Postpartum care and postpartum morbidity in Morocco: a mixed methods study
Authors:   , Habib Asmaa 
Published: April 2024

The postpartum period is high-risk for women’s physical and psychological health. This is why the World Health Organisation recommends that women receive four postpartum consultations within six weeks of giving birth, particularly in low-and-middle income countries (LMIC) where maternal mortality and morbidity remain a concern. In Morocco, the use of postpartum care (PPC) has stagnated at a low level (21%) since 2011, while the prevalence of postpartum morbidity (PPM) remains high (28.1%). Very few studies have investigated PPC and its potential relation to PPM in Morocco. In addition, the relationship between the non-utilisation of PPC and PPM has not been systematically researched. This thesis addresses this public health problem in order to understand the factors associated with the low rate of PPC utilisation in Morocco, as well as the relationship between PPC and the occurrence of PPM. The overarching aim of the research is to offer practical recommendations to increase PPC uptake and, ultimately, improve women’s health. The research answered five objectives: 1) to describe PPC uptake in LMIC, 2) to determine the patterns of PPC uptake in Morocco and the factors associated with it, 3) to investigate the relationship between PPC uptake and PPM occurrence in Morocco, 4) to explore women’s experience and perception of PPC and PPM in Morocco, and finally, 5) to examine healthcare professionals’ experience in providing PPC in Morocco. These objectives were addressed using a pragmatic approach based on the use of mixed methods. Three studies were conducted: 1) a systematic review and meta�analysis, 2) a secondary data analysis of a nationally representative database on Moroccan maternal health representing 5593 women of childbearing age, and 3) a qualitative study in two phases: the first one focusing on 17 women’s experiences of PPC and the second one on 19 health professionals’ perceptions and experiences of delivering it. The qualitative data were collected through semi-structured interviews conducted face-to-face in diverse health facilities, at women’s homes in Morocco or via phone calls. Concerning PPC uptake and the factors associated with it, the systematic review and meta-analysis presented an overview of the uptake of PPC in 35 LMIC, which provided the context within which to explore and understand the findings relating to the Moroccan situation. Altogether, the prevalence of PPC utilisation in LMIC within six weeks post-delivery was 55.4%. Twenty-one sociodemographic, environmental, and obstetric factors were reviewed. Among them, urban place of residence, education, exposure to mass media, antenatal care check-ups, wanted pregnancy, primiparity, and delivery in a health facility by caesarean section all facilitated PPC utilisation. Conversely, other factors hindered PPC utilisation namely the lack of knowledge about PPC, poverty, women’s unemployment, women’s low level of autonomy in decision�making, disrespectful maternity care and young age (15-19 years old). From this dataset, a meta-analysis based on 9 population-based studies analysing the Demographic Health Survey concluded that the positive associations of urban place of residence, women’s education level and employment as well as middle and higher socioeconomic level were more strongly associated with PPC uptake within six weeks after delivery (later PPC) than PPC provision within 48 hours post-delivery (early PPC). Based on these findings, several hypotheses on the association between sociodemographic, environmental, and obstetric factors and PPC uptake were tested in the Moroccan context. The sequential data analysis of the Moroccan data (quantitative and qualitative) produced interesting results that corroborated some of the findings related to PPC uptake in other LMIC. The quantitative study showed that in Morocco, between 2013 and 2017, the proportion of women who received early PPC before discharge (EPPC) was 62.6% and 21.3% later within six weeks post-delivery (LPPC). The logistic regression findings indicated that PPC utilisation before discharge was more likely to occur for women who gave birth by caesarean section and those who received postnatal care for their newborn baby. LPPC uptake was also more likely to be associated with these two factors as well as women’s age (30-39), level of education (some education versus none), socio-economic status (rich(er) vs poorer socioeconomic status) and the frequency of antenatal consultations (at least one vs none). Conversely, the multivariate analysis revealed that assisted delivery with only nurses or midwives present (without doctor) was a barrier to LPPC uptake. Other barriers were identified with the univariate analysis namely the absence of PPM, the lack of knowledge and awareness of PPC, financial constraints, and the unavailability of PPC provision. These findings were partly corroborated by the qualitative investigations which highlighted that the mode of delivery (caesarean) and place of delivery (private setting), good relationship between women and health professionals (HPs) and good quality of care were important factors for women when choosing to attend PPC consultations. On the other hand, the reasons explaining the non-utilisation of PPC reported by women were related to the absence of knowledge and awareness of PPC importance, not feeling PPM symptoms, the shortage of financial resources, and the lack of PPC provision in public health centres. Finally, cultural barriers were also reported by HPs as hindering women’s PPC utilisation. With regards to PPM and their development, at the national scale, the quantitative analyses showed that the prevalence of PPM (at least one) reached 28.3%, including pelvic infections (76.2%), breast issues (51%), postpartum haemorrhage (16.7%) and oedema (14.4%). The risk factors for developing PPM included vaginal delivery with instruments and the occurrence of morbidities during pregnancy. Conversely, PPM were less likely to occur among women with secondary and higher education and those who attended antenatal consultations (at least one). The qualitative analysis also highlighted the occurrence of psychological PPM, but these were largely under�reported by women and under-diagnosed by HPs. Other factors contributing to PPM onset included women’s negative delivery experience as reported by the women, and family’s influence and cultural practices as stated by HPs. Finally, in this thesis the relationship between PPC uptake and PPM occurrence in Morocco was also investigated and the results indicate that EPPC provided before discharge was associated with LPPC utilisation and lower PPM onset. The results also show that women seem to use LPPC if they experience PPM. In fact, the provision of PPC was perceived as preventive by HPs, whereas it was seen as a curative recourse by women. The contribution to knowledge of this work is to provide insights into a wider range of factors, compared to existing literature, associated with the low rate of PPC utilisation in Morocco. The research also identified novel inter-personal and ‘softer’ factors that are hindering or contributing to PPC utilisation including family’s influence, cultural beliefs and practices, relationship between HPs and women, alongside differences in quality of care between public and private health structures. These are in addition to demographic and socio-economic factors, which constitute a social gradient and result in health inequalities. The research also brings new insights into the women’s and HPs’ perceptions of PPC – with the former viewing it as a curative measure while the latter consider it to be preventive. In addition, the research contributes new knowledge by furthering our understanding of the way psychological PPM are disclosed and managed. It also sheds light on the relationship between PPC uptake and PPM occurrence, with the association between the two variables relating to the timing of PPC use, that is to say that receiving EPPC before discharge prevents PPM onset whereas receiving LPPC within six weeks post-discharge was associated with PPM symptoms. The research has important practical implications with a need for a holistic approach including the views of women, HPs and policymakers to increase PPC uptake and prevent PPM. This implies a need for behaviour change from all parties, a need to change some healthcare practices and organisation of care, and a need for health promotion interventions to raise the awareness of women and their families about the importance of PPC to prevent or treat PPM. Measures aimed at women, HPs and policymakers could positively contribute towards Morocco’s aim to comply with the WHO recommendations on PPC utilisation and, by extension, to decrease maternal mortality and morbidity.