sample size: Sample size of this study was decided on the basis of anticipated value of morbidity as 50%. Fifty percent of the reproductive age group women in the population might be suffering from some kind of illness at a time. As per WHO practical manual on sample size determination in health studies by Lwanga and Lemeshow[3]. N = Zα2PQ/l2 Where, Zα =1.96 at 5% significance level, N= required sample size, P=proportion or prevalence of interest, Q=100-p, l=allowable error. So when absolute error taken as 5%, P is taken as 50%, so as q=50%. Then, sample size would be, N = (1.96)2 *50*50/5x5 = 384.16. Considering the non-response rate/loss of sample = 10% of sample size, total sample size came out to 422.16 study subjects, which was made in round figure of 450 study subjects.

Study population: The study group comprised of 450 women of reproductive age group of rural areas of study district.

Inclusion criteria:

  • Ever Married, Reproductive age group women (15-49 years),
  • Willing to participate
  • Not Pregnant Presently


Sampling technique: Study subjects were selected by multistage sampling. Out of the total 7 blocks in the district, 3 blocks were selected randomly. Five Primary Health Centres were selected from each of the blocks by simple random sampling. From each PHC three sub centres were selected by simple random sampling method. So total 45 sub centres were selected from 3 blocks. Sub centre was taken as natural cluster. Thus total 45 clusters were selected. From the one geographically identified point, one direction was chosen randomly and from each cluster 10 women were selected and interviewed till the desired number was achieved in each cluster. So total 450 women were recruited.

Data collection: Data was collected in a pre-designed and pre-tested Proforma by interviewing woman. The study was carried out by undertaking house to house visits of the area of each cluster. Proforma consist of sociodemographic profile, past obstetric profile & any antenatal, Intranatal, & postnatal morbidities.

Ethical clearance: The study protocol was reviewed and approved by the institutional ethical committee of the institution. Prior written informed consent was taken from the paticipants after fully explaining the purpose of the study.

Data entry and analysis: The data entry was done in Microsoft Office Excel 2007. Analysis was done using Epi info and Microsoft office Excel2007 & SPSS. Chi square test was used to test the significance of difference between various variable. P value<0.05 was considered as statistical significance.
Table 1: Socio-demographic profile of study subjects (n=450)

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Figure 1: Distribution of women according to presence of Maternal Morbidity

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  Results Top


There was even distribution among various age groups of reproductive age group women except for15-19 years and 40-44 years. Majority belonged to middle and lower socio economical class. Higher literacy rate among husbands of participants (71.43%) found than females (56%). Most of the women were engaged in house hold activities (74%) where as their husbands were engaged in labour work (40.81%), some kind of business (20.40%) and farming (14.81%).

Of 450 women, 71 women did not conceive till date, thus they were excluded from the analysis & maternal morbidity variables were analysed for 379 women. Around eighty four percent of women had some form of morbidity during pregnancy, child birth and till the six week puerperium. Maternal Morbidity is one of the reasons for the reduced life expectancy of the women. Estimates of disability adjusted life-years (DALYs) provide an indicator of one part of the indirect costs, women's loss of productive life. An estimated 5 million DALYs are lost per year by women of reproductive age as a result of mortality and morbidity from unsafe abortion.[4] However, this rate probably underestimates the true burden because of limitations in the methods of estimating DALYs resulting from maternal causes.[5] Maternal morbidities could be present during antenatal, intranatal & postnatal period. Almost half of the morbidities were present during pregnancy period & half of the morbidities were present in intranatal & postnatal period.
Table 2: Distribution of women according to morbidity pattern during antenatal period (n=164)

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Antenatal morbidities were most common among all the types of maternal morbidities. The most common complaint was weakness, which may be due to the dilutional anaemia, a physiological effect of pregnancy. It was found in 93.29% of study subjects. Second most common complaint was vaginal discharge in 71.34%, followed by abdominal pain in 57.32%, headache in 54.27%, vomiting in 42.07%, oedema leg in 37.80%, fever in 34.15%, bleeding per vaginum in 22.56%, leaking per vaginum in 7.93%, decreased foetal movement in 3.66% and blurring of vision in 3.05% and oligohydroamnios in 10.37% of the participants.
Table 3: Distribution of women according to Morbidity pattern during labour (Intranatal period) (n=34)

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Considering intranatalmorbidities, Prolongation of labour was found in 67.64% of women, premature rupture of the membrane was present in 32.35% while 8.82% had convulsions, and 29.41% women gave history of meconium stained liquor suggesting foetal distress. Haemorrhage was present in 5.88%. On examination 38.24% were told that their pregnancy had malpresentation.
Table 4: Distribution of women according to morbidity pattern during puerperium (postnatal) (n=119)

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Common post-partum morbidities found were backache in 78.15%, weakness in 62.18%, pain in stitches in 21.85 %, delayed milk output in 27.73%. Other problems were infection of stitches in 10.08 %, mastitis in 5.88% and post-partum haemorrhage in 5.04% women, while other problems like fever, diarrhoea, bleeding from tear etc. were present.
Table 5: Distribution of Maternal Morbidity according to different variable

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There was no statistical difference in occurrence of maternal morbidity in different age groups, religion, social class, educational status of women, except educational status of husbands.

