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

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 often-quoted 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 well-being. 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 well-being and/ This is an open access article distributed under the terms of the Creative Commons Attribution IGO License which permits unrestricted use, distribution and reproduction in any medium, provided that the original work is properly cited. In any reproduction of this article there should not be any suggestion that WHO or the article endorse any specific organization or products. The use of the WHO logo is not permitted. This notice should be preserved along with the article's URL.
consistently measured at the healthcare facility and community level across varying country and regional settings. Beyond establishing the burden of disease, would the approach be able to document the issues that are important to women themselves?
The group's early discussions focused on identifying the starting point for this body of work. It was decided that, to facilitate the necessary innovative thinking, each expert member should discard their own notions about maternal morbidity and think instead from the woman's perspective, starting by asking a basic, yet surprisingly bold, Ending preventable maternal mortality remains relevant and fundamental to achieving global development goals. 6 Embracing the human-rights-based approach, all women, everywhere, need to receive the same level of high-quality care before pregnancy and during pregnancy, labor, childbirth, and the postpartum period; the current reality falls short of this, and the risk of death remains tragically high. However, it is also imperative to expand the myopic focus on mortality to include morbidity, and to broaden the medicalized per- There is an urgent need to communicate the new conceptual framework on maternal morbidity and translate it for use by healthcare providers, academics, and decision makers. In order to "mainstream" the identification and management of maternal morbidity, the MMWG recognizes the need for continued refinement and development of the framework and related tools. Prior to global scale-up, additional empirical research, peer review, and implementation activities are needed to guide efficient, evidence-based, and sustainable roll-out. To achieve this, the mantra of "health, empowerment, and well-being" must be embedded in the daily lives of all women. The simplicity of the message belies the seriousness of the rallying call to bring attention to the urgent, unmet needs of women, their families, and communities. The findings of the MMWG clearly show that the ability to survive and thrive, and to participate productively in transforming society and the world, is not | 3 EDITORIAL a privilege to be enjoyed by the few. Just as prevention of maternal mortality supports the human right to life, 10 if the global community is to have a meaningful impact on maternal health then the reduction of maternal morbidity must also be recognized as a basic right.

AUTHOR CONTRIBUTIONS
LS and DC conceptualized and steered the work from its initial development, and drafted and finalized the manuscript.