# **Title:** **Maternal morbidity in labour and puerperium in rural homes and the need for medical attention: A prospective observational study in Gadchiroli, India**

**Authors:**

Rani A Bang, MD, MPH; SEARCH, Gadchiroli, 442-605, India

Abhay T Bang, MD, MPH**;** SEARCH, Gadchiroli, 442-605, India

M. Hanimi Reddy, PhD**.** SEARCH, Gadchiroli, 442-605, India

Mahesh D Deshmukh, M.Sc. SEARCH, Gadchiroli, 442-605, India

Sanjay B Baitule, DHMS SEARCH, Gadchiroli, 442-605, India

Veronique Filippi, Ph.D. London School of Hygiene and

Tropical Medicine, London, UK.

**Address for correspondence and reprint request:**

Dr.Abhay Bang

Director, SEARCH

GADCHIROLI, 442 605, India.

**Short Headline:**

# Maternal morbidity in India

E-mail: <search@satyam.net.in>

# Fax: +91-7132-233403

# Tel: +91-7138-255407 

**Abstract:**

**Objectives:** To estimate the incidence of maternal morbidity during
labour and purperium in rural homes, their association with perinatal
outcomes, and the proportion of women needing medical attention.

**Design:** Prospective observational study nested in a neonatal care
trial

**Setting:** 39 villages in Gadchiroli district, Maharashtra, India

**Sample:** 772 women recruited over a one year period (1995-96) and
followed-up from the seventh month in pregnancy to 28 days postpartum
(up to 10 visits in total)

**Methods:** Observations at home by trained village health workers,
validated by a physician. Diagnosis of morbidities by computer program.

**Main outcomes:** Direct obstetric complications during labour and the
puerperium, breast problems, psychiatric problems and need for medical
attention

**Results:** The incidence of maternal morbidity was 52.6%, 17.7% during
labour and 42.9% during puerperium. The most common intrapartum
morbidities were prolonged labour (10.1%), prolonged rupture of
membranes (5.7%), abnormal presentation (4.0%) and primary postpartum
haemorrhage (3.2%). The postpartum morbidities included breast problems
(18.4%), secondary postpartum haemorrhage (15.2%), puerperal genital
infections (10.2%) and insomnia (7.4%). Abnormal presentation and some
puerperal complications (infection, fits, psychosis and breast problems)
were significantly associated with adverse perinatal outcomes; but
prolonged labour was not. A third of the mothers were in need of medical
attention: 15.3% emergency obstetric care and 24.0% non-emergency
medical attention.

**Conclusions:** Nearly 15% of women who deliver in rural homes
potentially need emergency obstetric care. Frequent (43%) postpartum
morbidity and their association with adverse perinatal outcomes suggest
the need of home-based postpartum care in developing countries for both
mother and baby.

**Introduction**

Information on maternal morbidity at home could provide the evidence
necessary for planning safe motherhood outreach activities in developing
countries. The data on the types and incidence of maternal morbidities
in communities with limited access to health services are scarce.
Estimates in developing countries vary between 16.5 pregnancy-related
complications to more than 100 acute complications per maternal
death^(1,\ 2)^. However, maternal deaths themselves may be
under-reported. International organizations anticipate that 15% of
pregnancies develop complications which necessitate medical care. This
estimate has not been thoroughly validated ^(3,\ 4)^.

Even though 63% of deliveries globally, and 75% in India, occur at home,
these are rarely observed^(5,\ 6)^. Most of the reported information on
maternal morbidity is based on hospital deliveries or women's
self-reports ^(7)^. However, hospital deliveries are likely to be a
selected group and hence not representative of the events in community.
For a decade, efforts have gone into improving the measurement of
morbidity through household surveys. However, retrospective data from
individual interview surveys now appear of limited value for obtaining
estimates of biomedical maternal morbidity in settings where a large
proportion of women deliver at home. Cross-sectional surveys using model
questionnaires show wide differences in self-reported prevalence across
countries and sub-populations^(8,\ 9)^. Although it is tempting to
interpret these differences as reflecting true variation in disease
prevalence and health service use, a more likely explanation is the lack
of robustness of using questionnaires for measuring biomedically defined
morbidity. Second, validation studies have shown a poor concordance of
women's self-reports of obstetric complications with medical data**.**
Morbidity on a continuum, such as intrapartum bleeding, appears
particularly difficult to ascertain because the threshold at which
normal becomes abnormal may be perceived differently by women and the
providers. Puerperal fever is also difficult to assess by retrospective
inquiry in areas where other fevers are common^(10)^.

There is no satisfactory substitute for direct observation at home. So
far, this has not been possible because of the absence of a suitable
observer to record events during delivery and puerperium at home. This
study aimed to estimate the type and incidence of intrapartum and
postpartum maternal morbidity and the proportion of women needing
medical attention during labour and puerperium when observed at home by
trained village health workers (VHWs) in a rural area of India.

