Maternal Health Research Priorities PDF
Maternal Health Research Priorities PDF
Maternal Health Research Priorities PDF
Abstract
Background: Maternal mortality has declined by nearly half since 1990, but over a quarter million women still die
every year of causes related to pregnancy and childbirth. Maternal-health related targets are falling short of the
2015 Millennium Development Goals and a post-2015 Development Agenda is emerging. In connection with this,
setting global research priorities for the next decade is now required.
Methods: We adapted the methods of the Child Health and Nutrition Research Initiative (CHNRI) to identify and set
global research priorities for maternal and perinatal health for the period 2015 to 2025. Priority research questions
were received from various international stakeholders constituting a large reference group, and consolidated into a
final list of research questions by a technical working group. Questions on this list were then scored by the
reference working group according to five independent and equally weighted criteria. Normalized research priority
scores (NRPS) were calculated, and research priority questions were ranked accordingly.
Results: A list of 190 priority research questions for improving maternal and perinatal health was scored by 140
stakeholders. Most priority research questions (89%) were concerned with the evaluation of implementation and
delivery of existing interventions, with research subthemes frequently concerned with training and/or awareness
interventions (11%), and access to interventions and/or services (14%). Twenty-one questions (11%) involved the
discovery of new interventions or technologies.
(Continued on next page)
* Correspondence: jpsouza@fmrp.usp.br
1
UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research,
Development and Research Training in Human Reproduction (HRP),
Department of Reproductive Health and Research, World Health
Organization, Geneva, Switzerland
2
Department of Social Medicine, Ribeirão Preto Medical School, University of
São Paulo, Ribeirão Preto, São Paulo, Brazil
Full list of author information is available at the end of the article
© 2014 Souza et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
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the United States Agency for International Development researcher (JPS), who resolved discrepancies. A reduced
(USAID) Maternal and Child Health Integrated Pro- list of questions was then submitted to thematic analysis.
gram (MCHIP)). Those who responded positively to The thematic analysis consisted of grouping similar
the invitation became members of the reference group. questions together to identify research themes and sub-
All members of the reference group were invited to pro- themes. This allowed us to identify additional duplicates
vide three research questions in seven domains: obstet- and out-of-scope questions. Questions were edited for
ric haemorrhage, hypertensive disorders of pregnancy clarity and similar questions were merged. During this
(HDP), maternal sepsis, abortion, difficult/obstructed process, we aimed to achieve a certain level of detail
labour, preterm birth, and stillbirth. Maternal and peri- compatible with the concept of “research avenues” (i.e. a
natal health research questions identified through other research question that is not too broad, neither too spe-
processes (including a USAID priority setting exercise, cific, and could be answered through a set of individual
published WHO guidelines, and a previous WHO research projects); hence, very detailed and specific
CHNRI intrapartum priority setting exercise) were also questions were made more general. This process re-
included in the index list of research questions [12-16]. sulted in a refined list of questions for the technical con-
In Phase II, this long list of questions was independ- sultation meeting held in Geneva in April 2013. The
ently assessed by two researchers (MW and SJP) for large majority of the participants in this technical con-
identification of duplicate questions. Questions that were sultation was selected from amongst the reference group
out of scope (i.e. not pertaining to any of the previously and composed the technical working group. This tech-
mentioned domains), or that were too broad to be con- nical working group consisted of a diverse group of 22
sidered research questions (e.g. “research to reduce ma- participants that included clinical specialists, researchers,
ternal mortality”, “develop and test interventions for program managers, WHO officers, donor and consumer
reducing postpartum haemorrhage”), or that were con- representatives, and other stakeholders. During this
sidered epidemiological (non-intervention) research, technical consultation, the product of the thematic ana-
were excluded. This process was reviewed by a third lysis was reviewed, new questions were developed where
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omissions/gaps were identified, and similar questions included in the reference group. Of these, 339 participants
