Women's health after childbirth is attracting a more appropriate level of consideration than it has in the past (Vanderkruik et al, 2013). The incidence and prevalence of postpartum health issues include a range of physical and psychological health problems (Cooklin et al, 2015) that do not necessarily resolve in the 2 years after childbirth (Van der Woude et al, 2015). Health problems that persist during the first year of motherhood tend to be due to the physical experience of childbirth, not necessarily to the demands of caring for a new baby (Rouhi et al, 2012). These problems are usually not acute or life-threatening. However, the effects on daily functioning (childcare, household responsibilities, intimate relationships and employment) are not inconsequential for new mothers (Walker et al, 2015). Postpartum morbidity is a worldwide phenomenon and an estimated 94% of women report having problems related to childbirth during the 6 months postpartum (Van der Woude et al, 2015). For every maternal mortality of pregnancy-related causes, about 20 women experience acute or chronic morbidity, often with tragic consequences (Hardee et al, 2012).
As one of the eight Millennium Development Goals, improving maternal health and reducing related mortality is a key worldwide concern (Vanderkruik et al, 2013). However, to completely address this global ideal, it is important to highlight the entire spectrum of maternal morbidities (Vanderkruik et al, 2013).
The aim of this paper is to determine the prevalence of postpartum morbidities over 5 years post-childbirth in a cohort of Iranian women, and to compare these outcomes between primiparous and multiparous participants.
Material and methods
Population
West Azerbaijan province, with a population of 2.87 million, is the 8th largest province in Iran. For this cohort study, data were collected from Mahabad city, which is located in the southern region of the province, with a population of about 250 000 people. All six health-care centres in the province that provide antenatal, postnatal and paediatric care, immunisation, and family planning services by midwives or family health workers, were included in this study. The high levels of compliance with public immunisation programmes in Iran (Zahraei et al, 2014) ensure that the majority of new mothers attended these clinics at 2 months, 4 months, 6 months, 12 months, 18 months and 6 years postpartum to obtain paediatric immunisations. This provided the ideal forum to interview mothers about their postpartum experiences.
Consent and data collection
This is a cohort-longitudinal study conducted with a convenience sample of 311 Iranian women aged 18–42 years attending health-care centres in the province of West Azerbaijan for routine antenatal care in the period May 2009 to September 2013. Following their routine antenatal assessment, the participants were assessed for their eligibility to enter the study, including giving consent to allow researchers to conduct follow-up interviews by phone. Permission to perform this study and ethical approval were obtained from the Nursing and Midwifery College of Azad University, Mahabad Branch, and the West Azerbaijan District Health Centre (229-5/231131-07/24/2009). Informed consent was obtained from all participants prior to interview.
A baseline questionnaire was completed by the participant at her routine antenatal visit in the third trimester. Participants completed the questionnaire in a private room with the help of a staff member if they were unable to read the questionnaire. Demographic characteristics, risk factors for depression, information on personal and family relationships, and maternal and child data were collected.
Women were invited to participate if they met the following inclusion criteria:
Based on previously reported Iranian postpartum morbidity data (Rouhi et al, 2011), it was estimated that the prevalence rate of postpartum morbidity is 20–80%. The required sample size for this non-randomised, observational study, calculated to detect at least 30% of symptoms for a population with 10 000 deliveries, 5% absolute precision and 95% confidence limits, was estimated at 311 pregnant women. One week after birth, one woman died, and two of the women moved to other cities. Five years after childbirth, 29 women had moved or experienced another pregnancy; as a result, 279 women were assessed 5 years after birth (Figure 1).
In this study, postpartum morbidities are defined as women's experience of any physical or mental health problems after giving birth. Maternal morbidity was measured by the women's responses to a list of possible health problems after birth. Women were also asked, in an open-ended question, to give details of other health problems that had not been included in the list.
The checklist included the following problems:
The questionnaires were developed by Rouhi et al (2011) in Persian dialect and piloted with 80 women in a different setting from the settings used to recruit participants. Some changes were made to the questionnaires to improve understanding of the questions and the flow of the interview.
Data were entered and analysed using SPSS software. Chi-square statistics with continuity correction were used to compare proportions. Significance level was set at 5%.
Results
A total of 311 women were eligible and recruited into the study at the last antenatal visit. At the first interview (1 week postpartum), three were lost to follow-up. The remaining 308 women completed the questionnaire via telephone at 1 week, 8 weeks and 12 months postpartum. At the final stage (5 years postpartum) a total of 279 participants were available for interview (Figure 1).
