The effects of obstetric
complications on the health
and socio-economic wellbeing
of women and their families in
1
Burkina Faso
The effects of obstetric
complications on the health and
socio-economic wellbeing of
women and their families in
Burkina Faso
(V Filippi, N Meda, R Ganaba, S Murray, T Marshall, S Russell, K Storeng, P Iboulo, M Akoum)
Hewlett Foundation / ESRC funded
2
Types of health / well-being outcomes
with examples of negative consequences of maternal near miss
infertility
no living
child
damaged pelvic
structure
anaemia
impaired
functionality
Physical health
consequences
marital disharmony
household
dissolution
depression
Mental health
consequences
Social
consequences
migration
suicide
social isolation
impaired productivity
Economic
consequences
stigmatization
asset depletion
borrowing &
debt
income
poverty
food
insecurity
3
Well-being following a pregnancy,
childbirth or complications
[The delivery] is a little bit dangerous. But there is
also happiness. After the delivery, if everything
went well, and you see the child, you are happy
(Burkinabè mother)
Because I was losing urine, I did not want to get
pregnant before my fistula was repaired. [My
husband] used to threaten me with a knife,
accusing me of having sexual relationships with
other men (18-year old Burkinabè woman with vesico-vaginal fistula)
4
Well-being following a pregnancy,
childbirth or complications
“Even yesterday they were speaking about it. They
were saying that if it hadn’t been for the cost of
my operation, the problem of buying [food]
wouldn’t have been as bad, because we could
have spent the money that we spent on the
operation to buy millet. When they say things
like this, I just get up and leave the room and
wait until they have finished before I go back in
and join them”.
5
Rationale
•
Burden of disease from maternal causes underestimated due to
lack of attention to outcomes after pregnancy
•
Emergency medical care saves lives, but those surviving near miss
may face potentially disabling consequences. But inadequate
support for those women who survive such experiences
•
The research also relevant to wider social protection debates. Illhealth is a shock to household resources and livelihood activities 
impoverishment
•
Identify factors influencing vulnerability and resilience to such
shocks
•
Inform social protection policy, including health policy, to enhance
resilience. Growing research in this policy area but not for maternal
health.
6
A “near-miss” event
operational definitions
• Dystocia: uterine rupture, bandl ring
• Haemorrhage: blood loss with shock, blood transfusion,
hysterectomy or troubles of coagulation
• Infections: hyperthermia, hypothermia, with ‘foyer evident’
and signs of shock
• Hypertension: eclampsia and severe pre-eclampsia
• Anemia: HB<4g/dl or 4-7 g/dl with signs of shock or blood
transfusion
• Others: renal dysfunctions, ICU admission etc
• Maternal deaths before discharge are not selected
7
Our basic hypotheses
• Near-miss complications are likely to be associated with
long-term health, social and economic consequences
• The consequences experienced by women will depend
in part on the type or child outcome of near-miss
complication experienced by the woman.
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Overview of longitudinal design
First cohort study
(2004-6)
Current follow-up study
(fieldwork now ongoing)
Live birth n=199
Women with
near miss
(n=337)
Early pregnancy loss n=64
Still birth / neonatal death n=74
New control group
Women with
normal delivery
(n=677)
Months
postpartum
2004
0
3
6 12
2005
36
2006
2007
2008
48
2009
9
First study - Key findings
10
High mortality after
hospital discharge
Women's survival
2% of women died after discharge
in the near miss group,
equivalent to a MMR of 1800
100%
98%
97%
96%
95%
0
3
6
9
12
Follow-up time since end of pregnancy (months)
Severe obstetric complications
Infants' survival
Uncomplicated deliveries
100%
95%
8% mortality in babies
born to women in near miss group
Survival (%)
Survival (%)
99%
90%
85%
80%
75%
0
3
6
9
Follow-up time since end of pregnancy (months)
severe obstetric complications
12
11
Uncomplicated deliveries
Morbidity – mental health, risk of
depression
% women with K10 score ≥14
30%
Depression – K10 score
NM live birth
25%
NM early pregnancy loss
NM perinatal death
20%
Normal delivery
15%
10%
5%
0%
3 months
6 months
12 months
Follow-up time
12
Morbidity – mental health, suicidal
thoughts
Suicidal thoughts in past year
% women reporting suicidal thoughts in the
past year
16%
NM live birth
14%
NM early pregnancy loss
12%
NM perinatal death
Normal delivery
10%
8%
6%
4%
2%
0%
3 months
6 months
12 months
Follow-up time
“Have you ever thought about taking your own life, even if you knew you
weren’t actually going to do it?”