While analysing for prevalence of maternal morbidity in various age groups, 24.92% women among age group 20-24 years had any type of morbidity, where as in other groups it was around 15% except for age group 15-19 years. It could be due to small sample size in 15-19 years who would have conceived.

Among hindus, 69.73% women had maternal morbidity, & among muslims 75% had maternal morbidity, and the difference in occurrence of morbidity was not statistically significant.

In lower socio economical class, 37.22% whereas about 49.21% women in middle class & 13.6% women in upper class respectively women suffered from some kind of maternal mortality. The difference among various social classes was not statistically proved.

More than 50% morbidities occurred in the women who had literacy status below the secondary & higher secondary class, the difference was not significant statistically.

On statistical analysis there was significant difference in occurrence of the morbidities among various education statuses of women's husbands. 61% morbidities were in women whose husbands studied up to primary class.

The difference among various groups of parity & place of delivery and the occurrence of maternal morbidities was statistically significant. Among contraceptive users, prevalence of morbidity was 68.87%, & among non-users it was 72.53%. The difference was not significant statistically. No difference in age at marriage & maternal morbidities was found.

Among overweight women, prevalence of morbidity was 61.51%, where as in underweight group it was 9.15%. Those who had normal weight prevalence were 29.34%. The difference between these groups was not statistically significant.

Maximum proportion of morbidity was found in women who had 3rd parity i.e., 31.55% the difference was statistically significant. There was no statistical significant difference in occurrence of maternal morbidity & termination of pregnancy. Place of the delivery played important role in determination of maternal morbidities. Home delivery women suffered from maternal morbidities in high proportion i.e. 65.62% while institutional delivery had 34.38% occurrence and the difference between these two groups was statistically significant.
Figure 2: Distribution of women according to any medical complication during their pregnancy : (n=379)

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When looked at overall medical complications during pregnancy, 30.87% suffered from fever, 23.48% suffered from any episode of diarrhoea, 33.51% had complaints of respiratory problems, like cough, cold, throat problem, & few had lower respiratory complaints. Around 3% women were diagnosed as cases of malaria, 22.69% had urinary problems like burning micturation and 13.98% had complaints of abdominal pain. Other complaints were episode of breathlessness, jaundice etc.


  Discussion Top


Majority i.e. 74% women were housewives and remaining of them were engaged in agriculture, & labour activities. About 40.81% of the women's husbands were labourer and remaining of them were in occupations like agriculture, service or business. Social class distribution showed half of the subjects belonged to middle class, one third belonged to lower class wereas rest of them i.e. 14% belonged to upper class. About one quarter women married before the legal age of marriage, suggesting till child marriages are in practice, which affects her health in all aspects. The same was found among their husbands i.e. around 28% married before legal age of marriage. Mean age of women at 1st conception was 17.21 years. More than half of the women conceived before the ideal age for conception i.e. before 20 years and half of the women had safe child bearing age.

In a study by Davara Kajal (2013) in the same district, about one third, i.e. 38.2% women belonged to 25-29 years age group, followed by 20.4% women in 30-34 years age group, 19% women in 20-24 years age group, and 12.2% women in 35-39 years age group.[6]

According to DLHS-1 (2011), 95.8% were Hindu and 4.2% were Muslim in the Jamnagar district.[7] Majority i.e. 60.9% belonged to Joint family, 27.1% were from nuclear family and 12% belonged to three generation family in a study by Nimavat Khyati[8] According to DLHS-1, 35.6% women were illiterate in this district.[7] According to census 2011 of India; Literacy rate of females in the same district was 65.97%.[9] In a study by Koringa Hetal (2013), 23.77% women’s’ husband were illiterate, while 31.33%, 22.45% and 12.23% women's husband had education up to primary level, secondary level and higher secondary level respectively. Only 10.22% women's husbands were graduate.[10] In a study by Koringa Hetal (2013) majority i.e.76.67% women were house wives. Only 12.89% were labourers, 7.33% were service class, 2% were involved in agriculture and 1.11% were involved with gainful employment.[10]

