Early Postpartum Complications and their Determinants: A Cross-Sectional Study from a Tertiary Care Hospital

Abstract

Background:

The postpartum period, critical for maternal health, is vulnerable to complications such as hemorrhage, infections, and hypertensive disorders, leading to significant maternal morbidity and mortality worldwide. In India, postpartum hemorrhage is a major cause of maternal deaths. Early identification and management of these complications can prevent long-term disabilities.

Aim and Objective:

This study aimed to estimate the occurrence of early postpartum complications and their determinants among women at a tertiary care hospital in Jabalpur, Madhya Pradesh, India.

Materials and Methods:

This hospital-based cross-sectional study was conducted at a tertiary care hospital in Jabalpur, Madhya Pradesh, India, from October 2023 to March 2024. During the study period, there were 4,996 postpartum admissions. Of these, 4,918 women provided informed consent and were enrolled in the study. Data were collected via a structured questionnaire covering demographic, antenatal, obstetric, and postpartum complications.

Results:

Among 4,918 postpartum women, 69.1% experienced complications, including pain/fatigue (63.5%), perineal morbidities (41.3%), and infections (15.5%). Higher complication rates were seen in women younger than 25 or older than 35 years, with lower education, underweight, fewer than four antenatal care (ANC) visits, inadequate iron/calcium supplementation, and short interpregnancy intervals.

Conclusion:

Strengthening postpartum care, especially for high-risk groups such as younger and older mothers, and those with inadequate ANC, is crucial. Interventions should include ensuring at least four ANC visits, adequate iron and calcium supplementation, proper nutrition, and education on birth spacing to reduce complications.

INTRODUCTION

The postpartum period is a critical phase in the continuum of maternal care, encompassing the first six weeks following delivery. During this time, women undergo significant physiological and psychological adjustments, rendering them particularly vulnerable to various complications. Early postpartum complications, such as postpartum hemorrhage (PPH), infections, hypertensive disorders, and thromboembolic events, are among the leading contributors to maternal morbidity and mortality worldwide. Studies indicate that the highest maternal and newborn morbidity and mortality occur in the immediate postnatal period, particularly within the first 24 hours after birth. Despite this, postnatal care remains one of the most neglected components of the obstetric continuum of care, with coverage levels significantly lower than those of antenatal care (ANC) and intrapartum care. Failure to conduct timely postpartum assessments and delayed identification of obstetric complications are critical missed opportunities to reduce maternal mortality and morbidity.[1]

Globally, over 300,000 women die annually from pregnancy-related complications, with approximately 75% of these deaths occurring during the postpartum period, many of which are preventable through timely risk management. Additionally, 15% of pregnant women—around 20 million globally—experience severe obstetric complications such as hemorrhage, obstructed labor, preeclampsia, puerperal sepsis, and septic abortion. In India, early postpartum complications remain a public health challenge, with PPH being a leading cause of maternal deaths. Regional disparities underscore the need for localized data to guide healthcare policies.[2]

The consequences of postpartum morbidity are multifaceted, ranging from immediate issues such as postpartum infections, perineal tears, urinary tract infections, and depression to long-term disabilities, including incontinence, fistula, pelvic inflammatory disease, genital prolapse, hypertension, hemorrhoids, nerve damage, pituitary failure, anemia, and infertility. Most of these conditions are treatable and preventable with prompt recognition and initiation of high-quality care.[2]

This study aims to estimate the occurrence of early postpartum complications and identify their determinants among women admitted to a tertiary care hospital in Jabalpur, Madhya Pradesh. The findings are expected to provide evidence-based insights to enhance postpartum care and reduce maternal morbidity and mortality in similar settings.

MATERIALS AND METHODS

Study design and setting: This hospital-based cross-sectional study was conducted at a tertiary care hospital in Jabalpur, Madhya Pradesh, India, over a period of 6 months, from October 2023 to March 2024. This tertiary care center caters to urban and rural populations from surrounding districts and serves as a referral center for high-risk pregnancies, with a substantial proportion of patients referred from peripheral health facilities.

Study population: The study included all postpartum women in the immediate postpartum period, defined as the first 48 hours following delivery, at the hospital during the study period. Women who provided informed consent were enrolled in the study. Sample Size: During the study period, there were 4,996 postpartum admissions. Of these, 4,918 women provided informed consent and were enrolled in the study. The participant selection process is presented in Figure 1.

