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

尽管自2000年以来孕产妇存活率有了显著改善，但2017年全球估计有29.5万例孕产妇死亡，妇女和女孩一生中面临的孕产妇死亡风险为190分之一（世卫组织2019年）。每有一名妇女死亡，就有20多名妇女将经历被称为“产妇未遂”的危及生命的并发症；更多的人将经历非危及生命的并发症（同上）。基于低资源环境下孕产妇死亡率和发病率研究的关键知识缺口，本博士项目将回答四个研究问题：1。2.世卫组织对产妇死亡的定义——仅包括分娩或终止妊娠后42天内发生的死亡——在多大程度上根据分娩后死亡率过高的持续时间是合理的？死因推断方法——在没有民事死亡登记时用于确定死因——在多大程度上对世卫组织规定的42天产妇死亡阈值敏感？3. 实验室、临床和管理标记如何用于识别产妇近漏并发症影响低资源背景下的发生率估计？经历产妇未遂并发症对妇女未来的生育意向、日常功能、身心健康结果有什么影响？对产后护理有什么影响？该博士项目将通过提供影响国际孕产妇保健标准和多边卫生政策的大量证据，产生工具性影响。产后死亡风险持续时间的估计可以与其他研究一起，为修订世卫组织用于死亡率监测的孕产妇死亡定义提供信息。我的研究还可以就在非洲三个资源匮乏的地区应用世界卫生组织的产妇差点错过标准的可行性提出具体的建议。最后，估计几乎错过的幸存者的具体身体、性和精神健康需求可以影响适当提供产后护理的指导方针和改善生活质量的全球最佳做法。这个博士项目涉及多个研究机构之间的重要合作。我将使用健康和人口监测系统（HDSS）的数据，这需要与管理监测点的研究人员密切合作。这包括冈比亚医学研究单位，以及INDEPTH网络中的其他非洲站点——一个由HDSS站点和附属研究中心组成的全球网络。对于孕产妇发病率的分析，我使用了来自PRECISE网络的数据，这是一项旨在加强非洲研究能力的妊娠结局前瞻性队列研究。与PRECISE网络合作涉及与世界各地多个学术机构的研究人员和卫生专家以及冈比亚、肯尼亚和莫桑比克HDSS站点的研究人员合作。在这个博士项目中，我正在发展我的技术技能。通过我在欧洲人口博士学院的一年多的学习，我已经在人口统计方法、生存分析和先进的统计技术方面积累了经验。我将在博士期间利用这一经验，利用HDSS和PRECISE数据来发展我作为孕产妇健康流行病学和人口统计学定量研究人员的能力。通过对precision中经历过差之毫厘的女性进行定性子研究，我也将发展我的定性研究技能。最后，这个博士项目将培养我的协作能力，以及我与一系列利益相关者有效沟通的能力。这些技能将帮助我开展有影响力的研究，以重新制定针对低收入和中等收入背景下孕产妇发病率的政策问题。

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.