ArticlePDF Available

Maternal and perinatal health research priorities beyond 2015: An international survey and prioritization exercise

August 2014
Reproductive Health 11(1):61

August 2014
11(1):61

DOI:10.1186/1742-4755-11-61

Source
PubMed

License
CC BY 2.0

Authors:

João Paulo Souza

University of São Paulo

Ahmet Metin Gülmezoglu

Concept Foundation

Theresa A Lawrie

Show all 35 authorsHide

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. 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. 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. Key research priorities in maternal and perinatal health were identified. The resulting ranked list of research questions provides a valuable resource for health research investors, researchers and other stakeholders. We are hopeful that this exercise will inform the post-2015 Development Agenda and assist donors, research-policy decision makers and researchers to invest in research that will ultimately make the most significant difference in the lives of mothers and babies.

Breakdown of research question flow by themes

…

Study and analysis flow.

…

Priority research questions (N = 190) by theme.

…

Figures - uploaded by João Paulo Souza

Content may be subject to copyright.

Content uploaded by João Paulo Souza

Content may be subject to copyright.

Available via license: CC BY 2.0

Content may be subject to copyright.

Available via license: CC BY 2.0

Content may be subject to copyright.

Content uploaded by Ahmet Metin Gülmezoglu

Content may be subject to copyright.

R E S E A R C H Open Access

Maternal and perinatal health research priorities

beyond 2015: an international survey and

prioritization exercise

Joao Paulo Souza

1,2*

, Mariana Widmer

, Ahmet Metin Gülmezoglu

, Theresa Anne Lawrie

Ebunoluwa Aderonke Adejuyigbe

, Guillermo Carroli

, Caroline Crowther

, Sheena M Currie

, Therese Dowswell

Justus Hofmeyr

, Tina Lavender

, Joy Lawn

, Silke Mader

, Francisco Eulógio Martinez

, Kidza Mugerwa

Zahida Qureshi

, Maria Asuncion Silvestre

, Hora Soltani

, Maria Regina Torloni

, Eleni Z Tsigas

, Zoe Vowles

Léopold Ouedraogo

, Suzanne Serruya

, Jamela Al-Raiby

, Narimah Awin

, Hiromi Obara

, Matthews Mathai

Rajiv Bahl

, José Martines

, Bela Ganatra

, Sharon Jelena Phillips

, Brooke Ronald Johnson

, Joshua P Vogel

1,27

Olufemi T Oladapo

and Marleen Temmerman

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

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

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

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.

Souza et al. Reproductive Health 2014, 11:61

http://www.reproductive-health-journal.com/content/11/1/61

(Continued from previous page)

Conclusions: Key research priorities in maternal and perinatal health were identified. The resulting ranked list of

research questions provides a valuable resource for health research investors, researchers and other stakeholders.

We are hopeful that this exercise will inform the post-2015 Development Agenda and assist donors, research-policy

decision makers and researchers to invest in research that will ultimately make the most significant difference in the

lives of mothers and babies.

Keywords: Research priorities, CHNRI, Maternal and perinatal health

Background

In 2000, heads of States and Governments gathered at the

United Nations General Assembly and agreed to put in

place an international effort to eradicate extreme poverty

and promote human development. The 2000 Millennium

Summit resulted in a series of time-bound targets (the

Millennium Development Goals - MDGs) which include

improving maternal health and reducing child mortality

by 2015. Improving maternal health, considered a crucial

element to combat poverty and underdevelopment on a

global scale, consisted of two components: reducing ma-

ternal mortality, and achieving universal access to repro-

ductive health services [1].

Maternal mortality has declined by nearly half since

1990, but this progress falls short of the MDG target

and over a quarter million women still die every year of

causes related to pregnancy and childbirth [2,3]. Mater-

nal health-related indicators are among the worst per-

forming in the MDG effort; and only a small number of

countries will reach their maternal mortality targets by

2015 [3]. Despite this relatively slow progress, it is widely

believed that the interventions needed to reduce mater-

nal mortality ratios (MMR) to less than 50 deaths per

100,000 live births per year globally, already exist [4].

Obstacles to implementing effective interventions and

disseminating knowledge delay progress, particularly in

the least developed countries and most vulnerable popu-

lations. With the deadline for the MDGs approaching,

the international community is currently mobilizing to

develop plans for the post-MDG era [4]. As a part of this

global effort, we conducted an international survey and

prioritization exercise to identify key research priorities

that could accelerate improvement in maternal and peri-

natal health from 2015 to 2025.

The Child Health and Nutrition Research Initiative

(CHNRI) has developed a method to assist policy makers,

donors and stakeholders in understanding the potential of

different research avenues to contribute to reducing the

burden of disease and disability [5]. This method is par-

ticipatory, identifies weaknesses and strengths of proposed

research options and enables transparent prioritization for

research investment [5-7]. The CHNRI methods have

been adapted and applied at national and international

levels in various fields and the World Health Organization

(WHO) has used these methods for several previous

research prioritization exercises [8-11]. In this paper, we

present the results of the WHO research prioritization

exercise using adapted CHNRI methods to identify global

research priorities for maternal and perinatal health.

Methods

The CHNRI methods have been previously published to-

gether with detailed guidelines for implementation [5].

The goal of our priority setting exercise was to identify

research questions with the potential to have an impact

on maternal and perinatal health indicators between

2015 and 2025. In this context, maternal health’relates

to conditions affecting women during pregnancy, child-

birth/abortion and up to six weeks postpartum/post-

abortion, and ‘perinatal health’relates to conditions

affecting offspring from the time of fetal viability to the

first 28 postnatal days. This process was managed by the

WHO and implemented in three phases: (1) the gener-

ation and collection of research questions, (2) thematic

analysis and consolidation of research questions, and (3)

prioritization of research questions using a scoring sys-

tem based on five criteria. Figure 1 illustrates this

process.

Phase I was initiated by establishing a reference group

of researchers, health care providers, program man-

agers, and other stakeholders (including representatives

of consumer groups and donors). An invitation was sent

to a large number of active researchers in the field of

maternal and perinatal health, identified through bib-

liographic metrics and other information available in

the “BiomedExperts”database. This database includes

over 400,000 registered members and 1.8 million pre-

generated profiles of life science researchers (http://

www.biomedexperts.com/). Potential participants were

identified in the BiomedExperts database using a pre-

specified search strategy available in Appendix 1. The

identification of researchers was stratified to ensure

participation of researchers from both developed and

developing countries. In addition, invitations were also

sent to program managers and policymakers identified

in contact lists of WHO and partner organizations (e.g.

