Maternal morbidity: Time for reflection, recognition, and action

Efforts to improve maternal health globally are often viewed simply as measures to avoid maternal death. While declining mortality can be a useful proxy measure for improved health when it comes to setting goals in line with the global sustainable development agenda, it is doubtful that any woman, mother, family member, or community considers “good maternal health” to mean simply surviving pregnancy and childbirth. How women experience pregnancy and childbirth is rarely documented or discussed by policy makers, program managers, or healthcare providers, nor is it commonly reflected upon by the woman’s family or possibly even herself. Possible reasons for this lack of consideration—and lack of even a common understanding of “wellbeing” during pregnancy, labor, childbirth, and in the immediate postpartum period—could be that pregnancy and childbirth are accepted as transitory life events that are not as salient as a death or a severe complication, or that as “experiences” they are too difficult to describe, quantify, or analyze. Yet, given the opportunity, almost every person and community has a story to tell about pregnancy and childbirth, from their own personal experience or those of their relatives, friends, or fellow community members. The quantifiable aspects of these “stories” are occasionally described in the literature, such as the oftenquoted statistic that there are 20–30 cases of morbidity for every maternal death,1,2 and thematic narrative summaries have been provided on this topic in the reports of some qualitative ethnographic studies. Quantitative descriptions that compare binary assessments of morbidity (i.e. “yes/ some” versus “no” morbidity) may not be sufficient for assessment of maternal morbidity. Perhaps a complementary and more holistic approach—which acknowledges the combined influence/impact of the woman’s own experiences, her environment, and current biomedical knowledge/technology—could shed more light on the experience of maternal health and wellbeing. In 2012, WHO initiated a fiveyear project, funded by the Bill & Melinda Gates Foundation, with the aim of developing the evidence base on maternal morbidity through improving the scientific basis for defining, measuring (and estimating), and monitoring it. A multidisciplinary group was convened including academics, clinicians, and public health program managers from six continents and a variety of settings, bringing together their cumulative knowledge and expertise. The dedicated members of this collaboration—the Maternal Morbidity Working Group (MMWG)—systematically unpacked the meaning of maternal morbidity, and examined in depth how best to define, describe, and measure it for the purposes of research, epidemiology, and ultimately to improve women’s experience of the care they receive. Throughout the process, the aim was to close the gap between measuring morbidity for programmatic purposes and assessing its actual impact on a woman’s life (including describing the experience of it)—the aspect that had previously been neglected. The definition for maternal morbidity that the MMWG eventually arrived at was: “any health condition attributed to and/or complicating pregnancy and childbirth that has a negative impact on the woman’s wellbeing and/ or functioning”.3 This definition allows for conditions to be understood from a woman’s point of view and assessed in terms of how they affect her life. Next, keeping this definition firmly in mind, the challenge was to establish how maternal morbidity could be meaningfully and