Giving women WOICE postpartum: Prevalence of maternal morbidity in high-risk pregnancies using the WHO-WOICE instrument

Giving women WOICE postpartum: Prevalence of maternal morbidity in high-risk pregnancies using the WHO-WOICE instrument | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Giving women WOICE postpartum: Prevalence of maternal morbidity in high-risk pregnancies using the WHO-WOICE instrument Martha Narvaez Lamus, Stephanie Lozano, Charles MPoca, Jose Paulo Guida, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-26017/v3 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 May, 2021 Read the published version in BMC Pregnancy and Childbirth → Version 3 posted 7 You are reading this latest preprint version Show more versions Abstract Background: There are no accurate estimates of the prevalence of non-severe maternal morbidities. Given the lack of instruments to fully assess these morbidities, the World Health Organization (WHO) developed an instrument called WOICE. Objective: To evaluate the prevalence of non-severe maternal morbidities in puerperal women and factors associated to impaired clinical, social and mental health conditions. Method: A cross-sectional study with postpartum women at a high-risk outpatient clinic in southeast Brazil, from November 2017 to December 2018. The WOICE questionnaire included three sections: the first with maternal and obstetric history, sociodemographic data, risk and environment factors, violence and sexual health; the second considers functionality and disability, general symptoms and mental health; and the third includes data on physical and laboratory tests. Data collection was supported by Tablets with REDCAP software. Initially, a descriptive analysis was performed, with general prevalence of all variables contained in the WOICE, including scales on anxiety and depression (GAD-7 and PHQ-9- impaired if ≥10), functionality (WHODAS- high disability scores when ≥37.4) and data on violence and substance use. Subsequently, an evaluation of cases with positive findings was performed, with a Poisson regression to investigate factors associated to impaired non-clinical and clinical conditions. Results: 517 women were included, majority (54.3%) multiparous, between 20 and 34 years (65.4%) and with a partner (75,6%). Over a quarter had (26.2%) preterm birth. Around a third (30.2%) reported health problems informed by the physician, although more than 80% considered having good or very good health. About 10% reported any substance use and 5.9% reported exposure to violence. Anxiety was identified in 19.8% of cases, depression in 36.9% and impaired functioning in 4.4% of women. Poisson regression identified that poor overall health rating was associated to increased anxiety/depression and impaired functioning. Having a partner reduced perception of women on the presence of clinical morbidities. Conclusion: During postpartum care of a high-risk population, over one third of the considered women presented anxiety and depression; 10% reported substance use and around 6% exposure to violence. These aspects of women´s health need further evaluation and specific interventions to improve quality of care. Maternal & Fetal Medicine Maternal Morbidity mental health functionality depression puerperium WHODAS 2.0 PHQ-9 GAD-7. Figures Figure 1 Background To ensure a healthy life and promote well-being for all is among the new objectives of the Sustainable Development Goals for 2030, including the improvement of maternal health and reduction of maternal mortality (1). It has been suggested that, for each maternal death, 20-30 women suffer from some morbidity; however, these numbers are not based on standardized methods of assessment (2, 3). In the last decade, there has been important progress in the study of severe maternal morbidity (SMM), with standard criteria for the identification of potentially life-threatening conditions (PLTC) and Maternal Near Miss (MNM) (4). Nevertheless, there is growing interest in understanding morbidity in a broader way, including non-severe morbidity. Non-severe morbidity are conditions that may influence and affect women's health and well-being; they include impairment of women's physical, sexual or mental health, and the ability to function in certain domains (cognition, mobility, participation in society), and also the image of their body and their economic and social status (5). Most of these are not routinely evaluated in the clinical setting with potentially significant impact in women´s life. In 2012, the World Health Organization (WHO) Maternal Morbidity Working Group (MMWG) initially developed a new definition of maternal morbidity as "Any health condition attributed to the complication of pregnancy and / or childbirth that may have a negative impact on the well-being and / or functionality of women" (1, 5). The relevance of such definition is the innovation in capturing broadly the entire spectrum of morbidity, not excluding the well-known severe maternal morbidity conditions, but also including the non-severe morbidity as well (3). The MMWG further developed an instrument called WOICE, to measure maternal morbidity, focusing on the health and well-being perception that women have about themselves (1, 6, 7). The main purpose of this instrument is to identify women suffering of non-severe maternal morbidities, allowing professionals to give adequate care to those conditions, which may not be clearly identified during routine care. This instrument also standardizes the measurement of non-severe maternal morbidities, by using a common framework, allowing different settings and regions to share data and provide strong evidences during pregnancy and the postpartum period. WOICE comprises tools already developed and validated in the literature, and the results of the pilot study have already been published (6, 8). The pilot study using WOICE occurred in three different countries: Jamaica, Kenya and Malawi, between 2015 and 2016 (6) in pregnant women (around 28 weeks) and puerperium (between 6 and 12 weeks), mostly in centers with medical care for low risk pregnancies including a total sample of 1490 female participants (750 pregnant and 740 postpartum) (9). It highlighted the high occurrence of non-severe morbidity in those countries, a condition not correctly identified in other studies that focused only severe maternal morbidity. WOICE instrument is intended to give voice to neglected conditions in routine care. Lack of knowledge about such conditions lead to inadequate care of these women and contributes to possible short and long- term consequences. Those women who are neglected in the puerperium, return to their homes, with unidentified needs, thus impacting life with their family, newborn and spouse (10). WOICE represents a new approach towards measuring non-severe maternal morbidity, allowing health professionals to have a broader understanding of women beyond clinical diseases (10, 11). The objective of the present study is to evaluate the prevalence of non-severe maternal morbidity among puerperal women and analyze factors associated with impaired clinical, social and mental health conditions in a middle – income setting using WOICE. Methods This cross-sectional study used a questionnaire (which includes several instruments) developed by the WHO to assess maternal morbidity in its various aspects. The questionnaire was applied at the postpartum outpatient clinic of the University of Campinas, a public university hospital, in a single encounter with women from 6 to 12 weeks postpartum (scheduled for medical care and follow-up as routine care). This public health outpatient clinic is a referral center for women who delivered at the maternity hospital and cases scheduled include high-risk women, due to a clinical underlying condition or any complication diagnosed during pregnancy or childbirth. The maternity hospital is a referral center for women with conditions such as hypertension, diabetes, preterm labor and preterm rupture of membranes. Overall patients are from low-income background. WOICE includes several tools that have already been previously translated and adapted to Portuguese. It includes the 12-item version of the World Health Organization's Disability Assessment Schedule (WHODAS 2.0). This tool evaluates the functionality and ability to perform daily tasks (12-14). WOICE also includes a tool that evaluates mental health, the General Anxiety Disorder 7-item test (GAD-7), and the 9-item Patient Health Questionnaire (PHQ-9), to assess depression, both already adapted to Portuguese (15, 16). To measure substance use and abuse, WOICE includes Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) (17). For sexual satisfaction and sexual and domestic violence, parts of some scores already validated are within the WOICE, such as the Brief Sexual Symptom Checklist for Women (BSSC-W) and some questions from a questionnaire used in the Multi-country Study on Women’s Health and Domestic Violence against Women of the WHO (18, 19). Only those last two tools were not previously validated into Portuguese versions, however they contributed with only 5 questions on a total of 126. Finally, WOICE gathers data on woman’s background, current clinical symptoms and physical examination. The name of the tool precisely refers to the importance of not only consulting a woman during pregnancy and postpartum, but also of “listening” to her voice, complaints and needs. The proposal was approved by the local Institutional Review Board. All women with age higher than 18 years that agreed to participate signed an