Souza et al. Reproductive Health 2014, 11:61 Page 2 of 9

http://www.reproductive-health-journal.com/content/11/1/61

the United States Agency for International Development

(USAID) Maternal and Child Health Integrated Pro-

gram (MCHIP)). Those who responded positively to

the invitation became members of the reference group.

All members of the reference group were invited to pro-

vide three research questions in seven domains: obstet-

ric haemorrhage, hypertensive disorders of pregnancy

(HDP), maternal sepsis, abortion, difficult/obstructed

labour, preterm birth, and stillbirth. Maternal and peri-

natal health research questions identified through other

processes (including a USAID priority setting exercise,

published WHO guidelines, and a previous WHO

CHNRI intrapartum priority setting exercise) were also

included in the index list of research questions [12-16].

In Phase II, this long list of questions was independ-

ently assessed by two researchers (MW and SJP) for

identification of duplicate questions. Questions that were

out of scope (i.e. not pertaining to any of the previously

mentioned domains), or that were too broad to be con-

sidered research questions (e.g. “research to reduce ma-

ternal mortality”,“develop and test interventions for

reducing postpartum haemorrhage”), or that were con-

sidered epidemiological (non-intervention) research,

were excluded. This process was reviewed by a third

researcher (JPS), who resolved discrepancies. A reduced

list of questions was then submitted to thematic analysis.

The thematic analysis consisted of grouping similar

questions together to identify research themes and sub-

themes. This allowed us to identify additional duplicates

and out-of-scope questions. Questions were edited for

clarity and similar questions were merged. During this

process, we aimed to achieve a certain level of detail

compatible with the concept of “research avenues”(i.e. a

research question that is not too broad, neither too spe-

cific, and could be answered through a set of individual

research projects); hence, very detailed and specific

questions were made more general. This process re-

sulted in a refined list of questions for the technical con-

sultation meeting held in Geneva in April 2013. The

large majority of the participants in this technical con-

sultation was selected from amongst the reference group

and composed the technical working group. This tech-

nical working group consisted of a diverse group of 22

participants that included clinical specialists, researchers,

program managers, WHO officers, donor and consumer

representatives, and other stakeholders. During this

technical consultation, the product of the thematic ana-

lysis was reviewed, new questions were developed where

Figure 1 Study and analysis flow.

Souza et al. Reproductive Health 2014, 11:61 Page 3 of 9

http://www.reproductive-health-journal.com/content/11/1/61

omissions/gaps were identified, and similar questions

were further consolidated.

Phase III consisted of scoring the final list of research

questions. To reduce bias due to participant fatigue, we

prepared six spreadsheets that differed in the order in

which the research questions were presented. Each mem-

ber of the reference group received one of these electronic

spreadsheets via e-mail, accompanied by a score sheet

consisting of five criteria to be used for scoring the ques-

tions. These five criteria included answerability, effective-

ness, deliverability, maximum potential for disease burden

reduction, and equity (Table 1). They are described in de-

tail in the CHNRI guidelines [5]. The participants were

instructed to score the questions one criterion at a time

using a binary score system (1: Yes, 0: No). If they were

not sure, did not know, or were not able to make a judg-

ment, they were asked to leave the question blank. The

completed spreadsheets, when returned by the partici-

pants, were integrated into a database.

A research priority score was generated for each ques-

tion by summing up the scores attributed to each criter-

ion. No special weighting of criteria was applied. Thus,

for each individual respondent, each research question

could have a priority score ranging from 0 to 5. The

overall research priority score was computed as the sum

of all individual research priority scores. For each ques-

tion, the overall research priority score was normalized

(i.e. considering all questions, the overall research prior-

ity score for the question was subtracted by the mini-

mum research priority score among all questions, and

divided by the range: (x −min)/(max −min)). The nor-

malized research priority score (NRPS) was analyzed and

the cut-off point, enabling identification of the upper

quartile (questions with the highest normalized research

priority scores), was determined. Online Google® forms

were used to capture online data from the reference

group and Microsoft Excel (2010) spreadsheets were

used to score and analyze the responses provided.

Results

A total of 650 stakeholders responded positively to our

initial invitation to participate in this exercise and were

included in the reference group. Of these, 339 participants

(52%) provided 980 research ideas or questions; these were

considered together with 95 research questions generated

through other recent research prioritization processes. Par-

ticipants from 67 countries provided research ideas or

questions (22 developed countries contributed with 44% of

participants, 45 developing countries contributed with 56%

of participants). Researchers (37%; 125/339), Clinician phy-

sicians (27%; 92/339); program managers and policy makers

(20%; 67/339) were the main providers of research ques-

tions. Midwives, donor representatives, consumers and

other stakeholders provided also research questions. After

exclusion of duplicates, thematic analysis and editing, 234

questions were discussed by the technical working group,

working closely with the WHO management team, at the

technical consultation meeting held in Geneva. The tech-

nical consultation produced a consolidated list with 190

research questions, which was sent to the reference group

for scoring. A total of 140 participants (22%) of the refer-

ence group scored the questions and returned completed

spreadsheets, which were integrated into one database.

The distribution of research questions generated per

theme is shown in Figure 2. Overall, most of the research

questions (89%) address the implementation of existing

interventions or knowledge (delivery/implementation re-

search); 21 questions (11%) address research to discover

new interventions or technologies (discovery research).

Additional file 1 contains the database with all re-

search priority questions and criteria scores. Normalized

scores for the 190 questions ranged from 0 to 100.

Questions with a NRPS of 76 and above formed part of

the upper quartile of highest ranked questions (56 in

total). These were fairly evenly distributed, with each of

the main themes attracting six to nine questions in the

upper quartile (Table 2).

The top 20 highest ranked questions overall are pre-

sented in Table 3. Abortion research makes up 25% (n = 5)

of the top 20 list with other major themes including health

systems research (n = 4), obstetric haemorrhage (n = 3),

neonatal care (n = 3), and labour/delivery (n = 2). Training

and/or awareness interventions comprise 30% (n = 6) of

the sub-themes of these top 20 research priorities.

Hypertensive disorders of pregnancy (HDP) is not rep-

resented in the top-20 list but comprises 14% of the

questions in the upper quartile. Similarly, none of the

upper quartile questions were ‘discovery’questions. The

five highest scoring discovery questions with their rank-

ing can be found in Table 4.

Discussion

The current exercise led to the identification of research

questions that are mostly related to implementation of

existing interventions and the development of simplified,

more cost-effective versions of existing interventions

Table 1 Scoring criteria for setting research priorities

1. Answerability The research question can be ethically answered.

2. Effectiveness The new knowledge is likely to result in an effective

intervention or program.

3. Deliverability The intervention or program will be deliverable,

acceptable and affordable.

4. Potential

impact

The intervention or program has the potential to

substantially reduce maternal and perinatal

mortality, morbidity and long term disabilities.

