title: Non-Life Threatening Maternal Morbidity: Cross Sectional Surveys from Malawi and Pakistan.
abstract: BACKGROUND
  For more accurate estimation of the global burden of pregnancy associated disease, clarity is needed on definition and assessment of non-severe maternal morbidity. Our study aimed to define maternal morbidity with clear criteria for identification at primary care level and estimate the distribution of and evaluate associations between physical (infective and non-infective) and psychological morbidities in two different low-income countries.
  
  
  METHODS
  Cross sectional study with assessment of morbidity in early pregnancy (34%), late pregnancy (35%) and the postnatal period (31%) among 3459 women from two rural communities in Pakistan (1727) and Malawi (1732). Trained health care providers at primary care level used semi-structured questionnaires documenting signs and symptoms, clinical examination and laboratory tests which were bundled to reflect infectious, non-infectious and psychological morbidity.
  
  
  RESULTS
  One in 10 women in Malawi and 1 in 5 in Pakistan reported a previous pregnancy complication with 1 in 10 overall reporting a previous neonatal death or stillbirth. In the index pregnancy, 50.1% of women in Malawi and 53% in Pakistan were assessed to have at least one morbidity (infective or non-infective). Both infective (Pakistan) and non-infective morbidity (Pakistan and Malawi) was lower in the postnatal period than during pregnancy. Multiple morbidities were uncommon (<10%). There were marked differences in psychological morbidity: 26.9% of women in Pakistan 2.6% in Malawi had an Edinburgh Postnatal Depression Score (EPDS) > 9. Complications during a previous pregnancy, infective morbidity (p <0.001), intra or postpartum haemorrhage (p <0.02) were associated with psychological morbidity in both settings.
  
  
  CONCLUSIONS
  Our findings highlight the need to strengthen the availability and quality of antenatal and postnatal care packages. We propose to adapt and improve the framework and criteria used in this study, ensuring a basic set of diagnostic tests is available, to ensure more robust assessment of non-severe maternal morbidity.
authors.affiliation: Health Services Academy, Islamabad, Pakistan.
authors.forename: Shamsa
authors.initials: S
authors.lastname: Zafar
authors.affiliation: Oxford Epidemiology Services, Oxford, United Kingdom.
authors.forename: Rachel
authors.initials: R
authors.lastname: Jean-Baptiste
authors.affiliation: Department of Mental Health and Well-Being, University of Liverpool, Liverpool, United Kingdom.
authors.forename: Atif
authors.initials: A
authors.lastname: Rahman
authors.affiliation: Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom.
authors.forename: James P
authors.initials: JP
authors.lastname: Neilson
authors.affiliation: Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
authors.forename: Nynke R
authors.initials: NR
authors.lastname: van den Broek
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D008295:Malawi / Q000453:epidemiology; D063130:Maternal Death / Q000209:etiology / Q000523:psychology; D010154:Pakistan / Q000453:epidemiology; D011247:Pregnancy; D011248:Pregnancy Complications / Q000453:epidemiology* / Q000401:mortality / Q000523:psychology; D011251:Pregnancy Complications, Infectious / Q000453:epidemiology / Q000401:mortality / Q000523:psychology; D012424:Rural Population; D055815:Young Adult