Figure 1.

STROBE participant flow diagram. STROBE = Strengthening the Reporting of Observational Studies in Epidemiology

Ethical considerations: The study was approved by the Institutional Ethics Committee of the tertiary care hospital (IEC/2023/6480 Date: 07/27/2024). Written informed consent was obtained from all participants before their inclusion in the study.

Inclusion criteria: All women who delivered at the study hospital during the data collection period and remained admitted for the immediate postpartum assessment period (up to 48 hours) and those who gave written informed consent were eligible for inclusion.

Exclusion criteria: Women who were referred out or discharged before completion of the initial postpartum assessment, those who were critically ill or requiring intensive care and therefore unable to participate, and those with incomplete or missing essential data were excluded from the study.

Data collection tools: Data were collected using a structured questionnaire administered to postpartum women. The questionnaire was pre-tested on 50 postpartum women (approximately 1% of the sample) to assess clarity and feasibility. Inter-rater reliability for clinical assessments showed good agreement (Cohen’s kappa = 0.78). The questionnaire included demographic information, ANC details, obstetric history and postpartum complications. Details such as height, weight, and body mass index (BMI) were obtained from the Mother and Child Protection (MCP) card. Socioeconomic status was assessed using the Modified BG Prasad classification based on per capita monthly income.

Information on postpartum complications was obtained through both self-report and clinical diagnosis, depending on the nature of the outcome. Self-reported outcomes included pain (abdominal, perineal, back, limb pain), fatigue, and initial complaints of breast discomfort. Clinically diagnosed outcomes included perineal tears, perineal swelling, wound infections, urinary tract infections (UTIs), fever, mastitis, PPH, bladder or bowel injury, deep vein thrombosis (DVT), and vaginal hematoma. Hemoglobin levels were recorded at admission and in the postpartum period to distinguish antenatal and postpartum anemia.

Operational definitions[3]

Early postpartum complications: Any maternal morbidity occurring within 48 hours after childbirth, including pain and fatigue, perineal morbidities, infections (UTI, wound infection, fever), breast complications (engorgement, mastitis, flat/retracted nipple), postpartum hemorrhage, other complications (DVT, bladder/bowel injury, hematoma).

Pain: Any of the following self-reported symptoms: abdominal pain, backache, pain in arms and legs, perineal pain.

Fatigue: Self-reported feeling of tiredness or lack of energy interfering with daily activities in the early postpartum period.

Perineal morbidities: Pain, swelling, or tears of the perineum identified either by Clinical assessment by a doctor, or Self-report of perineal pain or discomfort.

Postpartum infections: Confirmed based on a) clinical diagnosis of UTI, wound infection, or fever by a treating doctor; b) laboratory investigations when available; and c) fever defined as ≥38°C within 48 hours postpartum.

Breast complications: Clinically assessed or self-reported breast engorgement, mastitis, nipple fissures, or flat/retracted nipples occurring within 48 hours.

PPH: Blood loss ≥500 mL after vaginal delivery or ≥1000 mL after lower segment cesarean section (LSCS), clinically diagnosed by the obstetrician.

Statistical analysis: Data were analyzed using International Business Machines Statistical Package for the Social Sciences (IBM SPSS) Statistics for Windows, Version 25.0 (IBM Corp., Armonk, NY, USA). Categorical variables are presented as frequency and percentage. Associations between categorical variables were evaluated using Chi-square tests, with a P value <0.05 considered statistically significant. Missing data (<2%) were handled using listwise deletion. Multicollinearity among independent variables was assessed using variance inflation factor (VIF), and model calibration was evaluated using the Hosmer–Lemeshow goodness-of-fit test.

RESULTS

During the study period, there were 4,996 postpartum admissions. Of these, 4,918 women provided informed consent and were enrolled in the study.

A total of 4,918 postpartum women were included. The mean age was 25.8 ± 4.7 years, with most belonging to the 25–34-year age group. The majority were Hindu, from rural areas, and belonged to socially and economically marginalized groups. Nearly half had only primary education, and most were unemployed. One-fourth of the women were underweight [Table 1].

Table 1.

