Maternal morbidity in the first year after childbirth in Mombasa Kenya; a needs assessment

Background: In sub-Saharan Africa, few services specifically address the needs of women in the first year after childbirth. By assessing the health status of women in this period, key interventions to improve maternal health could be identified. There is an underutilised opportunity to include these interventions within the package of services provided for woman-child pairs attending child-health clinics. Methods: This needs assessment entailed a cross-sectional survey with 500 women attending a child-health clinic at the provincial hospital in Mombasa, Kenya. A structured questionnaire, clinical examination, and collection of blood, urine, cervical swabs and Pap smear were done. Women’s health care needs were compared between the early (four weeks to two months after childbirth), middle (two to six months) and late periods (six to twelve months) since childbirth. Results: More than one third of women had an unmet need for contraception (39%, 187/475). Compared with other time intervals, women in the late period had more general health symptoms such as abdominal pain, fever and depression, but fewer urinary or breast problems. Over 50% of women in each period had anaemia (Hb <11 g/l; 265/489), with even higher levels of anaemia in those who had a caesarean section or had not received iron supplementation during pregnancy. Bacterial vaginosis was present in 32% (141/447) of women, while 1% (5/495) had syphilis, 8% (35/454) Trichomonas vaginalis and 11% (54/496) HIV infection. Conclusion: Throughout the first year after childbirth, women had high levels of morbidity. Interface with health workers at child health clinics should be used for treatment of anaemia, screening and treatment of reproductive tract infections, and provision of family planning counselling and contraception. Providing these services during visits to child health clinics, which have high coverage both early and late in the year after childbirth, could make an important contribution towards improving women's health. © 2009 Chersich et al; licensee BioMed Central Ltd.

At Coast Provincial General Hospital in Mombasa, Kenya, 500 women attending an immunization and acute care paediatric clinic participated in a cross-sectional survey to describe the levels of maternal morbidity in the year after childbirth. The survey, held in 2006, also investigated the feasibility of providing HIV testing and counselling, and the levels of HIV-related disease in this population [25,26]. Study activities formed part of a project to improve maternal health services in Coast Province Kenya. From 2002 to 2005 this project focused on strengthening antenatal and intrapartum services; however as it appeared that few women attended postpartum services and their needs were ill defined, this survey was planned to assess women's needs after childbirth and to define a service package that could be provided for women bringing their child for health care. The study was approved by the Kenyatta National Hospital Ethics and Research Committee. The study population consisted of consecutive women who were older than 16 years, biological mothers of the child, and between four weeks and one year after childbirth. After completion of the child-health visit, women were approached and invited to participate in the study. Those willing to participate gave written informed consent and were interviewed using a pre-tested structured questionnaire administered in Swahili, the local language. Besides information on demographic characteristics, data were collected on access to sexual and reproductive health services; family planning needs and sexual health status. Women were screened for mild and major depression (using ICD-10 definitions [27]) and for harmful alcohol use with the AUDIT tool [28]. Thereafter study nurses did a clinical examination and collected blood, urine, a cervical swab and a Pap smear. Full details of test procedures and the sample size calculation are provided elsewhere [26]. Urine dipstick detected nitrites and leucocytes. Blood samples were used for malaria microscopy, RPR test for syphilis and serial rapid HIV testing. Trichomonas vaginalis and candida were detected in a wet mount, and Nugent's criteria used for diagnosing bacterial vaginosis. Participants were advised to return for test results and, if required, received treatment according to local guidelines. For conditions such as syphilis, malaria and severe anaemia, women with positive results were contacted and asked to return to the clinic immediately. All participants were offered HIV counselling and same-day testing; those testing positive were enrolled in an HIV care and treatment clinic at the study site. Data collected during interviews and laboratory investigations were double entered using Statistical Package for Social Science, version 11.5 (Chicago, USA). For analysis, women were divided into three groups according to the time period since childbirth: early (four weeks to two months), middle (two to six months) and late periods(six to twelve months). These categories were selected to be broadly consistent with the local child immunization schedule and the anticipated patterns of illness in women. Sexually-active women not using contraceptive methods were defined as having an unmet need for contraception. Lactational amenorrhea (exclusive breastfeeding and amenorrhea) was classified as a contraceptive method. Haemoglobin levels below 11 g/l were considered anaemia and a mean corpuscular volume below 81fl microcytic [29]. Intercooled Stata 8.0 (Stata Corporation, College Station, Texas, USA) was used to assess the distribution of sexual behaviour, contraceptive need, morbidity and other variables among women presenting in the early, middle and late periods. Also, the demographic and reproductive health characteristics of these three groups were compared to assess whether systematic differences exist which might be explained by differential health-seeking patterns. For example, we assessed whether poorer or multiparous women were less likely to attend visits in the late period. A chi-square test was used for analysis of binary variables and Mantel-Haenszel odds ratios were calculated. For continuous variables, a Student's t test and Wilcoxon's rank-sum test were used for comparing variables with a normal or non-normal distribution respectively. One way analysis of variance was used to compare means of continuous variables in each of the time periods.

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• chersich, matthew f.
• kley, nicole
• luchters, stanley
• njeru, carol
• yard, elodie
• othigo, mary j.
• temmerman, marleen