Search

© 2018 World Health Organization; licensed by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics. The maternal health agenda is undergoing a paradigm shift from preventing maternal deaths to promoting women's health and wellness. A critical focus of this trajectory includes addressing maternal morbidity and the increasing burden of chronic and noncommunicable diseases (NCD) among pregnant women. The WHO convened the Maternal Morbidity Working Group (MMWG) to improve the scientific basis for defining, measuring, and monitoring maternal morbidity. Based on the MMWG's work, we propose paradigms for conceptualizing maternal health and related interventions, and call for greater integration between maternal health and NCD programs. This integration can be synergistic, given the links between chronic conditions, morbidity in pregnancy, and long-term health. Pregnancy should be viewed as a window of opportunity into the current and future health of women, and offers critical entry points for women who may otherwise not seek or have access to care for chronic conditions. Maternal health services should move beyond the focus on emergency obstetric care, to a broader approach that encompasses preventive and early interventions, and integration with existing services. Health systems need to respond by prioritizing funding for developing integrated health programs, and workforce strengthening. The MMWG's efforts have highlighted the changing landscape of maternal health, and the need to expand the narrow focus of maternal health, moving beyond surviving to thriving.

© 2018 World Health Organization; licensed by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics. Objective: To field test a standardized instrument to measure nonsevere morbidity among antenatal and postpartum women. Methods: A cross-sectional study was conducted in Jamaica, Kenya, and Malawi (2015–2016). Women presenting for antenatal care (ANC) or postpartum care (PPC) were recruited if they were at least 28 weeks into pregnancy or 6 weeks after delivery. They were interviewed and examined by a doctor, midwife, or nurse. Data were collected and securely stored electronically on a WHO server. Diagnosed conditions were coded and summarized using ICD-MM. Results: A total of 1490 women (750 ANC; 740 PPC) averaging 26 years of age participated. Most women (61.6% ANC, 79.1% PPC) were healthy (no diagnosed medical or obstetric conditions). Among ANC women with clinical diagnoses, 18.3% had direct (obstetric) conditions and 18.0% indirect (medical) problems. Prevalences among PPC women were lower (12.7% and 8.6%, respectively). When screening for factors in the expanded morbidity definition, 12.8% (ANC) and 11.0% (PPC) self-reported exposure to violence. Conclusion: Nonsevere conditions are distinct from the leading causes of maternal death and may vary across pregnancy and the puerperium. This effort to identify and measure nonsevere morbidity promotes a comprehensive understanding of morbidity, incorporating maternal self-reporting of exposure to violence, and mental health. Further validation is needed.

© 2018 World Health Organization; licensed by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics. Background: Globally, there is greater awareness of the plight of women who have complications associated with pregnancy or childbirth and who may continue to experience long-term problems. In addition, the health of women and their ability to perform economic and social functions are central to the Sustainable Development Goals. Methods: In 2012, WHO began an initiative to standardize the definition, conceptualization, and assessment of maternal morbidity. The culmination of this work was a conceptual framework: the Maternal Morbidity Measurement (MMM) Framework. Results: The framework underscores the broad ramifications of maternal morbidity and highlights what types of measurement are needed to capture what matters to women, service providers, and policy makers. Using examples from the literature, we explain the framework's principles and its most important elements. Conclusions: We express the need for comprehensive research and detailed longitudinal studies of women from early pregnancy to the extended postpartum period to understand how health and symptoms and signs of ill health change. With respect to interventions, there may be gaps in healthcare provision for women with chronic conditions and who are about to conceive. Women also require continuity of care at the primary care level beyond the customary 6 weeks postpartum.