5. Equity The intervention or program will reach the most

vulnerable groups.

Souza et al. Reproductive Health 2014, 11:61 Page 4 of 9

http://www.reproductive-health-journal.com/content/11/1/61

(e.g. oxytocin and misoprostol for PPH prevention and

treatment or magnesium sulfate for eclampsia). A lim-

ited number of questions related to the discovery of new

solutions were proposed (e.g. new uterotonics for PPH

or new ways to identify PPH). The opinions expressed

by the participants through their input in this process

appear to corroborate the notion that the biggest

challenge in current maternal and perinatal health is to

increase the outreach of existing effective solutions for

those who need them most.

These results represent the consensus view of a large

number of researchers, policymakers and other stake-

holders internationally, and provide the essential routes to

action to eliminate preventable maternal deaths by 2025.

Figure 2 Priority research questions (N = 190) by theme.

Table 2 Breakdown of research question flow by themes

Research themes and common sub-themes Total questions

(N = 190)

Top-ranked questions*

(n = 56)

Top-twenty questions

(n = 20)

Labour and delivery: Preterm birth, difficult/obstructed labour, fetal

monitoring, the partograph, training and/or awareness, caesarean section,

management of the third stage, induction of labour

39 (21%) 6 (11%) 2 (10%)

Obstetric haemorrhage: Misoprostol access, uterotonics (type, dose, route),

screening and detection, training and/or awareness, care quality, blood

transfusions, management of the third stage

28 (15%) 8 (14%) 3 (15%)

Hypertensive disorders of pregnancy: Screening and detection, magnesium

sulphate, biochemical markers, anticonvulsants, antihypertensive agents,

training and/or awareness, prevention

21 (11%) 8 (14%) 0 (0%)

Abortion: Post-abortion contraception, misoprostol access, post-abortion

follow-up, abortion in restricted settings, second trimester abortion, training

and/or awareness

20 (11%) 8 (14%) 5 (25%)

Antenatal care: Screening and detection (including impaired fetal growth,

infection, preterm birth, anaemia), ultrasound access, nutrition, malaria, diabetes

care

21 (11%) 6 (11%) 2 (10%)

Health systems: Transport and communication, service quality, emergency

services, mobile community health services, supervision and mentoring, service

utilization, monitoring and audits

19 (10%) 8 (14%) 4 (20%)

Neonatal care: Neonatal resuscitation, hypoxic ischaemic encephalopathy,

screening and detection, kangaroo mother care, cord care, care of preterm

neonates, training and/or awareness

26 (14%) 9 (16%) 3 (15%)

Other: Puerperal sepsis, postnatal care, improving attitudes/behaviour of

healthcare workers

16 (8%) 2 (4%) 1 (5%)

*Upper quartile questions with a normalized research priority score (NRPS) of 76 and above.

Souza et al. Reproductive Health 2014, 11:61 Page 5 of 9

http://www.reproductive-health-journal.com/content/11/1/61

CHNRI methods aim to standardize and make more

transparent the highly complex process of setting research

priorities. Overall, these methods are perceived as robust,

but there are some concerns related to the ability of these

methods to identify all relevant research ideas. In general,

most of the previous CHNRI exercises have relied on rela-

tively small reference groups (in general, < 100 partici-

pants). Small reference groups are more likely to be biased

by various elements of their composition and more

dominant individuals within the group. In the present ex-

ercise, we tried to overcome these potential weaknesses by

increasing the number of participants and using distance-

based methods for collecting and scoring questions. Thus,

this became the largest exercise for prioritizing research

questions in maternal and perinatal health to date, involv-

ing a large number of experts and stakeholders, and with

a very large number of questions generated. However,

some limitations should be noted. Having a large group of

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

contraception uptake and continuance, and reduce repeat abortion

100 Abortion

Evaluate the effectiveness and costs of strategies to improve the quality and utilization of maternity services (e.g.

maternity waiting homes, improved communication via mobile phones, community awareness strategies) to improve

early detection and management of antenatal and intrapartum complications

95 Health systems

Develop and evaluate strategies for locally appropriate transport, communication and referral systems for obstetric and

newborn emergencies

94 Health systems

Evaluate the effectiveness and cost of strategies to prevent, detect and treat causes of anaemia in pregnancy (e.g.

malaria, occult bleeding disorders, nutritional deficiencies)

93 Antenatal care

Evaluate the effectiveness and cost of training interventions for frontline healthcare workers (paramedics, doctors, CHWs,

midwives, nurses) to diagnose, manage and refer women with obstetric haemorrhage

92 Obstetric

haemorrhage

Evaluate the effectiveness and cost of a package of community level interventions for preterm babies (e.g. implementing

and providing guidelines for kangaroo mother care, home visits by CHWs, infection prevention strategies)

92 Neonatal care

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

health workers, to detect and treat neonatal sepsis (or to provide pre-referral treatment only)

90 Neonatal care

Develop and evaluate community-based awareness programs to reduce unwanted pregnancies and encourage women

to seek help early

89 Abortion

Evaluate the effectiveness and cost of training interventions for skilled birth attendants to gain and maintain

competence in the management of obstructed labour, and assisted delivery techniques

88 Labour and

delivery

Evaluate the effectiveness and cost of training skilled birth attendants in intrapartum fetal monitoring and neonatal

resuscitation for reducing stillbirths and deaths/disability due to perinatal asphyxia

88 Neonatal care

Evaluate the effectiveness and cost of a package of interventions for the prevention, early detection and treatment of

puerperal sepsis (e.g. sterile birth kits, access to antibiotics, automated thermometers)

88 Other (puerperal

sepsis)

Evaluate the effectiveness and cost of a package of mobile service interventions delivered at community level, including

mobile clinics and home-based care, on maternal and perinatal health outcomes

87 Health systems

Evaluate the effectiveness, safety and timing of the initiation of post-abortion contraception (hormonal and IUDs) with

respect to abortion outcomes, contraceptive effectiveness, uptake, continuance, and repeat abortions

87 Abortion

Develop and evaluate the effectiveness and cost of strategies to improve access of women with obstetric haemorrhage

to blood and blood replacement products in settings without transport capabilities

87 Obstetric

haemorrhage

Develop and evaluate the effectiveness of strategies to increase access of women to misoprostol at community level

where oxytocin is not available/feasible, by dispensing it antenatally as part of a birthing kit, or at the time of delivery via

the attending CHW or nurse/midwife, to prevent and treat PPH

87 Obstetric

haemorrhage

Develop and evaluate strategies to increase appropriate use of the partograph, including decision-making and action, to

improve maternal and perinatal health outcomes

85 Labour and

delivery

Evaluate the effectiveness and cost of strategies, including task-shifting, to increase access of women to high quality

post-abortion care to improve early detection of complications

85 Abortion

Assess the effectiveness and cost of implementing a package of screening and treating syphilis and HIV in women of

reproductive age to improve maternal and perinatal health outcomes.