were further consolidated. (52%) provided 980 research ideas or questions; these were
Phase III consisted of scoring the final list of research considered together with 95 research questions generated
questions. To reduce bias due to participant fatigue, we through other recent research prioritization processes. Par-
prepared six spreadsheets that differed in the order in ticipants from 67 countries provided research ideas or
which the research questions were presented. Each mem- questions (22 developed countries contributed with 44% of
ber of the reference group received one of these electronic participants, 45 developing countries contributed with 56%
spreadsheets via e-mail, accompanied by a score sheet of participants). Researchers (37%; 125/339), Clinician phy-
consisting of five criteria to be used for scoring the ques- sicians (27%; 92/339); program managers and policy makers
tions. These five criteria included answerability, effective- (20%; 67/339) were the main providers of research ques-
ness, deliverability, maximum potential for disease burden tions. Midwives, donor representatives, consumers and
reduction, and equity (Table 1). They are described in de- other stakeholders provided also research questions. After
tail in the CHNRI guidelines [5]. The participants were exclusion of duplicates, thematic analysis and editing, 234
instructed to score the questions one criterion at a time questions were discussed by the technical working group,
using a binary score system (1: Yes, 0: No). If they were working closely with the WHO management team, at the
not sure, did not know, or were not able to make a judg- technical consultation meeting held in Geneva. The tech-
ment, they were asked to leave the question blank. The nical consultation produced a consolidated list with 190
completed spreadsheets, when returned by the partici- research questions, which was sent to the reference group
pants, were integrated into a database. for scoring. A total of 140 participants (22%) of the refer-
A research priority score was generated for each ques- ence group scored the questions and returned completed
tion by summing up the scores attributed to each criter- spreadsheets, which were integrated into one database.
ion. No special weighting of criteria was applied. Thus, The distribution of research questions generated per
for each individual respondent, each research question theme is shown in Figure 2. Overall, most of the research
could have a priority score ranging from 0 to 5. The questions (89%) address the implementation of existing
overall research priority score was computed as the sum interventions or knowledge (delivery/implementation re-
of all individual research priority scores. For each ques- search); 21 questions (11%) address research to discover
tion, the overall research priority score was normalized new interventions or technologies (discovery research).
(i.e. considering all questions, the overall research prior- Additional file 1 contains the database with all re-
ity score for the question was subtracted by the mini- search priority questions and criteria scores. Normalized
mum research priority score among all questions, and scores for the 190 questions ranged from 0 to 100.
divided by the range: (x − min)/(max − min)). The nor- Questions with a NRPS of 76 and above formed part of
malized research priority score (NRPS) was analyzed and the upper quartile of highest ranked questions (56 in
the cut-off point, enabling identification of the upper total). These were fairly evenly distributed, with each of
quartile (questions with the highest normalized research the main themes attracting six to nine questions in the
priority scores), was determined. Online Google® forms upper quartile (Table 2).
were used to capture online data from the reference The top 20 highest ranked questions overall are pre-
group and Microsoft Excel (2010) spreadsheets were sented in Table 3. Abortion research makes up 25% (n = 5)
used to score and analyze the responses provided. of the top 20 list with other major themes including health
systems research (n = 4), obstetric haemorrhage (n = 3),
Results neonatal care (n = 3), and labour/delivery (n = 2). Training
A total of 650 stakeholders responded positively to our and/or awareness interventions comprise 30% (n = 6) of
initial invitation to participate in this exercise and were the sub-themes of these top 20 research priorities.
Hypertensive disorders of pregnancy (HDP) is not rep-
Table 1 Scoring criteria for setting research priorities resented in the top-20 list but comprises 14% of the
1. Answerability The research question can be ethically answered. questions in the upper quartile. Similarly, none of the
2. Effectiveness The new knowledge is likely to result in an effective upper quartile questions were ‘discovery’ questions. The
intervention or program. five highest scoring discovery questions with their rank-
3. Deliverability The intervention or program will be deliverable, ing can be found in Table 4.
acceptable and affordable.