© 2018 World Health Organization; licensed by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics. Objective: To field test a standardized instrument to measure nonsevere morbidity among antenatal and postpartum women. Methods: A cross-sectional study was conducted in Jamaica, Kenya, and Malawi (2015–2016). Women presenting for antenatal care (ANC) or postpartum care (PPC) were recruited if they were at least 28 weeks into pregnancy or 6 weeks after delivery. They were interviewed and examined by a doctor, midwife, or nurse. Data were collected and securely stored electronically on a WHO server. Diagnosed conditions were coded and summarized using ICD-MM. Results: A total of 1490 women (750 ANC; 740 PPC) averaging 26 years of age participated. Most women (61.6% ANC, 79.1% PPC) were healthy (no diagnosed medical or obstetric conditions). Among ANC women with clinical diagnoses, 18.3% had direct (obstetric) conditions and 18.0% indirect (medical) problems. Prevalences among PPC women were lower (12.7% and 8.6%, respectively). When screening for factors in the expanded morbidity definition, 12.8% (ANC) and 11.0% (PPC) self-reported exposure to violence. Conclusion: Nonsevere conditions are distinct from the leading causes of maternal death and may vary across pregnancy and the puerperium. This effort to identify and measure nonsevere morbidity promotes a comprehensive understanding of morbidity, incorporating maternal self-reporting of exposure to violence, and mental health. Further validation is needed.

© 2018 World Health Organization; licensed by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics. Objectives: To compare scores on the 36-item WHO Disability Assessment Schedule 2.0 tool (WHODAS-36) for postpartum women across a continuum of morbidity and to validate the 12-item version (WHODAS-12). Methods: This is a secondary analysis of the Brazilian retrospective cohort study on long-term repercussions of severe maternal morbidity. We determined mean, median, and percentile values for WHODAS-36 total score and for each domain, and percentile values for WHODAS-12 total score in postpartum women divided into three groups: “no,” “nonsevere,” and “severe” morbidities. Results: The WHODAS-36 mean total scores were 11.58, 18.31, and 19.19, respectively for no, nonsevere, and severe morbidity. There was a dose-dependent effect on scores for each domain of WHODAS-36 according to the presence and severity of morbidity. The diagnostic validity of WHODAS-12 was determined by comparing it with WHODAS-36 as a “gold standard.” The best cut-off point for diagnosing dysfunctionality was the 95th percentile. Conclusion: The upward trend of WHODAS-36 total mean value scores of women with no morbidity compared with those with morbidity along a severity continuum may reflect the impact of morbidity on postpartum functioning.

© 2018 World Health Organization; licensed by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics. Objective: To validate the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0) 12-item tool against the 36-item version for measuring functioning and disability associated with pregnancy and the occurrence of maternal morbidity. Methods: This is a secondary analysis of the Brazilian retrospective cohort study on long-term repercussions of severe maternal morbidity (SMM) among women who delivered at a tertiary facility (COMMAG study). We compared WHODAS-12 and WHODAS-36 scores of women with and without SMM using measures of central tendency and variability, tests for instruments’ agreement (Bland-Altman plot), confirmatory factor analysis (CFA), and Cronbach alpha coefficient for internal consistency. Results: The COMMAG study enrolled 638 women up to 5 years postpartum. Although the median WHODAS-36 and -12 scores for all women were statistically different (13.04 and 11.76, respectively; P<0.001), there was a strong linear correlation between them. Furthermore, the mean difference and the differences in variance analyses demonstrated agreement of total scores between the two versions. CFA demonstrated how the WHODAS-12 questions are divided into six previously defined factors and Cronbach alpha showed good internal consistency. Conclusion: WHODAS-12 demonstrated agreement with WHODAS-36 for total score and was a good instrument for screening functioning and disability among postpartum women, with and without SMM.