Sociodemographic characteristics of study participants (n=4,918)

Characteristics		Frequency (%)*
Age groups (years)
15–24		1,832 (37.3%)
25–34		3,024 (61.5%)
≥ 35		62 (1.3%)
Mean±SD		25.83±4.75
Religion
Hindu		4,717 (95.9%)
Muslim		197 (4.0%)
Christian		4 (0.1%)
Caste
Schedule Tribe		1,134 (23.1%)
Schedule Caste		581 (11.8%)
OBC		2,021 (41.1%)
General		1,189 (24.2%)
Residence
Urban		2,019 (41.1%)
Rural		2,899 (58.9%)
Education
Illiterate		639 (13.0%)
Primary		2,100 (42.7%)
Secondary		1,015 (20.6%)
Higher secondary		979 (19.9%)
Graduate and above		185 (3.8%)
Occupation
Unemployed		4,175 (84.9%)
Unskilled		399 (8.1%)
Semiskilled		283 (5.8%)
Skilled		25 (0.5%)
Semi professional		36 (0.7%)
Socioeconomic class
Class I		184 (3.7%)
Class II		1,124 (22.9%)
Class III		1,608 (32.7%)
Class IV		922 (18.7%)
Class V		1,080 (22.0%)
Type of family
Joint		3,260 (66.3%)
Nuclear		1,658 (33.7%)
Body mass index
Underweight		1,220 (24.8%)
Normal		3,372 (68.6%)
Overweight		189 (3.8%)
Obese		137 (2.8%)
Tobacco use
No		4,817 (97.9%)
Yes		101 (2.1%)
Alcohol use
No		4,886 (99.3%)
Yes		32 (0.7%)

SD standard deviation, OBC=other backward classes. *Percentages are calculated column-wise

Two-thirds of the women completed ≥4 ANC visits, and most received iron and calcium supplementation. Normal vaginal delivery accounted for a higher proportion of births, and nearly half were primiparous. Anemia was the most common medical condition, followed by thyroid disorders and hypertensive disorders, while diabetes, human immunodeficiency virus, epilepsy, and cardiac disease were rare [Table 2].

Table 2.

Antenatal care of study participants (n=4,918)

Antenatal characteristics		Frequency (%)*
No. of ANC visits
≥ 4		3,263 (66.3%)
< 4		1,655 (33.7%)
Iron supplementation
Yes		3,974 (80.8%)
No		944 (19.2%)
Calcium supplementation
Yes		4,060 (82.6%)
No		858 (17.4%)
Tetanus injection received
Yes		4,117 (83.8%)
No		801 (16.2%)
Mode of delivery
NVD		3,056 (62.1%)
LSCS		1,862 (37.9%)
Parity
Primi		2,498 (50.8%)
Multipara		2,216 (45.1%)
Grand multipara		204 (4.1%)
Gestational age
Preterm		1,903 (38.7%)
Full term		3,015 (61.3%)
Multiple pregnancy
Yes		30 (0.6%)
No		4,888 (99.4%)
Birth interval in multipara (n=2420)
< 24months		751 (31.0%)
≥ 24months		1,669 (69.0%)
Medical disorder
Anemia		1,491 (30.3%)
-Mild		901 (18.3%)
-Moderate		519 (10.6%)
-Severe		71 (1.4%)
Hypertensive disorder		157 (3.2%)
-Chronic hypertension		99 (2.0%)
-Gestational hypertension		58 (1.2%)
Diabetes mellitus		64 (1.3%)
Thyroid disorder		161 (3.3%)
-Hypothyroidism		156 (3.2%)
-Hyperthyroidism		5 (0.1%)
HIV		7 (0.1%)
Epilepsy		12 (0.2%)
Cardiac disease		9 (0.2%)

ANC=antenatal care, NVD=normal vaginal delivery, LSCS=lower segment cesarean section, HIV=human immunodeficiency virus. *Percentages are calculated column-wise

Overall, 69.1% of women reported at least one postpartum complication. Pain and fatigue were the most commonly reported issues, followed by perineal morbidities and postpartum infections, especially UTIs. Breast complications, PPH, and other serious conditions such as bladder/bowel injury, DVT, and vaginal hematoma were uncommon [Table 3].

Table 3.