Girls who marry earlier in life are less likely to be informed about reproductive issues,[11] and because of this, pregnancy-related deaths are known to be the leading cause of mortality among married girls between 15 and 19 years of age.[12] These girls are twice more likely to die in childbirth than girls between 20 and 24 years of age. Girls younger than 15 years of age are 5 times more likely to die in childbirth.[13]

Infants born to mothers under the age of 18 are 60% more likely to die in their first year than to mothers over the age of 19. If the children survive, they are more likely to suffer from low birth weight, malnutrition, and late physical and cognitive development.[14]

According to UNICEF data, Incidence of child marriage for year 2005-2006 was 52.5% in India.[15] According to NFHS, 2005-2006, Mean age at marriage for males in rural area was 21.5 years.[15]

83.64% women had any kind of morbidity during pregnancy, child birth or puerperium. Of which 36.44% women had antenatal morbidities, 7.55% women had intranatal morbidities and 26.44% had postnatal morbidities. Most common form of antenatal morbidities was weakness in 91.62%, vaginal discharge in 71.34%, abdominal pain in 57.32%, and headache in 54.27%. Around 20-40% had suffered from various health problems like vomiting, oedema leg, fever, bleeding P/V, oligohydroamnios. Few women had complaints of visual disturbances, decreased foetal movement and leaking P/V.

Considering the intranatal morbidities, prolongation of labour was found in 67.64% of women, premature rupture of the membrane was present in 32.35%, 8.82% had convulsions, 29.41% women told had the meconium stained liquor suggesting foetal distress. Haemorrhage was present in 5.88%. On examination 38.24% were told that their pregnancy had malpresentation.

From the women who had post-partum morbidities, common morbidities found were backache (78.15%), weakness in (62.18%), pain in stitches in (21.85%), delayed milk output (27.73%). 15-19% had complaints of breast engorgement, fever & abdominal pain. Other problems were infection of stitches in 10.08%, mastitis 5.88% and post-partum haemorrhage was found in 5.04% women, while only about 2% had diarrhoea, bleeding from tear etc.

During pregnancy, 30.87% suffered from fever, 23.48% suffered from any episode of diarrhoea, 33.51% had complaints of respiratory problems, like cough, cold, throat problem, & few had lower respiratory complaints. Around 3% women diagnosed with malaria, 22.69% had urinary problems like burning micturition. 13.98% had complaints of abdominal pain.

The study conducted by Patel Neha in same district (2012) found that 302(67.11%) women had suffered from any type of maternal morbidity during their pregnancy, childbirth or puerperium. While rest 148(32.89%) did not have any morbidity.[16] The study by Neha Patel (2012) revealed that from the women, who had any kind of morbidity, 55.56% women had morbidity during their antenatal period, 20.22% women had morbidity during intranatal period and 24.44% women had morbidity during their post-partum period.[16]

Current study has higher rate of maternal morbidity than a report by WHO regional health Forum (1996), in which maternal morbidity were reported as below, maternal morbidity of the last pregnancy in 5 CHN-III Provinces, SKRT 1995.[17]

Nimavat Khyati (2013) in her study in same district found pre-eclampsia (swelling of legs and blurring of vision) i.e. 32.5%. Other health problems of women were abdominal pain -22.5%, severe weakness- 20%, severe vomiting- 10%, high fever- 10%, leaking per vaginum- 7.5%, bleeding per vaginum- 5%, severe anaemia- 5%, decrease fetal movement- 5% and early cervical dilatation- 2.5%.

Study by Patel Neha et al (2012) revealed that, from the women who had antenatal morbidity, majority had complaint of weakness (70.4%). Other morbidities found were hyper emesis gravidarum (25.2%), swelling of legs (25.2%), hypertensive Disorder (Pregnancy Induced hypertension) (14.4%), bleeding P/V (11.6%), headache (8.8%), blurring of vision (8.4%), eclampsia (1.6%) and fever with vaginal discharge (6%).[16]

Khyati Nimavat et al (2013) said women who suffered from intrapartum morbidity, majority i.e. (40.9%) women had prolonged labour, followed by premature rupture of membrane in 27.3%, convulsions in (18.1%), bleeding in (18.1%) and mal presentation in (13.6%).[8]

Patel Neha et al (2012) stated from the women who had intrapartum morbidity, major cause found were prolonged labour -34.6%, premature rupture of membrane - 31.86%, oligohydroamnios 18.68%, malpresentation- 12.08% and foetal distress-12.08%. Very few women had complaint of MAS -5.5%, polyhydroamnios -3.3% and 2.2% women suffered from primary post-partum haemorrhage.[16] The same study observed that 22.72% had backache, 18.18% had pain in stitches, Infection of stitches in 13.63%, 10% had mastitis, 9.1% had weakness as well as delayed milk output, whereas haemorrhage was found in 3.63%, and only 1% had septicaemia & eclampsia.[16]