## Methods

A field trial of home-based neonatal care was conducted during 1995-'98
in rural Gadchiroli.^(11)^ In the first year of the trial the mothers
and neonates were prospectively observed at home in 39 villages without
interventions.^(12)^ This report is based on these observations.

***Study area and setting:***

The Gadchiroli district in the state of Maharashtra, India, is an
underdeveloped district with Hindu and tribal farming populations. The
Government health services consist of one district hospital (where a
caesarian section can be performed) for a population of approximately
one million, one Primary Health Centre with two non-specialist doctors
per 20,000 population, and one nurse-midwife per 3000 population. In
addition, private unqualified doctors provide medical treatment in
villages.

SEARCH (Society for Education, Action and Research in Community Health)
is a voluntary organization working in Gadchiroli since 1986 with a
community health care and research program. Male village health workers,
one per 2,000 population, collect vital statistics^(11)^. Traditional
birth attendants (TBAs), usually one per 500 population, were trained by
SEARCH in 1988-89 and since then they provide basic care during
pregnancy, delivery and puerperium, and also treat pneumonia in children
with co-trimoxizole^(13,\ 14)^. TBAs do not keep records except for the
list of deliveries conducted.

***Data collection:***

In 1994, SEARCH selected 39 female village health workers (VHWs) in 39
intervention villages in the field trial. The VHWs had usually five to
ten years of school education and had permanent residence in the
village. They were trained over a period of six months to interview
pregnant women, record maternal history, observe and record events and
time during labour and puerperium. After a pilot phase, they started
collecting data in April 1995 in their own villages ^(11)^, and
collected baseline morbidity data for one year. Since most deliveries in
the area were conducted by TBAs, who were associated with SEARCH, the
VHWs worked in co-operation with TBAs.

The data collection methods have been published.^(11,12)^ Here we shall
describe data collection primarily in relation to mothers' health. The
VHW made a list of the pregnant women in her village and periodically
updated it. She visited them during the 7^th^, 8^th^, and 9^th^ month of
pregnancy and, using a structured questionnaire, recorded information on
obstetrical history, last date of menstruation and health complaints.
The mother\'s height was measured using a tape measure and wooden rule.

The VHW instructed pregnant women to inform her as soon as the mild
labour pain started. She visited the woman at the onset of labour pain,
asked information and, using the wrist watch, recorded the time of onset
of labour pain and of rupture of membranes (\"*Mutondi Futne*\"). She,
along with the TBA, again visited when the strong labour pain started
and made records. TBA and family members conducted the delivery, while
the VHW observed various events, practices, timings and made records on
the printed form. Though hospital deliveries were uncommon, private
doctors, most often unqualified, or nurses were some times called at
home. They usually give oxytoxic injections to speed up the delivery.
Mothers were shifted to hospitals only in desperate situations and often
very late. If a doctor or nurse was called during the delivery and
he/she gave treatment, or if the TBA put her hand inside the vagina or
interfered in any other way, it was recorded. The blood loss during
labour was qualitatively recorded by the VHW as normal or excessive. She
also recorded whether the mother was unconscious or cold to touch at the
end of delivery. Axillary temperature was recorded using a digital
thermometer (*Sakura, Japan*).

The VHW subsequently visited on the 2^nd^, 3^rd^, 5^th^, 7^th^, 14^th^,
21^st^, and the 28^th^ day after delivery to collect information by
inquiring about and/or observing fever (axillary temperature), nature
and odour of the vaginal discharge, blood loss, number of pads changed,
breast problems, insomnia, abnormal speech or behaviour and fits.

All women who delivered in 39 study villages during April 1995 to March
1996 were recruited including those from other villages who had come to
deliver in their parent\'s house. Women who went in to labour in the
village but were subsequently shifted to hospital, or those who, after a
hospital delivery, returned to the village and spent the postpartum
period in the village were also observed at home and the observed period
was included in the study. We observed mothers till the completion of
the neonatal period (28^th^ day). If the mother left the village before
28^th^ day, the period of observation remained incomplete.

TBAs had been trained to advise referral when indicated. SEARCH made
available free ambulance transport to the nearest Government hospital if
the family wanted to shift the mother.

***Quality control**:*

Once every 15 days, a physician visited every village, and therein,
every house with a delivery. He checked the information recorded by the
VHWs, crosschecked it by questioning the mother, family and the TBA,
made his own observations and corrected and re-trained VHWs if any
errors were detected. To assess the quality of data collected by the
VHWs, he filled parallel forms independently on 119 consecutive mothers
and neonates. Information on 18 variables related to maternal
morbidities, was compared to estimate the agreement between VHWs and the
physician.

