INTRODUCTION

The Demographic and Family Health Survey - ENDES is a continuous statistical investigation that is carried out at the national level to obtain updated information about health indicators of the population. This survey is carried out by duly trained personnel, through direct interviews and through home visits to a representative sample of selected households to collect data on maternal and child health, use of health services, chronic non-communicable diseases, nutrition and other important aspects that can be used to follow up, propose health policies and programs. Likewise, this source of information, being freely accessible and having current and true information, can be used by the academic community for future research.

Obstetric complications are a cause of maternal morbidity and mortality worldwide, these can occur during pregnancy, childbirth, or the puerperium. Immediate, mediate and late postpartum complications are important events because it is a stage where physiological and emotional changes occur and the high mortality they produce¹.

In Peru, it was shown that in 2019 and 2020, the stage with the highest frequency of maternal mortality due to direct obstetric causes was the puerperium, with 59.7% and 63.3% respectively, with the leading causes being hemorrhage and sepsis with 55.7%. The highest amount of maternal mortality in 2020 was reported in the departments of Lima Metropolitan, Loreto, Ucayali, Lambayeque, La Libertad, Junín and Cusco^2,3.

Despite the fact that our country managed to reduce maternal mortality by 73%, it is still considered a great threat to pregnant women and constitutes an important public health problem. Therefore, it is essential to identify which complications can occur, and at what stage it can occur⁴.

Although obstetric factors are the most studied, sociodemographic factors must also be taken into account, since they have been identified in some studies that are associated with higher maternal mortality, such as the prevalence in young people between 18 and 35 years old, with low socioeconomic status or low level of education, which make it difficult to access information and health services. Therefore, it is important to know the situation in which the Peruvian population finds itself in order to propose health policies that help to reduce morbidity and mortality⁵.

The objective of this study is to determine the factors associated with postpartum complications, according to ENDES from 2019 to 2020, and thus contribute with results that help prevent and reduce maternal morbidity and mortality.

METHODS

RESULTS

The initial sample consisted of 19,248 records, which, considering the inclusion and exclusion criteria, a sample size of 18,115 women aged 12 to 49 years was obtained, interviewed in the 2019-2020 Demographic and Family Health Survey.

The prevalence of postpartum complications in 2019-2020 is 37.7% of the total. In 2019, 38.1% of the women aged 12 to 49 presented complications after childbirth. Likewise, in 2020, 37.2% of women presented complications after childbirth. When carrying out the analysis of the geographical distribution of postpartum complications, it was found that the departments San Martín, Cusco, Apurímac, Arequipa, Ayacucho, Huancavelica, Madre de Dios, Pasco, Amazonas and La Libertad present a higher prevalence of 38, 8%-42.5% of postpartum complications, followed by the departments of Moquegua, Junín, Ancash, Huánuco, Lambayeque and Loreto with a prevalence of 35.4%-38.8%. (Figure 1).

Figure 1. Geographic distribution of complications after childbirth, in women aged 12 to 49 years, according to ENDES 2019-2020 

Regarding the general characteristics of the interviewees in the ENDES 2019-2020, the following stands out: In relation to sociodemographic factors, 65.2% of the women are between 20 and 35 years old, 49.7% are from mixed race, 46.3% have a secondary education degree, 59.2% have a marital status of cohabiting, 75.1% live in the urban area, 56.1% are from the Coast region and in terms of the index of wealth 67.7% have little income; regarding obstetric factors, 97.9% had postnatal check-ups, 63.9% did not have a cesarean delivery, 67.8% had the public sector as the place of delivery, and 66.8% had no complications during delivery. ; regarding domestic violence, 67.9% experienced physical and emotional violence during pregnancy.

Furthermore, the coefficient of variation was obtained for each of the variables, where the percentage of said coefficient was less than 15% in most of the variables, this gives us an assurance that the sample obtained is adequate for our research. (Table No. 1).