Participant characteristics
Of the 308 participants interviewed in the last antenatal visit, the mean age was 26.5 years (standard deviation (SD) 5). The majority of the participants were unemployed (n=248, 80.8%) and had graduated from high school (n=235, 76.3%). There was not a balanced representation of primiparous (n=253, 82.1%) and multiparous (n=55, 17.9%) participants (Table 1).
| Variable | Number (n=308) | % |
|---|---|---|
| Age (years) | ||
| ≤19 | 40 | 13 |
| 20–29 | 190 | 61.7 |
| ≥30 | 78 | 25.3 |
| Education | ||
| Primary school | 24 | 7.8 |
| High school | 235 | 76.3 |
| University | 49 | 15.9 |
| Work/job | ||
| Unemployed | 248 | 80.8 |
| Employed | 60 | 19.5 |
| Family income | ||
| ‘Enough’ | 227 | 73.7 |
| ‘Poor’ | 81 | 26.3 |
| Para | ||
| 0 | 253 | 82.1 |
| ≥1 | 55 | 17.9 |
Prevalence of postpartum morbidities
Nearly all participants (n=289, 94%) reported one or more health problems that started after the birth and in the first week postpartum, at 8 weeks 90% (n=277), 12 months after birth 83% (n=255) and 5 years later 26% (n=72).
The reported prevalence of maternal health problems during the first 5 years postpartum is shown in Table 2. In the first week after childbirth, backache (n=196, 63.6%) and fatigue (n=193, 62.7%) were the most commonly reported problems, and haemorrhoids (n=3, 1.0%) was the least reported. Eight weeks after childbirth, fatigue (n=184, 59.7%) and backache (n=185, 60.1%) remained as the most commonly reported problems, with difficulty voiding (n=11, 3.6%) the least reported. By 12 months after birth, fatigue (43.2%) continued to be the most reported morbidity, and 2.6% of participants (n=8) reported they had difficulty voiding. By 5 years, a large proportion of participants complained of backache (n=127, 45.5%) and to a lesser extent, abnormal vaginal discharge (n=22, 7.9%) that they identified as having started postpartum. The most common postpartum morbidities experienced by this cohort over 5 years were: backache, fatigue, headache, sleep problems and sexual problems.
| Morbidities | 1 week | 8 weeks | 12 months | 5 years | ||||
|---|---|---|---|---|---|---|---|---|
| n=308 | n=308 | n=308 | n=279 | |||||
| n | % | n | % | n | % | n | % | |
| Backache | 196 | 63.6 | 185 | 60.1 | 107 | 34.7 | 127 | 45.5 |
| Headache | 145 | 47.1 | 105 | 34.1 | 38 | 12.3 | 40 | 14.3 |
| Wound infection | 21 | 6.8 | 14 | 4.5 | – | – | – | – |
| Constipation | 66 | 21.4 | 38 | 12.3 | 40 | 13.0 | 48 | 17.2 |
| Breast problems | 89 | 28.9 | 45 | 14.6 | 32 | 10.4 | – | – |
| Abnormal vaginal bleeding | 29 | 9.4 | 30 | 9.7 | – | – | – | – |
| Difficulty voiding | 23 | 7.5 | 11 | 3.6 | 8 | 2.6 | – | – |
| Urinary incontinence | 12 | 3.9 | 21 | 6.8 | 25 | 8.1 | 42 | 15.1 |
| Urinary tract infection | 25 | 8.1 | 30 | 9.7 | 23 | 7.5 | – | – |
| Abnormal vaginal discharge | – | – | 53 | 17.2 | 39 | 12.7 | 22 | 7.9 |
| Fatigue | 193 | 62.7 | 184 | 59.7 | 133 | 43.2 | 88 | 31.5 |
| Postpartum ‘blues’ | 46 | 14.9 | – | – | – | – | – | – |
| Sexual problems | – | – | 47 | 15.3 | 82 | 26.6 | 92 | 33.0 |
| Sleep problems | 97 | 31.5 | 143 | 46.4 | 110 | 35.7 | 88 | 31.5 |
| Haemorrhoids | 3 | 1.0 | 13 | 4.2 | 13 | 4.2 | 38 | 13.6 |
Differences by parity
Table 3 shows the association between postpartum morbidities and parity. At 1 week after childbirth, primipara were more likely than multipara to report backache (odds ratio (OR)=2.07), constipation (OR=2.08), fatigue (OR=2.16) and sleep problems (OR=7.41). Multiparous women reported more breast problems (OR=0.59) urinary incontinence (OR=0.28) and haemorrhoids (OR=0.10).