© 2018 World Health Organization; licensed by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics. Objective: To assess the scores of postpartum women using the WHO Disability Assessment Schedule 2.0 36-item tool (WHODAS-36), considering different morbidities. Methods: Secondary analysis of a retrospective cohort of women who delivered at a referral maternity in Brazil and were classified with and without severe maternal morbidity (SMM). WHODAS-36 was used to assess functioning in postpartum women. Percentile distribution of total WHODAS score was compared across three groups: Percentile (P)<10, 1090. Cases of SMM were categorized and WHODAS-36 score was assessed according to hypertension, hemorrhage, or other conditions. Results: A total of 638 women were enrolled: 64 had mean scores below P<10 (1.09) and 66 were above P>90 (41.3). Of women scoring above P>90, those with morbidity had a higher mean score than those without (44.6% vs 36.8%, P=0.879). Women with higher WHODAS-36 scores presented more complications during pregnancy, especially hypertension (47.0% vs 37.5%, P=0.09). Mean scores among women with any complication were higher than those with no morbidity (19.0 vs 14.2, P=0.01). WHODAS-36 scores were higher among women with hypertensive complications (19.9 vs 16.0, P=0.004), but lower among those with hemorrhagic complications (13.8 vs 17.7, P=0.09). Conclusions: Complications during pregnancy, childbirth, and the puerperium increase long-term WHODAS-36 scores, demonstrating a persistent impact on functioning among women, up to 5 years postpartum.

© 2018 World Health Organization; licensed by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics. The maternal health agenda is undergoing a paradigm shift from preventing maternal deaths to promoting women's health and wellness. A critical focus of this trajectory includes addressing maternal morbidity and the increasing burden of chronic and noncommunicable diseases (NCD) among pregnant women. The WHO convened the Maternal Morbidity Working Group (MMWG) to improve the scientific basis for defining, measuring, and monitoring maternal morbidity. Based on the MMWG's work, we propose paradigms for conceptualizing maternal health and related interventions, and call for greater integration between maternal health and NCD programs. This integration can be synergistic, given the links between chronic conditions, morbidity in pregnancy, and long-term health. Pregnancy should be viewed as a window of opportunity into the current and future health of women, and offers critical entry points for women who may otherwise not seek or have access to care for chronic conditions. Maternal health services should move beyond the focus on emergency obstetric care, to a broader approach that encompasses preventive and early interventions, and integration with existing services. Health systems need to respond by prioritizing funding for developing integrated health programs, and workforce strengthening. The MMWG's efforts have highlighted the changing landscape of maternal health, and the need to expand the narrow focus of maternal health, moving beyond surviving to thriving.

© 2018 World Health Organization; licensed by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics. Objective: To validate the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0) 12-item tool against the 36-item version for measuring functioning and disability associated with pregnancy and the occurrence of maternal morbidity. Methods: This is a secondary analysis of the Brazilian retrospective cohort study on long-term repercussions of severe maternal morbidity (SMM) among women who delivered at a tertiary facility (COMMAG study). We compared WHODAS-12 and WHODAS-36 scores of women with and without SMM using measures of central tendency and variability, tests for instruments’ agreement (Bland-Altman plot), confirmatory factor analysis (CFA), and Cronbach alpha coefficient for internal consistency. Results: The COMMAG study enrolled 638 women up to 5 years postpartum. Although the median WHODAS-36 and -12 scores for all women were statistically different (13.04 and 11.76, respectively; P<0.001), there was a strong linear correlation between them. Furthermore, the mean difference and the differences in variance analyses demonstrated agreement of total scores between the two versions. CFA demonstrated how the WHODAS-12 questions are divided into six previously defined factors and Cronbach alpha showed good internal consistency. Conclusion: WHODAS-12 demonstrated agreement with WHODAS-36 for total score and was a good instrument for screening functioning and disability among postpartum women, with and without SMM.

