Reproductive Health Matters, No 4, November 1994

0m n% Und rs n ling of Pregnancy M0rbi [ y Rum

Mawaheb E1-Mouelhy, Mahinaz E1-Helw, Nabil Younis, Hind Khattab and Huda Zurayk

This paper examines the problems experienced by Egyptian women during their most recent pregnancy, delivery and post-partum period, based on their own reports. It finds an often low level of awareness among them of the causes and seriousness of maternal health problems, which influences their health-seeking behaviour. Many women did not identify certain symptoms with pregnancy but instead with "normality 5 making the symptoms less serious in their eyes, even signs o f potentially serious conditions. This helps to explain why women do not always seek appropriate help for obstetric morbidity and indicates a need for appropriate health education and services.

i S S E S S M E N T S of t he p r e v a l e n c e of medic - a l ly -asce r t a ined obs t e t r i c m o r b i d i t y n e e d to b e c o m p l e m e n t e d by i n f o r m a t i o n on w o m e n ' s e x p e r i e n c e s of t h o s e h e a l t h con-

di t ions . T h o u g h i n f o r m a t i o n o n m o r b i d i t y as pe r - ce ived a n d r e p o r t e d by w o m e n is of l imi ted va lue for e s t i m a t i n g p r e v a l e n c e o r i n c i d e n c e ra tes , it does give p o l i c y m a k e r s a n d se rv i ce p r o v i d e r s an u n d e r s t a n d i n g of the level of a w a r e n e s s a m o n g w o m e n a b o u t t h e c a u s e s a n d s e r i o u s n e s s of t h e i r hea l th p r o b l e m s a n d t he f ac to r s i n f l uenc i ng t h e i r h e a l t h - s e e k i n g b e h a v i o u r . S u c h i n f o r m a t i o n is n e c e s s a r y for t a i l o r i ng h e a l t h p r o g r a m m e s to a d d r e s s w o m e n ' s h e a l t h n e e d s effectively.

The r e s e a r c h o n w h i c h th i s p a p e r is b a s e d w a s c a r r i e d ou t as p a r t of t h e Giza M o r b i d i t y S tudy on r e p r o d u c t i v e h e a l t h p r o b l e m s a n d r e l a t ed morb id i ty . 1,2 E g y p t ' s h i g h m a t e r n a l mor t a l i t y ra te , 177 m a t e r n a l d e a t h s p e r 100,000 live b i r ths , 3 a n d tota l fer t i l i ty r a t e of 3.94 s u g g e s t t h a t t he p r o b l e m of r e p r o d u c t i v e m o r b i d i t y is se r ious . The s tudy was c a r r i e d ou t in t w o ru ra l v i l lages of t he Giza g o v e r n o r a t e in Egyp t in 1989-1990. It was m o t i v a t e d b y t he n e e d to a s se s s t he levels of r e p r o d u c t i v e m o r b i d i t y at c o m m u n i t y level a n d to ga in a n u n d e r s t a n d i n g of w o m e n ' s p e r c e p - t ions a n d a w a r e n e s s of t h e s e cond i t i ons .

The m e d i c a l e x a m i n a t i o n r e q u i r e d to s t u d y g y n a e c o l o g i c a l c o n d i t i o n s is cu l tura l ly u n a c c e p t - ab le to p r e g n a n t w o m e n , b e c a u s e t h e y a re a f ra id of m i s c a r r i a g e . Thus , c u r r e n t l y p r e g n a n t w o m e n

r

w e r e n o t i n c l u d e d in t he overa l l s t u d y n o r was m ed ica l e v a l u a t i o n of obs t e t r i c o r p r e g n a n c y - r e l a t ed m o r b i d i t y c a r r i e d out.

Da ta co l l ec ted o n g y n a e c o t o g i c a l m o r b i d i t y a re r e p o r t e d e l s e w h e r e . 5 This p a p e r r e p o r t s on t he o b s t e t r i c c o m p o n e n t of t he s tudy. It con- c e n t r a t e s o n t he h e a l t h p r o b l e m s e x p e r i e n c e d by w o m e n d u r i n g t h e i r m o s t r e c e n t p r e g n a n c y , de l ive ry a n d p o s t - p a r t u m per iod , b a s e d o n t h e i r o w n r epo r t s . T h e s e r e p o r t s , b o t h s p o n t a n e o u s a n d elicited, m a k e it c l ea r t h a t t h e w o m e n pe r - ce ived s o m e h e a l t h c o n d i t i o n s to b e s e r i ous a n d o t h e r s ' n o r m a l ' . T h e s e u n d e r s t a n d i n g s in f luence w h e n t h e y go to h e a l t h ca re se rv ices fo r t r ea t - m e n t a n d w h e n t h e y rely o n s e l f -med i ca t i on a n d / o r h o m e r e m e d i e s , o r do n o t h i n g .

SUBJECTS A N D METHODS Of the 509 e v e r - m a r r i e d w o m e n w h o w e r e no t c u r r e n t l y p r e g n a n t a n d w h o p a r t i c i p a t e d in the Giza M o r b i d i t y Study, t h e r e w e r e 262 w h o s e m o s t r e c e n t p r e g n a n c y h a d e n d e d w i t h i n t he p r e v i o u s t w o yea r s a n d w h o w e r e t hus el igible to take p a r t in t h e o b s t e t r i c c o m p o n e n t of t he s tudy. P r e f e r e n c e w a s g i v e n to t h o s e w h o s e las t p r e g - n a n c y was m o r e r e c e n t a n d t h o s e w h o could r e s p o n d to a o n e - h o u r i n t e r v i e w q u e s t i o n n a i r e . A s a m p l e of 207 was a c h i e v e d w h o w e r e f o u n d to h a v e s imi la r c h a r a c t e r i s t i c s to t he l a r g e r g r o u p of 262 el igible w o m e n .

