Title: Postpartum preparedness, womens work, wellbeing, and - PDF document

Title: Postpartum preparedness, women’s work, wellbeing, and productivity: findings from a prospective cohort study in Bobo-Dioulasso, Burkina Faso Jenny A. Cresswell London School of Hygiene & Tropical Medicine, London, UK. jenny.cresswell@lshtm.ac.uk Rasmané Ganaba AFRICSanté, Bobo-Dioulasso, Burkina Faso. rganaba.muraz@fasonet.bf Véronique Filippi London School of Hygiene & Tropical Medicine, London, UK. veronique.filippi@lshtm.ac.uk

Abstract: Description of topic : Good health is essential to productivity and development. In Burkina Faso, it is common for women to work late in pregnancy and resume work relatively soon after delivery. We investigate whether the concept of birth preparedness can be usefully extended to preparedness for the postpartum period, and investigate whether women who plan in advance by identifying people who can help with their workload and/or saving money and/or using family planning postpartum have better health and wellbeing. Theoretical focus: How well do women currently prepare for the postpartum period? Is postpartum preparedness associated with improved postpartum wellbeing and functioning, including economic functioning such as ability to work and productivity? Data & research methods: We use quantitative data from a population-based prospective cohort in Burkina Faso (N=839). Women were recruited during the third trimester of pregnancy (December 2013 to March 2014) and subsequently followed over nine months. Results: Around a third had saved money for the postpartum period; and approximately two thirds had identified someone (nearly always a family member) to help with domestic work postpartum. We expect that women who are better prepared for the postpartum period will have better health and wellbeing after the delivery.

Postpartum preparedness, wom en’s work, wellbeing, and productivity: findings from a prospective cohort study in Bobo-Dioulasso, Burkina Faso Jenny A. Cresswell, Rasmané Ganaba, Véronique Filippi BACKGROUND We have entered a new era defined by the Sustainable Development Goals (SDGs) which recognise the need to focus on health in the broadest sense, encompassing women’s wellbeing and ability to be productive and fully participate in economic activities; including the recognising and valuing unpaid care and domestic work (Goal 5) which constitute a substantial part of women’s work in settings like Burkina Faso. At the micro-level, we need to have good understanding of the ways in which women’s reproductive health , wellbeing, and capacity to participate in economic activities interact. Health is essential to productivity and ultimately development; in a context such as Burkina Faso, a low-income country in West Africa where women (52% of the population) have on average six live births during their lifetime, women spend a substantial proportion of their adult working years either pregnant or postpartum. It is common for women to work very late in pregnancy and resume work relatively soon after delivery. However, the extent to which pregnancy and maternal morbidity impact upon women’s functioning and ability to participate in economic and other productive activities is poorly understood. Anthropological work has shown how reproduction and productivity are mutually reinforcing domains in settings such as Burkina Faso, sometimes constraining and sometimes compensating for each other. Birth preparedness and complications readiness have previously been promoted as a way to improve maternal health, by increasing women’s knowledge of the s igns of delivery complications and encouraging her to make practical plans to deliver within an appropriate health facility. In this paper, we propose extending the concept of birth preparedness to preparedness for the postpartum period: for example by saving money specifically for expenses in the postpartum period (such as buying necessities for the baby) which are incurred at a time when the woman herself may be unable to continue with her own usual income-generating activities, by identifying person(s) who can assist with productive activities (be they domestic, income-generating or non-income generating) in the postpartum period, making plans for how and when she intends to return to work, and whether to use family planning to space subsequent births.

The paper will propose a new concept of preparedness for the postpartum period. We will describe how long women in Bobo-Dioulasso, Burkina Faso stop i) domestic, ii) income-generating activities around the time of childbirth, how the symptoms they experience affect their functioning, and the average loss of income or additional expenses incurred during this period.We will investigate whether postpartum preparedness associated with improved economic wellbeing and functioning postpartum. METHODS We conducted an observational prospective cohort study following a population-representative sample of pregnant and early postpartum women living in Bobo-Dioulasso, second city of Burkina Faso, and surrounding rural areas. Women were selected using a stratified (urban vs. rural) multi- stage sampling design. We recruited 839 women living in the study area who were between seven months’ gestation and three months postpartum at baseline (December 2013 to March 2014). Three structured questionnaires were administered over a nine-month follow-up period, with a period of 2-3 months between each interview. Fieldwork ended in December 2014. The follow-up rate was 93%. Women were included regardless of whether the infant was live or stillborn. The data presented in this paper focuses on the 424 women who were pregnant at baseline (and thus could report prospectively on their expectations and preparedness for return to work during the postpartum period). RESULTS Over 95% of women delivered vaginally; the majority delivered in a CSPS (health centre). Preparedness for the postpartum period has been measured using variables presented in Table 1 . Around a third of mothers had saved money for the postpartum period; and approximately two thirds had identified someone (nearly always a family member) to help with domestic work during the postpartum period. Women said that they expected to rest for approximately 40 days after the delivery, in line with dominant cultural practices, before resuming productive activities within and outside the household. In practice, most women resumed domestic work within a week or less of the delivery ( Figure 1 ). Women with an informal sector job, such as street vending, resumed this work a median of two months post-delivery, whilst women in salaried employment resumed paid work a median of three months after the birth.

Most women rated their own health as good and reported that their health did not cause them difficulties in completing work-related activities ( Table 2 ), however a minority of women persistently did report problems. Two thirds of women reported one or more symptom of physical discomfort during the postpartum period ( Table 3 ). These were most common during pregnancy or the early postpartum period, and generally improved over time. CONCLUSIONS In this region of Burkina Faso women overwhelmingly work outside of the formal sector, with consequent insecure labour conditions and lack of access to social security benefits such as maternity leave. Our study found that it was women who worked in the informal sector, particularly doing jobs such as street vending, who often experienced the greatest difficulties during the postpartum period. This group of women does not have access to maternity leave but face greater practical difficulties in returning to work than those whose principal work was domestic or based in subsistence agriculture. This group is likely to increase in importance as Burkina Faso develops economically and urbanises. The income women generate, either in cash or kind, is usually small in absolute terms. However, this income is very important to them and their sense of empowerment and independence, since it is one of the few streams of income that women typically have control over how it is spent. We know from qualitative work that women often face a gruelling “double burden” of domestic and income - generating activities and can feel pressure to return to work before they are fully recovered from the birth, particularly if additional expenses were occurred due to a complicated delivery, or if the delivery did not result in a live child.