Postnatal morbidity: prevalent, enduring, and neglected
Authors: None The Lancet Global Health
Journal: The Lancet Global Health (2023)

As a global health journal, we are acutely aware of the huge mortality burden that pregnancy and childbirth still confer. According to a 2023 report, a woman dies from preventable causes related to pregnancy and childbirth every 2 mins, and almost 95% of maternal deaths occur in low-income and middle-income countries (LMICs). Death is, of course, the most severe possible obstetric outcome, and the unacceptably high mortality rates must be addressed urgently. However, death is not the only concern. On Dec 6, with eClinicalMedicine, we co-published a Series of papers on Maternal Health in the Perinatal Period and Beyond. The third paper, a global systematic analysis, found an alarmingly high prevalence of morbidity directly arising from pregnancy or childbirth that persists beyond 6 weeks. Pain during sexual intercourse (dyspareunia) is most prevalent, affecting more than a third (35%) of women beyond the customary postnatal period of 6 weeks. But low back pain (32%), anal incontinence (19%), urinary incontinence (8–31%), anxiety (9–24%), depression (11–17%), perineal pain (11%), fear of childbirth (tokophobia; 6–15%), and secondary infertility (11%) all affected notably high proportions of birthing parents (herein referred to as women, for brevity, but acknowledging that pregnancy can occur in adolescents, transgender men, and gender-diverse individuals). Other conditions—such as pelvic organ prolapse, post-traumatic stress disorder, and HIV seroconversion—were less prevalent but can have severe impacts on women's health and wellbeing. This Series ambitiously aims to prompt a paradigm shift in maternal health. The current dictum from health authorities is that the 6 weeks after birth constitute the postnatal period. This timeframe is too short, and it does a huge disservice to women who still experience the effects of pregnancy and childbirth months, years, or even decades later, but who have felt abandoned by health services that no longer include them in postnatal care. Notably, paper 3 found a dearth of high-quality prevalence data on obstetric conditions in LMICs. The authors also found no high-quality guidelines for management of 13 (40%) of the 32 priority conditions identified (such as secondary infertility and neuropathies) and—crucially—none were developed in LMICs. The Series calls for a perspective change. Pregnancy and childbirth are not a single health event that occurs in isolation, in which the only important outcome is whether a woman or her infant die: pregnancy and childbirth are experienced by a woman within the broad, rich context of her life. To prevent and treat maternal morbidity and mortality, the authors recommend a holistic, human-centred approach that looks not only at the proximal causes of obstetric conditions, but distal causes and long-term effects. In their introductory paper, the authors describe the vast array of determinants that occur upstream of severe morbidity and death. These risk factors can exist before a woman even conceives, and we can leverage them to reduce the likelihood of adverse maternal outcomes. For instance, promoting gender equality at a national level can improve the health and wellbeing of women both directly (eg, by preventing femicide during pregnancy) and indirectly (eg, via improvements in female education and earning potential). Ultimately, high-quality universal health coverage will be an essential component in reducing maternal morbidity and mortality. A strong health system is well placed to reduce obstetric risk by mitigating the impact of broader inequities (such as of race or economic class), as well as preventing ill health. It was a deliberate choice that this Series focused on the pregnant person and not on the infant. Women are often considered only as part of a mother–infant dyad, given that the health and survival of both are often influenced by similar determinants. However, there are many obstetric outcomes that only affect the person who has given birth. A must-read Comment was written to accompany the Series, by Sayeba Akhter, an obstetrician who suffered obstetric fistula and a negative delivery experience. As she powerfully says: “the joy of having a newborn is cherished by everyone, but the pain, physical exertion, psychological trauma, and other sequelae of pregnancy and labour are borne by the mother alone.” We must finally recognise postnatal morbidity as enduring but neglected. Women should not bear the load of this morbidity alone, unrecognised, nor unaided.