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Of the 207 w o m e n , 188 h a d c a r r i e d t he re- p o r t e d p r e g n a n c y to t e rm . All b u t t w o of the w o m e n w h o s e p r e g n a n c i e s w e n t to t e r m h a d a live b i r th . Two w o m e n h a d s t i l lb i r ths . Two o t h e r s los t t h e i r bab ie s , o n e w i t h i n a f ew h o u r s a f te r b i r t h a n d t he o t h e r 40 days a f t e r b i r th . N i n e t e e n w o m e n r e p o r t e d a n a b o r t i o n , o f w h i c h five w e r e sa id to h a v e o c c u r r e d in t he s e c o n d t r i m e s t e r of p r e g n a n c y . T h r e e w o m e n sa id t he a b o r t i o n was i n d u c e d a n d 16 t h a t it w a s s p o n t a n e o u s .

The y o u n g e s t w o m a n in t h e s a m p l e w as 15 yea r s of age at t h e t ime of h e r las t de l ive ry a n d t he o ldes t w a s 45; t he a v e r a g e age w a s 25. O n e q u a r t e r of t he w o m e n h a d h a d five o r m o r e deliv- e r ies p r i o r to t h e i r m o s t r e c e n t p r e g n a n c y , whi l e t h o s e w h o w e r e 35 y e a r s of a g e or o lde r h a d h a d a b o u t seven . E i g h t y p e r c en t of t he w o m e n w e r e n o t l i te ra te , a n d v e r y f ew h a d a t t a i n e d an educ- a t iona l level a b o v e p r i m a r y school . The ma jo r i t y (66 p e r cent) w e r e m a r r i e d b e f o r e t he age of 16, w h i c h is t he legal a ge fo r m a r r i a g e in Egypt . A l m o s t o n e t h i r d w e r e m a r r i e d b e f o r e t he age of 14.

The i n t e r v i e w s w e r e c o n d u c t e d by t r a i n e d social r e s e a r c h e r s . The w o m e n w e r e a sked to de- s c r ibe t h e i r obs t e t r i c h i s t o r y a n d any c o m p l a i n t s t h e y h a d h a d d u r i n g t h e i r las t p r e g n a n c y a n d de l ive ry a n d p o s t - p a r t u m p e r i o d to o b t a i n s p o n t a n e o u s r e p o r t s of t h e i r expe r i ence s . Next, all t h e w o m e n w e r e a s k e d if t h e y h a d h a d med ic - a l ly -def ined c o m p l a i n t s of specif ic cond i t i ons , to elicit f u r t h e r i n f o r m a t i o n . This w as fo l lowed by q u e s t i o n s on w h e t h e r t h e w o m e n d id s o m e t h i n g t h e m s e l v e s for t h e i r com p l a i n t s . The t e r m ' h o m e r e m e d i e s ' was used, to i nc lude use of m e d i c a - t i ons w i t h o u t p r e s c r i p t i o n , d r i n k i n g ce r t a i n h e r b s a n d o t h e r i n d i g e n o u s p r a c t i c e s t he w o m e n u s e d t h e m s e l v e s . They w e r e a lso a sked w h e t h e r t h e y h a d c o n s u l t e d a phys i c i an . E v e n t s a f te r t he o n s e t of l a b o u r a n d r e f e r r a l s due to compl i ca - t ions w e r e r e c o r d e d . W e also a s k e d q u e s t i o n s a b o u t t h e w o m a n ' s a t t i t ude a n d b e h a v i o u r to- w a r d s a n t e n a t a l a n d p o s t - n a t a l c a r e a n d h e r cho ice of p lace of del ivery.

of t h e compla in t s . A s u b s t a n t i a l p r o p o r t i o n of t h e w o m e n com-

p l a i n e d of s y m p t o m s such as nausea , o c c a s i o n a l vomi t i ng , d izz iness , f a in tness , h e a r t b u r n , lack of appe t i t e , a b d o m i n a l d i scomfor t , c o n s t i p a t i o n , b a c k pa in , leg pa in , a s e n s a t i o n of pelvic heav i - ness a n d p a i n d u r i n g i n t e r c o u r s e - s y m p t o m s w h i c h a re usua l ly c o n s i d e r e d p a r t of t h e n o r m a l e x p e r i e n c e of p r e g n a n c y .

The w o m e n felt t h a t t h e s e s y m p t o m s g rea t ly i n t e r f e r e d w i t h t h e i r daily lives, p o s s i b l y due to t h e i r h e a l t h b e i n g p o o r w h e n t h e y c o m m e n c e d p r e g n a n c y . F o r example , a g o o d m a j o r i t y of the w o m e n in t h e s e v i l lages h a v e c h r o n i c a n a e m i a a n d a n a e m i a is e v e n m o r e c o m m o n a m o n g t h o s e w h o h a v e r e c e n t l y b e e n p r e g n a n t . 5

"I used to feel dizzy and w h e n I did one chore after

the other, I felt that everything around me had

turned yellow."

( s e c o n d t r i m e s t e r )

"I felt dizzy and because o f severe weakness i

could not see wha t was in front o f me."

( s e c o n d t r i m e s t e r )

"I felt a heaviness we igh ing on m y ches t [short-

hess o f breath] and because I felt so feeble I could

not see."

( th i rd t r i m e s t e r )

Aga in , a s e n s a t i o n of pelvic h e a v i n e s s was felt m o r e s t r o n g l y by t h e w o m e n w h o w e r e su f f e r i ng f r o m gen i t a l p r o l a p s e , a c o n d i t i o n t h a t w a s f o u n d to affect m o r e t h a n ha l f of the w o m e n in th i s c o m m u n i t y . 5

"In m y fifth and sixth mon ths o f p regnancy I had

belly aches, and d o w n b e l o w I was uncomfortable

and it bo thered me as i f it wou ld fall out o f me."

Six w o m e n r e p o r t e d t h a t t hey h a d h a d b leed- ing d u r i n g p r e g n a n c y , o f t en c o u p l e d w i t h a p p r e - h e n s i o n a b o u t w h e t h e r t h e b a b y w a s m o v i n g .