13
Social impact: relationship with
husband
Unhappy relationship with husband
Worse relationship with husband compared to before the
end of pregnancy
NM live birth
25%
NM early pregnancy
25%
20%
15%
20%
NM perinatal death
15%
Normal delivery
10%
10%
5%
5%
0%
3 months
6 months
12 months
0%
3 months
Physical abuse since end of pregnancy/last interview
8%
6 months
12 months
Sexual abuse since end of pregnancy/ last interview
8%
6%
6%
4%
4%
2%
2%
0%
3 months
6 months
12 months
0%
3 months
6 months
*including only women reporting as married/cohabiting at recruitment
12 months
14
Economic impacts: long-lasting
burdens
• Higher fees and direct cost burdens for nearmiss cohort
• Higher levels of debt
• Slower repayment of debt among debt-takers
who had near-miss complications: 12.0% in
debt vs. 3.7% at 12 months
• Small levels of debt contributed to everyday
struggle for survival for poor households
• But in general economic findings more limited
in first study
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Summary of findings
•
High level of postpartum morbidity for all women
•
Evidence of near-miss effect but also ‘no baby’ effect
•
Near-miss effect:
–
–
–
•
•
Significant increased mortality in near-miss women and babies after discharge
negative feelings, lack of self esteem up to a year postpartum
More likely to have debts up to 1 year postpartum
‘No baby’ effect:
–
Women with early pregnancy loss at much higher risk for severe anaemia& ill health
–
Women with perinatal mortality at increased risk for mental health problems
–
Marital disharmony in early postpartum, and sexual violence remains at 12 months
–
Pressure to have another pregnancy again quickly
Limited role of socio-economic status in explaining health findings
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Methods for follow up study
•
Find the women in the original cohort and seek
informed consent to do follow up visits
•
Re-visit the women in the cohort at 36 and 48 months
•
Add a comparison group of women who delivered at
home or in a health centre (neighbourhood sampling
approach)
•
Select a small purposive sample for in depth
qualitative follow up
17
Re-recruiting women for the study
% of previous sample found
Re-recruiting women to the study
(as at September 2008)
100
90
80
70
60
50
40
30
20
10
0
BoboDoulasso
(n=173)
Dédougou
(n=113)
Houndé
(n=67)
Nouna (n=82) Ouagadougou
(n=284)
Tenkodogo
(n=26)
TOTAL
(n=745)
Location
% of previous cohort found
% we still hope to find
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Quantitative data collection
Interviews with women at 36/48 months on economic and social well being:
•
Subjective health measures: perceived physical health and mental health
(K10), child health and mortality (incl. children born after the index birth)
•
Objective health measures: rapid medical check up at home
(haemoglobin, anthropometry, urine tests, fever, blood pressure)
•
Physical assets: household construction and items
•
Food security index
Interviews with men
•
Physical and natural assets (Housing, HH items, livestock…)
•
Food production
•
Key expenditure items
Standardised instruments and questions developed on the basis of literature
A note on socio-economic concepts: a multi-dimensional approach to socioeconomic well-being / poverty measurement: assets, command over
commodities, and functionings and capabilities (Sen)
19
Qualitative data collection
1. The effect of a specific traumatic event on social and
economic well-being: caesarian-section (n=20)
– C-section incurred high / catastrophic direct costs
– Has implications for subsequent pregnancies and delivery
2. Long–term consequences of economic shock on women’s
livelihood and socio-economic well-being (n=22)
– Explore changes in women’s lives, e.g. relationships and social
status
– Coping strategies and outcomes 4 years later – resilience?
• Taped interviews. Analysis using Nvivo software and joint
analysis workshops
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Ethical dilemmas
•
Big debate among team, and some disagreement, on whether and
how the research project can act when suffering and dangers to health
identified among research subjects, especially during in depth repeat
visits.
•
In first study overwhelming amount of suffering found in repeated
visits: depression, fistulae, extreme hunger, violence,
•
At that time difficult to decide on a threshold at which to intervene
•
Team has now established some basic guidelines for the researchers
in the field on whether and when to take action, and what action to
take.
•
Length of questionnaire also a concern
•
At end of first study, community dissemination with theatre forums well
received and well attended
21
Policy implications
•
Programmes must consider the implications of severe, near-miss
complications with sequelae for women who survive, not only in evaluation
but also programmatically.
•
Rethink postnatal care: target ‘near-misses’ in the post-partum as they may
have long term ill health
•
It is essential to develop innovative mechanisms for financing maternal
healthcare that do not place the burden on the household and contribute to
further impoverishment
•
Greater government provision for expensive emergency care, not just
skilled birth attendance
•
Measures to increase awareness of risks in pregnancy and initiatives to
address gender inequalities that place some women at disproportionate risk
•
•
E.g. White Ribbon Alliance for Safe Motherhood (in Burkina Faso)
E.g. Income generating schemes for women?
22
Further research needed
• Intervention studies testing innovative
strategies, not only before or during
pregnancy or delivery, but also after
complications have occurred
• Evaluate effects of changes in user fees or
other financing mechanisms to protect the
poor on long term economic outcomes
23
Acknowledgments
• Funders:
• Immpact (Burkina Phase 1)
• Hewlett Foundation/ESRC (Burkina Phase 2)
• Research teams:
• Burkina Phase 1: Veronique Filippi, Rasmane Ganaba,
Thomas Ouedraogo, Tom Marshall, Issiaka Sombie, Melanie
Akoum, Fatou Ouattara, Becky Baggaley and Nicolas Meda
• Burkina Phase 2: Veronique Filippi, Rasmane Ganaba, Tom
Marshall, Melanie Akoum, Nicolas Meda , Susan Murray, Steve
Russell
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Concepts and indicators
Wellbeing
dimension
1 The resources that a person can
command
2 What they are able to do and
achieve with those resources
3 Meanings of what
they do/ achieve
Functionings & capabilities
Livelihood activities, being busy
Concepts /
variables
Assets
Human
Physical
Natural
Financial
Social
Entitlements
Food security
Health service
access
Command over
other commodities
Physical health
Mental health
Relationships
Taking part in family life without shame
Taking part in community life without shame
Motherhood and being a ‘normal’ mother
Self-esteem
Agency – decision-making and choices about future
reproductive health
Measures
indicators
HH size
No of adults able to
work
House floor material
Water supply
Land
Livestock
Debt / saving level
Meals per day
Portion size
Skipping meals
Frequency going
hungry etc…
(food security index)
Paid hospital bill
Expenditure on key
items
Main occupational activities
Main reproductive / HH activities
Women activity days
Child development indicators
Mental health measures / scores
Physical health measures – objective (BMI, haemoglobin…)
Subjective health measures
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