© 2018 World Health Organization; licensed by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics. Objective: To assess the scores of postpartum women using the WHO Disability Assessment Schedule 2.0 36-item tool (WHODAS-36), considering different morbidities. Methods: Secondary analysis of a retrospective cohort of women who delivered at a referral maternity in Brazil and were classified with and without severe maternal morbidity (SMM). WHODAS-36 was used to assess functioning in postpartum women. Percentile distribution of total WHODAS score was compared across three groups: Percentile (P)<10, 1090. Cases of SMM were categorized and WHODAS-36 score was assessed according to hypertension, hemorrhage, or other conditions. Results: A total of 638 women were enrolled: 64 had mean scores below P<10 (1.09) and 66 were above P>90 (41.3). Of women scoring above P>90, those with morbidity had a higher mean score than those without (44.6% vs 36.8%, P=0.879). Women with higher WHODAS-36 scores presented more complications during pregnancy, especially hypertension (47.0% vs 37.5%, P=0.09). Mean scores among women with any complication were higher than those with no morbidity (19.0 vs 14.2, P=0.01). WHODAS-36 scores were higher among women with hypertensive complications (19.9 vs 16.0, P=0.004), but lower among those with hemorrhagic complications (13.8 vs 17.7, P=0.09). Conclusions: Complications during pregnancy, childbirth, and the puerperium increase long-term WHODAS-36 scores, demonstrating a persistent impact on functioning among women, up to 5 years postpartum.

© 2018 World Health Organization; licensed by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics. Background: Globally, there is greater awareness of the plight of women who have complications associated with pregnancy or childbirth and who may continue to experience long-term problems. In addition, the health of women and their ability to perform economic and social functions are central to the Sustainable Development Goals. Methods: In 2012, WHO began an initiative to standardize the definition, conceptualization, and assessment of maternal morbidity. The culmination of this work was a conceptual framework: the Maternal Morbidity Measurement (MMM) Framework. Results: The framework underscores the broad ramifications of maternal morbidity and highlights what types of measurement are needed to capture what matters to women, service providers, and policy makers. Using examples from the literature, we explain the framework's principles and its most important elements. Conclusions: We express the need for comprehensive research and detailed longitudinal studies of women from early pregnancy to the extended postpartum period to understand how health and symptoms and signs of ill health change. With respect to interventions, there may be gaps in healthcare provision for women with chronic conditions and who are about to conceive. Women also require continuity of care at the primary care level beyond the customary 6 weeks postpartum.

© 2017 The Author(s). Background: Mental health is a significant contributor to global burden of disease and the consequences of perinatal psychiatric morbidity can be substantial. We aimed to obtain global estimates of puerperal psychosis prevalence based on population-based samples and to understand how postpartum psychosis is assessed and captured among included studies. Methods: In June 2014, we searched PubMed, CiNAHL, EMBASE, PsycINFO, Sociological Collections, and Global Index Medicus for publications since the year 1990. Criteria for inclusion in the systematic review were: use of primary data relevant to pre-defined mental health conditions, specified dates of data collection, limited to data from 1990 onwards, sample size >200 and a clear description of methodology. Data were extracted from published peer reviewed articles. Results: The search yielded 24,273 publications, of which six studies met the criteria. Five studies reported incidence of puerperal psychosis (ranging from 0.89 to 2.6 in 1000 women) and one reported prevalence of psychosis (5 in 1000). Due to the heterogeneity of methodologies used across studies in definitions and assessments used to identify cases, data was not pooled to calculate a global estimate of risk. Conclusions: This review confirms the relatively low rate of puerperal psychosis; yet given the potential for serious consequences, this morbidity is significant from a global public health perspective. Further attention to consistent detection of puerperal psychosis can help provide appropriate treatment to prevent harmful consequences for both mother and baby.