Distribution of early postpartum complications among study participants*

Complication		Frequency (n=4,918)
Pain and fatigue		3,121 (63.5%)
-Pain in arm & legs		1,770 (36.0%)
-Pain abdomen		262 (5.3%)
-Backache		300 (6.1%)
-Fatigue		885 (18.0%)
Perineal conditions		2,031 (41.3%)
-Perineal pain		2,026 (41.2%)
-Perineal tear		14 (0.3%)
-Perineal swelling		5 (0.1%)
Postpartum infection		764 (15.5%)
-UTI		414 (8.4%)
-Wound infection		88 (1.8%)
-Only Fever		262 (5.3%)
Breast condition		81 (1.6%)
-Breast engorgement		49 (1.0%)
-Mastitis		26 (0.5%)
-Flat or retracted nipple		14 (0.3%)
PPH		45 (0.9%)
Others		39 (0.8%)
-Bladder/bowel Injury		21 (0.4%)
-DVT		15 (0.3%)
-Vaginal hematoma		5 (0.1%)

UTI=urinary tract infection, PPH=postpartum hemorrhage, DVT=deep vein thrombosis. *Multiple complications were observed; therefore, the sum of individual complications exceeds the total number of women. Percentages are calculated using the total study population (n=4918) as the denominator

Maternal complications were significantly more common among women who were younger (<25 years) or older (≥35 years), less educated, from marginalized groups, or underweight. Obstetric and care-related factors—such as <4 ANC visits, inadequate iron or calcium intake, LSCS, short birth interval, and preterm delivery—were also significantly associated with higher complication rates. No significant associations were found with socioeconomic class, religion, occupation, tobacco/alcohol use, tetanus inoculation, or parity [Table 4].

Table 4.

Association of sociodemographic, obstetric factors with postpartum complications

Risk factors		Early postpartum complications				Odds ratio (95% CI)		Test of association
		Present (n=3,399)		Absent (n=1,519)
Age (in years)
< 25 & ≥35 (n=1,894)		1,352 (71.4%)		542 (28.6%)		1.19 (1.05 to 1.35)		χ2=7.26, P=0.007
25 to 34 (n=3,024)		2,047 (67.7%)		977 (32.3%)
Religion
Hindu (n=4,717)		3,256 (69%)		1,458 (30.9%)		0.95 (0.70 to 1.29)		χ2=0.05, P=0.81
Other (n=201)		143 (71.1%)		61 (30.3%)
Caste
SC/ST (n=1,715)		1,222 (71.3%)		493 (28.7%)		1.17 (1.03 to 1.33)		χ2=5.49, P=0.01
OBC & General (n=3203)		2,177 (68%)		1,026 (32%)
Residence
Urban (n=2,019)		1,432 (70.9%)		587 (29.1%)		1.16 (1.02 to 1.31)		χ2=5.12, P=0.02
Rural (n=2,899)		1,967 (67.9%)		932 (32.1%)
Education of mother
Illiterate, primary & middle (n=2,739)		1,980 (72.3%)		759 (27.7%)		1.34 (1.24 to 1.58)		χ2=28.8, P<0.001
High school & above (n=2,179)		1,419 (65.1%)		760 (34.9%)
Occupation of mother
Not working (n=4,175)		2,864 (68.6%)		1,311 (31.4%)		0.84 (0.71 to 1.01)		χ2=3.27, P=0.07
Working (n=743)		535 (72%)		208 (28%)
Socioeconomic class
Class I, II & III (n=2,916)		2,056 (70.5%)		860 (29.5%)		1.17 (1.03 to 1.32)		χ2=6.36, P=0.01
Class IV & V (n=2,002)		1,343 (67.1%)		659 (32.9%)
Type of family
Nuclear (n=1,658)		1,126 (67.9%)		532 (32.1%)		0.91 (0.81 to 1.04)		χ2=1.6, P=0.2
Joint family (n=3,260)		2,273 (69.7%)		987 (30.3%)
Body mass index
Underweight (n=1,220)		874 (71.6%)		346 (28.4%)		1.17 (1.02 to 1.35)		χ2=4.69, P=0.03
Normal, overweight, obese (n=3,698)		2,525 (68.3%)		1,173 (31.7%)
Tobacco use
Yes (n=101)		75 (74.3%)		26 (25.7%)		1.30 (0.82 to 2.03)		χ2=1.04, P=0.3
No (n=4,817)		3,324 (69%)		1,493 (31%)
Alcohol use
Yes (n=32)		25 (78.1%)		7 (21.9%)		1.60 (0.69 to 3.71)		χ2=0.83, P=0.36
No (n=4,869)		3,374 (69.3%)		1,512 (31.1%)
ANC visits
≥ 4 (n=3,263)		2,186 (67%)		1,077 (33%)		1.35 (1.19 to 1.54)		χ2=20.1, P<0.001
< 4 (n=1,655)		1,213 (73.3%)		442 (26.7%)
Iron supplementation
No (n=944)		692 (73.3%)		252 (26.7%)		1.27 (1.10 to 1.51)		χ2=9.37, P=0.002
Yes (n=3,974)		2,707 (68.1%)		1,267 (31.9%)
Calcium supplementation
No (n=858)		627 (73.1%)		231 (26.9%)		1.26 (1.07 to 1.49)		χ2=7.42, P=0.006
Yes (n=4,060)		2,772 (68.3%)		1,288 (31.7%)
Tetanus injection
No (n=801)		559 (69.8%)		242 (30.2%)		1.04 90.88 to 1.22)		χ2=0.16, P=0.68
Yes (n=4117)		2,840 (68.9%)		1,277 (31%)
Mode of delivery
NVD (n=3,056)		1,993 (65.2%)		1,063 (34.8%)		1.64 (1.44 to 1.87)		χ2=56.9, P<0.001
LSCS (n=1,862)		1,406 (75.5%)		4,56 (24.5%)
Gestational age
Preterm (n=1,903)		1,374 (72.2%)		529 (27.8%)		1.27 (1.12 to 1.44)		χ2=13.6, P=0.0002
Full term (n=3,015)		2,025 (67.2%)		990 (32.8%)
Parity
Primi (n=2,498)		1,749 (70.0%)		749 (30.0%)		1.09 (0.96 to 1.23)		χ2=1.85, P=0.17
Multipara & grand multipara (n=2,420)		1,650 (68.2%)		770 (31.8%)
Birth interval (n=2,420)*
< 24 months (n=751)		558 (74.3%)		193 (25.7%)		1.48 (1.2 to 1.79)		χ2=15.9, P=< 0.001
≥ 24 months (n=1,669)		1,103 (66.1%)		566 (33.9%)