Informed Consent form before interview. For adolescents (age bellow 18 years at the time of the interview), written consent and parental consent were both waived, due the consideration that a written consent and a parental consent could put the subject at risk, since violence is one of the conditions evaluated by the study, and it is well known that in cases of domestic violence, the perpetrator is often responsible or very close to the adolescent. However, interviews were conducted only after clarification and verbal consent, in a reserved room. The local Institutional Review Board of approved this procedure. The maternal morbidity measurement questionnaire called WOICE was originally developed in English and further translated into the Brazilian Portuguese. The review was conducted by experienced obstetric investigators and the version was tested (pilot interviews) to measure the time of application and then adapt and modify some words to ascertain accurate understanding. In order to ensure the high quality and reliability of the information collected, the researchers were previously trained to ensure adequate use of the tablets and instruments included in the WOICE questionnaire. Women were recruited sequentially according to their scheduled postpartum visit, during the data collection period (from November 2017 to December 2018). The postpartum outpatient clinic works every week day, a mean of 6 new cases/day, and they are scheduled according to availability. All women were invited and those who agreed to participate were interviewed. Sample size was estimated in 500 participants for convenience sample, as a pilot study, taking into account that the WOICE instrument had not been previously published by the time when data collection was initiated. The only previous study using such instrument presented 250 women during postpartum care (PPC) for each considered country (9). Data collection was supported by tablets (Samsung Galaxy Tab Tablets S3 – Android), with further transmission, verification and storage of data protected to ensure confidentiality. Each interview was around 30-40 minutes. The questionnaire was always performed after the scheduled medical consultation and with no interference in the woman’s medical follow-up. Since some of the questions could potentially lead to unpleasant memories and reveal exposure to violence and substance abuse, additional support was always offered. Data processing and collection were supported by REDCAP software and later transferred to the SPSS program. The information gathered was stored in a server located in the informatic department of the institution. A descriptive analysis was performed, including socio-demographic data, clinical and obstetric history, as well as the general prevalence of scores of instruments considered for functional and mental health. Continuous variables were presented on mean (M) and Standard Deviation (SD) and categorical variables in percentage (%) of frequency. An evaluation of abnormal conditions was performed, considering scores ≥10 for anxiety and depression (20). For WHODAS-12, according to a previous study published, dysfunctionality was considered with the score of ≥ 37.4 (95 th percentile as the cutoff point) (12). Missing data was described in tables. Further, a Poisson multiple regression analysis was performed, providing the respective Prevalence Ratio (PR) and 95% confidence intervals (CI), considering three models for evaluating factors associated with impaired conditions. Predictors were chosen considering those with a p-value lower that 0.05 and excluding variables that are highly correlated (we included education level and not illiteracy). The first model considered as outcome abnormal mental health (score ≥ 10 for anxiety and depression questionnaire), the second model considered abnormal functioning. The predictors tested were: maternal age, marital status, education, , employed, travel time to facility, parity, gestational age, BMI (≥30 kg/m2), overall health rating, any clinical condition, preexisting conditions, taking any medication. The third model of logistic regression considered impaired clinical condition (women who answered “yes” to the question: “have you been told you have anything wrong or any medical condition?”) as outcome. The tested predictors were the same used in the previous models, also in addition to impaired mental health, abnormal functioning, substance use, sexual satisfaction and violence. In order to understand if the same women were at risk of combined morbidities in clinical, social, sexual and mental health (all conditions included in the WOICE instrument), we performed also a descriptive analysis of impaired conditions and its combinations two by two. This analysis intended to present if there was significant overlap of diagnosis within the instruments considered. For this analysis, we considered the seven domains evaluated by the WOICE instrument (sexual health, anxiety, depression, functioning, use of substances, violence and clinical conditions). Impaired sexual health was defined as a negative response to sexual satisfaction; substance abuse was considered when a woman declared that used any substance after childbirth; violence was defined if woman reported any physical of psychological violence after childbirth. Reporting of any clinical condition after childbirth demanding medical assistance was considered as an impairment of clinical health. For the anxiety and depression instruments, a score higher than 10 was considered positive for any of those conditions, while a WHODAS score ≥ 37.4 defined an impaired functioning. Results In the present study, 519 postpartum women were invited to participate, 2 declined and the 2 women provided only sociodemographic data, therefore 515 gave full consent (Fig 1) . The mean age was 28 years, women mostly had a partner, more than 50% were multiparous, the illiteracy level was less than 2.4% and most participants had a secondary level of education and were employed. Over one third of the population took 30-60 minutes to arrive from their house to the health service (Table 1). Clinical conditions were initially considered through the question: "Since childbirth, have you been informed that there is something wrong / some medical condition?" and 30.2% of the women had a health condition reported by the attending physician, although more than 80% reported good or very good health. Considering the gestational results, a quarter (26.2%) had preterm birth, and 58.3% delivered by cesarean section; however, predominantly with good perinatal outcomes, 95.7% reported “good baby health” in the postpartum evaluation, with 88.1% of exclusive breastfeeding (Table 2). Looking into detail in cases of clinical conditions, based on the question: "any pre-existing condition", the majority (51.7%) reported having a condition before pregnancy and childbirth (Table 2) . A list of conditions, classified them as direct and indirect, of which 13.8% had gestational diabetes, followed by gestational hypertension (13.4%), preeclampsia (10.7%), chronic hypertension (8.2%) and, operative wound infection (1.7%), as the most prevalent types of diseases (Table 2). An important approach, besides evaluating pre-existing conditions, was to evaluate the amount of abnormal conditions diagnosed or identified by WOICE. We found that (53.1%) had at least one abnormal condition identified by WOICE, a quarter of women (26%) had two concomitant conditions identified by WOICE and only 4.0% had no abnormal condition (Table 2). We identified, through the WOICE questionnaire in this group of women, the use of substances, asking participants whether they used (cigarettes, alcoholic beverages, marijuana, inhalants, sedatives or sleeping pills, hallucinogens, opioids and/or injectable drugs for non-medical use) and 10.0% of the participants used some type of substance during pregnancy (Table 3). In this group of questions, we also asked "during pregnancy, someone (friend, relative or anyone) expressed concern about the use of any substance" and 66.7% expressed such concern, followed by 50% of women that "tried to reduce or stop consumption of any substance ". Around 1/3 of women had already resumed their sex life after giving birth and 89.2% felt they were satisfied with their sex lives, however 55.6% (n=10) reported pain during intercourse (Table 3). Around 39% of the women used contraception and 77.2% of them were prescribed with a method during their first postpartum care medical visit. Using the WOICE tool, tool, we explored exposure to domestic and sexual violence by asking participants "whether or not they were afraid of the current partner / most recent spouse or any other person" if the spouse / or any other person who pushed, hit and kicked”. In our sample, 5.9% reported to have suffered violence (Table 3). As part of the Mental Health assessment of our study, we used the validated scales (PHQ-9 and GAD-7). Abnormal conditions were considered if scores ≥ 10 (20, 21) and almost 20% of the women had anxiety symptoms, followed by 36.9% with depressive symptoms. For the evaluation of functionality or ability to perform daily tasks, used WHODAS-12 version 2.0 and verified that the mean score was 10.9 (±12.9), we found 4.4% of the women had high disability scores (score≥37.4) (12). (Table 4). Among the included women, 28.3% used such support, of those 97% psychological support and 6.6% social service support (Table 5). In order to investigate factors independently associated with impaired functioning, mental health and clinical conditions, we performed three multiple