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Background
Maternal morbidity occurs several times more frequently than mortality, yet data on morbid-
ity burden and its effect on maternal, foetal, and newborn outcomes are limited in low- and
middle-income countries. We aimed to generate prospective, reliable population-based
data on the burden of major direct maternal morbidities in the antenatal, intrapartum, and
postnatal periods and its association with maternal, foetal, and neonatal death in South Asia
and sub-Saharan Africa.Methods and findings
This is a prospective cohort study, conducted in 9 research sites in 8 countries of South Asia
and sub-Saharan Africa. We conducted population-based surveillance of women of reproduc-
tive age (15 to 49 years) to identify pregnancies. Pregnant women who gave consent were
include in the study and followed up to birth and 42 days postpartum from 2012 to 2015. We
used standard operating procedures, data collection tools, and training to harmonise study
implementation across sites. Three home visits during pregnancy and 2 home visits after birth
were conducted to collect maternal morbidity information and maternal, foetal, and newborn out-
comes. We measured blood pressure and proteinuria to define hypertensive disorders of preg-
nancy and woman’s self-report to identify obstetric haemorrhage, pregnancy-related infection,
and prolonged or obstructed labour. Enrolled women whose pregnancy lasted at least 28
weeks or those who died during pregnancy were included in the analysis. We used meta-analy-
sis to combine site-specific estimates of burden, and regression analysis combining all data
from all sites to examine associations between the maternal morbidities and adverse outcomes.
Among approximately 735,000 women of reproductive age in the study population, and
133,238 pregnancies during the study period, only 1.6% refused consent. Of these, 114,927
pregnancies had morbidity data collected at least once in both antenatal and in postnatal
period, and 114,050 of them were included in the analysis. Overall, 32.7% of included preg-
nancies had at least one major direct maternal morbidity; South Asia had almost double the
burden compared to sub-Saharan Africa (43.9%, 95% CI 27.8% to 60.0% in South Asia;
23.7%, 95% CI 19.8% to 27.6% in sub-Saharan Africa). Antepartum haemorrhage was
reported in 2.2% (95% CI 1.5% to 2.9%) pregnancies and severe postpartum in 1.7% (95%
CI 1.2% to 2.2%) pregnancies. Preeclampsia or eclampsia was reported in 1.4% (95% CI
0.9% to 2.0%) pregnancies, and gestational hypertension alone was reported in 7.4% (95%
CI 4.6% to 10.1%) pregnancies. Prolonged or obstructed labour was reported in about
11.1% (95% CI 5.4% to 16.8%) pregnancies. Clinical features of late third trimester antepar-
tum infection were present in 9.1% (95% CI 5.6% to 12.6%) pregnancies and those of post-
partum infection in 8.6% (95% CI 4.4% to 12.8%) pregnancies. There were 187 pregnancy-related deaths per 100,000 births, 27 stillbirths per 1,000 births, and 28 neonatal deaths per
1,000 live births with variation by country and region. Direct maternal morbidities were asso-
ciated with each of these outcomes.Conclusions
Our findings imply that health programmes in sub-Saharan Africa and South Asia must
intensify their efforts to identify and treat maternal morbidities, which affected about one-third of all pregnancies and to prevent associated maternal and neonatal deaths and
stillbirths. |
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