***Case definitions of maternal morbidities** are presented in box 1*.

#### Box 1: Case definitions

+-----------------------------------------------------------------------+
| *1*. *Prolonged repture of membranes*: more than 24 hours between     |
| loss of water *(Mutondi Futne)* and onset of labour pain.             |
|                                                                       |
| 2.  *Prolonged labour***:** labour duration greater than 24 hours     |
|     from the onset of mild pains to the birth of baby.                |
|                                                                       |
| 3.  *Abnormal presentation***:** Presenting part face, hand,          |
|     shoulder, hand or breech.                                         |
|                                                                       |
| 4.  *Retained placenta***:** Placenta did not come out for more than  |
|     one hour after baby's birth.                                      |
|                                                                       |
| 5.  *Excessive bleeding on 1^st^ day:* Excessive bleeding as          |
|     perceived by female VHW.                                          |
|                                                                       |
| 6.  *Primary postpartum haemorrhage (PPH):* Excessive bleeding on     |
|     1^st^ day and mother hypothermic (\<35.0^0^C) or unconscious.     |
|                                                                       |
| *7. Secondary postpartum haemorrhage***:** 5 days after delivery,     |
| mother used more than 5 pads a day or increased vaginal bleeding      |
| after bleeding had decreased or stopped; or any increase in use of    |
| pads (by at least 2) after it was less or none.                       |
|                                                                       |
| *8. Puerperal fever:* Temperature \> 37.8^0^ C on any day during 2-28 |
| days after delivery*.*                                                |
|                                                                       |
| *9. Puerperal infection of genital tract*: Foul smelling vaginal      |
| discharge and fever; or foul smelling vaginal discharge and secondary |
| PPH.                                                                  |
|                                                                       |
| *10. Breast Problems*: Retracted or cracked nipple (day 1); or        |
| painful lumps in breast after delivery; or difficulties in breast     |
| feeding.                                                              |
|                                                                       |
| *11. Need of emergency obstetric care:* Presence of primary PPH or    |
| retained placenta or prolonged labour or fits. (These complications   |
| are serious and can kill immediately.)                                |
|                                                                       |
| *12. Need of medical attention ( non-emergency):* Presence of         |
| abnormal presentation or puerperal infection or psychosis or          |
| secondary PPH or breast problems with fever. (These complications are |
| serious but do not kill immediately.)                                 |
+-----------------------------------------------------------------------+

***Consent and ethical approval:***

Written consent for the observational and interventions (neonatal)
studies were taken from the community leaders and women\'s groups in 39
villages. Ethical clearance was given by an external advisory committee
formed for this study^(11,12)^.

***Data analysis:***

We analysed the data using SPSS (version 7.1) and Epi-info (version
5.0). We used Taylor series 95 % confidence intervals for relative risk
and Chi -- square tests with Yate's correction to compare the groups.
The total number of deliveries (completed 28 weeks of gestation) in the
study villages was recorded by the independent system of vital
statistics collection (using male workers) which was assessed to be
99.5% complete ^(11)^. The proportion of mothers and deliveries observed
by VHWs and hence included in this study was estimated by comparing with
these independent data. The mothers, studied and unstudied, were
assessed for any selection bias by comparing the still birth rate,
neonatal mortality rate and proportion of hospital delivery in the two
groups.

**Results:**

A total of 1050 births (live + stillbirths) occurred in the 39 study
villages from April 1995 to March 1996. Since 10 pairs of twins were
born, total 1040 mothers delivered. Out of these, 772 (74.2%) women were
recruited by VHWs into the study; 268 were not included mainly because
VHWs were not aware about the pregnancy or were not informed about the
delivery. This occurred most often when a woman from outside moved to
the parents' house in study village a few days before delivery. Since
this was the first year of the field trial of neonatal care, some
families did not bother to inform VHWs about onset of delivery. The
neonatal mortality rates in the births included and not included in the
study were not significantly different (52.4 vs 47.5) but the still
birth rates were; 24.3 Vs 56.0; (p\<0.02). The proportion of women
hospitalised during delivery was 5.1% (39/772) in the women observed Vs
17.9% (48/268) in the women not observed. (p\<0.001).

The characteristics of the 772 women studied are presented in table 1.

Most, 733 / 772 (94.9 %) delivered at home, and among the home delivered
(percentages are out of total 772 deliveries) :

627 (81.2 %) deliveries were conducted by TBA alone;

30 (3.9 %) by only relative;

13 (1.7 %) by only nurse;

15 (1.9 %) by only doctor;

47 (6.1 %) by nurse or doctor with TBA;

1 (0.1 %) information was missing

Thus 75 (9.7 %) home deliveries were conducted by either nurse or doctor
or both. Hospital deliveries 39 / 772 (5.1 %) were conducted by nurse or
doctor.

Hospital deliveries included in this study are those 39 (5.1%) women who
delivered in the hospital but returned home and were observed in
villages during the postpartum period. Out of these 39 hospital
deliveries, 20 (2.6%) were shifted to hospital due to labour
complications (mainly prolonged labour) even though delivery started at
home, 15 (1.9%) women voluntarily went to hospital for delivery. In 4
(0.5%) deliveries, the reasons for hospitalisation were not recorded.
Information on hospital deliveries was partly observed by VHWs and was
included in the analysis.