regression analyzes. For the first model, that considered WHODAS≥37.4 as the outcome, the condition independently associated with abnormal functioning was the presence of impaired clinical health. Nevertheless, less education and having a partner were protective conditions towards the report of impaired functioning (table 6). In model 2, considering as outcome abnormal anxiety and depression (scores ≥10), poor overall health rating was associated with increased anxiety/depression. However, increased parity was protective. In model 3, the clinical conditions reported by the woman (defined when the woman reported having been informed of a clinical diagnosis after delivery) were considered as outcomes and we identified that the variable evaluated in the questionnaire about violence, as: "whether or not they were afraid of the current partner / most recent spouse or any other person", was positively associated to the perception of impaired clinical condition (Table 6) . To understand if the same women suffer from combined conditions, or if there was a pattern in the combination of abnormal findings, we presented a figure that evaluates each parameter and its combinations. Almost a quarter of the participants included in this analysis presented depression and anxiety (38.6%), followed by clinical conditions associated to depression (14.6%), anxiety with clinical conditions (13.3%) (Table 7). The denominators for each of the presented variables varied, according to the number of missing information. There was a large number of “missing” for the variables depression and sexual satisfaction; for sexual satisfaction, the reason was that women who declared no sexual activity after childbirth were not further asked about satisfaction. For “missing” on the depression variable, the depression instrument was only applied if women answered that they were “feeling depressed or hopeless” in the first question. Discussion 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 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 perpetrators, who are people of their 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. In Brazil, physical, sexual and psychological violence against women are gaining awareness with increase in legal protections and enhanced tools for reporting agressors. Data suggest that it has always been a major hidden problem in the country. From 2011 to 2017, almost half a million cases of intimate partner violence against women were registered in a national database of surveillance. Among pregnant women, data is scarce, and a recent study obtained similar rates of physical and sexual violence as ours (12.1% and 2.8%). We believe that violence against women is underreported and an adequate surveillance is mandatory to understand the dimension of the problem and to propose national policies to guarantee the needed support. 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 (29), 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 no morbidities. 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. Poisson regression presented that having a partner decreased the women's perception of clinical morbidities and functionality impairment; that might just reflect more care and support. Primary education (or less) was a protective condition towards functionality impairment evaluated by WHODAS. The underlying explanation for such finding is not clear yet and needs further studies, however, could represent the decreased ability to report or even less awareness towards the evaluated conditions in the WHODAS instrument. 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 (30) 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 (31, 32). 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. The study was performed in a referral center for high risk pregnancies. Women with underlying medical conditions, are frequently under increased clinical surveillance during pregnancy and postpartum and motivated to adhere to treatment because of fetal health. Therefore, many times they feel they are in “good health” and we hypothesize that such answer is a consequence of adequate healthcare. An 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 (PPC) 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). A relevant limitation is that the WOICE has not been translated and validated into different languages, as Portuguese, and it may difficult comparisons with data obtained using the 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. Conclusions The WOICE-WHO instrument allows for an overall evaluation of maternal morbidity. During postpartum care, women presented high frequency of anxiety and depression and relevant frequency of substance use and violence. These aspects of women ́s health need further evaluation and specific interventions to improve quality of care. Abbreviations ANC Antenatal Care ASSIST Alcohol, Smoking and Substance Involvement Screening Test BSSC-W Brief Sexual Symptom Checklist for Women GAD-7 General Anxiety Disorder 7 MNM Maternal Near Miss MMWG Working Group Maternal Morbidity PHQ-9 Patient Health Questionnaire 9 PLTC Potentially Life- Threatening Conditions PPC Postpartum Care PR Prevalence Ratio REDCAP Research Electronic Data Capture SD Standard Desviation SMM Severe Maternal Morbidity SPSS Statistical Package for the Social Sciences WHO World Health Organization WHODAS World Health Organization Disability Assessment Schedule 2.0 Declarations Ethics approval and consent to participate Data collection started only after approval of the research protocol by the local Research Ethics Committee of the Medical Science School of the University of Campinas. Written consent to participate was obtained for all women with age higher than 18 years; written consent and parental consent was waived for women with age bellow than 18 years, however verbal consent was obtained for this group before interview. The Research Ethics Committee of the Medical Science School of the University of Campinas approved this approach to adolescents, and considered that this group could be at risk, since violence is one of the conditions evaluated by the study and it is well known that in cases of domestic violence, the perpetrator is often responsible or very close to the adolescents. Because of this condition, the Research Ethics Committee waived written consent and parental consent specifically for this group. The study was approved by the Research Ethics Committee of the Medical Science School of the University of Campinas, under the number of approval 78497817.0.0000.5404 and opinion number 2.386.001. Consent for publication Not applicable Competing interests The corresponding author, Maria Laura Costa is an Associate Editor of this journal. None of the other authors have any competing interests. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Funding No specific funding for this study. Authors' contributions CML, CJG and PMA had the initial idea for the sutudy. LMN, LS, CMC and GJP were responsible for data collection. GJP, LMN, CJG and CML were responsible for planning the analysis and interpretation of data. LMN and CML wrote the first draft of the paper. VMF,LS, CD helped in the interpretation of the analysis. All authors read and approved the final manuscript. Acknowledgements “Not applicable” in this section. References Chou D, Tuncalp O, Firoz T, Barreix M, Filippi V, von Dadelszen P, et al. 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A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092-7. Ramires de Jesus G, Ramires de Jesus N, Peixoto-Filho FM, Lobato G. Caesarean rates in Brazil: what is involved? Bjog. 2015;122(5):606-9. Nakamura-Pereira M, do Carmo Leal M, Esteves-Pereira AP, Domingues RM, Torres JA, Dias MA, et al. Use of Robson classification to assess cesarean section rate in Brazil: the role of source of payment for childbirth. Reprod Health. 2016;13(Suppl 3):128. Leal MD, Esteves-Pereira AP, Nakamura-Pereira M, Torres JA, Theme-Filha M, Domingues RM, et al. Prevalence and risk factors related to preterm birth in Brazil. Reprod Health. 2016;13(Suppl 3):127. Garcia-Moreno C, Jansen HA, Ellsberg M, Heise L, Watts CH. Prevalence of intimate partner violence: findings from the WHO multi-country study on women's health and domestic violence. Lancet. 2006;368(9543):1260-9. WHO | Violence against women. WHO. 2016. Mascarenhas MDM, Tomaz GR, Meneses GMS, Rodrigues MTP, Pereira VOM, Corassa RB. Analysis of notifications of intimate partner violence against women, Brazil, 2011-2017. Rev Bras Epidemiol. 2020;23 Suppl 1:e200007.SUPL.1. Ribeiro MRC, Batista RFL, Schraiber LB, Pinheiro FS, Santos AMD, Simões VMF, et al. Recurrent Violence, Violence with Complications, and Intimate Partner Violence Against Pregnant Women and Breastfeeding Duration. J Womens Health (Larchmt). 2020. Lamounier JA. [Breastfeeding in preterm infants: public health policy in primary care]. Rev Paul Pediatr. 2016;34(2):137-8. Firoz T, McCaw-Binns A, Filippi V, Magee LA, Costa ML, Cecatti JG, et al. A framework for healthcare interventions to address maternal morbidity. Int J Gynaecol Obstet. 2018;141 Suppl 1:61-8. Giordano JC, Parpinelli MA, Cecatti JG, Haddad SM, Costa ML, Surita FG, et al. The burden of eclampsia: results from a multicenter study on surveillance of severe maternal morbidity in Brazil. PLoS One. 2014;9(5):e97401. Zanette E, Parpinelli MA, Surita FG, Costa ML, Haddad SM, Sousa MH, et al. Maternal near miss and death among women with severe hypertensive disorders: a Brazilian multicenter surveillance study. Reprod Health. 