4. Potential The intervention or program has the potential to Discussion
impact substantially reduce maternal and perinatal The current exercise led to the identification of research
mortality, morbidity and long term disabilities.
questions that are mostly related to implementation of
5. Equity The intervention or program will reach the most existing interventions and the development of simplified,
vulnerable groups.
more cost-effective versions of existing interventions
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(e.g. oxytocin and misoprostol for PPH prevention and challenge in current maternal and perinatal health is to
treatment or magnesium sulfate for eclampsia). A lim- increase the outreach of existing effective solutions for
ited number of questions related to the discovery of new those who need them most.
solutions were proposed (e.g. new uterotonics for PPH These results represent the consensus view of a large
or new ways to identify PPH). The opinions expressed number of researchers, policymakers and other stake-
by the participants through their input in this process holders internationally, and provide the essential routes to
appear to corroborate the notion that the biggest action to eliminate preventable maternal deaths by 2025.
Table 2 Breakdown of research question flow by themes
Research themes and common sub-themes Total questions Top-ranked questions* Top-twenty questions
(N = 190) (n = 56) (n = 20)
Labour and delivery: Preterm birth, difficult/obstructed labour, fetal 39 (21%) 6 (11%) 2 (10%)
monitoring, the partograph, training and/or awareness, caesarean section,
management of the third stage, induction of labour
Obstetric haemorrhage: Misoprostol access, uterotonics (type, dose, route), 28 (15%) 8 (14%) 3 (15%)
screening and detection, training and/or awareness, care quality, blood
transfusions, management of the third stage
Hypertensive disorders of pregnancy: Screening and detection, magnesium 21 (11%) 8 (14%) 0 (0%)
sulphate, biochemical markers, anticonvulsants, antihypertensive agents,
training and/or awareness, prevention
Abortion: Post-abortion contraception, misoprostol access, post-abortion 20 (11%) 8 (14%) 5 (25%)
follow-up, abortion in restricted settings, second trimester abortion, training
and/or awareness
Antenatal care: Screening and detection (including impaired fetal growth, 21 (11%) 6 (11%) 2 (10%)
infection, preterm birth, anaemia), ultrasound access, nutrition, malaria, diabetes
care
Health systems: Transport and communication, service quality, emergency 19 (10%) 8 (14%) 4 (20%)
services, mobile community health services, supervision and mentoring, service
utilization, monitoring and audits
Neonatal care: Neonatal resuscitation, hypoxic ischaemic encephalopathy, 26 (14%) 9 (16%) 3 (15%)
screening and detection, kangaroo mother care, cord care, care of preterm
neonates, training and/or awareness
Other: Puerperal sepsis, postnatal care, improving attitudes/behaviour of 16 (8%) 2 (4%) 1 (5%)
healthcare workers
*Upper quartile questions with a normalized research priority score (NRPS) of 76 and above.
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Table 3 Top 20 (highest scoring) research priority questions to improve maternal and/or perinatal health outcomes
between 2015 and 2025
Research question NRPS Theme
Evaluate the effectiveness of interventions (e.g. counselling or incentives, or home visits) to increase post-abortion 100 Abortion
contraception uptake and continuance, and reduce repeat abortion
Evaluate the effectiveness and costs of strategies to improve the quality and utilization of maternity services (e.g. 95 Health systems
maternity waiting homes, improved communication via mobile phones, community awareness strategies) to improve
early detection and management of antenatal and intrapartum complications
Develop and evaluate strategies for locally appropriate transport, communication and referral systems for obstetric and 94 Health systems
newborn emergencies
Evaluate the effectiveness and cost of strategies to prevent, detect and treat causes of anaemia in pregnancy (e.g. 93 Antenatal care
malaria, occult bleeding disorders, nutritional deficiencies)
Evaluate the effectiveness and cost of training interventions for frontline healthcare workers (paramedics, doctors, CHWs, 92 Obstetric
midwives, nurses) to diagnose, manage and refer women with obstetric haemorrhage haemorrhage
Evaluate the effectiveness and cost of a package of community level interventions for preterm babies (e.g. implementing 92 Neonatal care
and providing guidelines for kangaroo mother care, home visits by CHWs, infection prevention strategies)
Evaluate the effectiveness of integrating abortion services into existing family planning services 91 Abortion