The comparison of parallel data recorded by the VHWs and the physician
on 18 maternal variables in 119 consecutive births showed a mean 94.8 %
agreement (range 79.5 % to 100%) and mean kappa was 0.81 (s.d = 0.19).

Altogether, 17.7% of the women experienced a serious complication during
labour, and 42.9 % had a problem during the postpartum period (table 2).
Abnormal presentation was mostly a breech (27 out of 31 cases). Although
perceived excessive bleeding was recorded for 219 women (28.4%), it
became life-threatening (primary postpartum haemorrhage) only in 25
(3.2%) .

Medical presence or interventions at the time of labour took place in
217 (28%) cases. These included i) TBAs' insertion of hand to make
delivery (1%), ii) delivery attended by nurse or doctor or both at home
(9.7 %), iii) nurse/doctor called at home for delivery and providing
treatment to the mother (12.2 %) (mainly for giving oxytoxic injections
even though delivery was conducted by TBA) , iv) hospitalization before
or during delivery (5.1%). Of these 217 women, 63 (29.0 %) had a
maternal labour complication documented by the village health workers.

However, not all observed intrapartum complications were intervened
upon. Cases of primary postpartum haemorrhage had the highest rate of
intervention (56%) followed by prolonged labour (50%) and abnormal
presentation (48.4%). Only 20% of women with retained placenta were
intervened upon.

During the 28 days postpartum, 32.1% women reported foul smelling
vaginal discharge, but by our case definition 10.2 % had puerperal
infections of genital tract. The proportion of women with breast
problems was highest on the 5^th^ day postpartum (9.1%) but most
disappeared by day 28 (1.6%). Breast problems were associated with fever
in 20 women (2.6%).

The duration of bleeding showed considerable variation (table 3).
Bleeding stopped between 7-13 days after birth in 320 (41.4%) women.
However, 18.7% still had bleeding on 14^th^ day, and 3.6% complained of
bleeding on the 28^th^ day with half still using pads.

Altogether, 52.6 % reported at least one intrapartum or postpartum
morbidity and 23.7 % had two or more morbidities. Acute life-threatening
complications which indicated need of emergency obstetric attention
occurred in 118 (15.3%); women; and 185 women (24.0 %) needed
non-emergency medical attention. Some women had both types of problem;
altogether 34.7 % women had indications for medical attention.

No maternal death occurred in the 772 deliveries observed by VHWs or in
the 268 unobserved deliveres. However, there were 19 stillbirths, 27
cases of severe birth asphyxia and 41 perinatal deaths. Abnormal
presentation was strongly associated with these adverse perinatal
outcomes, so were breast problems (table 4). Purulent vaginal discharge
with fever, fits and psychosis showed significant association with
stillbirths, and to a lesser degree, with perinatal deaths (not
significant). Prolonged labour was not found to be associated with these
outcomes.

## Discussion

This is the first reported study in a rural setting in developing
country where labour and puerperium were prospectively observed at home
in a systematic and objective manner, to measure the incidence of
maternal morbidities*.* The study demonstrates that rural Indian women
experience a high (52.6%) burden of morbidity during labour and
puerperium at home. While complications in labour (17.7 %) were of a
more serious nature, problems in the postpartum period were more
frequent (42.9 %). One in three women had indications for medical
attention including one in six for urgent obstetric intervention because
their survival was at risk. The most common complications were secondary
postpartum haemorrhage, prolonged labour, puerperal infections and
breast problems. Abnormal presentation and post-partum morbidities such
as breast problems, puerperal infection, psychosis and fits were
associated with adverse perinatal outcomes.

This study also demonstrates that, using trained village health workers,
it is possible to obtain objective measurement of morbidity during
childbirth. Such data have remained very scarce because prospective
cohort studies to observe labour and puerperium at home in rural area
are not feasible in the absence of a trained observer present in
villages.

This study has certain limitations. Our sample may underestimate the
incidence of morbidities because many hospital deliveries (48/268) which
may have a higher proportion of problems were not studied. Indeed, the
proportion of hospital deliveries and still births were higher in the
268 women not studied than in the 772 women studied. We also
investigated a limited range of morbidities; for example, we do not have
information on vaginal tears, anaemia, urinary tract infections or
incontinence. Furthermore, our inquiry was limited to 28 days postpartum
rather than the standard 42 days (6 weeks) after delivery. Lastly, we do
not report on antenatal complications such as antepartum bleeding. For
all these reasons, the real incidence of morbidities may be higher. This
must be kept in mind while extrapolating the results of the study.