HEALTH PROBLEMS ENCOUNTERED Pregnancy O n e in t h r e e w o m e n m e n t i o n e d n o c o m p l a i n t s w h e n a s k e d if t hey h a d h a d any d u r i n g p r e g - nancy . W h e n w e m e n t i o n e d specif ic c o m p l a i n t s to t h e m , on ly o n e in five sa id t h e y h a d h a d n o n e

"Blood and a lot o f water came out and the baby

was not moving."

( s e c o n d t r i m e s t e r )

C o m p l a i n t s t h a t a re n o t c o n s i d e r e d ' n o r m a l ' , i n c l u d i n g o e d e m a in t he l o w e r l imbs, n o t fee l ing fetal m o v e m e n t , l e akage of w a t e r y fluid, a n d

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b leed ing , w h i c h the w o m e n k n o w is a s s o c i a t e d w i th t he r isk o f m i s c a r r i a g e , w e r e r e p o r t e d as well.

W i t h o u t b e i n g asked , t he w o m e n w e r e m o r e likely to r e p o r t t h o s e c o n d i t i o n s t h a t t h e y con- s i d e r e d to b e p r e g n a n c y - r e l a t e d , b o t h ' no rma l " s y m p t o m s a n d o t h e r s s u c h as vag i na l b l e e d i n g a n d o e d e m a , as well as c o n d i t i o n s t h a t a f fec ted t h e i r g e n e r a l w e l l - b e i n g d u r i n g p r e g n a n c y - pa r - t icular ly t h o s e t h a t p e r s i s t e d fo r a c o n s i d e r a b l e l e n g t h of t ime, w e r e p r e s e n t t h r o u g h o u t p r e g - nancy , o r w e r e deb i l i t a t i ng o r a g g r a v a t e d by p r e g n a n c y . T h o s e w o m e n w i t h a mul t ip l ic i ty of s p o n t a n e o u s c o m p l a i n t s o f ten sa id t h a t t hey ' h a d no t felt wel l ' d u r i n g t h a t p r e g n a n c y .

O n t he o t h e r h a n d , it w a s on ly w h e n t h e y w e r e a s k e d tt~at t he w o m e n w e r e likely to r e p o r t com- p la in t s w h i c h t h e y did n o t c o n s i d e r to b e p r e g - n a n c y - r e l a t e d , fo r i n s t ance , h e a d a c h e , vag ina l d i s c h a r g e , a n d b u r n i n g o r diff iculty w i th u r ina - t ion. T h e s e a re all s y m p t o m s of h i g h l y p r e v a l e n t c o n d i t i o n s in t h a t c o m m u n i t y - of a n a e m i a , r e p r o d u c t i v e t r a c t i n fec t ions a n d p ro l apse , a n d to a l e s se r e x t e n t u r i n a r y t r a c t i n f ec t i on a n d h i g h b l o o d p r e s s u r e . 5

It s e e m s t h a t w h e r e t h e r e is a h i g h p r e v a l e n c e of a p a r t i c u l a r cond i t ion , b o t h in a n d ou t of p r e g n a n c y , t he w o m e n t e n d e d to iden t i fy its s y m p t o m s wi th ' n o r m a l i t y ' to s o m e deg ree , b e c a u s e t h e y ge t u s e d to t h e m . This t e n d e d to m a k e t h e s y m p t o m s of t he u n d e r l y i n g cond i t ion , w h e t h e r o r n o t t hey e v e n r e l a t e d the t w o to e a c h o the r , a p p e a r no t to b e p r e g n a n c y - r e l a t e d a n d at t he s a m e t ime, to b e tess s e r i ous in t h e i r eyes.

One c o n d i t i o n t h a t w a s n o t m e n t i o n e d s p o n - t a n e o u s l y at all w a s h i g h b l o o d p r e s s u r e . S o m e of t he w o m e n h a d no t h a d t h e i r b l o o d p r e s s u r e c h e c k e d d u r i n g p r e g n a n c y . H o w e v e r , m a n y o t h e r s d id no t u n d e r s t a n d t h e c o n n e c t i o n be- t w e e n b l o o d p r e s s u r e a n d p r e g n a n c y , a n d m a d e c o m m e n t s like ' M y b l o o d p r e s s u r e is a lways low' , o r "I h a d it m e a s u r e d at t he b e g i n n i n g of p r e g - n a n c y a n d it w a s all r i gh t . '

Labour and delivery M o s t of t he w o m e n h a d d e l i v e r e d t h e i r m o s t r e c e n t p r e g n a n c y at h o m e . M o r e t h a n t h r e e q u a r t e r s w e r e a t t e n d e d by a daya ( t r ad i t iona l b i r t h a t t endan t ) . Only a few h o m e de l iver ies w e r e a t t e n d e d b y a phys i c i an , usual ly a w o m a n , or by a n u r s e - m i d w i f e .

E l e v e n of t h e 144 w o m e n de l ive r ing at h o m e r e p o r t e d p r o b l e m s , wh i l e 30 of t h e 44 w o m e n de l ive r ing in a m e d i c a l s e t t i ng r e p o r t e d p r o b - lerns. The ma jo r i t y of t he w o m e n w h o h a d a hosp i t a l de l ive ry h a d e i t h e r a n t i c i p a t e d com- p l i ca t ions o r h a d b e e n r u s h e d in as a n e m e r g - ency. E m e r g e n c y r e f e r r a l s w e r e m a i n l y fo r weak, p r o l o n g e d o r o b s t r u c t e d l abour , o r b e c a u s e of m a l p r e s e n t a t i o n . O n e w o m a n w h o h a d mal- p r e s e n t a t i o n h a d a s e q u e n c e of v e r y s e r i ous c o m p l i c a t i o n s l e ad ing to h y s t e r e c t o m y a n d t h r e e h a d c a e s a r e a n sec t ions .