Evaluate the effectiveness and cost of training frontline healthcare workers, including nurses, midwives and community 90 Neonatal care
health workers, to detect and treat neonatal sepsis (or to provide pre-referral treatment only)
Develop and evaluate community-based awareness programs to reduce unwanted pregnancies and encourage women 89 Abortion
to seek help early
Evaluate the effectiveness and cost of training interventions for skilled birth attendants to gain and maintain 88 Labour and
competence in the management of obstructed labour, and assisted delivery techniques delivery
Evaluate the effectiveness and cost of training skilled birth attendants in intrapartum fetal monitoring and neonatal 88 Neonatal care
resuscitation for reducing stillbirths and deaths/disability due to perinatal asphyxia
Evaluate the effectiveness and cost of a package of interventions for the prevention, early detection and treatment of 88 Other (puerperal
puerperal sepsis (e.g. sterile birth kits, access to antibiotics, automated thermometers) sepsis)
Evaluate the effectiveness and cost of a package of mobile service interventions delivered at community level, including 87 Health systems
mobile clinics and home-based care, on maternal and perinatal health outcomes
Evaluate the effectiveness, safety and timing of the initiation of post-abortion contraception (hormonal and IUDs) with 87 Abortion
respect to abortion outcomes, contraceptive effectiveness, uptake, continuance, and repeat abortions
Develop and evaluate the effectiveness and cost of strategies to improve access of women with obstetric haemorrhage 87 Obstetric
to blood and blood replacement products in settings without transport capabilities haemorrhage
Develop and evaluate the effectiveness of strategies to increase access of women to misoprostol at community level 87 Obstetric
where oxytocin is not available/feasible, by dispensing it antenatally as part of a birthing kit, or at the time of delivery via haemorrhage
the attending CHW or nurse/midwife, to prevent and treat PPH
Develop and evaluate strategies to increase appropriate use of the partograph, including decision-making and action, to 85 Labour and
improve maternal and perinatal health outcomes delivery
Evaluate the effectiveness and cost of strategies, including task-shifting, to increase access of women to high quality 85 Abortion
post-abortion care to improve early detection of complications
Assess the effectiveness and cost of implementing a package of screening and treating syphilis and HIV in women of 85 Antenatal care
reproductive age to improve maternal and perinatal health outcomes.
Develop and evaluate a health systems package for effective task shifting for the management of obstetric emergencies, 83 Health systems
including protocols, supervisory systems, and metrics
NRPS: Normalized research priority score. This was performed by subtracting the minimum research priority score from the index question score, and dividing by
the NRPS range, i.e. (x − min)/(max − min).
CHNRI methods aim to standardize and make more dominant individuals within the group. In the present ex-
transparent the highly complex process of setting research ercise, we tried to overcome these potential weaknesses by
priorities. Overall, these methods are perceived as robust, increasing the number of participants and using distance-
but there are some concerns related to the ability of these based methods for collecting and scoring questions. Thus,
methods to identify all relevant research ideas. In general, this became the largest exercise for prioritizing research
most of the previous CHNRI exercises have relied on rela- questions in maternal and perinatal health to date, involv-
tively small reference groups (in general, < 100 partici- ing a large number of experts and stakeholders, and with
pants). Small reference groups are more likely to be biased a very large number of questions generated. However,
by various elements of their composition and more some limitations should be noted. Having a large group of
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Table 4 Top five priority research questions addressing new health interventions (discovery questions) to improve
maternal and perinatal health
Research question NRPS Theme
Discover new formulations of uterotonics (e.g. low-cost, simple to use, non-invasive, heat-stable) to prevent and treat 72 Obstetric
PPH and improve maternal health outcomes. haemorrhage
Discover and evaluate a standardised method of measuring blood loss to improve the detection and management of 70 Obstetric
PPH, to improve maternal health outcomes. haemorrhage
Discover new technologies/screening tools for the detection of anaemia in pregnancy to improve maternal and 66 Antenatal care
perinatal health outcomes.