No maternal death occurred in the observed or unobserved deliveries.
This could be explained by the relatively small sample size of total
deliveries (1040), and the fact that the period of observation did not
include pregnancy up to 6 months or postpartum period beyond 28 days.
Moreover, maternal deaths regularly occurred in the study area in the
earlier as well as the later years. Hence, no maternal death in the
reported year appears to be only a random chance occurrence.

The major strength of the study is in observing and following up women
at home. The short timeframe of childbirth is a major difficulty in the
measurement of intrapartum maternal complications. Researchers found it
difficult to be with women at home at the time of delivery to observe
morbidities^(6,7)^. Because SEARCH health workers were residents of the
same village and worked alongside long-established TBAs, they were well
accepted by the population and could be present at the time of delivery.
Even then, information on some events could be recorded only in 600 out
of 772 women. (table 2). Information about duration of labour, retained
placenta, temperature, degree of haemorrhage were directly observed and
measured objectively. We used rigorous but practical case definitions of
maternal morbidities . For example, WHO defines prolonged labour as
labour lasting more than 12 hours after cervical dilatation had reached
3 cm (active labour) in spite of good uterine contractions^(15)^. Other
definitions of 24 hours, or with a distinction between primigravidae and
multigravidae are often used. As cervical dilatation was not assessed by
the TBAs, we used the interval between onset of mild labour pains to
delivery being greater than 24 hours as the definition of prolonged
labour.

Similarly, a difficulty in the identification of postpartum haemorrhage
(PPH) is to establish a threshold at which normal physiological bleeding
during childbirth becomes abnormal or dangerous so as to be called PPH.
To identify primary PPH, we used maternal hypothermia or loss of
consciousness associated with \`excessive bleeding' as the evidence of
severity. Our definition of secondary PPH uses information on the amount
of blood loss indicated by the number of pads used during puerperium or
increased bleeding after it had reduced or ceased.

The clinical diagnosis of puerperal infections of the genital tract is
usually based on a combination of signs such as sub-involution of the
uterus, uterine tenderness, purulent or foul smelling vaginal discharge
and fever. In our study, we used the latter two criteria as we did not
have information on sub-involution of the uterus and tenderness.

How does this study compare to others? Studies of medically defined
morbidity associated with rural home deliveries (as opposed to
self-reports) are rare. They include record reviews of traditional birth
attendants and barefoot doctors and a randomized control trial with
TBAs^(17,\ 18,\ 19)^. In 1965, Gordon and colleagues reported a
prospective study in rural Punjab, India, which used health visitors'
observations or information collected by interviews on 862 home
deliveries and puerperium, to estimate the incidence of morbidity^(20)^.
Ten percent of women had a complication during delivery, and 22% a
problem during the postpartum period, less than we found. Incidence of
retained placenta (\> 1 hour) was 3%, similar to our findings (2.5%).
However postpartum fever was reported only in 6% women, as against 12%
in our study. Unfortunately, these studies were restricted to a
particular type of complication or lacked objective measurements of
complications. Thus the Punjab study did not measure the blood loss, and
did not record vaginal discharge or other evidence of infection, and
thus may have underreported morbidities.

Prual and colleagues (2000) report incidence of severe maternal
morbidity from obstetric causes in a longitudinal multicentric study
with four contacts, twice during pregnancy, and one each at delivery and
on 60^th^ day postpartum in seven towns in West Africa^(16)^. A very
large proportion of the sampled women (80%) delivered in health
institutions. The information about direct obstetric complications
available for hospital deliveries was supplemented by self-reports of
complications during pregnancy and delivery or by interviews with
traditional birth attendants. The authors estimated the magnitude of
severe obstetric morbidity and hence the need for essential obstetric
care to be 3-9%. However, this study was conducted in an urban setting
with a majority of hospital deliveries. Its relevance to home deliveries
in rural setting is questionable.

Our study also presents unusual data from developing country on the
duration and pattern of blood loss (table 3). A detailed study of
postnatal blood loss in the UK found that 53% of women were still
reporting vaginal blood loss on 28^th^ day after delivery, and in 35%
the loss was red to pale pink^(21,\ 22)^. In contrast, in our study,
only 3.6% women reported continued bleeding on 28^th^ day. Rural Indian
women may report less, because they are less likely to use white pads or
observe these in adequate light. (The room in which home delivery and
postnatal care are conducted is often quite dark.) Moreover, it is
important to separate what may be natural and harmless from the
abnormal. With our case definition, one in seven (15.2 %) women in our
sample had secondary postpartum haemorrhage. This could indicate other
problems such as endometritis, retained products, or sloughing of dead
tissues after obstructed labour.

Data on the incidence of puerperal genital infections are patchy, but
indicate that it usually lies between 1% to 4% but could be as high as
36% in urban settings with high prevalence of sexually transmitted
diseases^(23)^. In this study, we observed it to be 10.2 %. We earlier
found a high prevalence of various types of reproductive tract
infections in women in rural Gadchiroli^(24)^. This, as well as retained
placenta, or medical interference could be the possible causes of the
observed incidence of puerperal infection in our study.