Over all medical complication during pregnancy were 7.78% amongst the women. Out of those who had medical complications, 34.28% women had Diarrhoea during pregnancy. 22.85% women had Fever due to any medical reason during their antenatal period and 8.57% had Reproductive Tract Infections. 5.7% women had Malaria during pregnancy. 20% women had other complication like Asthma, Jaundice, Rubella, Stone etc in a study by Patel Neha et al (2012).[16]

Conclusion: Eighty percent women suffered from maternal morbidities. Educational status, parity & place of delivery could be independent risk factors. Other factors did not found statistical significant difference in occurrence of maternal morbidity. Thus irrespective of sociodemographic variable, there is a chance of occurrence of maternal morbidity, so there is need to focus on this grey area.

Expanding the discourse around safe motherhood to use explicitly both the terms mortality and morbidity (or death and disability) would raise awareness of the need to address neglected morbidities, which have life-altering consequences for women and their families. Communities should be made aware of the hazards of utilizing untrained birth attendants for conducting delivery & simultaneously promotion of institutional delivery should be made. There is a special effort needed to map out those areas where home deliveries are high and persisting. Interventions before pregnancy can increase the health and well-being of adolescents, adult women and men, and improve subsequent pregnancy and child health outcomes.

Limitation of study: Relatively small sample size could be the limitation, for such type multicentre study should be conducted with larger sample size. Only variable of interest were included in study.

Conflict of interest:

Nil

Source of funding:

Nil



 
  References Top

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Programme, CSSM-Child Survival & Safe Motherhood. mohfw.nic. in/WriteReadData/l892s/6342515027file14. [Online]  Back to cited text no. 1
    
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Singh S, Darroch JE, Vlassoff M, Nadeau J. Adding it up. The benefits of investing in sexual and reproductive health care. New York.  Back to cited text no. 2
    
3.
Vlassoff M, Singh S, Darroch JE, Carbone E, Bernstein S. Assessing costs and benefits of sexual and reproductive health interventions. Occasional report No. 11. New York: The Alan Guttmacher Institute, 2004.  Back to cited text no. 3
    
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Davara KB, Mehta J, Parmar D. Female Foeticide; awareness and perceptionof married women in the reproductive age group in Jamnagar District. Int J Med Sci Public Health.2014;3(7):839-844  Back to cited text no. 4
    
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DLRHS-1, Evaluation of mch services in gujarat: district level rapid household suevey. Ministry of Health and Family Welafare, Government of Gujarat, Social Infrastructure Development Board, Gov. of Gujarat. s.l. : National Rural Health Mission. 2011.  Back to cited text no. 5
    
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Nimavat KA, Mangal AD, Unadkat SV, Yadav SB. A study on birth preparedness of women in Jamnagar District. Interntational Journal of Community Medicine and Public Health. 2016;3(9):2403-2408  Back to cited text no. 6
    
7.
Census of India. 2011.  Back to cited text no. 7
    
8.
A study on various factors affecting family planning practices among eligible couples by Dr. Hetal Koringa 2014. Jamnagar, India : s.n.  Back to cited text no. 8
    
9.
Factors Affecting Age and Marriage and Age at First Birth in India. Chandrasekhar, S. s.l. : Journal of Quantitative Economics, 2010, p. 83.  Back to cited text no. 9
    
10.
http://www.childinfo.org/marriage.html. [Online].  Back to cited text no. 10
    
11.
http://www. icrw.org/child-marriage-facts-and-figures. International center for Research on Women “Child Marriage Facts and Figures”.  Back to cited text no. 11
    
12.
UNICEF, “Child protection from violence, exploitation and abuse”. http://www.unicef.org/protection/57929_58008.html.  Back to cited text no. 12
    
13.
Marriage,Incidence of child. http://www.unicef.in/ documents/childmarriage.pdf.  Back to cited text no. 13
    
14.
Patel NA, Mehta JP, Unadkat S, Yadav SB. A study on various determinants of Maternal Morbidity and Mortality amongst the married women in reproductive age group in urban slums. Int J Cur Res Rev. 8(24):19-25  Back to cited text no. 14
    
15.
Djaja S, Agus. The Determinants of Maternal Morbidity in Indonesia. Regional Health Forum, WHO, Vol.4.  Back to cited text no. 15
    
16.
K.Park, text book of preventive & social medicine, page no. 833. Health care of the community. 2013, Vol. 22 Edition.  Back to cited text no. 16
    
17.
Reichenheim ME, Zylberstajn F, Moraes CL, Lobato G. Severe acute obstetric morbidity (near-miss): a review the relative use of its diagnostic indicators. Arch Gynecol Obstet. 2009; 280(3):337-43.  Back to cited text no. 17
    


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    Tables

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