T w e n t y - t w o p e r c e n t of t h e w o m e n p e r c e i v e d t h e i r l a b o u r a n d de l ive ry n o t to h a v e g o n e well. Difficult l abour , e p i s i o t o m y o r t e a r i n g of t h e pe r - i n e u m fo l lowed b y b l e e d i n g , any i n s t r u m e n t a l de l ivery a n d c a e s a r e a n sec t ion w e r e r e p o r t e d as a p r o b l e m . In fact, m o s t of t h e w o m e n p e r c e i v e d any i n t e r v e n t i o n w h a t s o e v e r in v a g i n a l chi ld- b i r t h a n d a n y t h i n g t h a t c a u s e d d i s comfor t , pa in o r i n c a p a c i t a t i o n as a compl i ca t ion .

Postpartum F o r t y p e r c en t of t h e w o m e n s p o n t a n e o u s l y r e p o r t e d a p o s t - p a r t u m c o m p l a i n t b u t m o s t of t h e s e w e r e n o r m a l p o s t - p a r t u m s y m p t o m s , such as a c h e s f r o m c o n t r a c t i o n s , pa in fu l b r e a s t s a n d n ipp les due to milk c o n g e s t i o n , a n d pa infu l s t i t ches t h a t m a d e t h e m u n a b l e to sit. A few w o m e n also s p o n t a n e o u s l y r e p o r t e d m o r e se r ious compla in t s .

P r o b i n g fo r specif ic c o m p l a i n t s r e s u l t e d in m a n y m o r e w o m e n r e p o r t i n g t h e m . Sixty p e r c en t of t he w o m e n w e r e f o u n d to h a v e h a d at leas t one p o s t - p a r t u m compla in t , wh i l e 20 p e r c en t h a d two o r m o r e . D i s c h a r g e / i n f l a m m a t i o n a n d f eve r (of ten t h e local w o r d fo r p u e r p e r a l f eve r w a s used) w e r e t he m o s t c o m m o n com- pla ints , f o l lowed b y d e p r e s s i o n a n d b l eed ing . In fact, 11 p e r c en t of t h e w o m e n r e p o r t e d h a v i n g feve r a n d d i s c h a r g e / i n f l a m m a t i o n , w h i c h poss - ibly i nd i ca t e s p u e r p e r a l seps is . One w o m a n r e p o r t e d se izu res w h i c h , f r o m t h e a s s o c i a t e d s y m p t o m s r e p o r t e d , w e r e m o s t likely r i g o r s due to p u e r p e r a l sepsis .

The w o m e n w h o s u f f e r e d f r o m d e p r e s s i o n of ten e l a b o r a t e d m o r e o n h o w t h e y h a d felt. R e a s o n s fo r d e p r e s s i o n i n c l u d e d lack of ca re a n d a t t e n t i o n o n t he p a r t o f family a f t e r deliv- ery, or fee l ing o v e r w h e l m e d by t h e ch i ld ren , t h e i r o w n h e a l t h p r o b l e m s o r t he b a b y ' s p o o r hea l th .

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"I felt I w a s choking , I w a n t e d to go ou t in the open air. S o m e t h i n g w e i g h e d heav i ly on m y chest."

"I was a lways sad and on the v e r g e o f tears. I u sed to s i t and cry and scream and hi t m y face in

despair."

Abortion S e v e n t e e n of the 19 w o m e n w h o s e p r e g n a n c i e s had e n d e d in an abor t ion r e p o r t e d at least one heal th p rob lem, wi th the n e e d for ' an ope ra t i on ' mos t c o m m o n , fo l lowed by fever and depress ion . It is in te res t ing that p o s t - a b o r t i o n dep re s s ion was r e p o r t e d only by w o m e n w h o had had a s p o n t a n e o u s abor t ion and less than five p rev ious del iveries. On the o t h e r hand, s o m e of the w o m e n w h o had had an induced abor t ion o r w e r e us ing a con t r acep t ive w h e n they go t p reg - nant exp re s sed rel ief tha t t he re wou ld not be ano the r child coming . Thus, r e p o r t i n g of post- abo r t ion dep re s s ion was re la ted to the d e g r e e the p r e g n a n c y was wan ted .

Relationship between age and reporting o f p r o b l e m s As was expected , the inc idence of all p r egnancy - re la ted heal th p r o b l e m s rose wi th the age of the w o m e n . H o w e v e r , we found tha t the inc idence of the "normal ' p r e g n a n c y s y m p t o m s dec l ined as they go t older. This is p robab ly part ly because the w o m e n go t used to these compla in t s wi th addi t ional p regnanc ies . Fo r t hose s y m p t o m s that a re s igns of anaemia , it may also be due to the dec rea se in the p reva l ence o f anaemia with age. 5 M o r e o v e r , the w o r k l o a d of o lder w o m e n is known to be l ower than that of younger , newly mar r i ed w o m e n . 6

It was the m o r e ma jo r obs te t r ic compl ica t ions that rose wi th the w o m e n ' s ages, especial ly oed- ema, b u r n i n g or difficulty wi th ur inat ion, head- ache and pos t -pa r tum fever in con junc t ion wi th d i scharge / in f l ammat ion . Thus, for example, post- p a r t u m d i scha rge a n d / o r in f l ammat ion r e p o r t e d joint ly wi th fever, poss ib ly ind ica t ing puerpera l sepsis, was r e p o r t e d s ignif icant ly m o r e often by w o m e n 35 years of age o r m o r e (29 pe r cent) than by the w o m e n as a who le (11 pe r cent).

HEALTH-SEEKING BEHAVIOUR The w o m e n in this s tudy live in a rural a rea but they have close access to medica l care. Thus, an

analysis of w h a t t hey did for the var ious hea l th p r o b l e m s they e n c o u n t e r e d du r ing p regnancy , delivery, p o s t - p a r t u m and pos t - abor t ion p ro- v ides s o m e revea l ing and impor t an t ins ights into the i r a s se s smen t of the se r iousness of the i r heal th p r o b l e m s and of w h e t h e r and w h e n they t h o u g h t it w a s a p p r o p r i a t e and neces sa ry to seek medica l care.