Self-reports of breast problems in developing countries range from 1% to
14%^(9,\ 20,\ 25,\ 26)^ with a variety of case definitions. In developed
countries, such figures are usually higher; for example, self-reports of
breast problems in a prospective study were as high as 33% on the first
day in hospital and 22% at home up to 8 weeks after delivery in the
UK.^(27)^ A study in Australia reports a mastitis prevalence of 17% over
six month postpartum^(28)^. Breast problems were common (18.4%) in our
sample, and declined with time as to be expected. The higher prevalence
compared to other developing country data (1% to 14%) may be related to
the frequency of the observations and the inclusion of engorgement
(painful lumps) in our case-definition. If the presence of fever along
with breast problems is considered to suggest mastitis, its incidence
was 2.6%, much lower than in the developed countries. Breast problems
were associated with adverse outcomes, in particular perinatal deaths
and stillbirths, presumably because women had engorgements because they
could not breastfeed. Alternatively, breastfeeding was not established
which led to death.

Many postpartum morbidities had significant associations with adverse
perinatal outcomes. (table 4). Adequate care during the postpartum
period is needed for the sake of the mother as well as the neonate.
Interestingly, prolonged labour was not associated with stillbirth,
severe birth asphyxia or perinatal death, although it was associated
with higher proportion of medical interventions. Other studies also have
found a lack of association between duration of second stage of labour
and perinatal outcome^(29,\ 30,\ 31,\ 32,\ 33)^.

Our estimate of acute life-threatening complications (15.3%) appears to
validate the WHO estimate that the expected number of serious
obstetrical complications is about 15% of the live births^(34)^. This
15% is the basic assumption for assessing whether the needs of pregnant
women for essential obstetric services are being met. For example, the
minimum acceptable standard of care for the proportion of births which
should take place in health facilities has been set up at 15%^(3)^. Our
study validates this assumption. Nevertheless, 24.0 % women had other
problems which also necessitate medical care, if not emergency obstetric
services.

Several studies have found a high prevalence of self-reported ill-health
(from 23% to 92%) in the postpartum period^(9,25,26,\ 27,\ 35,\ 36)^.
This study found it to be 42.9 % when prospectively observed. The
difference could be partly due to local variation, but it also indicates
the unreliability of the self reported data on maternal morbidities.

In many developing countries, postpartum care is not provided to women
at home. Only 17% of home delivered women in India received a visit by
health worker within 2 months after delivery. ^(37)^ Further research on
the timing of postpartum health problems could help in deciding the
timing of postnatal visits and set up targeted outreach activities for
mothers at home.

# **Significance**

Our findings have three programmatic implications. First, nearly 15%
women who deliver in rural homes potentially need emergency obstetric
care for safe motherhood. Second, since 24.0 % women needed
non-emergency medical attention, it should be available to home
delivered women. And third, since 42.9 % women had problems during
postpartum period, and since these were associated with adverse
perinatal outcome, home-based post-partum care is necessary -- both for
the mother and the baby.

**References:**

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6.  International Institute of Population Sciences. National Family
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Perinatal outcome in relation to second stage of labour. [American
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maternal morbidity in relation to the length of the second stage of
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(NFHS-2): Key findings (1998-99). IIPS, Mumbai, (2000). P.14.

  ---------------------------------------------- ------------ --------- --- -- --
  **Table 1: Socioeconomic and demographic                                     
  characteristics of mothers**                                                 

  **(n=772)**                                                                  

  **Characteristics**                            **Number**   **%**            

  **Age (years)**                                                              

  \< 15                                          1            0.1              

  15-19                                          75           9.7              

  20-24                                          337          43.7             

  25-29                                          261          33.8             

  ≥30                                            92           11.9             

  Not recorded                                   6            0.8              

                                                                               

  **Education**                                                                

  Illiterate                                     468          60.6             

  1 - 4 years                                    89           11.5             

  5 - 10 years                                   197          25.5             

  \> 10 years                                    17           2.3              

  Not recorded                                   1            0.1              

                                                                               

  **Occupation of mothers**                                                    

  Agricultural work                              763          98.8             

  Trade/craft                                    3            0.4              

  Salaried employment                            5            0.7              

  Not recorded                                   1            0.1              

                                                                               

  **Parity**                                                                   

  0                                              232          30.1             

  1 - 4                                          507          65.7             

  5 - 6                                          27           3.5              

  \> 6                                           6            0.7              

                                                                               

  **Past history of**                                                          

  Still birth                                    50           6.5              

  Neonatal death                                 95           12.3             

  No still birth or neonatal death               640          82.9             

                                                                               

