Table 1.
Recommendations for Improving Population-based Research on SMM
| 1. Conceptual and theoretical frameworks to guide SMM research |
| 1A. Reproductive health |
| SMM research should be grounded in the broader context of reproductive health (not just “pregnancy” health), acknowledging that reproductive health is |
| • Multilevel - Supported by the Social-Ecological Model, this framework recognizes the influence of multilevel domains of influence on reproductive health, including individual, neighborhood, health system, and societal factors (McLeroy et al., 1988). |
| • Life course health - Pregnancy outcomes like SMM are affected by life course experiences, and SMM may in turn affect subsequent life course health (Lu & Halfon, 2003). |
| • Intergenerational health - Historic context of one’s family and society affect the reproductive health of current and subsequent generations (e.g., intergenerational trauma, slavery, genocide of Native populations) (Halfon & Hochstein, 2002; McLeroy et al., 1988). |
| 1B. Health and racial equity |
| Given stark disparities by race and social disadvantage, SMM research should be centered on achieving equity, within a framework that is informed by multiple relevant movements and theories, including, for example, Critical Race Theory, EcoSocial Theory, Intersectionality, and Reproductive Justice (BlackWomen Scholars and the Research Working Group of the Black Mamas Matter Alliance, 2020; Roberts, 1998; Ford & Airhihenbuwa, 2010; Krieger, 2020; Ross, 2017) [see references for further explication]. |
| 1C. Community-engaged research |
| SMM research should be guided by principles of community-engaged research, which acknowledge that contributions from people with lived experience and highest burden, at every stage of the research process, are essential to its effectiveness (Ortiz et al., 2020; Wang et al., 2020b). |
| 2. Defining SMM |
| 2A. Timing of SMM |
| • SMM indicators should characterize severe complications that arise during pregnancy or postpartum, and not situations at risk of leading to severe complications. |
| 2C. Indicators |
| • Standardized approaches that link precursor clinical conditions with SMM events are needed to fully understand the causes of SMM, how best to approach it analytically, and how to prevent it. |
| 2C. Transparency |
| • Research should provide a clear definition of SMM, report all codes and criteria that are used, and use existing validated indices whenever possible. |
| • Coding experts should be included in the development and revision of SMM indices. |
| • If transfusion is included in the definition of SMM and volume of transfusion is not available, findings should be reported with and without including transfusion as an indicator. |
| • Research should state the timing of SMM events that are included, provide justification, and discuss potential concomitant limitations. |
| 2D. Continuum of care |
| • When possible, research should include SMM events that arise during pregnancy or childbirth, through at least 42 days postpartum, and the approach should be clearly described. |
| • Further research is needed that compares SMM that emerges during the prenatal, peripartum, and postpartum periods. |
| 3. Data improvements |
| • Improve the availability of data resources that |
| - Allow rigorous characterization of SMM |
| - Include critical individual-level sociodemographic variables (e.g., maternal race-ethnicity, age, parity, socioeconomic status) |
| and |
| - Enable characterization of social and structural determinants (see Figure 2 for examples). |
| • Some suggested strategies are as follows: |
| - Develop state-based datasets that link vital records with maternal and infant hospital discharge records, including indicators of where people live so that social and structural determinants can be studied. |
| - Improve the quality of maternal health information recorded in vital records. Using current versions of birth and fetal death certificates to study SMM is not recommended. |
| - Improve the quality of social determinant information in hospital discharge records. |
| - Fund the exploration of birthing people’s and communities’ perspectives and priorities regarding SMM. |
Abbreviation: SMM, severe maternal morbidity.