CI=confidence interval, SC/ST=schedule caste/schedule tribe, OBC=other backward classes, ANC=antenatal care, NVD=normal vaginal delivery, LSCS=lower segment cesarean section. *Analysis restricted to multiparous women (n=2,420), as birth interval is not applicable to primiparous women

The strongest independent predictor was a short birth interval (<24 months), which increased the odds of PPC over threefold (adjusted odds ratio [AOR] = 3.41; P < 0.001). Other major risk factors, including preterm gestational age (AOR = 2.37; P < 0.001), inadequate ANC visits (<4) (AOR = 1.66; P = 0.001), low maternal education (AOR = 1.76; P = 0.001), and delivery by LSCS (AOR = 1.45; P = 0.001), elevated the risk. Iron and calcium supplementation were excluded from the multivariable analysis due to collinearity with ANC utilization variables (VIF >5). No significant multicollinearity was observed among other independent variables (all VIF <5), and the model demonstrated adequate fit [Table 5].

Table 5.

Multivariable logistic regression analysis of risk factors for postpartum complications

Risk factor		Adjusted OR (95% CI)		P		VIF
Age (< 25 years & ≥35 years)		0.78 (0.56 to 1.23)		0.34		1.42
Caste (SC/ST)		0.76 (0.54 to 1.45)		0.33		1.58
Residence (Urban)		1.35 (0.84 to 1.57)		0.12		1.73
Education (≤Middle school)		1.76 (1.12 to 2.45)		0.001		1.89
Occupation of mother (Working)		0.54 (0.23 to 1.23)		0.54		1.36
Socioeconomic status (Lower)		1.48 (0.83 to 2.37)		0.87		1.21
Family type (Nuclear)		1.62 (0.88 to 1.89)		0.13		1.47
Underweight		1.34 (0.89 to 1.87)		0.25		1.32
ANC visits (<4)		1.66 (1.25 to 2.50)		0.001		2.48
Mode of delivery (LSCS)		1.45 (1.10 to 2.76)		0.001		1.84
Birth interval (<24 months)		3.41 (1.82 to 5.67)		< 0.001		1.52
Gestational age (Preterm)		2.37 (1.68 to 5.32)		< 0.001		1.76
Parity (Primipara)		0.87 (0.76 to 1.65)		0.59		1.41

