This study represents the continuation of an initiative led by the WHO Maternal Morbidity Working Group (MMWG), and represents the implementation the WOICE 2.0 questionnaire to measure non-severe maternal morbidity for the postpartum (PPC) women considering a broad approach of conditions that can impact maternal health, in a high-risk setting (11).
The pilot study conducted in Jamaica, Kenya and Malawi tested the WOICE in pregnant and postpartum women, for the first time, in a mostly low risk and low-income settings, with a total sample of 1490 women (6). In comparison to their findings, our sample included older, more educated women and mostly women with partners. In the pilot study, (6.1%) of the women reported having a health problem informed by the attending physician and in our study, this number was much higher, (over 50%), with more C-section and preterm birth.
Cesarean section rates are increasing worldwide, with Brazil among the most impressive figures (over 50%) (22, 23). Our sample represents a referral center and there is possible selection bias through postpartum scheduled visits, since mostly complicated cases are the ones followed at the institution, therefore not representing the overall cesarean rate in the institution.
Another marker of high-risk assessment is the rate of prematurity. Preterm birth is the main risk factor for infant morbidity and mortality, not only during the neonatal period but also in childhood, it can affect the cognitive dimensions, physical health and behavior, so it is one of the most important challenges for public health. Brazil has rates of preterm birth around 11.5% (24).
We evaluated the exposure to violence in the WOICE questionnaire, where we could identify that in this group of women surveyed, 5.9% of the participants were exposed to some type of violence (domestic-sexual). Previous reports showed exposure to domestic violence against women as a global phenomenon and these victims are frequently very familiar with their authors, who are people their of daily life. This violence is accepted as "normal" in many societies of the world (25). Estimates by the WHO say that 1 in 3 women worldwide suffer from physical and / or sexual partner and sexual violence by third parties at some point in their life (26) Violence is a sensitive subject, since women are often afraid to talk about it, because of the possible repercussions. Our findings with low frequency of violence, might reflect such fear of the truth.
The high frequency of breastfeeding in our sample must be highlighted, especially considering the high-risk background and frequency of prematurity. Studies show that one of the priorities of these women is the good development of the baby that is supplied in large part by the mother's milk, thus reducing early weaning (27), this might support such levels of breastfeeding, adding the hospital´s active work in campaigns, programs to inform women about the benefits of breastfeeding for the baby.
According to a study carried out in 2017 on the indicators of breastfeeding in Brazil in the last three decades, they have led Brazil to be considered a successful country in the implementation of policies and programs to promote breastfeeding with all the necessary tools, knowing that the breastfeeding is not only the responsibility of women, it is also shared with society. The prevalence of exclusive breastfeeding for children under 6 months of age in 2013 was 52.1% (11).
When considering abnormal conditions evaluated by the WOICE instrument, it was striking to observe less than 5% of women with none alteration. This supports the understanding of multiple aspects that are able to influence women´s wellbeing and that during postpartum, women need multidisciplinary support. As a limitation, we do not have prospective assessment of women, in order to pursue the real impact of gestation throughout the reproductive cycle.
Multiple regression presented that having a partner decreased the women's perception of clinical morbidities and that might just reflect more care and support. Having a clinical diagnosis was an independent factor associated to impaired mental health and functioning. This is expected, but rarely reported in a systematic way. Knowing that clinical conditions can be associated to further impairment can guide interventions and improve care (28) In our sample, there was a significant number of women with complications due to hypertension. It is important to highlight that preeclampsia and eclampsia are major causes of morbidity and mortality, especially in low and middle-income settings (29, 30).
It is important to note that 96% of women reported at least one morbidity evaluated by the WOICE instrument, during pregnancy or postpartum period. Performing regular care, we are most likely underreporting the occurrence of morbidities, if we consider the current WHO maternal morbidity framework. WOICE strengths the need to give voice to women during care: if we do not actively ask, we probably will not diagnose non-clinical and non-severe morbidities. However, if we really want to understand in depth the burden of maternal morbidity, we have to apply instruments that may bring to surface some underlying conditions.
Those conditions may be extremely harmful to women, such as intimate partner violence or substance abuse. However, due to social stigmas, those conditions may be source of shame and not reported in routine care; we cannot consider that a woman with those conditions will undergo a positive pregnancy experience, and we will only conduct it properly if we ask.
Another interesting point of our results is that the majority of women reported good or very good health at the time of the interview. Our study design does not allow us to affirm any cause-consequence relation, however we suppose that such result is a consequence of the perception of good healthcare. Some morbid conditions may have occurred and since solved through the puerperium period (due to timely and adequate care, or even due to luck).
Other important concern regarding our results is that our sample represents a population attended in a high risk setting, and results may not be generalizable for the general obstetric population, or even those followed in low-risk settings. However, it highlights the importance of not only considering clinical morbidities, but also other morbidities, even in women with known underlying disease.
Postpartum care would need to provide much more than contraceptive method orientation, it needs to ensure the opportunity to promote women's health and well-being, and postpartum visits should include a thorough assessment of physical, social, psychological and mental health (10). It is necessary to know all these dimensions and possibilities of alterations in the puerperium, so that it is possible to establish adequate interventions in each scenario.
An important limitation is that WOICE has not been translated and validated into different languages, as Portuguese, and it may difficult comparisons with data obtained using English version. However, the tool is based on several instruments that have been previously validated, and this should be considered when analyzing its results. Another limitation is that questionnaires were answered through an interview administered by a researcher. This methodology may underreport the occurrence of morbidities, notably drugs consumption and intimate partner violence, however such approach was considered to allow the inclusion of women with low-education level.
More research and studies are needed with this instrument to validate it globally, identifying problems and conditions that are not evaluated in a common medical consultation, improving care for women after childbirth.