| Stages | 1 week (n=308) | 8 weeks (n=308) | 12 months (n=308) | 5 years (n=279) | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Morbidities | Primipara (n=253) | Multipara (n=55) | 95% CI | OR | Primipara (n=253) | Multipara (n=55) | 95% CI | OR | Primipara (n=253) | Multipara (n=55) | 95% CI | OR | Primipara (n=253) | Multipara (n=55) | 95% CI | OR |
| Backache | 50.2% | 32.7% | 1.12–3.83 | 2.07 | 34.0% | 34.5% | 0.52–1.80 | 0.97 | 12.3% | 12.7% | 0.39–2.30 | 0.95 | 28.1% | 27.6% | 0.57–2.39 | 1.17 |
| Headache | 67.2% | 47.3% | 1.26–4.12 | 2.28 | 57.7% | 70.9% | 0.29–1.05 | 0.56 | 34.8% | 34.5% | 0.45–1.86 | 1.01 | 48.1% | 58.3% | 0.32–1.24 | 0.66 |
| Wound infection | 7.5% | 3.6% | 0.48–9.5 | 2.15 | 3.2% | 10.9% | 0.08–0.80 | 0.26 | – | – | – | – | – | – | – | – |
| Constipation | 23.3% | 12.7% | 0.89–4.85 | 2.08 | 14.2% | 3.6% | 1.02–1.84 | 4.3 | 14.2% | 7.3% | 0.72–6.21 | 2.11 | 11.3% | 8.3% | 0.49–4.19 | 1.39 |
| Breast problems | 26.9% | 38.2% | 0.32–1.09 | 0.59 | 14.6% | 14.5% | 0.44–2.30 | 1.0 | 11.9% | 3.6% | 0.82–15.38 | 3.56 | – | – | – | – |
| Abnormal vaginal bleeding | 9.9% | 7.3% | 0.46–4.19 | 1.39 | 9.1% | 12.7% | 0.27–1.68 | 0.68 | – | – | – | – | – | – | – | – |
| Difficulty voiding | 7.5% | 7.3% | 0.33–2.17 | 1.03 | 3.2% | 5.5% | 0.14–2.20 | 0.56 | 2.8% | 1.8% | 0.18–12.74 | 1.53 | – | – | – | – |
| Urinary incontinence | 2.8% | 9.1% | 0.08–0.93 | 0.28 | 5.5% | 12.7% | 0.15–1.04 | 0.40 | 7.1% | 12.7% | 0.25–1.32 | 0.52 | 2.6% | 4.2% | 0.12–3.13 | 0.61 |
| Urinary tract infection | 5.9% | 18.2% | 0.12–0.6 | 0.28 | 6.3% | 25.5% | 0.09–0.43 | 0.19 | 7.5% | 7.3% | 0.33–3.17 | 1.03 | – | – | – | – |
| Abnormal vaginal discharge | – | – | – | – | 15.4% | 25.5% | 0.26–1.07 | 0.53 | 11.9% | 16.4% | 0.30–1.54 | 0.68 | – | – | – | – |
| Fatigue | 66.0% | 47.3% | 1.20–3.90 | 2.16 | 63.6% | 41.8% | 1.34–4.40 | 2.43 | 45.5% | 32.7% | 1.92–3.16 | 1.71 | 50.2% | 25.0% | 1.29–6.10 | 3.02 |
| Postpartum ‘blues’ | 14.6% | 16.4% | 0.39–1.93 | 0.87 | – | – | – | – | – | – | – | – | – | – | – | – |
| Sexual problems | – | – | – | 12.3% | 29.1% | 0.17–0.68 | 0.34 | 22.5% | 45.5% | 0.19–0.64 | 0.34 | 8.2% | 22.9% | 0.13–0.68 | 0.30 | |
| Sleep problems | 36.8% | 7.3% | 2.59–21.1 | 7.41 | 41.9% | 67.3% | 0.18–0.65 | 0.35 | 33.2% | 47.3% | 0.30–1.00 | 0.55 | – | – | – | – |
| Haemorrhoids | 0.4% | 3.6% | 0.009–1.18 | 0.10 | 4.3% | 3.6% | 0.25–5.59 | 1.2 | 3.6% | 7.3% | 0.13–1.58 | 0.47 | 4.8% | 4.2% | 0.24–5.36 | 0.15 |
CI–confidence interval, OR–odds ratio
Eight weeks postpartum, multiparous women reported significantly more problems than primipara. Multiparous women reported more wound infections (OR=0.26), urinary tract infections (OR=0.19), abnormal vaginal discharge (OR=0.53), sleep problems (OR=0.35) and sexual problems (OR=0.34), but primiparous women reported more fatigue (OR=2.43) and constipation (OR=4.3).