85 Antenatal care

Develop and evaluate a health systems package for effective task shifting for the management of obstetric emergencies,

including protocols, supervisory systems, and metrics

83 Health systems

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).

Souza et al. Reproductive Health 2014, 11:61 Page 6 of 9

http://www.reproductive-health-journal.com/content/11/1/61

experts and stakeholders was a positive factor because it

ensured broader representation and a very large pool of

research questions. However, managing a large number of

questions was technically challenging for all involved, par-

ticularly at list preparation (phase I) and scoring (phase II)

stages. Given the broad scope of this exercise (maternal

and perinatal health) and the long list of priority questions

to be scored, participant fatigue and time constraints were

of concern. For the set of 190 questions that was sent to

the reference group, each respondent had to attribute a

total of 950 scores (190 questions times five criteria),

which was a very time-intensive task. Anecdotal accounts

suggest that the time required to complete the task was

approximately four hours, however, some respondents re-

ported taking eight hours or more. This may explain the

substantial drop in response rate during phase III. Devel-

oping and testing simplified versions of the CHNRI

process could be explored as a way to strike a balance

between the necessary methodological rigor and practical

implementation. Another limitation of this method is

an apparent trend towards prioritizing implementation

research questions over discovery questions. This was

observed in this exercise and it has been a feature of other

CHNRI prioritization exercises; for example, in a similar

exercise for setting global mental health research prior-

ities, new interventions and technologies comprised seven

out of the ten lowest-scoring priorities, and none of the

top ten scoring priorities [17]. A possible explanation for

this could be that discovery questions tend to be more in-

novative and inherently riskier in terms of research invest-

ment while implementation research question seem to

respond concretely to immediate needs. Consensus-driven

processes are conservative by nature and as a result, re-

search questions that seem “safer”(e.g. implementation

research questions) could be more appealing to large con-

sultation groups. An additional explanation is that some

stakeholders are simply not aware of some of the new

technologies that are in earlier phases of development.

Thus, when asked to list research questions, they could

focus on the technologies that they know about. One may

question the validity of the CHNRI methodology to assess

research that is at the discovery stage as criteria such as

effectiveness, deliverability and equity are less relevant at

the discovery stage (though they may become more rele-

vant later, depending on the outcome of the primary re-

search). The method thus tends to systematically attribute

lower scores to discovery research. As future advances in

the field would depend on discovery research, in future

exercises, exploring ways of counter-balancing this trend

would be advisable; for example, conducting dedicated

modules with more relevant criteria (such as safety or

innovation) on discovery questions could avoid competi-

tion between different types of research questions.

The high ranking of priority research for abortion

and obstetric haemorrhage in this exercise reflects the

substantial contribution of these aspects to maternal

mortality and morbidity rates. Recurring sub-themes for

abortion research were mainly concerned with training

and/or awareness interventions, access to abortion, and

post-abortion care and contraception. Similarly, for ob-

stetric haemorrhage, training and/or awareness interven-

tions, and access to existing uterotonics were common

sub-themes. Given that both abortion and haemorrhage

are the most avoidable causes of maternal morbidity and

mortality, it is no surprise that priority questions focused

on the implementation/delivery of known effective inter-

ventions. Another recurring theme is research to address

cost-effectiveness knowledge gaps, which denotes the

importance of sustainability of new health technologies.

Health systems research had the second most research

questions in the top-20 list, illustrating the need for ef-

fective health systems to enable effective service delivery.

This emphasis on implementation research and health

system research suggest that the international commu-

nity is keen in overcoming barriers for using what is

already available rather than developing new technolo-

gies that may be not used due to the same reasons that

are currently preventing the use of existing health tech-

nology. As emphasis shift towards light technologies (i.e.

focus on work processes and system thinking) further

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

PPH and improve maternal health outcomes.

72 Obstetric

haemorrhage

Discover and evaluate a standardised method of measuring blood loss to improve the detection and management of

PPH, to improve maternal health outcomes.

70 Obstetric

haemorrhage

Discover new technologies/screening tools for the detection of anaemia in pregnancy to improve maternal and

perinatal health outcomes.

66 Antenatal care

Discover and evaluate new methods/technologies to prevent and treat obstetric haemorrhage and improve maternal

health outcomes.

55 Obstetric

haemorrhage

Discover and evaluate new pharmaceutical treatments for eclampsia to improve maternal and perinatal outcomes. 48 HDP

HDP: hypertensive disorders of pregnancy.

Souza et al. Reproductive Health 2014, 11:61 Page 7 of 9

http://www.reproductive-health-journal.com/content/11/1/61

methodological developments to ensure proper evidence

generation are needed.

In this exercise, members of the reference group were

drawn from a diverse and widely representative group of

stakeholders, who contributed to, and scored, questions

according to well-defined criteria; therefore we consider

this exercise to reflect the priorities for global research

in maternal and perinatal health going forward. Unlike

most other priority setting exercises using the CHNRI

approach, we did not weight the criteria used for setting

priorities, but have published the complete list of re-

search questions with individual criteria scores. This

should enable stakeholders to generate customized re-

search priorities according to their own weightings (e.g.

a donor agency may wish to promote research questions

that contribute more to health equity, or a governmental

foundation may wish to tackle research questions that

will have the largest impact on the disease burden), and

risk management preferences.

Conclusions

Key research priorities in maternal and perinatal health

were identified. The resulting ranked list of research

questions provides a valuable resource for health re-

search investors, researchers and other stakeholders. We

are hopeful that this exercise will inform the post-2015

Development Agenda and assist donors, research-policy

decision makers and researchers to invest in research

that will ultimately make the most significant difference

in the lives of mothers and babies.

Appendix 1

BiomedExperts search strategy

BiomedExperts is a free online service for the life sciences

community to connect, network, communicate and col-

laborate. BiomedExperts contains the research profiles of

more than 1.8 million life science researchers, represent-

ing over 26 million connections from over 2,700 institu-

tions in more than 160 countries. These profiles were

generated from author and co-author information from

18 million publications published in over 20,000 journals.

Search strategy

Keywords/areas of research searched:

Caesarean section

Eclampsia

Fistula

Labour complications

Maternal mortality

Postpartum haemorrhage

Preeclampsia

Pregnancy induced hypertension

Preterm births

Sepsis

Still births

Identification of researchers

For each of the above areas, we chose the first 20 authors

at “Global”level that published the highest number of arti-

cles related to that area, the first 10 authors at coauthors

level 1 (“your coauthors”) and the first 10 authors at coau-

thors level 2 (“coauthors of your coauthors”). The identifi-

cation of researchers was stratified to ensure participation

of researchers from both developed and developing

countries.

