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Background: Little is known about the impact of life-threatening obstetric complications (‘near miss’) on women’s mental health in low- and middle-income countries. Aims: To examine the relationships between near miss and postpartum psychological distress in the Republic of Benin. Method: One-year prospective cohort using epidemiological and ethnographic techniques in a population of women delivering at health facilities. Results: In total 694 women contributed to the study. Except when associated with perinatal death, near-miss events were not associated with greater risk of psychological distress in the 12 months postpartum compared with uncomplicated childbirth. Much of the direct effect of near miss with perinatal death on increased risk of psychological distress was shown to be mediated through wider consequences of traumatic childbirth. Conclusions: A live baby protects near-miss women from increased vulnerability by giving a positive element in their lives that helps them cope and reduces their risk of psychological distress. Near-miss women with perinatal death should be targeted early postpartum to prevent or treat the development of depressive symptoms.
This combined epidemiological and ethnographic prospective cohort study was conducted in southern Benin, a country with little social protection for the poor and with high maternal mortality (840 deaths per 100 000 live births)9 despite 80% of mothers attending antenatal clinics and 78% of deliveries occurring in health facilities.10 Because of the difficulty of determining with sufficient accuracy if a woman has experienced an obstetric complication if she has not used health services, the study population was recruited from six referral hospitals within the study area.11,12 All near-miss women and a sample of women with uncomplicated childbirth who delivered in the hospitals between September 2004 and January 2005 and lived within 30 km of the recruitment site were approached for inclusion in the study. The catchment area for the sample was mostly urban, but included some rural areas with difficult access to services. Near-miss women were categorised according to the pregnancy outcome: women with near-miss deliveries with a live baby; and women with near-miss deliveries but whose baby died before the woman was discharged from hospital. The exposure status of the women (uncomplicated delivery, near miss with live baby or near miss with perinatal death) was determined by research midwives on the basis of clinical signs and symptoms of complications, as well as clinical procedures. Those classified as near misses included five categories of complications at term: haemorrhage (leading to shock, emergency hysterectomy and blood transfusion); pregnancy-induced hypertensive disorders (eclampsia and severe pre-eclampsia); dystocia (uterine rupture and impending rupture); infections (hyper/hypothermia and/or clear source of infection with clinical signs of shock); and anaemia (haemoglobin levels below or equal to 50 g/l or clinical signs of severe anaemia). For each near miss, two unmatched controls with uncomplicated deliveries were selected; uncomplicated delivery was defined as having given birth vaginally to healthy infants, with no deformities, weighing at least 2500 g and at term (37–42 weeks) and whose medical records revealed no prenatal, labour or immediate postpartum complications. On exit from hospital, research midwives summarised each woman’s medical records using a structured instrument. Data were recorded on medical history, risk factors, signs and symptoms, treatments and medical interventions, mode of delivery and baby’s health status on exit from hospital. Within a fortnight following discharge, the research midwives conducted home visits and, using a structured questionnaire with standardised instruments adapted for use in Benin,10,13 collected baseline data on the women’s health, socioeconomic status and pregnancy experiences. The women were interviewed again at 6 and 12 months following discharge, to gather information on consequences and experiences after delivery (Fig.1). The structured questionnaires included questions on women’s relationships with family members, perceived physical health and negotiation of hospital fees associated with the delivery. The interviews also incorporated an adapted version of the K10 screening tool to measure the risk of psychological distress in the study population.14,15 This tool elicits symptoms of anxiety and depression and has been validated specifically for the detection of depressive symptoms in the postnatal period in neighbouring Burkina Faso (see Appendix).16 Schematic of eligibility, recruitment and follow-up, by delivery status (normal delivery, near-miss live birth, near-miss perinatal death). PP, postpartum. The ethnographic sample consisted of 40 women, selected in the immediate postpartum period from the larger cohort. Women were selected randomly from predefined quota sampling, on the basis of socioeconomic status and parity, according to the larger epidemiological sample. This sampling method was chosen to ensure the inclusion of socially marginalised participants, as well as to ensure sufficient heterogeneity of the sample according to economic status and parity, given the small sample size. In total, 11 women were a near miss with a perinatal death, 15 near miss with a live birth and 14 had uncomplicated deliveries. Two sociologists and an anthropologist conducted repeated qualitative interviews with these women using an in-depth interview guide to generate information on delivery experiences, recovery, other social and economic changes or consequences in the postpartum