© 2017 The Author(s). Background: Mental health is a significant contributor to global burden of disease and the consequences of perinatal psychiatric morbidity can be substantial. We aimed to obtain global estimates of puerperal psychosis prevalence based on population-based samples and to understand how postpartum psychosis is assessed and captured among included studies. Methods: In June 2014, we searched PubMed, CiNAHL, EMBASE, PsycINFO, Sociological Collections, and Global Index Medicus for publications since the year 1990. Criteria for inclusion in the systematic review were: use of primary data relevant to pre-defined mental health conditions, specified dates of data collection, limited to data from 1990 onwards, sample size >200 and a clear description of methodology. Data were extracted from published peer reviewed articles. Results: The search yielded 24,273 publications, of which six studies met the criteria. Five studies reported incidence of puerperal psychosis (ranging from 0.89 to 2.6 in 1000 women) and one reported prevalence of psychosis (5 in 1000). Due to the heterogeneity of methodologies used across studies in definitions and assessments used to identify cases, data was not pooled to calculate a global estimate of risk. Conclusions: This review confirms the relatively low rate of puerperal psychosis; yet given the potential for serious consequences, this morbidity is significant from a global public health perspective. Further attention to consistent detection of puerperal psychosis can help provide appropriate treatment to prevent harmful consequences for both mother and baby.

© 2015 Andreucci et al. Background: Because there is a lack of knowledge on the long-term consequences of maternal morbidity/near miss episodes on women's sexual life and function we conducted a systematic review with the purpose of identifying the available evidence on any sexual impairment associated with complications from pregnancy and childbirth. Methods: Systematic review on aspects of women sexual life after any maternal morbidity and/or maternal near miss, during different time periods after delivery. The search was carried out until May 22nd, 2015 including studies published from 1995 to 2015. No language or study design restrictions were applied. Maternal morbidity as exposure was split into general or severe/near miss. Female sexual outcomes evaluated were dyspareunia, Female Sexual Function Index (FSFI) scores and time to resume sexual activity after childbirth. Qualitative syntheses for outcomes were provided whenever possible. Results: A total of 2,573 studies were initially identified, and 14 were included for analysis after standard selection procedures for systematic review. General morbidity was mainly related to major perineal injury (3rd or 4th degree laceration, 12 studies). A clear pattern for severity evaluation of maternal morbidity could not be distinguished, unless when a maternal near miss concept was used. Women experiencing maternal morbidity had more frequently dyspareunia and resumed sexual activity later, when compared to women without morbidity. There were no differences in FSFI scores between groups. Meta-analysis could not be performed, since included studies were too heterogeneous regarding study design, evaluation of exposure and/or outcome and time span. Conclusion: Investigation of long-term repercussions on women's sexual life aspects after maternal morbidity has been scarcely performed, however indicating worse outcomes for those experiencing morbidity. Further standardized evaluation of these conditions among maternal morbid

© 2015 Andreucci et al. Background: Because there is a lack of knowledge on the long-term consequences of maternal morbidity/near miss episodes on women's sexual life and function we conducted a systematic review with the purpose of identifying the available evidence on any sexual impairment associated with complications from pregnancy and childbirth. Methods: Systematic review on aspects of women sexual life after any maternal morbidity and/or maternal near miss, during different time periods after delivery. The search was carried out until May 22nd, 2015 including studies published from 1995 to 2015. No language or study design restrictions were applied. Maternal morbidity as exposure was split into general or severe/near miss. Female sexual outcomes evaluated were dyspareunia, Female Sexual Function Index (FSFI) scores and time to resume sexual activity after childbirth. Qualitative syntheses for outcomes were provided whenever possible. Results: A total of 2,573 studies were initially identified, and 14 were included for analysis after standard selection procedures for systematic review. General morbidity was mainly related to major perineal injury (3rd or 4th degree laceration, 12 studies). A clear pattern for severity evaluation of maternal morbidity could not be distinguished, unless when a maternal near miss concept was used. Women experiencing maternal morbidity had more frequently dyspareunia and resumed sexual activity later, when compared to women without morbidity. There were no differences in FSFI scores between groups. Meta-analysis could not be performed, since included studies were too heterogeneous regarding study design, evaluation of exposure and/or outcome and time span. Conclusion: Investigation of long-term repercussions on women's sexual life aspects after maternal morbidity has been scarcely performed, however indicating worse outcomes for those experiencing morbidity. Further standardized evaluation of these conditions among maternal morbid