Habib, Asmaa (2023) Postpartum care and postpartum morbidity in Morocco: a mixed methods study. Doctoral thesis, University of West London.

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Abstract

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
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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.
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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
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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.

Item Type:	Thesis (Doctoral)
Identifier:	10.36828/xvqy0597
Subjects:	Medicine and health > Midwifery Medicine and health > Primary health
Depositing User:	Marc Forster
Date Deposited:	22 Dec 2023 16:14
Last Modified:	15 Apr 2024 07:27
URI:	https://repository.uwl.ac.uk/id/eprint/10597

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