  **Height (cm)**                                                              

  \< 135                                         3            0.4              

  135 - 139                                      5            0.6              

  140 - 144                                      59           7.7              

  145 - 149                                      310          40.2             

  150 - 154                                      272          35.2             

  \> 154                                         106          13.7             

  Not recorded                                   17           2.2              

                                                                               

  Mean height (s.d)                              149.6        (4.9)            

                                                                               

                                                                               

                                                                               
  ---------------------------------------------- ------------ --------- --- -- --

  ----------------------------------------------- ------------ ---------- ------------
  **Table 2: Maternal morbidities during labour                           
  and puerperium (n=772)**                                                

  **Type of morbidity**                           **Number**   **%**      **(95%
                                                                          C.I.)**

  **During labour**                                                        

  Prolonged rupture of membranes^(a)^             40           5.7         

  Prolonged labour                                78           10.1        

  Abnormal presentation                           31           4.0         

  Retained placenta^(b)^                          15           2.5         

  Perceived excessive bleeding on 1^st^ day       219          28.4        

  Primary postpartum hemorrhage                   25           3.2         

  **Any serious problem during labour^(c)^**      **137**      **17.7**   **(15.0 -
                                                                          20.4)**

  **During puerperium**                                                    

  Secondary postpartum hemorrhage                 117          15.2        

  Puerperal fever                                 93           12.0        

  Puerperal infection of genital tract            79           10.2        

  Fits during puerperium                          9            1.2         

  Psychosis                                       2            0.3         

  Severe anxiety or depression (insomnia)         57           7.4         

  Breast problems                                 142          18.4        

  Breast problems with fever                      20           2.6         

  **Any of the above morbidities in puerperium**  **331**      **42.9**   **(39.4 -
                                                                          46.4)**

  **Any maternal morbidity in labour or           **406**      **52.6**   **(49.1 -
  puerperium^(c)^**                                                       56.1)**

  **A. Need of emergency obstetric care**         **118**      **15.3**   **(12.8 -
                                                                          17.8)**

  **B. Need of medical attention                  **185**      **24.0**   **(21.0 -
  (non-emergency)**                                                       27.0)**

  **Total mothers in need of medical attention (A **268**      **34.7**   **(31.3 -
  or B)**                                                                 38.1)**

                                                                          

  a : corresponding denominator is 696,                                   
  information was missing on the rest;                                    

  b: corresponding denominator is 600;                                    

  c: does not include perceived excessive                                 
  bleeding.                                                               

                                                                          
  ----------------------------------------------- ------------ ---------- ------------

  -------------- ------------ --------- ------------ --------- ------------ --------- -------- --------- -------- ---------
  **Table 3:                                                                                                      
  Blood loss on                                                                                                   
  different days                                                                                                  
  (n=772)**                                                                                                       

  **Postpartum   **Bleeding             **Still                **Amount**                                         
  day**          stopped on             bleeding**                                                                
                 or before**                                                                                      

                                                                                                                  

                                        **Total**              **0 pads**             **1-4              **≥ 5    
                                                                                      pads**             pads**   

  ** **          **No**       **(%)**   **No**       **(%)**   **No**       **(%)**   **No**   **(%)**   **No**   **(%)**

  2^nd^          97           (12.6)    675          (87.4)    6            (0.8)     653      (84.5)    16       (2.1)

  3^rd^          96           (12.4)    676          (87.6)    6            (0.8)     666      (86.3)    4        (0.5)

  5^th^          131          (17.0)    641          (83.0)    18           (2.3)     621      (80.4)    2        (0.3)

  7^th^          308          (39.9)    464          (60.1)    22           (2.8)     442      (57.3)    0        (0.0)

  14^th^         628          (81.3)    144          (18.7)    34           (4.4)     110      (14.3)    0        (0.0)

  21^st^         715          (92.6)    57           (07.4)    25           (3.2)     32       (04.2)    0        (0.0)

  28^th^         744          (96.4)    28           (03.6)    13           (1.7)     15       (01.9)    0        (0.0)

                                                                                                                  

                                                                                                                  

                                                                                                                  
  -------------- ------------ --------- ------------ --------- ------------ --------- -------- --------- -------- ---------

  ------------------------------------- ------------ -------------- -------------
  **Table 4: Association of maternal                                
  morbidities with adverse perinatal                                
  outcomes**                                                        

  **( Relative risk and 95% confidence                              
  interval )**                                                      

  **Maternal morbidity**                **Still      **Severe       **Perinatal
                                        birth**      birth**        death**

  ** **                                              **asphyxia**   ** **

  ** **                                 **(n=19)**   **(n=27)**     **(n=41)**

  **During labour**                                                  

  Prolonged rupture of membranes        2.1          0.7            1.4

                                        (0.5 - 8.6)  (0.1 - 4.7)    (0.5 - 4.4)

                                                                     

  Prolonged labour                      1.7          0.7            1.0

                                        (0.5 - 5.6)  (0.2 - 3.0)    (0.4 - 2.6)

                                                                     