2014;11(1):4. Tables Due to technical limitations, full-text HTML conversion of the Tables could not be completed. However, the tables can be downloaded and accessed in the Supplementary Files. Supplementary Files STROBEchecklistcrosssectional.doc Table1.docx Table2.docx Table3.docx Table4.docx Table5.docx Table6R3.docx Table7R3.docx Cite Share Download PDF Status: Published Journal Publication published 05 May, 2021 Read the published version in BMC Pregnancy and Childbirth → Version 3 posted Editorial decision: Minor revision 31 Jan, 2021 Review # 1 received at journal 17 Jan, 2021 Reviewer # 1 agreed at journal 16 Jan, 2021 Reviewers invited by journal 12 Jan, 2021 Editor assigned by journal 06 Jan, 2021 Submission checks completed at journal 06 Jan, 2021 Editor invited by journal 06 Jan, 2021 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-26017","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":7821519,"identity":"be702dd1-6c1b-4453-8bbf-234c22ced7ba","order_by":0,"name":"Martha Narvaez Lamus","email":"","orcid":"","institution":"Fundacion Valle del Lili","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Martha","middleName":"Narvaez","lastName":"Lamus","suffix":""},{"id":7821520,"identity":"05968a48-c030-4ea5-8cb9-f1e7dbc2e215","order_by":1,"name":"Stephanie Lozano","email":"","orcid":"","institution":"Fundacion Valle del 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17:42:21","extension":"docx","order_by":8,"title":"","display":"","copyAsset":false,"role":"supplement","size":16399,"visible":true,"origin":"","legend":"","description":"","filename":"Table7R3.docx","url":"https://assets-eu.researchsquare.com/files/rs-26017/v3/3f02be03fd054cd9d49df8ca.docx"}],"financialInterests":"","formattedTitle":"Giving women WOICE postpartum: Prevalence of maternal morbidity in high-risk pregnancies using the WHO-WOICE instrument","fulltext":[{"header":"Background","content":"\u003cp\u003eTo ensure a healthy life and promote well-being for all is among the new objectives of the Sustainable Development Goals for 2030, including the improvement of maternal health and reduction of maternal mortality\u0026nbsp;(1). It has been suggested that, for each maternal death, 20-30 women suffer from some morbidity; however, these numbers are not based on standardized methods of assessment\u0026nbsp;(2, 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the last decade, there has been important progress in the study of severe maternal morbidity (SMM), with standard criteria for the identification of potentially life-threatening conditions (PLTC) and Maternal Near Miss (MNM)\u0026nbsp;(4). \u0026nbsp;Nevertheless, there is growing interest in understanding morbidity in a broader way, including non-severe morbidity. Non-severe morbidity are conditions that may influence and affect women\u0026apos;s health and well-being; they include impairment of women\u0026apos;s physical, sexual or mental health, and the ability to function in certain domains (cognition, mobility, participation in society), and also the image of their body and their economic and social status\u0026nbsp;(5). Most of these are not routinely evaluated in the clinical setting with potentially significant impact in women\u0026acute;s life.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn 2012, the World Health Organization (WHO) Maternal Morbidity Working Group (MMWG) initially developed a new definition of maternal morbidity as \u0026quot;Any health condition attributed to the complication of pregnancy and / or childbirth that may have a negative impact on the well-being and / or functionality of women\u0026quot;\u0026nbsp;(1, 5). The relevance of such definition is the innovation in capturing broadly the entire spectrum of morbidity, not excluding the well-known severe maternal morbidity conditions, but also including the non-severe morbidity as well\u0026nbsp;(3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe MMWG further developed an instrument called WOICE, to measure maternal morbidity, focusing on the health and well-being perception that women have about themselves\u0026nbsp;(1, 6, 7). The main purpose of this instrument is to identify women suffering of non-severe maternal morbidities, allowing professionals to give adequate care to those conditions, which may not be clearly identified during routine care. This instrument also standardizes the measurement of non-severe maternal morbidities, by using a common framework, allowing different settings and regions to share data and provide strong evidences during pregnancy and the postpartum period.\u003c/p\u003e\n\u003cp\u003eWOICE comprises tools already developed and validated in the literature, and the results of the pilot study have already been published\u0026nbsp;(6, 8). The pilot study using WOICE occurred in three different countries: Jamaica, Kenya and Malawi, between 2015 and 2016\u0026nbsp;(6)\u0026nbsp;in pregnant women (around 28 weeks) and puerperium (between 6 and 12 weeks), mostly in centers with medical care for low risk pregnancies including a total sample of 1490 female participants (750 pregnant and 740 postpartum)\u0026nbsp;(9). It highlighted the high occurrence of non-severe morbidity in those countries, a condition not correctly identified in other studies that focused only severe maternal morbidity.\u003c/p\u003e\n\u003cp\u003eWOICE instrument is intended to give voice to neglected conditions in routine care. Lack of knowledge about such conditions lead to inadequate care of these women and contributes to possible short and long- term consequences. Those women who are neglected in the puerperium, return to their homes, with unidentified needs, thus impacting life with their family, newborn and spouse\u0026nbsp;(10).\u003c/p\u003e\n\u003cp\u003eWOICE represents a new approach towards measuring non-severe maternal morbidity, allowing health professionals to have a broader understanding of women beyond clinical diseases\u0026nbsp;(10, 11).\u003c/p\u003e\n\u003cp\u003eThe objective of the present study is to evaluate the prevalence of non-severe maternal morbidity among puerperal women and analyze factors associated with impaired clinical, social and mental health conditions in a middle \u0026ndash; income setting using WOICE.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis cross-sectional study used a questionnaire (which includes several instruments) developed by the WHO to assess maternal morbidity in its various aspects. The questionnaire was applied at the postpartum outpatient clinic of the University of Campinas, a public university hospital, in a single encounter with women from 6 to 12 weeks postpartum (scheduled for medical care and follow-up as routine care). This public health outpatient clinic is a referral center for women who delivered at the maternity hospital and cases scheduled include high-risk women, due to a clinical underlying condition or any complication diagnosed during pregnancy or childbirth. The maternity hospital is a referral center for women with conditions such as hypertension, diabetes, preterm labor and preterm rupture of membranes. Overall patients are from low-income background.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWOICE includes several tools that have already been previously translated and adapted to Portuguese. It includes the 12-item version of the World Health Organization\u0026apos;s Disability Assessment Schedule (WHODAS 2.0). This tool evaluates the functionality and ability to perform daily tasks\u0026nbsp;(12-14).\u003c/p\u003e\n\u003cp\u003eWOICE also includes a tool that evaluates mental health, the General Anxiety Disorder 7-item test (GAD-7), and the 9-item Patient Health Questionnaire (PHQ-9), to assess depression, both already adapted to Portuguese\u0026nbsp;(15, 16).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo measure substance use and abuse, WOICE includes Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)\u0026nbsp;(17). For sexual satisfaction \u0026nbsp;and sexual and domestic violence, parts of some scores already validated are within the WOICE, \u0026nbsp;such as the Brief Sexual Symptom Checklist for Women (BSSC-W) \u0026nbsp;and some questions from \u0026nbsp;a questionnaire \u0026nbsp;used in the \u0026nbsp; Multi-country Study on Women\u0026rsquo;s Health and Domestic Violence against Women of the WHO\u0026nbsp;(18, 19). Only those last two tools were not previously validated into Portuguese versions, however they contributed with only 5 questions on a total of 126.\u003c/p\u003e\n\u003cp\u003eFinally, WOICE gathers data on woman\u0026rsquo;s background, current clinical symptoms and physical examination. The name of the tool precisely refers to the importance of not only consulting a woman during pregnancy and postpartum, but also of \u0026ldquo;listening\u0026rdquo; to her voice, complaints and needs.\u003c/p\u003e\n\u003cp\u003eThe proposal was approved by the local Institutional Review Board. All women with age higher than 18 years that agreed to participate signed an Informed Consent form before interview. For adolescents (age bellow 18 years at the time of the interview), written consent and parental consent were both waived, due the consideration that a written consent and a parental consent could put the subject at risk, since violence is one of the conditions evaluated by the study, and it is well known that in cases of domestic violence, the perpetrator is often responsible or very close to the adolescent. However, interviews were conducted only after clarification and verbal consent, in a reserved room. The local Institutional Review Board of approved this procedure.