As was said above, the compla in ts the w o m e n r e p o r t e d spon taneous ly , because they a p p e a r e d to take t h e m m o r e seriously, w e r e m o r e of ten those that they cons ide r ed to be re la ted to p r eg - nancy and fertility. This was con f i rmed by our f inding that the la rges t p r o p o r t i o n of the w o m e n wi th a p o s t - a b o r t i o n heal th p r o b l e m sough t medica l help, fo l lowed by a lmost two- th i rds of those with a p r e g n a n c y - r e l a t e d p rob lem, whi le the p r o p o r t i o n of w o m e n seeking medica l help for a p o s t - p a r t u m p r o b l e m was cons ide rab ly less overall . W h a t they said about vagina l b l eed ing helps to explain why.

Bleed ing and o the r compl ica t ions dur ing p r e g n a n c y which indicate that a m i sca r r i age m a y be s tar t ing, m a d e m a n y of the w o m e n rush to the hospital . Many also r e t u r n e d to the hospi tal o r sough t o the r medica l care if they had any o the r pos t - abo r t i on complaint . One ex- p lanat ion for this h igh ra te of consul ta t ion was that the w o m e n w e r e w o r r i e d that their fertility, and t h e r e f o r e la ter p regnanc ies , migh t be ad- versely affected. In contrast , the w o m e n w e r e less w o r r i e d about these condi t ions pos t -pa r tum, because they t h o u g h t the condi t ions w e r e na tura l and expec t ed them to pass wi thou t dan- g e r o u s seque lae for thei r heal th o r fertility.

Thus, all five w o m e n w h o had pos t - abor t ion b leed ing s o u g h t medica l help, whi le 63 per cent of those w h o expe r i enced b leed ing dur ing p r e g n a n c y did, c o m p a r e d to 44 pe r cent of those wi th pos t -pa r tum bleeding. Use of h o m e remed ies to s top the b leed ing was relat ively u n c o m m o n . Both of the two (at the t ime pregnan t ) w o m e n w h o s tar ted off by using a h o m e r e m e d y to s top the bleeding, e.g. cold drinks, ended up consu l t ing a physician. A daya advised a n o t h e r w h o was in h e r second t r im- ester: 'The baby ' s head is c o m i n g out. You have to go to a doc to r . ' Similarly, the w o m e n with p o s t - p a r t u m b leed ing w h o t r ied to m a n a g e it at h o m e consu l ted a daya or the nurse f rom the heal th cen t re and w e r e advised to consul t a physic ian fo r medica t ion . W h e n bleeding, es-

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pecial ly p o s t - p a r t u m , w a s n o t p e r c e i v e d as severe , w o m e n d id n o t h i n g fo r it.

F e v e r w a s a n o t h e r c o n d i t i o n t h a t was gen - eral ly c o n s i d e r e d se r ious , espec ia l ly p o s t - p a r - tum. M o s t of t h e w o m e n d id n o t a l low it to go u n a t t e n d e d , e i t h e r d u r i n g p r e g n a n c y o r pos t - p a r t u m , n o r fo l lowing a b o r t i o n . A b o u t ha l f t h e w o m e n w i t h f eve r d u r i n g p r e g n a n c y c o n s u l t e d a phys ic ian , a n d a t h i r d u s e d s e l f - m e d i c a t i o n a n d h o m e r e m e d i e s . A l m o s t ha l f o f t h o s e w h o h a d feve r p o s t - p a r t u m s o u g h t med i ca l help , a n d t h e r e s t u sed h o m e r e m e d i e s a n d se l f -med ica t ion . F o u r of t he s e v e n w o m e n r e p o r t i n g pos t - a b o r t i o n feve r c o n s u l t e d a phys i c i an . H i g h feve r in a n d ou t of p r e g n a n c y is r e c o g n i s e d as a d a n g e r o u s s ign of ill hea l th . O n t h e o t h e r h a n d , t he fac t t h a t p u e r p e r a l seps i s is a m a j o r cause of m a t e r n a l d e a t h i nd i ca t e s t h a t s o m e w o m e n do no t seek ca r e in t i m e o r do n o t r ea l i se t he seve r i ty of t h e i r cond i t ion .

O e d e m a d u r i n g p r e g n a n c y w a s a n o t h e r com- p la in t for w h i c h p h y s i c i a n c o n s u l t a t i o n w a s f o u n d to b e re la t ive ly h igh . A l t h o u g h t h e p ro -

p o r t i o n of w o m e n w i t h th i s c o m p l a i n t w h o s o u g h t med i ca l he lp is less t h a n half, t h e r e w a s a re la t ive ly h i g h r a t e o f r e p e a t e d c o n s u l t a t i o n for. r e c u r r e n t e p i s o d e s a n d w h e n it b e c a m e un- c o m f o r t a b l e . O n e w o m a n r e p o r t e d u s i n g mas - s a g e as a h o m e r e m e d y .

A l m o s t ha l f of t h o s e w i t h b u r n i n g a n d dif- ficulty w i t h u r i n a t i o n d u r i n g p r e g n a n c y o p t e d for med i ca l help , wh i l e a n o t h e r q u a r t e r m a n a g e d t h e c o m p l a i n t b y d r i n k i n g v a r i o u s h o t d r i n k s o r o t h e r h o m e r e m e d i e s . 7 A l m o s t 60 p e r c en t of w o m e n w i t h p e r s i s t e n t h e a d a c h e s t o o k aspi r in , nova lg ine , o r o t h e r t a b l e t s w h i c h cou ld b e h a r m - ful to t h e fetus, w i t h o u t c o n s u l t i n g an y o n e .