At 12 months after childbirth, the majority of health problems were equally common among women having first births or subsequent births. The exceptions were breast problems (OR=3.56) and fatigue (OR=1.71) in primipara, and sexual problems (OR=0.34) and sleep problems (OR=0.55) in multipara.
Five years after childbirth, the corresponding variable in the primiparous women was fatigue (OR=3.02), and in multiparous women was sexual problems (OR=0.30).
Discussion
This study describes the burden and patterns of postpartum morbidities. It is one of a few studies to investigate postpartum morbidities in the 5 years postpartum prospectively, and clearly depicted the extent of morbidities in this cohort of Iranian women throughout this period. The majority of women reported a wide range of postpartum health problems, specifically among the group who were assessed during 12 months postpartum.
Literature from previous research shows that at 6 weeks postpartum, many women report a high level of postpartum morbidities (Webb et al, 2008; Rouhi et al, 2011; Kabakian-Khasholian et al, 2014; Singh and Kumar, 2014; Cooklin et al, 2015). This study is dissimilar to these studies as different questions were used and women were followed up at different points of the postpartum period.
In developing countries, many mothers suffer from long-term morbidities (Hardee et al, 2012) and most of these physical problems are hidden and untreated (Woolhouse et al, 2014). Consistent with other studies (Brown et al, 2006; Rouhi et al, 2011; Woolhouse et al, 2014; Cooklin et al, 2015), while some morbidities—such as constipation, breast problems, difficulty voiding and abnormal vaginal discharge—became less common over time, others persisted, became more common, or both.
Following childbirth, there are changes across time in the areas of physical health, physical role, bodily pain, vitality, emotional role and mental health (Emmanuel and Sun, 2014). The high levels of fatigue and backache reported by women at every time point up to 5 years postpartum are an important finding of this study. This result is in agreement with other studies reporting that fatigue is the most common symptom following childbirth (Thompson et al, 2002; McGovern et al, 2007; Rychnovsky and Hunter, 2009) and one of the major concerns among postpartum women (Schytt et al, 2005; McGovern et al, 2007; Rouhi et al, 2011; Song et al, 2014). Lack of sleep is probably one, but not the sole, explanation for the high proportion of women reporting fatigue (Schytt et al, 2005). Other reasons may be related to vitamin D deficiency (Hashemipour et al, 2004) or anaemia in Iranian people and elsewhere in the world (Milman, 2011; Goshtasebi et al, 2013). Furthermore, family changes, infant care, sleep status, domestic work and going back to the professional life are among other factors affecting fatigue (Kilic et al, 2015).
Of the urogenital problems, sexual problems were more frequent and intense in multiparous women than in primiparous women at 8 weeks, 12 months and 5 years after childbirth. Schytt et al (2005) found that the main factor in women postponing sexual relationships or having problems with this issue is pain. Other urogenital symptoms, such as perineal pain, were common at 1 week and 8 weeks postpartum, which troubled more than one third of multiparous women. These problems tend to happen during the early postpartum period (Brown and Lumley, 1998; Rouhi et al, 2011).
Limitations
This study had several limitations, the most important being the reliance on self-reported morbidities rather than diagnosis by a clinician. It is possible that cultural and economic factors may have caused women to over-report or under-report certain morbidities and symptoms. The authors recommend that further research be performed to determine which variables are most important in assessing morbidities in postpartum mothers.
Conclusions
The findings of this Iranian prospective cohort study showed that physical health problems commonly persist or recur throughout the first 5 years postpartum, with potential long-term consequences for women's health.
The most common postpartum morbidities experienced by this cohort over 5 years were: backache, fatigue, headache, sleep problems and sexual problems. The high levels of fatigue and backache reported by women at every time point up to 5 years postpartum are an important finding of this study.
Although the postpartum period is generally considered to include 6 weeks after pregnancy, it has recently been lengthened to the first postpartum year (Walker et al, 2015), though many women suffer from physical problems for more than a year. These changes suggest that health-care providers need to continually assess and support women in pregnancy and following childbirth for a long period of time.
Key Points
Conflict of interest: The authors declare that they have no competing interests.