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe maternal morbidity measurement questionnaire called WOICE was originally developed in English and further translated into the Brazilian Portuguese. The review was conducted by experienced obstetric investigators and the version was tested (pilot interviews) to measure the time of application and then adapt and modify some words to ascertain accurate understanding. In order to ensure the high quality and reliability of the information collected, the researchers were previously trained to ensure adequate use of the tablets and instruments included in the WOICE questionnaire.\u003c/p\u003e\n\u003cp\u003eWomen were recruited sequentially according to their scheduled postpartum visit, during the data collection period (from November 2017 to December 2018). The postpartum outpatient clinic works every week day, a mean of 6 new cases/day, and they are scheduled according to availability. All women were invited and those who agreed to participate were interviewed.\u0026nbsp;Sample size was estimated in 500 participants for convenience sample, as a pilot study, taking into account that the WOICE instrument had not been previously published by the time when data collection was initiated. The only previous study using such instrument presented 250 women during postpartum care (PPC) for each considered country\u0026nbsp;(9).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData collection was supported by tablets (Samsung Galaxy Tab Tablets S3 \u0026ndash; Android), with further transmission, verification and storage of data protected to ensure confidentiality. Each interview was around 30-40 minutes. The questionnaire was always performed after the scheduled medical consultation and with no interference in the woman\u0026rsquo;s medical follow-up. Since some of the questions could potentially lead to unpleasant memories and reveal exposure to violence and substance abuse, additional support was always offered.\u003c/p\u003e\n\u003cp\u003eData processing and collection were supported by REDCAP software and later transferred to the SPSS program. The information gathered was stored in a server located in the informatic department of the institution. A descriptive analysis was performed, including socio-demographic data, clinical and obstetric history, as well as the general prevalence of scores of instruments considered for functional and mental health. Continuous variables were presented on mean (M) and Standard Deviation (SD) and categorical variables in percentage (%) of frequency. An evaluation of abnormal conditions was performed, considering scores \u0026ge;10 for anxiety and depression\u0026nbsp;(20). For WHODAS-12, according to a previous study published, dysfunctionality was considered with the score of \u0026ge; 37.4 (95\u003csup\u003eth\u003c/sup\u003e percentile as the cutoff point)\u0026nbsp;(12). Missing data was described in tables.\u003c/p\u003e\n\u003cp\u003eFurther, a Poisson multiple regression analysis was performed, providing the respective Prevalence Ratio (PR) and 95% confidence intervals (CI), considering three models for evaluating factors associated with impaired conditions. Predictors were chosen considering those with a p-value lower that 0.05 and excluding variables that are highly correlated (we included education level and not illiteracy). The first model considered as outcome abnormal mental health (score \u0026ge; 10 for anxiety and depression questionnaire), the second model considered abnormal functioning. The predictors tested were: maternal age, marital status, education, , employed, travel time to facility, parity, gestational age, BMI (\u0026ge;30 kg/m2), overall health rating, any clinical condition, preexisting conditions, taking any medication. The third model of logistic regression considered impaired clinical condition (women who answered \u0026ldquo;yes\u0026rdquo; to the question: \u0026ldquo;have you been told you have anything wrong or any medical condition?\u0026rdquo;) as outcome. The tested predictors were the same used in the previous models, also in addition to impaired mental health, abnormal functioning, substance use, sexual satisfaction and violence.\u003c/p\u003e\n\u003cp\u003eIn order to understand if the same women were at risk of combined morbidities in clinical, social, sexual and mental health (all conditions included in the WOICE instrument), we performed also a descriptive analysis of impaired conditions and its combinations two by two. This analysis intended to present if there was significant overlap of diagnosis within the instruments considered.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor this analysis, we considered the seven domains evaluated by the WOICE instrument (sexual health, anxiety, depression, functioning, use of substances, violence and clinical conditions). Impaired sexual health was defined as a negative response to sexual satisfaction; substance abuse was considered when a woman declared that used any substance after childbirth; violence was defined if woman reported any physical of psychological violence after childbirth. Reporting of any clinical condition after childbirth demanding medical assistance was considered as an impairment of clinical health. For the anxiety and depression instruments, a score higher than 10 was considered positive for any of those conditions, while a WHODAS score \u0026ge; 37.4 defined an impaired functioning.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn the present study, 519 postpartum women were invited to participate, 2 declined and the 2 women provided only sociodemographic data, therefore 515 gave full consent \u003cstrong\u003e(Fig 1)\u003c/strong\u003e. The mean age was 28 years, women mostly had a partner, more than 50% were multiparous, the illiteracy level was less than 2.4% and most participants had a secondary level of education and were employed. Over one third of the population took 30-60 minutes to arrive from their house to the health service \u003cstrong\u003e(Table 1).\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eClinical conditions were initially considered through the question: \u0026quot;Since childbirth, have you been informed that there is something wrong / some medical condition?\u0026quot; and 30.2% of the women had a health condition reported by the attending physician, although more than 80% reported good or very good health. Considering the gestational results, a quarter (26.2%) had preterm birth, and 58.3% delivered by cesarean section; however, predominantly with good perinatal outcomes, 95.7% reported \u0026ldquo;good baby health\u0026rdquo; in the postpartum evaluation, with 88.1% of exclusive breastfeeding \u003cstrong\u003e(Table 2).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLooking into detail in cases of clinical conditions, based on the question: \u0026quot;any pre-existing condition\u0026quot;, the majority (51.7%) reported having a condition before pregnancy and childbirth\u003cstrong\u003e\u0026nbsp;(Table 2)\u003c/strong\u003e. A list of conditions, classified them as direct and indirect, of which 13.8% had gestational diabetes, followed by gestational hypertension (13.4%), preeclampsia (10.7%), chronic hypertension (8.2%) and, operative wound infection (1.7%), as the most prevalent types of diseases \u003cstrong\u003e(Table 2).\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn important approach, besides evaluating pre-existing conditions, was to evaluate the amount of abnormal conditions diagnosed or identified by WOICE. We found that (53.1%) had at least one abnormal condition identified by WOICE, a quarter of women (26%) had two concomitant conditions identified by WOICE and only 4.0% had no abnormal condition \u003cstrong\u003e(Table 2).\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe identified, through the WOICE questionnaire in this group of women, the use of substances, asking participants whether they used (cigarettes, alcoholic beverages, marijuana, inhalants, sedatives or sleeping pills, hallucinogens, opioids and/or injectable drugs for non-medical use) and 10.0% of the participants used some type of substance during pregnancy \u003cstrong\u003e(Table 3).\u0026nbsp;\u003c/strong\u003eIn this group of questions, we also asked \u0026quot;during pregnancy, someone (friend, relative or anyone) expressed concern about the use of any substance\u0026quot; and 66.7% expressed such concern, followed by 50% of women that \u0026quot;tried to reduce or stop consumption of any substance \u0026quot;.\u003c/p\u003e\n\u003cp\u003eAround 1/3 of women had already resumed their sex life after giving birth and 89.2% felt they were satisfied with their sex lives, however 55.6% (n=10) reported pain during intercourse \u003cstrong\u003e(Table 3).\u003c/strong\u003e Around 39% of the women used contraception and 77.2% of them were prescribed with a method during their first postpartum care medical visit.\u003c/p\u003e\n\u003cp\u003eUsing the WOICE tool, tool, we explored exposure to domestic and sexual violence by asking participants \u0026quot;whether or not they were afraid of the current partner / most recent spouse or any other person\u0026quot; if the spouse / or any other person who pushed, hit and kicked\u0026rdquo;. In our sample, 5.9% reported to have suffered violence \u003cstrong\u003e(Table 3).