D i s c h a r g e d u r i n g p r e g n a n c y led less t h a n a t h i r d of t h e w o m e n w h o h a d it to seek m e d i c a l help, e v e n t h o u g h w e u s e d the t e r m "heavy d i s c h a r g e ' w h e n w e a sked a b o u t it. N o t sur- pr i s ingly , c o n s u l t a t i o n fo r d i s c h a r g e w as m o r e p r o b a b l e if t h e w o m e n t h e m s e l v e s p e r c e i v e d it to b e a b n o r m a l a n d d e s c r i b e d it as ' i n f l a m m a t i o n ' , t h a t is, m a i n l y w h e n t h e y e x p e r i e n c e d a lot of i t ch iness , i r r i t a t ion , p a i n o r a b a d o d o u r . A b o u t

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a qua r t e r of the w o m e n w h o said they had d i s cha rge du r ing p r e g n a n c y and pos t -pa r tum t rea ted themse lves wi th a h o m e remedy. 7

The condi t ion for wh ich medica l consul ta t ion was m o s t u n c o m m o n was p o s t - p a r t u m dep res - sion, a l though f rom the i r r epor t s it is c lear that those w h o suffered f r o m it w e r e deeply affected. As one w o m a n said:

"I always felt apathetic and dispirited, i considered this to be someth ing psychological so I did no t bo ther about it."

In fact, a lmos t no w o m a n with dep re s s ion did any th ing for it. This may be expla ined by the m o r e gene ra l pa t te rn o f consu l ta t ion for psycho- logical compla in t s in Egypt , wh ich is ve ry low.

C O N C L U S I O N S Our da ta a l lowed us to c o m p a r e the ra te o f consul ta t ions wi th phys ic ians for obs te t r ic con- dit ions and for non-obs te t r ic , gynaeco log ica l complaints . W e found that medica l consul ta t ion for obs te t r ic compla in t s re la ted to p r e g n a n c y w e r e compara t ive ly h i g h e r than for non- obstet r ic , gynaeco log ica l compla in ts . Less than a th i rd of the w o m e n consu l ted a physic ian for d i scharge , s y m p t o m s of geni ta l p ro lapse o r u r ina ry infection, mens t rua l p rob l ems or l ower abdomina l pain; and even f e w e r consul ted a physic ian for p r o b l e m s wi th in te rcourse . The level of consul ta t ion for gynaeco log ica l com- plaints a p p r o a c h e s that of p r egnancy - r e l a t ed compla in t s only in the case of anxiety ove r in- ferti l i ty (54 pe r cent).

It is to be expec ted tha t the na tu re of the heal th care the w o m e n s o u g h t w o u l d vary for d i f ferent p r o b l e m s b e t w e e n medica l help, h o m e remed ies o r even do ing noth ing , and with pe rmuta t ions of these t o g e t h e r and separa te ly ove r t ime. W e d i scove red that these dec is ions w e r e some t imes based on a lack of k n o w l e d g e o r an incor rec t a s ses smen t of the se r iousness of specific com- plaints, inc luding thei r effects on future p reg - nancies and fertility, and w e r e t he re fo re no t always m a d e in the best in teres ts of the w o m e n ' s health.

A c c o r d i n g to a s tudy ca r r i ed out by the Egypt ian Minis t ry of Health, the th ree main causes of ma te rna l dea th in Egypt are haem- o r rhage , p r e g n a n c y - i n d u c e d hype r t ens ion and

sepsis. 8 There a re likely to be m a n y w o m e n suf fer ing l o n g - t e r m morb id i ty f rom these con- dit ions, even t h o u g h they have e scaped death. A m o n g the m a n y ba r r i e r s to r e d u c i n g ma te rna l mor ta l i ty and morb id i ty effect ively are that w o m e n a n d / o r the i r families fail to or delay seeking medica l care, and tha t heal th services p rov ide i n a d e q u a t e antenata l care. This s tudy t h r o w s l ight on h o w and w h y these ba r r i e r s mani fes t t hemse lves in Egypt and poin ts t o w a r d s s o m e a p p r o a c h e s to conce r t ed hea l th educa t ion effor ts and i m p r o v e m e n t in antenata l care.

High b lood pressure , in par t icular , is a condi t ion tha t c anno t be felt; it mus t be detected. Yet, hav ing no t m e n t i o n e d it unless p r o b e d and ra re ly re la t ing it to p regnancy , s o m e w o m e n did not have the i r b lood p re s su re m e a s u r e d at all du r ing p r egnancy . Mos t w e r e u n a w a r e of the s igni f icance of h igh b lood p r e s s u r e du r ing p regnancy , o r of the poss ible e leva t ion of b lood p re s su re at any t ime as p r e g n a n c y p r o g r e s s e s and hence , the need for r epea t ed m e a s u r e m e n t .

In a n u m b e r o f ins tances , w o m e n do not s eem to see the connec t ions b e t w e e n the s y m p t o m s of condi t ions that can b e c o m e ser ious and the i r causes. S y m p t o m s such as s t rong, pe rs i s ten t h e a d a c h e s w e r e no t pe rce ived as ser ious e n o u g h to seek medica l help, and w h a t is more , w e r e t r ea ted if at all by sel f -medicat ion, wh ich could be harmful . These par t icu lar s y m p t o m s may welt be indica t ive of hype r t ens ive d i so rde r s of p r e g n a n c y in s o m e of these w o m e n .

Again, abou t a th i rd of the w o m e n wi th b leed ing du r ing p r e g n a n c y did not do anyth ing abou t it, yet even spot t ing may indicate a condi t ion as ser ious as p lacenta praevia . Post- p a r t u m fever and heavy d i s cha rge w e r e per- ce ived not to w a r r a n t medica l ca re in m o r e than 50 pe r cent of cases. This is cause for concern , especial ly g iven that pue rpe ra l sepsis is an impor t an t cause of ma te rna l mortal i ty , let a lone infertility.

