Advances in the conceptualisation and measurement of maternal morbidity and mortality

Progress to improve maternal survival has stalled in the first five years of the Sustainable Development Goal (SDG) era. In the context of this stagnation and the rapidly changing epidemiological profile of maternal health, this thesis examines the reasons for, and limitations of, the focus of the international maternal health agenda on survival up to 42 days postpartum. Specifically, it advances the conceptualisation and measurement of maternal morbidity and mortality (1) in the extended postpartum period beyond 42 days; and (2) the cumulative burden across the reproductive life course. Part 1: The postpartum period is defined as the first 42 days following the termination of pregnancy. This definition influences the upper limit of the WHO’s recommended postpartum care schedule and serves as the cut-off for identifying maternal deaths. I interrogate this timeframe by examining women’s risk of death, causes of death, and recovery trajectories in the extended postpartum period and beyond. The findings support the need to re-envision models of postpartum care and the measurement of mortality beyond 42 days. Part 2: Existing measures of maternal morbidity estimate the obstetric risk associated with an individual pregnancy. However, risk accumulates across a woman’s life course, depending on repeated exposure (fertility levels) and reproductive age survival (mortality levels). I develop the methodology and derive the first cross-country estimates for two new measures of cumulative risk: the lifetime risk of maternal near miss and the lifetime risk of severe maternal outcome (near miss or maternal death). These metrics offer new perspectives on global inequity in maternal outcomes. Based on these findings, this thesis advocates for an ambitious expansion of the maternal health agenda. A reorientation towards the neglected medium- to long-term consequences of pregnancy and childbirth, and the cumulative burden of maternal morbidity across the reproductive life course, is essential in the post-SDG era.