  Abnormal presentation                 10.9         8.3            8.7

                                        (4.5 - 26.9) (3.8 - 18.1)   (4.8 - 15.7)

                                                                     

  Retained placenta                     **-**        3.6            1.3

                                                     (0.9 - 14.3)   (0.2 - 8.9)

                                                                     

  Primary postpartum hemorrhage         3.7          **-**          1.6

                                        (0.9 - 15.3)                (0.4 - 6.1)

                                                                     

  **During puerperium**                                              

  Secondary postpartum hemorrhage       **-**        1.3            0.3

                                                     (0.5 - 3.3)    (0.1 - 1.2)

                                                                     

  Puerperal fever                       2.0          1.3            1.3

                                        (0.7 - 5.7)  (0.5 - 3.6)    (0.5 - 2.9)

                                                                     

  Puerperal infection                                                

  Foul smelling vaginal discharge and   4.1          1.7            2.4
  fever                                                             

                                        (1.3 - 13.3) (0.4 - 7.0)    (0.9 - 6.2)

                                                                     

  Foul smelling vaginal discharge and                                

  secondary postpartum hemorrhage       **-**        2.8            0.8

                                                     (1.0 - 7.8)    (0.2 - 3.3)

                                                                     

  Fits during puerperium                10.0         3.3            4.4

                                        (2.7 - 37.0) (0.5 - 21.5)   (1.2 - 15.3)

                                                                     

  Psychosis                             21.3         **-**          10.1

                                        (5.0 - 91.8)                (2.4 - 41.8)

                                                                     

  Severe anxiety or depression          2.4          1.6            2.2
  (insomnia)                                                        

                                        (0.7 - 7.8)  (0.5 - 5.3)    (1.0 - 5.0)

                                                                     

  Breast problems                       4.9          2.8            5.4

                                        (2.0 - 11.9) (1.3 - 6.0)    (3.0 - 9.8)

                                                                     

                                                                    

  Note: \' **-** \' indicates RR can                                
  not be measured, as the outcome                                   
  associated with the morbidity was                                 
  zero.                                                             
  ------------------------------------- ------------ -------------- -------------

Optional table

  --------------------------------------- ------------- ------------- ---------------
  **Comparision of information recorded                               
  by VHWs and a physician**                                           

  **(n=119)**                                                         

  ** **                                                 ** **         **Kappa**

  **Maternal variable**                   **Type of     **%           **Statistic**
                                          variable**    Agreement**   

  Education (years)                       Categorical   099.0         0.97\*

  Gravida                                 Categorical   098.6         0.96\*

  Para                                    Categorical   085.5         0.61\*

  Height (cm)                             Continuous    089.9         0.95#

  White discharge in 3^rd^ trimester      Dichotomous   094.2         0.71

  Fever 7 days prior to delivery          Dichotomous   099.2         0.95

  Did TBA insert hand to make delivery ?  Dichotomous   099.2         0.98\$

  What was the first presenting part ?    Dichotomous   098.3         0.49

  Did TBA make efforts to make baby cry ? Dichotomous   097.3         0.81

  Did TBA insert hand to pull placenta ?  Dichotomous   099.2         0.98\$

  Consciousness on the day of delivery ?  Categorical   100.0         1.00

  Was the bleeding excessive on the day   Dichotomous   085.8         0.51
  of delivery ?                                                       

  Was mother\'s body cold to touch ?      Dichotomous   098.3         0.50

  Inverted nipples ?                      Dichotomous   098.3         0.96\$

  Bleeding still continuing (on 2-28)     Dichotomous   087.8         0.75
  days?                                                               

  Abnormal behaviour or speech ?          Dichotomous   100.0         1.00

  Induration in breasts or breast feeding Dichotomous   096.6         0.58
  problems ?                                                          

  Temperature (Celsius)                   Continuous    079.5         0.82#

  **Mean of above 18 variables**          ** **         **094.8**     **0.81**

  **S.d.**                                ** **         **006.3**     **0.19**

                                                                      

  \* : Weighted kappa; \# : Intra class                               
  correlation cofficent; \$: Prevalence                               
  and bias adjusted kappa                                             
  --------------------------------------- ------------- ------------- ---------------

##  Acknowledgement

We are grateful to the women, TBAs and VHWs in the 39 study villages.
The study would have been impossible without them.

The financial support for conducting the study was provided by The John
D and Catherine T. MacArthur Foundation, Chicago, and The Ford
Foundation, New Delhi.

Center for Population Sciences, London School of Tropical Medicine and
Hygiene provided the facilities to some of the authors for data
analysis. We thank Dr Rudiger Pittrof who gave useful suggestions and
Tom Marshall for commenting on an earlier version of the paper.

**IRB** **Approval and consent**

This study was reviewed and ethical clearance was given by an External
Advisory Committee. Written consent was taken from the leaders and
women's representatives of all the 39 study villages.