Article Text

Download PDFPDF

Burden of physical, psychological and social ill-health during and after pregnancy among women in India, Pakistan, Kenya and Malawi
  1. Mary McCauley1,
  2. Barbara Madaj1,
  3. Sarah A White1,
  4. Fiona Dickinson1,
  5. Sarah Bar-Zev2,
  6. Mamuda Aminu1,
  7. Pamela Godia3,
  8. Pratima Mittal4,
  9. Shamsa Zafar5,
  10. Nynke van den Broek1
  1. 1 Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK
  2. 2 Centre for Maternal and Newborn Health, Lilongwe Office, Lilongwe, Malawi
  3. 3 Centre for Maternal and Newborn Health, Nairobi Office, Nairobi, Kenya
  4. 4 Department of Obstetrics and Gynaecology, Safdarjung Hospital, New Delhi, India
  5. 5 Child Advocacy International Pakistan, Islamabad, Pakistan
  1. Correspondence to Dr Mary McCauley; mary.mccauley{at}


Introduction For every woman who dies during pregnancy and childbirth, many more suffer ill-health, the burden of which is highest in low-resource settings. We sought to assess the extent and types of maternal morbidity.

Methods Descriptive observational cross-sectional study at primary-level and secondary-level healthcare facilities in India, Pakistan, Kenya and Malawi to assess physical, psychological and social morbidity during and after pregnancy. Sociodemographic factors, education, socioeconomic status (SES), quality of life, satisfaction with health, reported symptoms, clinical examination and laboratory investigations were assessed. Relationships between morbidity and maternal characteristics were investigated using multivariable logistic regression analysis.

Results 11 454 women were assessed in India (2099), Malawi (2923), Kenya (3145), and Pakistan (3287). Almost 3 out of 4 women had ≥1 symptoms (73.5%), abnormalities on clinical examination (71.3%) or laboratory investigation (73.5%). In total, 36% of women had infectious morbidity of which 9.0% had an identified infectious disease (HIV, malaria, syphilis, chest infection or tuberculosis) and an additional 32.5% had signs of early infection. HIV-positive status was highest in Malawi (14.5%) as was malaria (10.4%). Overall, 47.9% of women were anaemic, 11.5% had other medical or obstetric conditions, 25.1% reported psychological morbidity and 36.6% reported social morbidity (domestic violence and/or substance misuse). Infectious morbidity was highest in Malawi (56.5%) and Kenya (40.4%), psychological and social morbidity was highest in Pakistan (47.3%, 60.2%). Maternal morbidity was not limited to a core at-risk group; only 1.2% had all four morbidities. The likelihood of medical or obstetric, psychological or social morbidity decreased with increased education; adjusted OR (95% CI) for each additional level of education ranged from 0.79 (0.75 to 0.83) for psychological morbidity to 0.91 (0.87 to 0.95) for infectious morbidity. Each additional level of SES was associated with increased psychological morbidity (OR 1.15 (95% CI 1.10 to 1.21)) and social morbidity (OR 1.05 (95% CI 1.01 to 1.10)), but there was no difference regarding medical or obstetric morbidity. However, for each morbidity association was heterogeneous between countries.

Conclusion Women suffer significant ill-health which is still largely unrecognised. Current antenatal and postnatal care packages require adaptation if they are to meet the identified health needs of women.

  • maternal health
  • obstetrics
  • cross-sectional survey

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

View Full Text

Statistics from


  • Handling editor Seye Abimbola

  • Contributors MM co-ordinated and supervised the in-country data collection, collected data, conducted data analysis and wrote the manuscript. BM supervised and monitored all data collection in each country. SAW helped design the study, checked all data analysis and performed further analyses. FD formatted the tool for electronic data collection onto tablets and helped oversee the data collection. MA imported electronic data and cleaned, processed, coded the datasets and performed preliminary analysis. SB-Z supervised data collection in Malawi, PG in Kenya, PM in India and SZ in Pakistan. NvdB developed the study design and protocol, oversaw the design and conduct of the study, data collection and analysis and wrote the manuscript. All authors have read, edited and approved the final manuscript for submission.

  • Funding This study was funded by two grants to the Centre for Maternal and Newborn Health at the Liverpool School of Tropical Medicine in the UK: Global Health Grant (OPP1033805) from Bill and Melinda Gates Foundation via WHO and a grant from the Department of International Development, London, UK, under the Making it Happen programme (202945-101).

  • Disclaimer The funders played no role in the writing of the manuscript or the decision to submit it for publication.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval The Liverpool School of Tropical Medicine, Liverpool, UK, granted full ethical approval (LSTM14.025). Ethical approval was also obtained from each country-specific research ethics committee: The College of Medicine Research and Ethics Committee, College of Medicine, Blantyre, Malawi (P.07/14/1600); Kenyatta National Hospital and University of Nairobi, Ethics and Research Committee, Nairobi, Kenya (P574/09/214); Research and Ethics Committee, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India (IEC/SJH/VMMC/Project/September-14/19/482) and the National Bioethics Committee, Islamabad, Pakistan (4-87/14/NBC-159/RDC/1850).

  • Provenance and peer review Not commissioned; externally peer reviewed.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.