Discover and evaluate new methods/technologies to prevent and treat obstetric haemorrhage and improve maternal 55 Obstetric
health outcomes. haemorrhage
Discover and evaluate new pharmaceutical treatments for eclampsia to improve maternal and perinatal outcomes. 48 HDP
HDP: hypertensive disorders of pregnancy.
experts and stakeholders was a positive factor because it question the validity of the CHNRI methodology to assess
ensured broader representation and a very large pool of research that is at the discovery stage as criteria such as
research questions. However, managing a large number of effectiveness, deliverability and equity are less relevant at
questions was technically challenging for all involved, par- the discovery stage (though they may become more rele-
ticularly at list preparation (phase I) and scoring (phase II) vant later, depending on the outcome of the primary re-
stages. Given the broad scope of this exercise (maternal search). The method thus tends to systematically attribute
and perinatal health) and the long list of priority questions lower scores to discovery research. As future advances in
to be scored, participant fatigue and time constraints were the field would depend on discovery research, in future
of concern. For the set of 190 questions that was sent to exercises, exploring ways of counter-balancing this trend
the reference group, each respondent had to attribute a would be advisable; for example, conducting dedicated
total of 950 scores (190 questions times five criteria), modules with more relevant criteria (such as safety or
which was a very time-intensive task. Anecdotal accounts innovation) on discovery questions could avoid competi-
suggest that the time required to complete the task was tion between different types of research questions.
approximately four hours, however, some respondents re- The high ranking of priority research for abortion
ported taking eight hours or more. This may explain the and obstetric haemorrhage in this exercise reflects the
substantial drop in response rate during phase III. Devel- substantial contribution of these aspects to maternal
oping and testing simplified versions of the CHNRI mortality and morbidity rates. Recurring sub-themes for
process could be explored as a way to strike a balance abortion research were mainly concerned with training
between the necessary methodological rigor and practical and/or awareness interventions, access to abortion, and
implementation. Another limitation of this method is post-abortion care and contraception. Similarly, for ob-
an apparent trend towards prioritizing implementation stetric haemorrhage, training and/or awareness interven-
research questions over discovery questions. This was tions, and access to existing uterotonics were common
observed in this exercise and it has been a feature of other sub-themes. Given that both abortion and haemorrhage
CHNRI prioritization exercises; for example, in a similar are the most avoidable causes of maternal morbidity and
exercise for setting global mental health research prior- mortality, it is no surprise that priority questions focused
ities, new interventions and technologies comprised seven on the implementation/delivery of known effective inter-
out of the ten lowest-scoring priorities, and none of the ventions. Another recurring theme is research to address
top ten scoring priorities [17]. A possible explanation for cost-effectiveness knowledge gaps, which denotes the
this could be that discovery questions tend to be more in- importance of sustainability of new health technologies.
novative and inherently riskier in terms of research invest- Health systems research had the second most research
ment while implementation research question seem to questions in the top-20 list, illustrating the need for ef-
respond concretely to immediate needs. Consensus-driven fective health systems to enable effective service delivery.
processes are conservative by nature and as a result, re- This emphasis on implementation research and health
search questions that seem “safer” (e.g. implementation system research suggest that the international commu-
research questions) could be more appealing to large con- nity is keen in overcoming barriers for using what is
sultation groups. An additional explanation is that some already available rather than developing new technolo-
stakeholders are simply not aware of some of the new gies that may be not used due to the same reasons that
technologies that are in earlier phases of development. are currently preventing the use of existing health tech-
Thus, when asked to list research questions, they could nology. As emphasis shift towards light technologies (i.e.
focus on the technologies that they know about. One may focus on work processes and system thinking) further
Souza et al. Reproductive Health 2014, 11:61 Page 8 of 9
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College of Health Sciences, Makerere University, Kampala, Uganda. Lawn JE, Manandhar DS, Mori R, Rasmussen KM, Sachdev HP, Singhal N,
15
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Preeclampsia Foundation, Melbourne, Florida, USA. 20International treatment of pre-eclampsia and eclampsia. Geneva: WHO; 2011.
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Received: 20 December 2013 Accepted: 22 July 2014
Published: 7 August 2014 doi:10.1186/1742-4755-11-61
Cite this article as: Souza et al.: Maternal and perinatal health research
priorities beyond 2015: an international survey and prioritization
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