Postpartum recovery after severe maternal morbidity in Kilifi, Kenya: a grounded theory of recovery trajectories beyond 42 days

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INTRODUCTION: The burden of severe maternal morbidity is highest in sub-Saharan Africa, and its relative contribution to maternal (ill) health may increase as maternal mortality continues to fall. Women's perspective of their long-term recovery following severe morbidity beyond the standard 42-day postpartum period remains largely unexplored. METHODS: This woman-centred, grounded theory study was nested within the Pregnancy Care Integrating Translational Science Everywhere (PRECISE) study in Kilifi, Kenya. Purposive and theoretical sampling was used to recruit 20 women who experienced either a maternal near-miss event (n=11), potentially life-threatening condition (n=6) or no severe morbidity (n=3). Women were purposively selected between 6 and 36 months post partum at the time of interview to compare recovery trajectories. Using a constant comparative approach of line-by-line open codes, focused codes, super-categories and themes, we developed testable hypotheses of women's postpartum recovery trajectories after severe maternal morbidity. RESULTS: Grounded in women's accounts of their lived experience, we identify three phases of recovery following severe maternal morbidity: 'loss', 'transition' and 'adaptation to a new normal'. These themes are supported by multiple, overlapping super-categories: loss of understanding of own health, functioning and autonomy; transition in women's identity and relationships; and adaptation to a new physical, psychosocial and economic state. This recovery process is multidimensional, potentially cyclical and extends far beyond the standard 42-day postpartum period. CONCLUSION: Women's complex needs following severe maternal morbidity require a reconceptualisation of postpartum recovery as extending far beyond the standard 42-day postpartum period. Women's accounts expose major deficiencies in the provision of postpartum and mental healthcare. Improved postpartum care provision at the primary healthcare level, with reach extended through community health workers, is essential to identify and treat chronic mental or physical health problems following severe maternal morbidity.

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