Measuring maternal mortality and morbidity and the sequalae of maternal near miss complications in Africa

Despite significant improvements in maternal survival since 2000, an estimated 295,000 maternal deaths occurred worldwide in 2017, with women and girls facing a 1 in 190 lifetime risk of maternal death (WHO 2019). For every woman who dies, 20 more women will experience a life-threatening complication known as "maternal near miss"; many more will experience non-life-threatening complications (ibid).

On the basis of critical knowledge gaps in the research on maternal mortality and morbidity in low-resource contexts, this PhD project will answer four research questions:
1. To what extent is the WHO's definition of maternal death - which only includes those deaths that occur within 42-days of delivery or termination - justified on the basis of the duration of excess mortality following delivery?
2. To what extent are verbal autopsy methods - used to assign cause of death when civil registration of deaths is not available - sensitive to the WHO's 42-day threshold for maternal death?
3. How do the laboratory, clinical and management markers used to identify maternal near miss complications affect estimates of incidence in low resource contexts?
4. What are the consequences of experiencing a maternal near miss complication on a woman's future fertility intentions, daily functioning, physical and mental health outcomes and what are the implications for postpartum care?

Impact
This PhD project will have an instrumental impact, by contributing to a body of evidence that influences international maternal care standards and multilateral health policy. Estimation of the duration of postpartum mortality risk can, alongside other research, inform a revision of the WHO's definition of maternal death used for mortality surveillance. My research can also contribute context-specific recommendations on the feasibility of applying the WHO's maternal near miss criteria in three low-resource contexts in Africa. Finally, estimating near miss survivors' specific physical, sexual and mental health needs can influence guidelines for the appropriate provision of postpartum care and global best practices to improve quality of life.

Collaborative research
This PhD project involves significant collaboration across multiple research institutions. I will use Health and Demographic Surveillance System (HDSS) data, which requires close collaboration with researchers who run the surveillance sites. This includes the Medical Research Unit The Gambia, in addition to other African sites in the INDEPTH Network - a global network of HDSS sites and affiliated research centres.

For the analysis of maternal morbidity, I am using data from the PRECISE Network - a prospective cohort study of pregnancy outcomes designed to strengthen research capacity in Africa. Working with the PRECISE Network involves collaborating with researchers and health experts across multiple academic institutions around the world, and with researchers at the HDSS sites in The Gambia, Kenya, and Mozambique.

Capacity building
Throughout this PhD project, I am developing my technical skills. Through my +1 year at the European Doctoral School of Demography, I have already gained experience in demographic methods, survival analysis, and advanced statistical techniques. I will build upon this experience during my PhD, using HDSS and PRECISE data to develop my capacity as a quantitative researcher in maternal health epidemiology and demography. By conducting a qualitative sub-study with women in PRECISE who have experienced a near miss, I will also develop my qualitative research skills.

Finally, this PhD project will develop my collaborative skills, and my ability to communicate effectively with a range of stakeholders. These skills will help me to develop impactful research to reframe policy issues towards maternal morbidity in low- and middle-income contexts.