By combining the search terms, 2840 studies were identified from the four databases and after screening for relevance, 58 were retrieved for full text review (Figure 1). Upon applying the eligibility criteria, 38 articles met the inclusion criteria. Two studies were conducted by the same authors group.15-18 In these publications, the same methodology was reported in two papers, but there was a different emphasis on the results and outcomes reported per publication. For the purposes of this review, the first publication is referenced in the methodology section.15,17 Both publications were included in the summary tables and measurements and/or associations for each publication are described in the results section. Most studies (92%; 33/36) were of medium quality, and the rest low quality (8%, 3/36).
Characteristics of studies
The 36 studies were from 17 different countries, with 15 from sub-Saharan Africa. Eleven were conducted in low-income countries and six in middle-income countries (four lower-middle and two upper-middle income countries).
Study design, source of data, data collection method and sample size
Twenty-six studies used cross-sectional survey study designs. Four were observational prospective cohort studies.15,19,20,21 One study was a case control.22 Twenty five studies used face-to-face interviews or consultations to collect self-reported primary data from women using questionnaires. Most studies that collected primary data relied on women’s self-reported symptoms (n=28). In four studies, clinical examination and/or laboratory tests were also conducted.6,20,23,24 Three studies extracted data using secondary data analysis of large databases of hospital admissions, discharges or birth registers.25,26,27 In these secondary data analyses authors used their own data collection tools with little details of the variables extracted. One study extracted data from medical case notes retrospectively (Supplementary Table 2).28 A total number of 71,229 women was assessed in the 36 studies: 60,911 during and 10,318 after pregnancy. In nine studies <500 women were assessed;24-33 thirteen assessed 500-999 women each.15,18,20,21,35-44 In nine studies 1000-1999 women were assessed;19,22,27,28,45-49 and five had sample sizes of ≥2000 women (Supplementary Table 2).6,25,26,50,51
Stages of pregnancy assessed
A total of 23 studies collected data from women during pregnancy: in the second trimester;16,19,32,41,48 in the third trimester;20,24,38 or at any time during pregnancy.19,29,32,33 In 11 of the 23 studies, the gestation was not given.32,37,39,-46, ,49,50 Seven studies assessed women within 12 weeks of childbirth.18,22,29,30,32,47,51 In one study, data was collected at three stages after childbirth: at 4-12 weeks; at 12-24 weeks; and at 24-56 weeks.23 Zafar et al collected data at three different assessment stages, during (early and late antenatal) and after pregnancy (Supplementary Table 2).6
Site of data collection
In studies that collected primary data (n=30), data collection took place during visits for routine antenatal or postnatal care in outpatient departments of healthcare facilities: tertiary/provincial hospitals;23,31,36,39,42,45,47 secondary level or district hospital,32,34,44 and primary healthcare facility level.15,18,37,40,48 For four studies the site was unclear.29,33,35,43 In 12 studies, this took place in the community or at women’s homes (Supplementary Table 2).6,19,20,22, 24,30,34,43,46,50,51
Maternal multimorbidity
All three types of maternal morbidity including physical, psychological and social ill-health were assessed in 12 studies;6,15,16,20,36-8,40,42,43,44,47,49 psychological and social ill-health were assessed in nine studies;18,25,29,31,32,35,36,40,43 physical and psychological ill-health in 11; 6,18,19,21,22,24,27,29,32,33,50 and physical and social ill-health in six (Supplementary Table 2).17,26,45,46,48,51
Physical morbidity
Twenty-nine studies reported on different types of physical morbidity; three of which assessed pre-selected populations including women with HIV36,43 or women with gestational diabetes.39 A variety of data collection tools were used, but generally not well described. The most commonly reported physical morbidities were anaemia in six studies (prevalence range 5.0-57.7%),6,20,22,23,32,50 and HIV in nine (prevalence range 3.0 - 16.0%).6,16,29,33,36,37,44,49,51 There was a variety of other types of physical morbidities, with wide ranges for some conditions such as antepartum haemorrhage; nausea and vomiting; preterm birth; malaria; reproductive or sexually transmitted infection; urinary tract infection (Supplementary Table 3). Some authors used summative aggregated measures, for example “gynaecological and obstetric problems” as occurring in 10-22% of women; “multiple morbidities” in 60% of women or “at least one reported symptom” (44% occurrence).22,47,50 One study used antenatal hospitalisation as a “proxy” for physical morbidities (55.4% of women)46 (Supplementary Table 3).
Psychological morbidity
Of the 32 studies that report psychological morbidities, the most commonly condition was depression with a prevalence range of 13.5-39.5% across 21 studies.18,20-24,27-35,36,39,42,50 Twelve studies described more than one psychological condition.15,16,19,25,35,38,43,44,47-50 Some authors described aggregates or a summative psychological condition; for example, “common mental disorders” and “symptoms of any mental distress”.15,16 There was a range of other types of psychological morbidity described, such as anxiety; suicidal ideation; and distress (Supplementary Table 4). Fourteen different data collection tools were used either alone or in combination (Table 1). The commonest tool was the Edinburgh Postnatal Depression Score (EPDS) questionnaire, used in fourteen studies.6,18,20,28-31,35,36,37,39,42,50 However, different studies used various cut-off scores (from ≥4 to ≥13) for the EPDS questionnaire and the Kessler scale (from >15 to >30). 6,18,20,28-31,35,36,37,39,42,50,56 54
Social morbidity
In total, 27 studies assessed social morbidity; the most commonly reported type of social morbidity was domestic violence in 14 studies.17,18,23,25,28,31,36,39,40,44,46,48,49,51 Substance abuse was assessed in nine studies (Supplementary Table 4).16,35,40,41,43,45,46,47,51 Three studies assessed both domestic violence and substance abuse.26,38,47 Eight studies assessed other aspects of social health including husband’s alcohol intake, poor social support, food insecurity and unplanned pregnancy.20,21,30,34,37,42,43,47
Domestic violence
Fourteen studies assessed domestic violence,17,18,23,25,28,31,36,39,40,44,46,48,49,51 and a variety of data collection tools were used. Most authors used their own definitions and questionnaires to screen for domestic violence. Four studies used all or part of internationally recognised questionnaires (Table 1).17,18,40,46,48 Different types of domestic violence included: disrespect, forced sex, intimate partner violence , physical assault , severe psychological and verbal abuse. Other authors used descriptions of domestic violence as aggregates or summative measures, for example, terms such as “multiple acts of physical violence” and “physical and/or sexual abuse”.39
Substance abuse
Nine studies assessed one or more forms of substance abuse,16,35,40,41,43,45,46,47,51 and only two of these studies used validated questionnaires.35,41 In general, substance abuse related to alcohol (9 studies; prevalence range 0-49.5%).16,35,40,41,42,45,46,47,51
Associations between different types of morbidity
For physical morbidity, there was an association between increased psychological morbidity in women with obstetric complications (haemorrhage, infections, incontinence, prolonged labour, Caesarean birth, low birthweight, stillbirth, neonatal death) (Table 2).6,26,42,46,51 In pre-selected populations, women with gestational diabetes were not more likely to have psychological morbidity (depression)39, but women with HIV were more likely to have social morbidity (domestic violence).18 Psychological morbidity was more common in younger women41 and among women with social morbidities such as domestic violence,25,36 unwanted pregnancy19,42,51, and poor social support (Table 2).42 For social morbidity, there was an association between women with substance abuse (alcohol) and domestic violence49; and domestic violence was also associated with neonatal death49 and maternal complications (Table 2).47 Due to heterogeneity, meta-analysis of associations were not possible.