The bivariate analysis of sociodemographic factors such as age, ethnicity, marital status and wealth index are statistically significantly associated with postpartum complications, with a p-value less than 0.050. There is evidence that being between 20 and 35 years of age (PR: 1.20, 95% CI: 0.99 to 1.21) increases the prevalence of postpartum complications. Regarding the wealth index variable: Low income (PR: 1.06, 95% CI: 1.01 to 1.10); being of black ethnicity (PR: 0.93, 95% CI: 0.87 to 0.99), mix race (PR 0.91, 95% CI 0.87 to 0.95) and marital status: single (PR: 0 .8, 95% CI: 0.79 to 0.95) decreases the probability of having complications after childbirth. Analyzing the level of education: without education (PRc: 1.02, CI95%: 0.87 to 1.21), primary (PRc: 0.97, CI95%: 0.91 to 1.02) and secondary (PRc : 1.01, 95% CI: 0.97 to 1.06), type of place of residence: urban (PRc: 0.99, 95% CI: 0.95 to 1.03) and region: Coast (PRc: 1 .01, 95% CI: 0.96 to 1.07) and mountain (PRc: 1.04, 95% CI: 0.98 to 1.11) no statistical association was found because the confidence interval of the PR contains the unit. (Table No. 2).

Obstetric factors such as postnatal checkups, place of delivery, complications during childbirth and violence factor, both physical and emotional, are associated in a statistically significant way with postpartum complications, with a p-value less than 0.050. It is evident that the following factors increase the prevalence of postpartum complications: Failure to present postnatal check-ups (PRc: 1.16, 95% CI: 1.03 to 1.30), place of delivery: public sector (PRc: 1.06 , 95% CI: 1.02 to 1.11) and having developed complications during childbirth. (PRc: 2.79, CI95%: 2.69 to 2.89), physical and emotional violence (PRc: 1.05, CI95%: 1.01 to 1.09). Regarding having a cesarean delivery (PRc: 0.96, 95% CI: 0.92 to 0.99), the probability of having complications after delivery decreases. (Table No. 3).

The results of the multivariate analysis show that the age of 20 to 35 years has a prevalence ratio of 1.12 of ending in complications after childbirth (PRa: 1.12, 95% CI: 1.07 to 1.18). Having complications during childbirth is 2.75 times more prevalent than complications after childbirth (PRa: 2.75, CI95%: 2.64 to 2866). Have a primary education level (RPa: 0.90, 95% CI: 0.84 to 0.96), secondary education (RPa: 0.94, 95% CI: 0.89 to 0.98) and have a single marital status (RPa 0.852, 95% CI: 0.76 to 0.94) decrease the probability of having complications after childbirth. (Table No. 4).

DISCUSION

In the present manuscript, regarding the prevalence of postpartum complications in women aged 12 to 49 years, according to ENDES 2019 and 2020, it is evident that of the total sample (18,115), 37.70% did present complications after childbirth, and 62.30% did not present them. At national level, these figures are similar to those obtained by Méndez and Morales according to ENDES 2017 to 2019, where the prevalence of postpartum maternal obstetric complications in the total sample was 28.7%⁷. Pereira, in his research carried out at the Hospital Maria Auxiliadora Hospital, showed a prevalence of 33.3% of postpartum complications and Vargas found a prevalence of postpartum complications of 13.8% at the Hospital Nacional Arzobispo Loayza^8,9.

Regarding international studies, Villarreal, at the Historic Center Health Center in Quito, observed that 12% of women presented some complication during the puerperium¹⁰. Likewise, in the study by Páez and Romero in Bogotá-Colombia, it was shown that 6.3% of the pregnant women attended in the high complexity hospital presented puerperal complications¹¹.

The prevalence obtained in our study together with the obtained in other national studies, have a higher percentage of puerperal complications unlike international studies, this could be due to the fact that in our country no greater measures and health policies have been taken for adequate care during the stage of pregnancy, through an adequate diagnosis, stabilization and timely referral to an establishment with greater resolution capacity¹².

Age in the range of 20 to 35 years old is a sociodemographic factor associated with postpartum complications (p<0.05). These results are similar to the study carried out at the national level by Vargas, who reported that the age group with the highest prevalence was between 18 and 35 years with 78.9%⁽⁹⁾. Zegarra, in his study, observes that the women who had the highest frequency of puerperal complications were in the group of 25 to 29 years, representing 25.1% of the population, but analyzing the 8 age groups used in his study, it is evident that 3 age groups that cover the ages between 20 to 34 years are the ones with the highest frequency of puerperal complications¹³.

At the international level, Villarreal in his study, observed that 37% of women aged between 20 and 24 years had a higher percentage of complications after childbirth¹⁰. This could be explained due to the lack of information of the young women about the warning signs and postpartum care¹³.