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs part of the Mental Health assessment of our study, we used the validated scales (PHQ-9 and GAD-7). Abnormal conditions were considered if scores \u0026ge; 10\u0026nbsp;(20, 21)\u0026nbsp;and almost 20% of the women had anxiety symptoms, followed by 36.9% with depressive symptoms. For the evaluation of functionality or ability to perform daily tasks, used WHODAS-12 version 2.0 and verified that the mean score was 10.9 (\u0026plusmn;12.9), we found 4.4% of the women had high disability scores (score\u0026ge;37.4)\u0026nbsp;(12). \u003cstrong\u003e(Table 4).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the included women, 28.3% used such support, of those 97% psychological support and 6.6% social service support \u003cstrong\u003e(Table 5).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn order to investigate factors independently associated with impaired functioning, mental health and clinical conditions, we performed three multiple regression analyzes. For the first model, that considered WHODAS\u0026ge;37.4 as the outcome, the condition independently associated with abnormal functioning was the presence of impaired clinical health. Nevertheless, less education and having a partner were protective conditions towards the report of impaired functioning \u003cstrong\u003e(table 6).\u003c/strong\u003e In model 2, considering as outcome abnormal anxiety and depression (scores \u0026ge;10), poor overall health rating was associated with increased anxiety/depression. However, increased parity was protective.\u003c/p\u003e\n\u003cp\u003eIn model 3, the clinical conditions reported by the woman (defined when the woman reported having been informed of a clinical diagnosis after delivery) were considered as outcomes and we identified that the variable evaluated in the questionnaire about violence, as: \u0026quot;whether or not they were afraid of the current partner / most recent spouse or any other person\u0026quot;, was positively associated to the perception of impaired clinical condition \u003cstrong\u003e(Table 6)\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo understand if the same women suffer from combined conditions, or if there was a pattern in the combination of abnormal findings, we presented a figure that evaluates each parameter and its combinations. Almost a quarter of the participants included in this analysis presented depression and anxiety (38.6%), followed by clinical conditions associated to depression (14.6%), anxiety with clinical conditions (13.3%)\u0026nbsp;\u003cstrong\u003e(Table 7).\u0026nbsp;\u003c/strong\u003eThe denominators for each of the presented variables varied, according to the number of missing information. There was a large number of \u0026ldquo;missing\u0026rdquo; for the variables depression and sexual satisfaction; for sexual satisfaction, the reason was that women who declared no sexual activity after childbirth were not further asked about satisfaction. For \u0026ldquo;missing\u0026rdquo; on the depression variable, the depression instrument was only applied if women answered that they were \u0026ldquo;feeling depressed or hopeless\u0026rdquo; in the first question.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis 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 women considering a broad approach of conditions that can impact maternal health, in a high-risk setting\u0026nbsp;(11).\u003c/p\u003e\n\u003cp\u003eThe 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\u0026nbsp;(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.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCesarean section rates are increasing worldwide, with Brazil among the most impressive figures (over 50%)\u0026nbsp;(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.\u003c/p\u003e\n\u003cp\u003eAnother 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%\u0026nbsp;(24).\u003c/p\u003e\n\u003cp\u003eWe 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 perpetrators, who are people of their daily life. This violence is accepted as \u0026quot;normal\u0026quot; in many societies of the world\u0026nbsp;(25).\u0026nbsp;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\u0026nbsp;(26)\u0026nbsp;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.\u003c/p\u003e\n\u003cp\u003eIn Brazil, physical, sexual and psychological violence against women are gaining awareness with increase in legal protections and enhanced tools for reporting agressors. Data suggest that it has always been a major hidden problem in the country. From 2011 to 2017, almost half a million cases of intimate partner violence against women were registered in a national database of surveillance. Among pregnant women, data is scarce, and a recent study obtained similar rates of physical and sexual violence as ours (12.1% and 2.8%). We believe that violence against women is underreported and an adequate surveillance is mandatory to understand the dimension of the problem and to propose national policies to guarantee the needed support.\u003c/p\u003e\n\u003cp\u003eThe 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\u0026apos;s milk, thus reducing early weaning\u0026nbsp;(29), this might support such levels of breastfeeding, adding the hospital\u0026acute;s active work in campaigns, programs to inform women about the benefits of breastfeeding for the baby.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAccording 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%\u0026nbsp;(11). \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhen considering abnormal conditions evaluated by the WOICE instrument, it was striking to observe less than 5% of women with no morbidities. This supports the understanding of multiple aspects that are able to influence women\u0026acute;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.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePoisson regression presented that having a partner decreased the women\u0026apos;s perception of clinical morbidities and functionality impairment; that might just reflect more care and support.\u0026nbsp;Primary education (or less) was a protective condition towards functionality impairment evaluated by WHODAS. The underlying explanation for such finding is not clear yet and needs further studies, however, could represent the decreased ability to report or even less awareness towards the evaluated conditions in the WHODAS instrument.\u0026nbsp;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\u0026nbsp;(30)\u0026nbsp;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\u0026nbsp;(31, 32).\u003c/p\u003e\n\u003cp\u003eIt 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.\u003c/p\u003e\n\u003cp\u003eThose 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.\u003c/p\u003e\n\u003cp\u003eAnother 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. The study was performed in a referral center for high risk pregnancies. Women with underlying medical conditions, are frequently under increased clinical surveillance during pregnancy and postpartum and motivated to adhere to treatment because of fetal health. Therefore, many times they feel they are in \u0026ldquo;good health\u0026rdquo; and we hypothesize that such answer is a consequence of adequate healthcare. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAn 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.\u003c/p\u003e\n\u003cp\u003ePostpartum care (PPC) would need to provide much more than contraceptive method orientation, it needs to ensure the opportunity to promote women\u0026apos;s health and well-being, and postpartum visits should include a thorough assessment of physical, social, psychological and mental health\u0026nbsp;(10).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA relevant limitation is that the WOICE has not been translated and validated into different languages, as Portuguese, and it may difficult comparisons with data obtained using the 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 \u0026nbsp;women with low-education level.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMore 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.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe WOICE-WHO instrument allows for an overall evaluation of maternal morbidity. During postpartum care, women presented high frequency of anxiety and depression and relevant frequency of substance use and violence. These aspects of women ́s health need further evaluation and specific interventions to improve quality of care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003col\u003e\n\u003cli\u003e\u003cstrong\u003eANC \u003c/strong\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;Antenatal Care\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eASSIST \u003c/strong\u003eAlcohol, Smoking and Substance Involvement Screening Test\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eBSSC-W \u003c/strong\u003eBrief Sexual Symptom Checklist for Women\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eGAD-7\u003c/strong\u003e General Anxiety Disorder 7\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eMNM \u003c/strong\u003eMaternal Near Miss\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eMMWG\u003c/strong\u003e Working Group Maternal Morbidity\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003ePHQ-9 \u003c/strong\u003ePatient Health Questionnaire 9\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003ePLTC \u003c/strong\u003ePotentially Life- Threatening Conditions\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003ePPC \u003c/strong\u003ePostpartum Care\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003ePR \u003c/strong\u003ePrevalence Ratio\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eREDCAP\u003c/strong\u003e Research Electronic Data Capture\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eSD \u003c/strong\u003eStandard Desviation\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eSMM \u003c/strong\u003eSevere Maternal Morbidity\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eSPSS \u003c/strong\u003eStatistical Package for the Social Sciences\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eWHO \u003c/strong\u003eWorld Health Organization\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eWHODAS \u003c/strong\u003eWorld Health Organization Disability Assessment Schedule 2.0\u003c/li\u003e\n\u003c/ol\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData collection started only after approval of the research protocol by the local Research Ethics Committee of the Medical Science School of the University of Campinas. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWritten consent to participate was obtained for all women with age higher than 18 years; written consent and parental consent was waived for women with age bellow than 18 years, however verbal consent was obtained for this group before interview. The Research Ethics Committee of the Medical Science School of the University of Campinas approved this approach to adolescents, and considered that this group could be at risk, since violence is one of the conditions evaluated by the study and it is well known that in cases of domestic violence, the perpetrator is often responsible or very close to the adolescents. Because of this condition, the Research Ethics Committee waived written consent and parental consent specifically for this group.\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Research Ethics Committee of the Medical Science School of the University of Campinas, under the number of approval 78497817.0.0000.5404 and opinion number 2.386.001.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe corresponding author, Maria Laura Costa is an Associate Editor of this journal.\u003c/p\u003e\n\u003cp\u003eNone of the other authors have any competing interests.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo specific funding for this study.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCML, CJG and PMA had the initial idea for the sutudy. LMN, LS, CMC and GJP\u003c/p\u003e\n\u003cp\u003ewere responsible for data collection. GJP, LMN, CJG and CML were responsible\u003c/p\u003e\n\u003cp\u003efor planning the analysis and interpretation of data. LMN and CML wrote the first\u003c/p\u003e\n\u003cp\u003edraft of the paper. VMF,LS, CD helped in the interpretation of the analysis. All\u003c/p\u003e\n\u003cp\u003eauthors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Not applicable\u0026rdquo; in this section.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eChou D, Tuncalp O, Firoz T, Barreix M, Filippi V, von Dadelszen P, et al. Constructing maternal morbidity - towards a standard tool to measure and monitor maternal health beyond mortality. 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Acta Med Port. 2019;32(4):279-88.\u003c/li\u003e\n\u003cli\u003eWHO | The ASSIST project - Alcohol, Smoking and Substance Involvement Screening Test. WHO. 2018.\u003c/li\u003e\n\u003cli\u003eWHO | WHO multi-country study on women's health and domestic violence against women. WHO. 2005.\u003c/li\u003e\n\u003cli\u003eKroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-13.\u003c/li\u003e\n\u003cli\u003eSpitzer RL, Kroenke K, Williams JB, Lowe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092-7.\u003c/li\u003e\n\u003cli\u003eRamires de Jesus G, Ramires de Jesus N, Peixoto-Filho FM, Lobato G. Caesarean rates in Brazil: what is involved? Bjog. 2015;122(5):606-9.\u003c/li\u003e\n\u003cli\u003eNakamura-Pereira M, do Carmo Leal M, Esteves-Pereira AP, Domingues RM, Torres JA, Dias MA, et al. Use of Robson classification to assess cesarean section rate in Brazil: the role of source of payment for childbirth. Reprod Health. 2016;13(Suppl 3):128.\u003c/li\u003e\n\u003cli\u003eLeal MD, Esteves-Pereira AP, Nakamura-Pereira M, Torres JA, Theme-Filha M, Domingues RM, et al. Prevalence and risk factors related to preterm birth in Brazil. Reprod Health. 2016;13(Suppl 3):127.\u003c/li\u003e\n\u003cli\u003eGarcia-Moreno C, Jansen HA, Ellsberg M, Heise L, Watts CH. Prevalence of intimate partner violence: findings from the WHO multi-country study on women's health and domestic violence. Lancet. 2006;368(9543):1260-9.\u003c/li\u003e\n\u003cli\u003eWHO | Violence against women. WHO. 2016.\u003c/li\u003e\n\u003cli\u003eMascarenhas MDM, Tomaz GR, Meneses GMS, Rodrigues MTP, Pereira VOM, Corassa RB. Analysis of notifications of intimate partner violence against women, Brazil, 2011-2017. Rev Bras Epidemiol. 2020;23 Suppl\u0026nbsp;1:e200007.SUPL.1.\u003c/li\u003e\n\u003cli\u003eRibeiro MRC, Batista RFL, Schraiber LB, Pinheiro FS, Santos AMD, Sim\u0026otilde;es VMF, et al. Recurrent Violence, Violence with Complications, and Intimate Partner Violence Against Pregnant Women and Breastfeeding Duration. J Womens Health (Larchmt). 2020.\u003c/li\u003e\n\u003cli\u003eLamounier JA. [Breastfeeding in preterm infants: public health policy in primary care]. Rev Paul Pediatr. 2016;34(2):137-8.\u003c/li\u003e\n\u003cli\u003eFiroz T, McCaw-Binns A, Filippi V, Magee LA, Costa ML, Cecatti JG, et al. A framework for healthcare interventions to address maternal morbidity. Int J Gynaecol Obstet. 2018;141 Suppl 1:61-8.\u003c/li\u003e\n\u003cli\u003eGiordano JC, Parpinelli MA, Cecatti JG, Haddad SM, Costa ML, Surita FG, et al. The burden of eclampsia: results from a multicenter study on surveillance of severe maternal morbidity in Brazil. PLoS One. 2014;9(5):e97401.\u003c/li\u003e\n\u003cli\u003eZanette E, Parpinelli MA, Surita FG, Costa ML, Haddad SM, Sousa MH, et al. Maternal near miss and death among women with severe hypertensive disorders: a Brazilian multicenter surveillance study. Reprod Health. 2014;11(1):4.\u003c/li\u003e\n\u003c/ol\u003e\n"},{"header":"Tables","content":"\u003cp\u003eDue to technical limitations, full-text HTML conversion of the Tables could not be completed. However, the tables can be downloaded and accessed in the Supplementary Files.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Maternal Morbidity, mental health, functionality, depression, puerperium, WHODAS 2.0, PHQ-9, GAD-7.","lastPublishedDoi":"10.21203/rs.3.rs-26017/v3","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-26017/v3","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThere are no accurate estimates of the prevalence of non-severe maternal morbidities. Given the lack of instruments to fully assess these morbidities, the World Health Organization (WHO) developed an instrument called WOICE. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e To evaluate the prevalence of non-severe maternal morbidities in puerperal women and factors associated to impaired clinical, social and mental health conditions. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethod:\u003c/strong\u003e A cross-sectional study with postpartum women at a high-risk outpatient clinic in southeast Brazil, from November 2017 to December 2018. The WOICE questionnaire included three sections: the first with maternal and obstetric history, sociodemographic data, risk and environment factors, violence and sexual health; the second considers functionality and disability, general symptoms and mental health; and the third includes data on physical and laboratory tests. Data collection was supported by Tablets with REDCAP software. Initially, a descriptive analysis was performed, with general prevalence of all variables contained in the WOICE, including scales on anxiety and depression (GAD-7 and PHQ-9- impaired if ≥10), functionality (WHODAS- high disability scores when ≥37.4) and data on violence and substance use. Subsequently, an evaluation of cases with positive findings was performed, with a Poisson regression to investigate factors associated to impaired non-clinical and clinical conditions. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003e517 women were included, majority (54.3%) multiparous,\u0026nbsp;between 20 and 34 years (65.4%) and with a partner (75,6%). Over a quarter had (26.2%) preterm birth. Around a third (30.2%) reported health problems informed by the physician, although more than 80% considered having good or very good health. About 10% reported any substance use and 5.9% reported exposure to violence. Anxiety was identified in 19.8% of cases, depression in 36.9% and impaired functioning in 4.4% of women. Poisson regression identified that poor overall health rating was associated to increased anxiety/depression and impaired functioning. Having a partner reduced perception of women on the presence of clinical morbidities. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eDuring postpartum care of a high-risk population, over one third of the considered women presented anxiety and depression; 10% reported substance use and around 6% exposure to violence. These aspects of women´s health need further evaluation and specific interventions to improve quality of care.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Giving women WOICE postpartum: Prevalence of maternal morbidity in high-risk pregnancies using the WHO-WOICE instrument","msid":"","msnumber":"","nonDraftVersions":[{"code":3,"date":"2021-01-15 17:39:19","doi":"10.21203/rs.3.rs-26017/v3","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2021-02-01T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-01-18T00:00:00+00:00","index":1,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nI still find table 7 difficult to understand. It is clear that the bases on which % were calculated varied, but it is still unclear what do they represent? is 5.6 the percent of women with clinical conditions who also had sexual dissatisfaction? or the other way around? ie the percent of women with sexual dissatisfaction who had clinical conditions?