W e found that ado lescen t w o m e n r e p o r t e d compla in t s far less f requent ly than o lder w o m e n , poss ib ly because y o u n g e r w o m e n feel less able to voice their heal th p rob lems , g iven the i r relat ively l o w e r status in the communi ty , than o lder w o m e n . 9 This has impl ica t ions for the i r hea l th - seek ing b e h a v i o u r and is a fac tor to bea r in mind w h e n des ign ing heal th serv ice delivery, as special efforts m a y be n e e d e d to reach out to this age g r o u p wi th any success.

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A n o t h e r i m p o r t a n t f i nd i ng is t h a t t he w o m e n do n o t s e e m to t ake as s e r ious ly c o n d i t i o n s t h a t t hey do n o t r e l a t e specif ical ly to c h i l d b e a r i n g a n d are m o r e w o r r i e d a b o u t c o n d i t i o n s t h a t t hey pe rce ive to h a v e a d i r ec t effect o n c h i l d b e a r i n g . I m p o r t a n t l y , a n d p e r h a p s th i s is b o t h cause a n d c o n s e q u e n c e , t hey a re m o r e likely to r ece ive t he s u p p o r t of t h e i r fami l ies a n d t h e c o m m u n i t y to seek m e d i c a l a t t e n t i o n fo r s u c h p r o b l e m s . 6

In con t r a s t , t h e w o m e n s e l d o m seek m ed i ca l he lp for p r o b l e m s s u c h as r e p r o d u c t i v e t r a c t in fec t ions o r u r i n a r y t r a c t in fec t ions , e v e n w h e n t h e s e o c c u r in p r e g n a n c y , b e c a u s e t hey do no t u n d e r s t a n d h o w or h o w m u c h t h e s e c o n d i t i o n s can affect t h e i r h e a l t h o r ferti l i ty. This i nc ludes ce r t a in g y n a e c o l o g i c a l c o n d i t i o n s fo r w h i c h t he w o m e n do n o t seek m e d i c a l ca re , s u c h as dis- cha rge , l o w e r a b d o m i n a l pa in , a n d pa in d u r i n g i n t e r cou r se . I ronical ly, if t h e y k n e w t h a t r e p r o - duc t ive t r a c t i n f ec t i ons c a n i n t e r f e r e w i t h con- cep t ion a n d in s o m e i n s t a n c e s c a u s e infert i l i ty, t hey w o u l d u n d o u b t e d l y be m o r e i nc l i ned to seek t r e a t m e n t fo r t h e m . As it is, t h e w o m e n e v e n n e g - lect s y m p t o m s s u c h as d i s c h a r g e p o s t - p a r t u m . Yet s u c h s y m p t o m s m a y b e i nd i ca t i ve o f s e r ious a n d l i f e - t h r e a t e n i n g cond i t i ons .

This i n f o r m a t i o n p o i n t s s t r o n g l y to t he n e e d for h e a l t h e d u c a t i o n p r o g r a m m e s a b o u t r isk f ac to r s a n d s y m p t o m s of p r e g n a n c y - r e l a t e d con- di t ions , so t h a t w o m e n seek a p p r o p r i a t e med ica l ca re i n s t e a d of a t t e m p t i n g to a l levia te s y m p t o m s t h r o u g h se l f -med ica t ion , w h i c h m a y be h a r m f u l to t h e m s e l v e s a n d t he p r e g n a n c y , r e s o r t i n g to ineffec t ive h o m e r e m e d i e s , o r even d o i n g n o t h i n g . A n o t h e r a r ea for h e a l t h educa t ion , d i r e c t e d b o t h at w o m e n a n d t h e c o m m u n i t y at large, is t h a t o f g y n a e c o l o g i c a l c o n d i t i o n s a n d the c a u s e s of infert i l i ty. This k n o w l e d g e w o u l d he lp w o m e n to ga in t he social s u p p o r t of t h e i r h u s b a n d s a n d o t h e r fami ly m e m b e r s to b e able to seek a n d s u s t a i n med i ca l ca re fo r a w i d e r r a n g e of cond i t i ons . 6

A s u b s t a n t i a l r e d u c t i o n in t h e h i g h toll of m a t e r n a l m o r b i d i t y in E g y p t calls for a com- p r e h e n s i v e r a n g e of r e p r o d u c t i v e h e a l t h se rv ices

for w o m e n . A n u m b e r of c o m p l a i n t s a s s o c i a t e d b y t h e w o m e n w i t h p r e g n a n c y w e r e a m a j o r cause for c o n c e r n a m o n g t h e m . Serv ice p ro - v ide r s also m a k e a s s u m p t i o n s a b o u t w h a t is ' no rma l " in p r e g n a n c y , a n d t e n d to " t reat ' t h e s e c o n d i t i o n s m e r e l y w i t h r e a s s u r a n c e . T h e s e com- p la in t s d e s e r v e g r e a t e r a t t en t ion , s ince t h e y can c o n t r i b u t e to s u s t a i n e d p e r i o d s of fee l ing unwel l a n d fo rce w o m e n to r e s t r i c t t h e i r act ivi t ies, s o m e t i m e s dras t ica l ly . T h e s e cond i t i ons , too, m a y b e s igns of u n d e r l y i n g c o n d i t i o n s like a n a e m i a b e c o m i n g w o r s e b e c a u s e o f p r e g n a n c y .

Thus , a n t e n a t a l c a r e n e e d s to b e t r a n s f o r m e d f r o m the m e r e s u p p l y of v i t a m i n s a n d i ron tab le ts , to ca re fu l h i s t o r y t ak ing , counse l l ing , s c r e e n i n g fo r ex i s t i ng r e p r o d u c t i v e a n d o t h e r h e a l t h p r o b l e m s , a n d a d e q u a t e l y d e a l i n g wi th these . The s a m e app l ies to p o s t - p a r t u m care. Finally, p o s t - p a r t u m d e p r e s s i o n s e e m s to be of c o n s i d e r a b l e s ign i f i cance to t he w o m e n , a n d su i t ab le h e a l t h s e rv i ces a re n e e d e d to a d d r e s s this .