Our results differ from studies,like Paéz and Romero's study for example, where the group older than 35 years was the most frequent with postpartum complications with 9.5%¹¹. Otherwise, Martínez and Brizuela, obtained a prevalence of 32% of complications in the puerperium in the age group between 15 and 19 years¹⁴. Furthermore, Sikder et al, showed in their multivariate analysis that women under 18 years of age (relative risk ratio [RRR] 1.26; 95% CI: 1.14-1.39) and over 35 years of age (RRR 1.23 95% CI: 1.09-1.38), significantly increased the risk of having obstetric complications during the puerperium¹⁵.

The education level is a sociodemographic factor associated with complications after childbirth. Having Primary (PRa: 0.90, CI95%: 0.84 to 0.96) and Complete Secondary (PRa: 0.94, CI95%: 0.89 to 0.98) decreases the probability of having complications after childbirth . This differs from Naula et al, who carried out their study at the Vicente Corral Moscoso hospital, in Cuenca-Ecuador, and observed that the complete secondary level predominated in the population of puerperal women who presented complications (47.2%), being these among the most frequent characteristics of your study¹⁶.

At the national level, Delgado observed that postpartum women who had complications were characterized by having completed secondary education in 29.89%¹⁷. Méndez and Morales determined the education level of women in the puerperium; mothers with no studies or with primary education (PR= 0.84; 95% CI= 0.78 - 0.90) and women with secondary education (PR= 0.93; 95% CI= 0.89 - 0.98 ) are less likely to present complications during the puerperium⁷. These data are compatible with the results of our study. Quispe showed that the puerperal women with the lowest percentage of bleeding complications had only primary level, representing 1.7% of the total of the educational level variable¹⁸. Our results could be due to the fact that the group of women with primary and secondary level surveyed did not understand well the interviewer's question about the symptoms of complications, they may have underestimated the intensity of the symptoms and did not consider them as a complication.

Marital status is an associated sociodemographic factor (p value <0.05). Being single (OR: 0.87, 95% CI: 0.79 to 0.95) decreases the probability of having complications after childbirth. This result coincides with international studies by Páez and Romero, where they showed that women with single marital status were the ones who presented the lowest percentage of puerperal complications with 23.8%¹¹. Unlike Villarreal, the group of women with single marital status obtained 37%, being the group with the highest percentage of complications after childbirth¹⁰. Likewise, Martinez and Brizuela in their study, observed that women with complications during the puerperium with single marital status reached 37.3%, being the second highest group within the marital status variable¹⁴. Naula et al, report that women with postpartum complications with married marital status and free union predominated with 42.5% and 43% respectively¹⁰. Our result could be explained by the fact that many of the single mothers in Peru have family support in terms of education, food, maintenance and protection, so they can go to health centers for postnatal medical check-ups¹⁹.

Regarding complications during childbirth, an association was found with complications after childbirth (p value <0.05). These include prolonged labor, excessive bleeding, fever with vaginal bleeding, seizures, and others. The Vargas study shows that 61% of patients with postpartum hemorrhage had a prolonged delivery. Likewise, it was recorded that 95.6% of women with postpartum complications presented excessive bleeding during childbirth⁹.

Huvin concludes that having had complications during childbirth is significantly associated with puerperal complications in Peruvian women, this being one of the main risk factors in their study, since they have a 2.25-fold probability of presenting complications during the puerperium. (p= 0.001)²⁰. Montenegro and Arango analyzed the perinatal variables in their study, where significance was only obtained for the presence of complications during childbirth, with an OR of 6.98 and a value of p=0.000²¹. This is due to the fact that the main puerperal pathologies that cause the highest mortality occur just after childbirth, in the immediate puerperium. Therefore, if complications occur during labor, they could influence the development of complications during the puerperium.

The main limitation of this research is that there was no access to hospital centers, so we worked with a source of secondary data, generating a limitation when choosing the study variables, such as postpartum complications, for this reason we did not could add more variables of importance. Furthermore, as it was a retrospective cross-sectional study, the association could be established, but not the causality between the variables studied. It is recommended to carry out prospective studies that identify other associated factors, this will be very helpful to identify patients with a high risk and thus intervene effectively to reduce the epidemiological impact of these complications on maternal morbidity and mortality both nationally and internationally.

CONCLUSION

In conclusion, the factors associated with postpartum complications, according to the ENDES, Peru - 2019-2020, are age and complications during childbirth.

The level of education and marital status were found to be protective factors.