\nI suggest to omit the %s and leave only the absolute numbers. \n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **No**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2021-01-17T00:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-01-13T00:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2021-01-07T00:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-01-06T23:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-01-06T23:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":2,"date":"2020-11-12 19:27:43","doi":"10.21203/rs.3.rs-26017/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-11-20T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-11-17T00:00:00+00:00","index":1,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nThis is a revision of the article and based on the authors responses to my comments on an earlier version and on the the corrected version of the article\n\nResponse to comment 3: Ok- but make sure it is consistent throughout the paper (including tables)\nNone morbidity? You probably mean \"no morbidity\"?\nResponse to comment 13: This is not a good reason to include highly correlated variables in the model. Illiteracy and low level of education are highly correlated by definition. Only one (the better predictor) should be included in the model. Including both variables in the model may result in PR \u003c0.01, which is hard to explain.\nI guess RP should be PR (prevalence ratio) -please correct in all tables\nTable 7:The data presented in Table 7 need explanations. What is/are the base/s for the calculated %?\nIn all tables pls define PPC\n\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **'I declare that I have no competing interests'**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **No**\n* Is the presentation of the work clear?: **No**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2020-11-08T00:00:00+00:00","index":1,"fulltext":""},{"type":"editorAssigned","content":"","date":"2020-11-05T00:00:00+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-11-05T00:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-11-04T23:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-11-04T23:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2020-05-12 19:14:19","doi":"10.21203/rs.3.rs-26017/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-10-09T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-08-05T12:00:00+00:00","index":1,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\nThis is a cross sectional study conducted in Brazil in a high risk clinic, applying an instrument developed by WHO to evaluate multi dimensional \"non severe\" maternal morbidity during the puerperal period. The objective of the paper is to estimate the prevalence of three dimensions of maternal \"non severe\" morbidity: functionality and disability, general symptoms and mental health. There is also an attempt to identify factors associated with these morbidity measures.\n\nI do have a problem with defining the conditions assessed by WOICE \"non severe\". Most of the evaluated conditions in WOICE, while not routinely evaluated in the clinical setting, can hardly be defined as non severe (eg: exposure to sexual violence).\n\nAs this study was conducted in a referral clinic for high risk pregnancies, the generalizability of the findings is limited to such segment of pregnant women. I suggest to change the title accordingly.\n\n\nComments\n\nGeneral:\n1. The paper needs language editing.\n2. Too many abbreviations, making reading difficult.\n3. The term \"alteration\" is frequently used to describe a score above a designated cutoff point. I suggest using different term in accordance to the condition described, eg: High disability score.\n\nAbstract:\n4. Should state where and when the study took place.\n5. It is not clear what \"cases with alterations\" means. After reading the paper I guess it means cases with scores above a certain cutoff point.\n6. According to the abstract the multivariable method used was logistic, while the text and tables say- Poisson. Please see below my comments on the choice of regression models.\n7. In the conclusions the authors say: \"women presented high frequency of anxiety and depression and relevant frequency of substance use and violence\". To be meaningful such statement has to include a comparison to some point of reference. \n\nBackground:\n8. P 5: line 14: I don't think \"low risk setting\" is the right terminology. Suggest: medical care for low risk pregnancies\n\nMethods:\n9. More information should be presented regarding data collection: When were women interviewed? before or after the medical evaluation? Were the interviewers part of the clinic staff? This information is presented in the Results section (p.12 lines 14-17). Please move to Methods section.\n10. Information should be given about the coverage of health care costs (medical insurance?) particularly of visits to this clinic. This is needed to assess the extent to which this study is representative of the Brazilian population in its socio-economic position.\n\nStatistical analysis:\n11. Multivariable analysis: the first two models (abnormal mental health and abnormal functioning) used, as I understand, binary outcome variables, why was a Poisson regression used rather than logistic regression?\n12. How were the predictors selected? Was a bivariate analysis conducted to examine which of the predictors are associated with the outcome? It is important to conduct this analysis and report the findings.\n13. It is also necessary to examine intercorrelation between the predictor variables. It seems that some predictor variables maybe highly correlated (eg: education and illiteracy, clinical conditions and medications). Including such highly correlated variables in the model may lead to an unstable model and wrong interpretations.\n14. This sentence (p. 10 3-5) is not clear, please clarify.\"In order to understand if the same women were at risk of combined alterations in clinical, social, sexual and mental health, we performed also a descriptive analysis of altered conditions and its combinations two by two\"\n\nResults:\n15. As mentioned earlier, more information should be given about the process of modelling (choice of model (Poisson or logistic), choice of variables in the model and the correlations between the predictor variables. \n\nDiscussion:\n16. p.14.line 22. \"authors\"? Should be perpetrators.\n17. How do these findings regarding prevalence of exposure to violence compare with other studies conducted in similar populations in Brazil?\n18. The results of the multivariable models are not fully discussed. How do the authors suggest to explain the seemingly protective association of lower education and illiteracy with WHODAS≥37.4. ( I would strongly suggest to run a model with only one of these two predictors at a time to avoid possible co-linearity)\n19. The argument on p.17 lines:3-8 regarding the fact that most women felt in good health in spite of many of them scoring high on the three WOICE scales attempting to assess maternal morbidity somehow undermines, I think, the notion that the conditions measured by WOICE reflect morbidity.\n\nTables:\n20. Check spelling and overlapping categories (eg Travel time to facility, mind 15 - 30 30 - 60 )\n21. I could not find Figure 2\n\n\n\n\n\n\n\nease include all comments for the authors in this box rather than uploading your report as an attachment. Please only upload as attachments annotated versions of manuscripts, graphs, supporting materials or other aspects of your report which cannot be included in a text format.\nPlease overwrite this text when adding your comments to the authors.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Declaration of competing interests: **'I declare that I have no competing interests'**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **No**\n* Are the methods sufficiently described to allow the study to be repeated?: **No**\n* Is the use of statistics and treatment of uncertainties appropriate?: **No**\n* Is the presentation of the work clear?: **No**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2020-07-20T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-06-18T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-05-07T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-05-06T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-05-05T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"eb204722-4864-409e-88f1-58805e55103a","owner":[],"postedDate":"January 15th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":1062133,"name":"Maternal \u0026 Fetal Medicine"}],"tags":[],"updatedAt":"2021-07-27T21:13:40+00:00","versionOfRecord":{"articleIdentity":"rs-26017","link":"https://doi.org/10.1186/s12884-021-03727-3","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2021-05-05 21:13:40","publishedOnDateReadable":"May 5th, 2021"},"versionCreatedAt":"2021-01-15 17:39:19","video":"","vorDoi":"10.1186/s12884-021-03727-3","vorDoiUrl":"https://doi.org/10.1186/s12884-021-03727-3","workflowStages":[]},"version":"v3","identity":"rs-26017","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-26017","identity":"rs-26017","version":["v3"]},"buildId":"oE6Zbj460LM0Up2FdVbMZ","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}