The n e e d as f a r as o b s t e t r i c se rv ices a re c o n c e r n e d is fo r a vas t ly i m p r o v e d c o v e r a g e , so t h a t t he m a j o r i t y o f w o m e n h a v e t r a i n e d a t t e n d - a n c e at del ivery. H e r e aga in , b e c a u s e the w o m e n c o n s i d e r e p i s i o t o m y a n d any f o r m of in te r - v e n t i o n in n a t u r a l v a g i n a l b i r t h as u n d e s i r a b l e , a pol icy of m i n i m a l i n t e r v e n t i o n excep t in an e m e r g e n c y m a y he lp in m a k i n g i n s t i t u t i o n - b a s e d a n d med ica l ly a t t e n d e d de l iver ies m o r e accep t - able a n d even tua l ly popu la r .

Acknowledgements The authors thank Dr Abdel-Moneim Farag for his valuable comments on the various drafts of this paper, and Olfia Kamal for her contribution to the data analysis and supervision of data col- lection. Permission for the project was given by the Ministry o f Health and the Central Agency for Public Mobilization and Statistics in Egypt. Activi- ties o f the project are sponsored by grants from the Population Council, the Ford Foundation, the World Health Organization, UNICEF, and the Government o f the Netherlands.

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R e f e r e n c e s

1. The Giza Morbidity Study was conducted by an interdisciplinary team of researchers. Eligible women were ever-married, currently non-pregnant women residing in one of the two villages. The age distribution was similar to that of the last Egyptian population census for these two villages. A random sample of streets, alleys and housing blocks was selected. All households in the selected areas were visited sequentially and eligible women were invited to join. An initial sample size of 509 women was achieved. All these women were interviewed about their background characteristics and symptoms of gynaecological and related morbidity conditions. They also underwent a medical

examination, including laboratory testing, at the time of interview. The results of the medical examination were published in [5l below.

2. Zurayk H et al, 1993. Concepts and measures of reproductive morbidity. Health Transition Review. 3(1):17-40

3. PAPCHILD, 1993. Egypt Maternal and Child Health Survey 1991. Central Agency for Public Mobilization and Statistics, Cairo, and League of Arab States.

4. Egypt Demographic and Health Survey 1992. Cairo National Population Council and Macro International Inc, Calverton MD, USA.

5. Younis Net al, 1993. A community study of gynaecological and related

morbidities in rural Egypt. Studies in Family Planning. 24(3):175-86.

6. Khattab H, 1992. The Silent Endurance: Social Conditions of Women's Reproductive Health in Rural Egypt. UNICEF, Amman and Population Council, Cairo.

7. This probably consists of sitting in a tub containing a powder or antiseptic lotion to treat the discharge. Vaginal douching would be avoided in pregnancy for fear of miscarriage.

8. National Maternal Mortality Study, Egypt, 1992-93 Findings and Conclusions. Ministry of Health, Child Survival Project. Cairo, 1994.

9. Khattab H, 1978. Role and status of women and their fertility behaviour. (unpublished)

RESUMEN Este en sayo r e s u m e los p r o b l e m a s de salud exper inqen tados p o r m u j e r e s d u r a n t e su m~is r ec ien te embarazo , p a r t o y p o s t - p a r t o , de acue rdo a i n fo rmes p r o v i s t o s p o r elias. Esta i n fo rmac i6n indica un nivel de c o n o c i m i e n t o s f r e c u e n t e m e n t e bajo e n t r e las muje res , en lo r e f e r e n t e a l a s causas y el g r a d o de g r a v e d a d de

los p r o b l e m a s de sa tud m a t e r n a , el cual influye s o b r e su c o m p o r t a m i e n t o a la h o r a de b u s c a r as i s tenc ia de salud. M u c h a s de es tas mu je r e s no

a soc i aban c ie r tos s i n t o m a s con el e m b a r a z o s ino con la "normal idad ' , 1o cual hac la que p e r c i b i e r a n d ichos s i n t o m a s c o m o m e n o s g raves , incluso los

que i n d i c a b a n c o n d i c i o n e s p o t e n c i a l m e n t e graves . Esta i n f o r m a c i 6 n c o n t r i b u y e a expl icar p o r qu6 la mu je r no s i e m p r e b u s c a la ayuda a p r o p i a d a p a r a e n f e r m e d a d e s obs t6 t r icas , y enfat iza la n e c e s i d a d de c o n t a r con educac i6n y serv ic ios de sa lud a d e c u a d o s .

RI~SUMI~ Des f e m m e s r a c o n t e n t c o m m e n t se s o n t pass6es leur d e r n i b r e g r o s s e s s e et leurs de rn ib re s couches . R 6 s u m a n t leur exp6r ience , ce t art icle m o n t r e c o m b i e n les f e m m e s on t s o u v en t peu c o n s c i e n c e des causes et de la g rav i t6 , des p r o b l b m e s de sant6 materne l le , ce qui inf luence leur c o m p o r t e m e n t lorsqu ' i l s ' ag i t de d e m a n d e r

des so ins de sant6. Beau co u p de f e m m e s n ' a s s o c i e n t pas ce r ta ins s y m p t T m e s avec la g r o s s e s s e , mais p e n s e n t que ' c ' e s t no rma le ' , ce qui r e n d g leurs yeux ces s y m p t T m e s m o i n s

g raves , m 6 m e lorsqu ' i l s t r a d u i s e n t des 6tats p o t e n t i e l l e m e n t s6rieux. Cet te i n f o r m a t i o n c o n t r i b u e g exp l ique r p o u r q u o i les f e m m e s ne r e c h e r c h e n t pas tou jours une a s s i s t ance a p p r o p r i 6 e sur le p lan de la morb id i t6 g rav id ique , et sou l igne la n6cess i t6 d ' u n e 6duca t ion san i t a i re et de se rv ices de sant~ appropr i6s .

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