AOR=adjusted odds ratio, CI=confidence interval, VIF=variance inflation factor, SC/ST=schedule caste/schedule tribe, ANC=antenatal care, LSCS=lower segment cesarean section. All VIF values <5 indicate absence of significant multicollinearity. Model fit was adequate based on the Hosmer–Lemeshow goodness-of-fit test

DISCUSSION

Sociodemographic characteristics of mothers

During the study period, there were 4,996 postpartum admissions at a tertiary care hospital in Jabalpur, Madhya Pradesh. Of these, 4,918 women provided informed consent and were enrolled in the study. Most (61.5%) were aged 25–34 years, Hindu (95.9%), from rural areas (58.9%), and belonged to the other backward classes (OBC) (41.1%) or general caste (23.1%) groups. In terms of education, 42.7% had completed primary education, whereas 13.0% were illiterate. Most were homemakers (84.9%), with 22.0% from the lower socioeconomic class. Nutritional assessment showed 24.8% were underweight, 3.8% overweight, and 2.8% obese. Tobacco and alcohol use were reported in 2.1% and 0.7% of cases, respectively.

Ferdous J et al.[2] reported that 15.9% were younger than 20 years, with most (31.5%) aged 20–24 years. Education levels were higher, with 43.7% completing at least eight years of schooling. A larger proportion (26.0%) belonged to the richest socioeconomic category, and 16.5% had a BMI below 18.5 kg/m², while 72.0% had a normal BMI. The younger age distribution and better socioeconomic status in their study may have contributed to higher education and nutritional levels. Iyengar K et al.[4] found that 78.2% were aged 20–29 years, with 60.2% belonging to the scheduled caste or scheduled tribe (SC/ST) group. Namutebi M et al.[5] reported that 55.3% were aged 20–29 years, with high rates of undernutrition (19.6%). Differences in healthcare access and utilization may explain their higher prevalence of anemia and undernutrition. Overall, these findings highlight sociodemographic differences influencing maternal health outcomes and emphasize the need for targeted interventions, particularly in improving nutrition and antenatal care compliance.

Antenatal care

In the present study, two-thirds (66.3%) attended at least four ANC visits, and iron and calcium supplementation were received by 80.8% and 82.6%, respectively. Iyengar K et al.[4] reported institutional deliveries in 68.6% of cases, with 97.8% having vaginal births and only 2.2% undergoing a cesarean section. Namutebi M et al.[5] reported high rates of anemia (47.1%) and undernutrition (19.6%). Additionally, only 60.8% attended recommended ANC visits, and 73.5% received iron supplementation, lower than in the present study. The relatively high proportion of preterm deliveries (38.7%) observed in this study is likely influenced by the referral nature of the tertiary care center, which caters to a higher proportion of high-risk pregnancies, thereby reflecting referral bias.

In the present study, postpartum anemia was observed in 30.3% of women, with mild (18.3%), moderate (10.6%), and severe anemia (1.4%). This is lower than in other low-resource settings, where postpartum anemia prevalence reached 70% in North India[6] and was similarly high in Vietnam (70.2%).[7] Iyengar K et al.[8] found hemoglobin ≤7 g/dL in 71.4% of women with severe postpartum complications, while Bangladesh reported 7% severe anemia.[9] Ferdous J et al.[2] documented severe (0.2%), moderate (3.4%), and mild anemia (28.3%). High-income countries report significantly lower rates.[10] Postpartum anemia, influenced by blood loss and delivery care, is linked to adverse outcomes such as low birth weight and preterm births, as well as fatigue and functional impairment.[8] The lower prevalence in this study may reflect better antenatal and intrapartum care, including iron supplementation, nutritional counseling, and early anemia management. Differences in study populations, hemoglobin assessment methods, and postpartum evaluation timing may also explain the variation in prevalence.