Additional file

Additional file 1: Final list of research questions.

Abbreviations

MDG: Millennium development goals; MMR: Maternal mortality ratios;

CHNRI: Child health and nutrition research initiative; WHO: World health

organization; USAID: The United States agency for international

development; MCHIP: Maternal and child health integrated program;

HDP: Hypertensive disorders of pregnancy; NRPS: Normalized research

priority score.

Competing interests

The authors declare that they have no competing interests.

Authors’contributions

AMG, JPS, MW, RB and JM, conceived the idea for the exercise. JPS and MW

led the international survey and prioritization exercise. JPS led the writing of

the paper with contributions from all authors. JPS and TAL prepared tables

and figures. All authors read and approved this manuscript.

Acknowledgements

We thank the participants of the reference group for contributing their time

and expertise to this exercise.

Funding

The 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, and The Bill & Melinda Gates Foundation provided financial

support for this project.

Author details

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.

Department of Social Medicine, Ribeirão

Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo,

Brazil.

Royal United Hospital, Bath, UK.

Faculty of Clinical Sciences, Obafemi

Awolowo University, Ile-Ife, Osun State, Nigeria.

Centro Rosarino de Estudios

Perinatales (CREP), Rosario, Santa Fé, Argentina.

Liggins Institute, The

University of Auckland, Grafton, Auckland, New Zealand.

Maternal and Child

Health Integrated Program (MCHIP), Johns Hopkins University Program for

International Education in Reproductive Health (JHPIEGO), Baltimore, USA.

Cochrane Pregnancy and Childbirth Group, Liverpool University, Liverpool,

UK.

Effective Care Research Unit, University of the Witwatersrand / University

of Fort Hare / Eastern Cape Department of Health, Amalinda DriveEast

London, Eastern Cape, South Africa.

School of Nursing, Midwifery & Social

Work, University of Manchester, Manchester, UK.

MARCH (Maternal,

Reproductive and Child Health) Center, London School of Hygiene and

Tropical Medicine, London, UK.

European Foundation for the Care of

Newborn Infants, Munich, Germany.

Department of Pediatrics, Ribeirão

Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo,

Souza et al. Reproductive Health 2014, 11:61 Page 8 of 9

http://www.reproductive-health-journal.com/content/11/1/61

Brazil.

Department of Obstetrics and Gynecology, School of Medicine,

College of Health Sciences, Makerere University, Kampala, Uganda.

Department of Obstetrics & Gynaecology, University of Nairobi, Nairobi,

Kenya.

Kalusugan ng Mag-Ina (Health of Mother and Child), Inc, New

Manila, Quezon City, Philippines.

Health and Social Care Research Centre,

Sheffield Hallam University, Sheffiled, UK.

Department of Obstetrics, School

of Medicine of São Paulo, São Paulo Federal University, São Paulo, Brazil.

Preeclampsia Foundation, Melbourne, Florida, USA.

International

Confederation of Midwives, The Hague, The Netherlands.

WHO Regional

Office for Africa, Brazzavile, Republic of the Congo.

Latin American Center

for Perinatology, Women and Reproductive Health, (CLAP/WR), WHO

Regional Office for the Americas, Montevideo, Uruguay.

WHO Regional

Office for the Eastern Mediterranean, Cairo, Egypt.

WHO Regional Office for

South East Asia, New Delhi, India.

WHO Regional Office for the Western

Pacific, Manila, Philippines.

Department of Maternal, Newborn, Child and

Adolescent Health, World Health Organization, Geneva, Switzerland.

School

of Population Health, Faculty of Medicine, Dentistry and Health Sciences,

University of Western Australia, Perth, Australia.

Received: 20 December 2013 Accepted: 22 July 2014

Published: 7 August 2014

References

1. Nations U: United Nations Millennium Project. New York: United Nations;

2002. Available at http://www.unmillenniumproject.org/.

2. World Health Organization, UNICEF, UNFPA and the World Bank: Trends in

maternal mortality: 1990 to 2010. Geneva: World Health Organization;

2012. World Health Organization website. Available: http://whqlibdoc.who.

int/publications/2012/9789241503631_eng.pdf. Accessed 2012 April 8).

3. United Nations: The Millenium Development Goals Report. New York;

2013. Available at http://www.un.org/millenniumgoals/pdf/report-2013/

mdg-report-2013-english.pdf.

4. Bustreo F, Say L, Koblinsky M, Pullum TW, Temmerman M, Pablos-Méndez A:

Ending preventable maternal deaths: the time is now. Lancet Glob Health

2013, 1(4):e176–e177.

5. Rudan I, Gibson JL, Ameratunga S, El Arifeen S, Bhutta ZA, Black M, Black RE,

Brown KH, Campbell H, Carneiro I, Chan KY, Chandramohan D, Chopra M,

Cousens S, Darmstadt GL, Meeks Gardner J, Hess SY, Hyder AA, Kapiriri L,

Kosek M, Lanata CF, Lansang MA, Lawn J, Tomlinson M, Tsai AC, Webster J,

Child Health and Nutrition Research Initiative: Setting priorities in global

child health research investments: guidelines for implementation of

CHNRI method. Croat Med J 2008, 49(6):720–733.

6. Rudan I, Gibson J, Kapiriri L, Lansang MA, Hyder AA, Lawn J, Darmstadt GL,

Cousens S, Bhutta ZA, Brown KH, Hess SY, Black M, Gardner JM, Webster J,

Carneiro I, Chandramohan D, Kosek M, Lanata CF, Tomlinson M, Chopra M,

Ameratunga S, Campbell H, El Arifeen S, Black RE: Child Health and

Nutrition Research Initiative (CHNRI): Setting priorities in global child

health research investments: assessment of principles and practice.

Croat Med J 2007, 48(5):595–604.

7. Kapiriri L, Tomlinson M, Chopra M, El Arifeen S, Black RE, Rudan I: Child

Health and Nutrition Research Initiative (CHNRI): Setting priorities in

global child health research investments: addressing values of

stakeholders. Croat Med J 2007, 48(5):618–627.

8. Rudan I, Theodoratou E, Zgaga L, Nair H, Chan KY, Tomlinson M, Tsai A,

Biloglav Z, Huda T, El Arifeen S, Chopra M, Campbell H: Setting priorities

for development of emerging interventions against childhood

pneumonia, meningitis and influenza. J Glob Health 2012, 2(1):10304.

doi:10.7189/jogh.02.010304.

