Concept of maternal morbidity: rationale
A standard definition for maternal morbidity does not exist nor does the literature report maternal morbidity systematically in a commonly agreed upon approach [
3]. On the basis of the background scoping exercise [
3], and building upon the WHO definition of health [
15] and maternal mortality [
16], the MMWG, by consensus, agreed on the definition for maternal morbidity and associated disability as “
any health condition attributed to and/or complicating pregnancy and childbirth that has a negative impact on the woman’s wellbeing and/or functioning.” Heretofore, the term ‘maternal morbidity’ refers specifically to this definition of the concept. This broad definition recognizes the impact that morbidity may have on different dimensions of health, beyond physical health and seeks to encompass the totality of a woman’s sense of wellbeing. Terminology used in this manuscript can be found in Table
2 below.
Maternal Death | The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes [ 17] |
Maternal Near-Miss | A woman who nearly died but survived a complication a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy [ 11]. Signs of organ dysfunction that follow life-threatening conditions are used to identify maternal near-misses and a set of near-miss indicators enables assessments of the quality of care provided to pregnant women [ 5]. |
Maternal morbidity and associated disability | Any health condition attributed to and/or complicating pregnancy and childbirth that has a negative impact on woman’s wellbeing and/or functioning. |
Functioning | Is an umbrella term for body functions, structures, activities and participation. It denotes the negative aspects of the interaction between an individual (with a health condition) and that individual’s contextual factors (environmental and personal factors) [ 29]. |
Disability | Is an umbrella term for impairments, activity limitations and participation restrictions. It denotes the negative aspects of the interaction between an individual (with a health condition) and that individual’s contextual factors (environmental and personal factors) [ 29]. |
Based on this definition and with the goal of developing identification criteria to be embedded within a measurement tool for maternal morbidity, we initially focused on formulating and populating a matrix of conditions, not limited by the obstetrical and gynecological perspective. A number of issues were identified by the MMWG to inform the basic premises of the matrix, which members deemed necessary to include or at least consider for inclusion: 1) obstetric morbidities, 2) previous/co-existing conditions, 3) mental conditions, 4) intervention related morbidities, 5) trauma (i.e. domestic violence), and 6) cultural practices (i.e. female genital mutilation). In order to identify cases of maternal morbidity according to the agreed upon definition and to strike a balance between feasibility and utility in identification of maternal morbidity cases, we adopted a set of guiding principles to proceed with this work:
1)
identification and measurement of the selected maternal conditions should be pragmatic, action oriented, evidence-based, feasible and applicable to different settings, with regional and international acceptance;
2)
maternal morbidity should not be viewed as consisting only of the conditions themselves, but also their consequences; and
3)
morbid conditions should be prioritized on the basis of their frequency and impact. In addition, we may focus on under- researched and neglected areas.
Balancing the tension between goals of being comprehensive and complete with usability and feasibility proved to be a challenge considering issues such as regional differences in disease incidence and prevalence, the spectrum of maternal morbidity, its occurrence, severity, duration, impact and how a morbidity affects the woman’s well-being. To focus on “what to measure”, we considered the role of prevalence and impact, while recognizing the need to better understand under-researched or neglected areas and the need to define what is intended by the qualifiers of “attributed to” or “complicating”. On “how to measure” maternal morbidity, we envisioned the development of a core module applicable to primary care settings. In either instance, the condition should be associated with a negative maternal outcome. We specified that the particular areas of interest would be the complications and/or manifestations of these conditions either during pregnancy or postpartum.
Maternal morbidity matrix: foundations of a measurement tool
To devise identification criteria we considered categorization of different markers anatomically or by system, as was done in the development of maternal near-miss concept. However, given the particularities of less-severe pregnancy related complications, a more holistic approach was favored. Unlike maternal near-miss events, which have by definition very specific clinical, laboratory and management markers, it was understood that such markers might not be sufficient enough to identify maternal morbidity [
5,
11]. As such, the maternal morbidity matrix consists of three dimensions (Figs.
1 2,
3 and
4).