In this study, hypertensive disorders were observed in 3.2% of postpartum women, including chronic hypertension (2.0%) and gestational hypertension (1.2%). Iyengar K et al.[8] reported eclampsia in 3.6% of cases, while Ferdous J et al.[2] found hypertension in 5.1% of women. A community-based study in Bangladesh reported a higher prevalence of hypertension at 11%.[9]

Early postpartum complication

In this study, 69.1% of participants experienced postpartum complications, similar to the 59.3% reported by Iyengar K et al.[8] Ferdous J et al.[2] found a lower prevalence (42%), and Namutebi M et al.[5] reported just 14.1%. Conversely, a community-based study in Dhaka recorded the highest prevalence (75%).[2] These variations may stem from differences in study populations, healthcare settings, complication definitions, or postpartum follow-up protocols.

In this study, 41.3% of postpartum women experienced perineal morbidities, with perineal pain being the most common (41.2%), while perineal tears (0.3%) and swelling (0.1%) were rare. Namutebi M et al.[5] reported a 13.5% prevalence of perianal tears and 10.8% for cervical tears, while Ferdous J et al.[2] found perineal tears in 11.2% of cases. A community-based study in Bangladesh reported a 17% prevalence.[9] Episiotomy appears to be a major contributor to postpartum perineal pain. In contrast, Iyengar K et al.[4] reported a much lower prevalence (4.5%). Variations in findings may stem from differences in study settings, obstetric practices (e.g., routine episiotomy), and cultural pain reporting. Episiotomies and perineal tears significantly impact postpartum recovery, causing pain, infection, and mobility restrictions. Despite its impact, perineal pain remains underrecognized in postpartum care, emphasizing the need for better management strategies.

In the present study, postpartum infections were reported in 15.5% of cases, with UTIs (8.4%) being most common, followed by wound infections (1.8%). Fever, an early sign, was seen in 5.3% of cases. Ferdous J et al.[2] reported higher rates of genital infections (19%) and UTIs (12.3%), while Iyengar K et al.[8] found lower puerperal sepsis (5.6%), fever (4.0%), and sepsis (1.3%). Rural Indian and South-East Asian studies reported postpartum fever in 8.9% and maternal sepsis at 4.5 per 100 live births, respectively.[11,12] Variations may be due to differences in settings, infection control, and follow-up. Because infections often appear post-discharge, home visits are crucial for early detection and management. Strengthening postnatal care and promoting hygienic childbirth can reduce postpartum morbidity.

In this study, breast-related complications were reported in 1.6%, including engorgement (1.0%), mastitis (0.5%), and flat or retracted nipples (0.3%). Iyengar K et al.[8] reported a higher prevalence (4.9%), with mastitis in 1.3% of women, while Ferdous J et al.[2] found breast problems in 0.6%. Mastitis incidence peaks at 4 and 12 weeks postpartum, affecting 3–20% of breastfeeding women, with cases occurring up to a year postpartum.[13] In developed countries, mastitis incidence remains below 10%.[14] The lower incidence in our study may be due to early postpartum data collection and the high prevalence of breastfeeding, which may reduce complications. Effective management of breast conditions is essential as they cause maternal discomfort, lead to serious complications, and increase healthcare costs.[15] Untreated infections are a leading cause of early breastfeeding cessation, posing risks to neonates.[15]

In this study, PPH was reported in 0.9% of women. Iyengar K et al.[8] reported PPH requiring blood transfusion in 4.8% of women, while Namutebi M et al.[5] observed a significantly higher PPH incidence of 67.6%. The lower PPH incidence in our study may be attributed to effective intrapartum care, including active management of the third stage of labor, timely uterotonic administration, and improved maternal nutrition. Early detection and management of hypertensive disorders may have also reduced severe PPH risk. Despite its lower incidence, PPH remains a critical obstetric emergency requiring vigilant monitoring and prompt intervention to prevent maternal morbidity and mortality.

In our study, no cases of obstetric fistula were identified, and the incidence is difficult to determine due to geographic variations and data limitations. Fistula is more common in Bangladesh, with estimates of 1.69 per 1,000 cases.[16] A rural India study also reported no cases.[11] Early recognition of prolonged labor and timely cesarean section are key in preventing fistula, with improved maternal healthcare contributing to a decline in prolonged obstructed labor. However, underreporting due to stigma remains a concern.