9. Rudan I, El Arifeen S, Bhutta ZA, Black RE, Brooks A, Chan KY, Chopra M,

Duke T, Marsh D, Pio A, Simoes EA, Tamburlini G, Theodoratou E, Weber

MW, Whitney CG, Campbell H, Qazi SA, WHO/CHNRI Expert Group on

Childhood Pneumonia: Setting research priorities to reduce global

mortality from childhood pneumonia by 2015. PLoS Med 2011,

8(9):e1001099.

10. Dean S, Rudan I, Althabe F, Webb Girard A, Howson C, Langer A, Lawn J,

Reeve ME, Teela KC, Toledano M, Venkatraman CM, Belizan JM, Car J, Chan

KY, Chatterjee S, Chitekwe S, Doherty T, Donnay F, Ezzati M, Humayun K,

Jack B, Lassi ZS, Martorell R, Poortman Y, Bhutta ZA: Setting research

priorities for preconception care in low- and middle-income countries:

aiming to reduce maternal and child mortality and morbidity. PLoS Med

2013, 10(9):e1001508. doi:10.1371/journal.pmed.1001508.

11. Bahl R, Martines J, Bhandari N, Biloglav Z, Edmond K, Iyengar S, Kramer M,

Lawn JE, Manandhar DS, Mori R, Rasmussen KM, Sachdev HP, Singhal N,

Tomlinson M, Victora C, Williams AF, Chan KY, Rudan I: Setting research

priorities to reduce global mortality from preterm birth and low birth

weight by 2015. J Glob Health 2012, 2(1):10403. doi:10.7189/jogh.02-010403.

PubMed PMID: 23198132.

12. World Health Organization: WHO recommendations for prevention and

treatment of pre-eclampsia and eclampsia. Geneva: WHO; 2011.

13. World Health Organization, WHO: WHO recommendations for induction of

labour. Geneva: WHO; 2011.

14. World Health Organization: WHO recommendations for prevention and

treatment of postpartum haemorrhage. Geneva: WHO; 2012.

15. World Health Organization: Safe abortion: technical and policy guidance for

health systems. Geneva: WHO; 2012.

16. World Health Organization: Neonatal Health Research Priorities. Geneva:

WHO; 2013.

17. Tomlinson M, Rudan I, Saxena S, Swartz L, Tsai AC, Patel V: Setting priorities

for global mental health research. Bull World Health Organ 2009,

87:438–446.

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

exercise. Reproductive Health 2014 11:61.

Submit your next manuscript to BioMed Central

and take full advantage of:

• Convenient online submission

• Thorough peer review

• No space constraints or color ﬁgure charges

• Immediate publication on acceptance

• Inclusion in PubMed, CAS, Scopus and Google Scholar

• Research which is freely available for redistribution

Submit your manuscript at

www.biomedcentral.com/submit

Souza et al. Reproductive Health 2014, 11:61 Page 9 of 9

http://www.reproductive-health-journal.com/content/11/1/61

Research prioritisation on prevention and management of preterm birth in low and middle-income countries (LMICs) with a special focus on Bangladesh using the Child Health and Nutrition Research Initiative (CHNRI) method

Article

Full-text available

Sep 2023

Background: Fifteen million babies are born preterm globally each year, with 81% occurring in low- and middle-income countries (LMICs). Preterm birth complications are the leading cause of newborn deaths and significantly impact health, quality of life, and costs of health services. Improving outcomes for newborns and their families requires prioritising research for developing practical, scalable solutions, especially in low-resource settings such as Bangladesh. We aimed to identify research priorities related to preventing and managing preterm birth in LMICs for 2021-2030, with a special focus on Bangladesh. Methods: We adopted the Child Health and Nutrition Research Initiative (CHNRI) method to set research priorities for preventing and managing preterm birth. Seventy-six experts submitted 490 research questions online, which we collated into 95 unique questions and sent for scoring to all experts. A hundred and nine experts scored the questions using five pre-selected criteria: answerability, effectiveness, deliverability, maximum potential for burden reduction, and effect on equity. We calculated weighted and unweighted research priority scores and average expert agreement to generate a list of top-ranked research questions for LMICs and Bangladesh. Results: Health systems and policy research dominated the top 20 identified priorities for LMICs, such as understanding and improving uptake of the facility and community-based Kangaroo Mother Care (KMC), promoting breastfeeding, improving referral and transport networks, evaluating the impact of the use of skilled attendants, quality improvement activities, and exploring barriers to antenatal steroid use. Several of the top 20 questions also focused on screening high-risk women or the general population of women, understanding the causes of preterm birth, or managing preterm babies with illnesses (jaundice, sepsis and retinopathy of prematurity). There was a high overlap between research priorities in LMICs and Bangladesh. Conclusions: This exercise, aimed at identifying priorities for preterm birth prevention and management research in LMICs, especially in Bangladesh, found research on improving the care of preterm babies to be more important in reducing the burden of preterm birth and accelerating the attainment of Sustainable Development Goal 3 target of newborn deaths, by 2030.

Research priorities for care of preterm or low birth weight infants: health policy

Article

Full-text available

Aug 2023

Research priorities for preterm or low birth weight (LBW) infants were advanced in 2012, and other research priority-setting exercises since then have included more limited, context-specific research priorities pertaining to preterm infants. While developing new World Health Organization (WHO) guidelines for care of preterm or LBW infants, we conducted a complementary research prioritisation exercise. A diverse, globally representative guideline development group (GDG) of experts – all authors of this paper along with WHO steering group for preterm-LBW guidelines – was assembled by the WHO to examine evidence and consider a variety of factors in intervention effectiveness and implementation, leading to 25 new recommendations and one good practice statement for care of preterm or LBW infants. The GDG generated research questions (RQs) based on contributions to improvements in care and outcomes of preterm or LBW infants, public health impacts, answerability, knowledge gaps, feasibility of implementation, and promotion of equity, and then ranked the RQs based on their likelihood to further change or influence the WHO guidelines for the care of preterm or LBW infants in the future. Thirty-six priority RQs were identified, 32 (89%) of which focused on aspects of intervention effectiveness, and the remaining four addressed implementation (“how”) questions. Of the top 12 RQs, seven focused on further advancing new recommendations – such as family involvement and support in caring for preterm or LBW infants, emollient therapy, probiotics, immediate KMC for critically ill newborns, and home visits for post-discharge follow-up of preterm or LBW infants – and three RQs addressed issues of feeding (breastmilk promotion, milk banks, individualized feeding). RQs prioritised here will be critical for optimising the effectiveness and delivery of new WHO recommendations for care of preterm or LBW infants. The RQs encompass unanswered research priorities for preterm or LBW infants from prior prioritisation exercises which were conducted using Child Health and Nutrition Research Initiative (CHNRI) methodology. Funding Nil.