Similar to the near-miss criteria, we sought to develop a set of locally relevant criteria which allow for comparisons between different settings, regions and countries. Therefore, the first dimension consists of the symptoms, signs, investigations and management strategies. Unlike near-miss, symptoms are included in the identification criteria of maternal morbidity, with the anticipation that they would correlate strongly with the associated disability (e.g. fatigue, shortness of breath) and thus, may be the primary reason for women to seek care. Signs are findings on physical examination and are similar to the clinical criteria of the near-miss criteria. The identification criteria also include investigations, which are broader in scope than the lab markers for the near-miss criteria, and are comprised of laboratory tests, imaging studies and diagnostic tests such as biopsies. Management strategies include treatment options like medications, surgical procedures and radiation.
Initially, the Group aimed to make the matrix as comprehensive as possible, representing both developing and developed country settings. Informed by the WHO scoping exercise on maternal morbidity [
3], reviews of published literature, relevant textbooks and the WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD-Maternal Mortality (ICD-MM) [
17], a set of conditions were selected. We considered conditions that may occur in women of reproductive age including those specific to pregnancy and postpartum. A matrix was developed, including each of these conditions and their relevant symptoms, signs, investigations and management strategies. The first version included 301 conditions, originally cross-referenced with 109 symptoms, 106 signs, 121 clinical tests and 91 management strategies [
2]. At this point, the MMWG recognized the existing health care structures in low- and middle-income countries (LMICs) to balance aspirational versus pragmatic approaches. Therefore, to further consolidate the matrix, the Group developed and agreed up the following criteria:
1)
conditions associated with a negative maternal outcome that are either exclusive to pregnancy, childbirth, and the postpartum state, with an estimated occurrence of >0.1 % in pregnancy; or
2)
conditions that are not exclusive to pregnancy, childbirth, and postpartum but which occur more frequently during pregnancy (i.e. pregnancy is a risk factor for the disease).
The cut-off of 0.1 % for occurrence (prevalence or incidence) was deemed to be a reasonable cut-off that distinguished between very rare diseases and diseases that are more common and was informed by current estimates of disease conditions in the published literature. When evidence was unavailable, the group used a consensus mechanism based on expert opinion. Additionally, to account for regional differences in prevalence of certain conditions, the Group intends for the tool, based on the matrix, to be revised for regional implementation.
Moreover, to frame the matrix we used the precedent of ICD-MM, a special adaption of the ICD-10 intended to improve the classification of maternal mortality and morbidity [
11,
17]. We grouped the domains in line with the ICD-MM, such as pregnancies with abortive outcome, obstetric hemorrhage or non-obstetric complications, with the intent of showing how data at different levels of detail may be aggregated together and to ensure continuity between the spectrum of morbidity through mortality [
17]. Additionally, though it is beyond the scope of this work to revisit the definition of “direct” and “indirect” maternal mortality (and by extension, morbidity); the work of this group in reviewing the conditions aligned to each category has been informing the discussion on whether the distinction between “direct” and “indirect” remain necessary or useful. As a result of the abovementioned process, the next version of the matrix includes 121 conditions cross-referenced with all identified criteria based on the ICD-MM groupings and generated 58 symptoms, 29 signs, 44 investigations and 35 management strategies. Conditions consistent with severe maternal morbidity as manifestations of maternal near-miss were not included in this consolidated matrix as they are already identified by the maternal near-miss tool [
11].
A
second dimension is the functional impact and disability assessing the loss of physical, psychological, cognitive, social and economic functions. Key concepts related to functioning and disability as conceptualized and defined in the International Classification of Functioning, Disability and Health (ICF) are incorporated [
11] thru the existing, validated tool, WHO Disability Assessment Schedule 2.0 (WHODAS 2.0) [
18]. This tool covers 6 domains in line with ICF (cognition, mobility, self-care, getting along, life activities and participation) and produces standardized disability levels and profiles using a short, simple and easy to administer questionnaire [
18]. In addition, preliminary findings from a systematic review on maternal morbidity and quality of life, currently in progress, will be used to refine our assessment tool to be more centered on maternal health to gauge women’s experiences.
The third dimension is the maternal history focusing on social and health related characteristics, which might help identify the maternal morbidity as well as influence the risk and severity of the morbidity. Some examples include socio-economic determinants, pre-existing conditions, care seeking during the pregnancy, etc. Incorporating maternal demographic characteristics, past obstetric history, history during index pregnancy and fetal outcome allows full elaboration of the “woman as a whole”. Inclusion of fetal measures in the index pregnancy appraises linkages between maternal morbidity and fetal outcomes, attesting to the irrefutable mother-baby dyad.