period, and social context in which the women experienced these changes. The ethnographic sample were interviewed at home at 3 and 6 months, and 20 (50%, owing to resource constraints, selected using purposive sampling) were interviewed again at 12 months postpartum. Women whose babies died following discharge were excluded from the analysis because subsequent baby deaths would be likely to distort relationships between delivery experiences and psychological distress. Stata/IC 10.0 for Windows was used to derive percentages, means, significance levels and regression coefficients comparing near-miss women with and without perinatal death to those with uncomplicated deliveries in the quantitative analysis. With limited information on temporal aspects of cause and effect, one cannot be certain whether specific parameters are a consequence or a cause of psychological distress. For example, it is difficult to determine the direction of any association between spousal abuse and K10 score when using measures taken at the same point in time, because, intuitively, spousal abuse could cause psychological distress, yet psychological distress may itself lead to a negative spousal relationship and violence. Therefore, although K10 measurements were taken at both 6 and 12 months, this analysis is limited to the K10 outcome at 12 months postpartum so that the effect of exposures measured at 6 months postpartum can be assessed. This takes advantage of the longitudinal nature of the data-set and facilitates investigation of the roles of debt, poor physical health and spousal abuse over the entire year postpartum. Associations between chronic debt, poor physical health and spousal abuse in the 6 months following delivery and K10 score at 12 months postpartum were investigated using linear regression adjusting for possible confounders of near-miss status, hospital of recruitment (associated with socioeconomic factors), parity, marital status and wealth quintile. Wealth quintiles were derived from a score of the asset ownership of each woman’s household using principal components analysis.17 Age and education were not used as confounders because of correlation with parity and wealth, respectively. Regression analyses were also controlled for exposures of ‘high’ and ‘low’ risk of psychological distress at 6 months (derived from K10) to account for any associations between debt, poor physical health and spousal abuse and depressive symptoms at 12 months that may be as a result of confounding between these factors and psychological distress at 6 months postpartum.16 Mediation analysis was based on the hypothesis that severe complications are more than a physical event – in addition to physical shock, there may be an economic impact in countries where treatment of such complications is not covered by health insurance. This may lead to adverse social consequences, as economic stress on the family unit may, in turn, lead to psychological distress. Psychological distress may also be an independent consequence of the loss of one’s baby through near miss. Linear regression models were fitted on the 12-month K10 score taking into account hypothesised hierarchical relationships between near miss, medical debt (measured as unpaid hospital debts at 6 or 12 months postpartum), poor physical health (measured as self-reported physical illness that prevents the woman from conducting her daily activities) and spousal abuse (measured as new events of physical, sexual or emotional abuse and/or neglect that women report as happening within the first 6 months postpartum and not occurring before or during pregnancy) to test how these risk factors may mediate the direct effect of near miss on psychological distress. In the first step of the analysis, near-miss status is entered along with potential confounding factors and the resulting regression coefficient represents the overall adjusted effect of near miss on K10 score. The subsequent stepwise addition of variables is used to identify the extent to which the effect of near-miss status is mediated through the other factors. In other words, the final model estimates the remaining independent effect of near miss on K10 score, or the effect not mediated through physical morbidity, initiation of spousal abuse and debt. Ethnographic analysis focused specifically on exploring the local salience of mediating factors between reproductive experiences and postpartum psychological distress. For this, two types of comparative analysis based on an in-depth case-study method were undertaken. The first mirrored the quantitative study, and compared women who had an uncomplicated delivery with those who had a near miss, both with and without perinatal death. Within these subgroups, women with high and low K10 scores, at either 6 or 12 months postpartum, were also compared. As a starting point, a 14-point cut-off was used to discern clinically significant mental morbidity.16 To increase our sample size, women with scores of 11 or above were considered at potential risk of mental morbidity and were also included in our comparative analysis. The second comparative analysis focused on comparing standard cases (women with near-miss experiences and high K10 scores) with what can be conceptualised as exceptions or ‘atypical cases’, that is, those women whose experiences and practices deviated from the general patterns established by the epidemiological analysis.18,19 Atypical cases, then, included women with near misses with or without perinatal deaths who demonstrated low K10 scores. The study was approved by the Ministry of Health, Benin and the ethics committee of The London School of Hygiene and Tropical Medicine, UK.
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