In our study, postpartum complications were significantly associated with sociodemographic, obstetric, and healthcare-related factors. Younger (<25 years) and older (≥35 years) mothers had higher complication rates (71.4% vs. 67.7%, P = 0.007), as did those with lower education (72.3% vs. 65.1%, P < 0.001). Namutebi M et al.[5] found no significant associations between maternal age and education with postpartum complications, highlighting population-specific differences. Obstetric factors such as LSCS (75.5% vs. 65.2%, P < 0.001), short interpregnancy interval (<24 months) (74.3% vs. 66.1%, P < 0.001), and preterm delivery (72.2% vs. 67.2%, P = 0.0002) were also significantly associated with complications. However, Namutebi M et al.[5] found no significant associations with neonatal factors, suggesting differences in healthcare practices.

The findings of this study have direct implications for national maternal health initiatives, particularly the Reproductive, Maternal, Newborn, Child, Adolescent Health Plus Nutrition (RMNCAH+N) strategy, which emphasizes continuum of care from pregnancy to the postpartum period. The high burden of early postpartum complications highlights the need to strengthen facility-based postpartum monitoring, ensure timely assessments within 48 hours, and focus attention on socially and economically marginalized women, those with inadequate ANC, and women with short birth intervals. Enhancing the quality of ANC—especially achieving four ANC visits and complete supplementation—can help reduce preventable postpartum morbidity.[17] The results also support reinforcing the LaQshya initiative, which aims to improve labor room and maternity operation theatre quality. Higher complications among women with LSCS, preterm births, and limited intrapartum monitoring underscore the importance of adhering to LaQshya standards for intrapartum care, infection control, and timely risk management.[18] Additionally, the presence of infections and breast-related morbidities highlights the critical role of home-based postnatal care (HBPNC) by Accredited Social Health Activists (ASHAs) in ensuring early detection, breastfeeding support, nutrition counseling, and prompt referral. Strengthening HBPNC coverage for high-risk women can significantly improve early postpartum outcomes.[19]

Limitation: As this was a tertiary-care hospital-based study, referral bias (Berkson’s bias) may be present, as such centers often manage more complicated or high-risk pregnancies. Hence, the findings may not be fully generalizable to community or primary care settings. The cross-sectional design restricts causal inference. As the study included only the first 48 hours postpartum, complications occurring after discharge may have been missed. Some outcomes were self-reported, introducing potential reporting bias. Important factors such as duration of labor, oxytocin use, episiotomy, and intrapartum complications were not assessed, which may have influenced the observed associations. Although the overall sample size was large, the number of events for rare complications (e.g. DVT, vaginal hematoma, and obstetric fistula) was very low, which may limit the reliability and stability of regression estimates for these outcomes due to a low event-per-variable ratio. Interaction effects between important variables, such as mode of delivery and gestational age, were not explored, which may have influenced the observed associations.

CONCLUSION

More than two-thirds of women (69.1%) experienced early postpartum complications, including pain, fatigue, perineal conditions, infections (UTIs, wound infections), and PPH. Complications were more common among younger (<25 years) and older (≥35 years) mothers, SC/ST caste groups, those with lower education, and underweight women. Higher prevalence was also noted in those with <4 ANC visits, inadequate supplementation, shorter birth intervals, and preterm deliveries.

It is essential to strengthen postpartum care services, particularly for high-risk groups such as younger and older mothers, and those with inadequate ANC. Focused interventions, including ensuring at least four antenatal visits, adequate iron and calcium supplementation, proper nutritional support, and education regarding birth spacing, are necessary to minimize complications.

Recommendation

Based on the study findings, it is recommended to strengthen postpartum surveillance through routine checkups within 48–72 hours, especially for high-risk groups such as women under 25 or over 35 years. ANC outreach should be enhanced by ensuring a minimum of four ANC visits and providing iron and calcium supplementation alongside nutrition counseling. Targeted health education for underprivileged and illiterate women is essential, emphasizing the importance of ANC, birth spacing, and early recognition of complications. Promoting family planning services can help reduce short interpregnancy intervals, which were linked to higher complication rates.

Author contributions

• Dr. Arvind Sharma: Defined intellectual content, performed literature review, and prepared the first draft of the manuscript.

• Dr. Sunita Patel: Conceptualized the study design and protocol, supervised manuscript preparation, editing, and critical revision.

• Dr. Aprajita: Executed the study protocol, managed data collection and analysis, prepared the manuscript and submitted it, and coordinated revisions.

• Dr. Prince Kumar Lodhi: Contributed to manuscript review, literature search, figure preparation, statistical analysis, and interpretation.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.