Global research priorities related to the World Health Organization Labour Care Guide: results of a global consultation

Article

Full-text available

Apr 2023
Reprod Health

Background: The World Health Organization (WHO) published the WHO Labour Care Guide (LCG) in 2020 to support the implementation of its 2018 recommendations on intrapartum care. The WHO LCG promotes evidence-based labour monitoring and stimulates shared decision-making between maternity care providers and labouring women. There is a need to identify critical questions that will contribute to defining the research agenda relating to implementation of the WHO LCG. Methods: This mixed-methods prioritization exercise, adapted from the Child Health and Nutrition Research Initiative (CHNRI) and James Lind Alliance (JLA) methods, combined a metrics-based design with a qualitative, consensus-building consultation in three phases. The exercise followed the reporting guideline for priority setting of health research (REPRISE). First, 30 stakeholders were invited to submit online ideas or questions (generation of research ideas). Then, 220 stakeholders were invited to score "research avenues" (i.e., broad research ideas that could be answered through a set of research questions) against six independent and equally weighted criteria (scoring of research avenues). Finally, a technical working group (TWG) of 20 purposively selected stakeholders reviewed the scoring, and refined and ranked the research avenues (consensus-building meeting). Results: Initially, 24 stakeholders submitted 89 research ideas or questions. A list of 10 consolidated research avenues was scored by 75/220 stakeholders. During the virtual consensus-building meeting, research avenues were refined, and the top three priorities agreed upon were: (1) optimize implementation strategies of WHO LCG, (2) improve understanding of the effect of WHO LCG on maternal and perinatal outcomes, and the process and experience of labour and childbirth care, and (3) assess the effect of the WHO LCG in special situations or settings. Research avenues related to the organization of care and resource utilization ranked lowest during both the scoring and consensus-building process. Conclusion: This systematic and transparent process should encourage researchers, program implementers, and funders to support research aligned with the identified priorities related to WHO LCG. An international collaborative platform is recommended to implement prioritized research by using harmonized research tools, establishing a repository of research priorities studies, and scaling-up successful research results.

SERAFIM-BR: uma proposta de Agenda de Pesquisa em Medicina de Família e Comunidade no Brasil

Article

Full-text available

Dec 2023

Introdução: A Medicina de Família e Comunidade (MFC) é a especialidade médica que atua essencialmente na atenção primária à saúde. No Brasil, temos a organização do sistema de saúde sendo construída com base na atenção primária à saúde. O último dado nacional sobre a cobertura da Estratégia de Saúde da Família em novembro de 2022 era de 48.601 equipes. Objetivo: O objetivo do presente artigo foi desenvolver uma proposta de agenda de pesquisa em MFC. Métodos: Estudo quanti-qualitativo que combinou e adaptou as metodologias Delphi e CHNRI. Por meio de ampla divulgação, MFC de todo o Brasil, associados da SBMFC, foram convidados. Em seguida, foi enviado para cada MFC o questionário SERAFIM-Q1. Além de informações sociodemográficas, foi solicitado que enviassem 2 sugestões de temas para pesquisa em MFC no Brasil. Na segunda fase, foi enviado para todos os MFC que participaram da primeira fase um novo questionário (SERAFIM-Q2) onde eram apresentados os 20 tópicos mais frequentes do SERAFIM-Q1 e solicitado que eles dessem uma nota (zero a 10) para cada tema. Por último, as notas de cada respondente foram somadas e hierarquizadas. Resultados: Um total de 304 MFC responderam ao SERAFIM-Q1. Após exclusões, obteve-se 200 participantes, que geraram 397 respostas (três MFC enviaram apenas 1 tema) com sugestões de temas de pesquisa em MFC. Os 20 temas mais frequentes foram: Ensino de MFC; Gestão em saúde — Nível macro; Acesso; Saúde mental; Ensino de MFC na graduação médica; Prevenção quaternária; Coordenação de cuidados; Habilidades de comunicação; MFC na saúde suplementar; Ensino de MFC na residência médica; Gestão em saúde — Nível micro; Saúde planetária; Tecnologia em saúde – Telemedicina; Saúde da população rural; Ferramentas do MFC — Gestão da clínica; Ensino de MFC — Capacitação de preceptores; Avaliação de qualidade — Indicadores de saúde; Indicadores de desempenho do(a) MFC; Acesso — Modelos de acesso; Saúde Pública. No SERAFIM-Q2, a lista dos 10 temas prioritários foi: 1) Acesso; 2) Saúde mental; 3) Ensino de MFC na graduação médica; 4) Ensino de MFC na residência médica; 5) Prevenção quaternária; 6) Avaliação de qualidade — Indicadores de saúde; 7) Ensino de MFC; 8) Habilidades de comunicação; 9) Ensino de MFC — Capacitação de preceptores; 10) Coordenação de cuidados. Conclusões: Este é, a priori, o primeiro estudo que propõe uma agenda de pesquisa em MFC no Brasil. Esperamos que os 10 temas prioritários de pesquisa mais bem votados auxiliem os pesquisadores, tanto norteando as pesquisas nesse campo quanto melhorando a saúde dos brasileiros e brasileiras.

Randomised trials in maternal and perinatal health in low and middle-income countries from 2010 to 2019: a systematic scoping review

Article

Full-text available

Jul 2022

Objectives To identify and map all trials in maternal health conducted in low and middle-income countries (LMIC) over the 10-year period from 2010 to 2019, to identify geographical and thematic trends, as well as comparing to global causes of maternal death and preidentified priority areas. Design Systematic scoping review. Primary and secondary outcome measures Extracted data included location, study characteristics and whether trials corresponded to causes of mortality and identified research priority topics. Results We searched the Cochrane Central Register of Controlled Trials database, a combined registry of trials from multiple sources. Our search identified 7269 articles, 874 of which were included for analysis. Between 2010 and 2019, maternal health trials conducted in LMICs more than doubled (50–114). Trials were conducted in 61 countries—231 trials (26.4%) were conducted in Iran. Only 225 trials (25.7%) were aligned with a cause of maternal mortality. Within these trials, pre-existing medical conditions, embolism, obstructed labour and sepsis were all under-represented when compared with number of maternal deaths globally. Large numbers of studies were conducted on priority topics such as labour and delivery, obstetric haemorrhage and antenatal care. Hypertensive disorders of pregnancy, diabetes and health systems and policy—despite being high-priority topics—had relatively few trials. Conclusion Despite trials conducted in LMICs increasing from 2010 to 2019, there were significant gaps in geographical distribution, alignment with causes of maternal mortality and known research priority topics. The research gaps identified provide guidance and insight for future research conduct in low-resource settings. Trial registration number 10.17605/OSF.IO/QUJP5.

Neglected medium-term and long-term consequences of labour and childbirth: a systematic analysis of the burden, recommended practices, and a way forward

Article

Dec 2023

Over the past three decades, substantial progress has been made in reducing maternal mortality worldwide. However, the historical focus on mortality reduction has been accompanied by comparative neglect of labour and birth complications that can emerge or persist months or years postnatally. This paper addresses these overlooked conditions, arguing that their absence from the global health agenda and national action plans has led to the misconception that they are uncommon or unimportant. The historical limitation of postnatal care services to the 6 weeks after birth is also a contributing factor. We reviewed epidemiological data on medium-term and long-term complications arising from labour and childbirth beyond 6 weeks, along with high-quality clinical guidelines for their prevention, identification, and treatment. We explore the complex interplay of human evolution, maternal physiology, and inherent predispositions that contribute to these complications. We offer actionable recommendations to change the current trajectories of these neglected conditions and help achieve the targets of Sustainable Development Goal 3. This paper is the third in a Series of four papers about maternal health in the perinatal period and beyond.

Conformación de la red de gestión de conocimiento, investigación e innovación en salud materna en Colombia

Article

Aug 2023

Objetivo: Establecer la metodología y los principales actores en la conformación de una red de gestión de conocimiento, investigación e innovación en salud materna en Colombia. Metodología: Enfoque triangular, cuyo componente principal es cualitativo con complemento cuantitativo, de alcance descriptivo, articulado en tres procesos centrales: levantamiento de información, sistemas de información y generación del conocimiento; dividido en dos etapas: planificación - conformación y madurez - sostenibilidad. Resultados: La información recolectada permitió identificar los actores que trabajan en áreas relacionadas a la salud materna en los territorios y los tipos de actividades que estos realizan: social, académica, investigativa, prestación de servicios de salud. Se delimitaron cinco regiones geográficas de influencia donde intervienen los actores, el 66,7% (97) se encuentran ubicados en la región andina, el 21,1% (31) se encuentran ubicados en la región caribe; el 6,1% (9) se encuentran ubicado en la región amazonia y el 2,7 % (4) se encuentra ubicados tanto en la región de la Orinoquia y 3,4% (5) de la región pacífica. Conclusiones: La conformación de esta red proporcionará una plataforma estratégica para la generación y gestión del conocimiento en salud materna que permitirá impulsar proyectos de investigación e innovación de manera colaborativa, apoyando la toma de decisiones para la intervención, desarrollo e implementación de políticas nacionales de salud pública en el marco del cumplimiento de los Objetivos de Desarrollo Sostenible en Colombia

Longitudinal Sleep Study in Pregnancy: Cohort Profile and Prevalence and Risk Factors for Sleep Symptoms in the First Trimester

Article

Full-text available

Jan 2023
Int J Environ Res Publ Health

Sleep disorders could influence pregnancy outcomes but evidence for longitudinal associations is scarce. We established a prospective cohort of women to determine incident sleep issues and their adverse health outcomes during pregnancy and beyond, and present here the baseline cohort profile. Antenatal women in gestational weeks 8–12 were recruited (n = 535) and followed-up in each trimester and at 5–6 weeks postpartum (no attrition). Sleep symptoms and disorders were measured using STOP-Bang and Berlin questionnaires and Pittsburgh Sleep Quality Index. Incident health outcomes were extracted from clinical records. At the time of recruitment, habitual snoring was present in 13.8% of participants; “excessive sleepiness during the day” (EDS) in 42.8%; short (<7 h) sleep duration in 46.4%; “having trouble sleeping” in 15.3%; and “poor subjective sleep quality” in 8.6%. Habitual snoring was strongly associated with irregular menstrual periods for one year preceding pregnancy (p = 0.014) and higher BMI (p < 0.001). Higher age was associated with less “trouble sleeping” (OR 0.9, p = 0.033) and longer sleep duration was associated with better “subjective sleep quality” (OR 0.8, p = 0.005). Sleep issues were highly prevalent at baseline and associated with age, irregular menstruation, and obesity. This cohort will provide a robust platform to investigate incident sleep disorders during pregnancy and their effects on adverse pregnancy outcomes and long-term health of women and their offspring.

Research priorities for maternal and perinatal health clinical trials and methods used to identify them: A systematic review

Article

Nov 2022
EUR J OBSTET GYN R B

Objective Research prioritisation helps to target research resources to the most pressing health and healthcare needs of a population. This systematic review aimed to report research priorities in maternal and perinatal health and to assess the methods that were used to identify them. Methods A systematic review was undertaken. Projects that aimed to identify research priorities that were considered to be amenable to clinical trials research were eligible for inclusion. The search, limited to the last decade and publications in English, included MEDLINE, EMBASE, CINHAL, relevant Cochrane priority lists, Cochrane Priority Setting Methods Group homepage, James Lind Alliance homepage, Joanna Brigg’s register, PROSPERO register, reference lists of all included articles, grey literature, and the websites of relevant professional bodies, until 13 October 2020. The methods used for prioritisation were appraised using the Reporting Guideline for Priority Setting of Health Research (REPRISE). Findings From the 62 included projects, 757 research priorities of relevance to maternal and perinatal health were identified. The most common priorities related to healthcare systems and services, pregnancy care and complications, and newborn care and complications. The least common priorities related to preconception and postpartum health, maternal mental health, contraception and pregnancy termination, and fetal medicine and surveillance. The most commonly used prioritisation methods were Delphi (20, 32%), Child Health Nutrition Research Initiative (17, 27%) and the James Lind Alliance (10, 16%). The fourteen projects (23%) that reported on at least 80% of the items included in the REPRISE guideline all used an established research prioritisation method. Conclusions There are a large number of diverse research priorities in maternal and perinatal health that are amenable to future clinical trials research. These have been identified by a variety of research prioritisation methods.

Facility Based Maternal and Perinatal Mortality: Evidence from Maternal and Perinatal Death Surveillance and Response, Gombe State, Nigeria

Article

Full-text available

Oct 2022

Background: Globally, women and their unborn babies continue to die from preventable causes. This study aims to highlight the causes of maternal and perinatal deaths and bring to the fore areas that need to be improved in order to improve maternal and perinatal health indices in Gombe State. Methodology: Information for this report was obtained from Maternal and Perinatal Deaths Surveillance and Response (MPDSR) desk officers and chairmen across MPDSR supported health facilities in the state. Secondary data abstraction from registers was conducted using an electronic questionnaire and was analysed using SPSS version 23. Findings: The Maternal Mortality Ratio (MMR) was 1,092/100,000 livebirths in 2019 and 993/100,000 live births in 2020. Majority of the women (84.3% and 86.7% in 2019 and 2020 respectively) were severely ill at presentation, while most maternal deaths were as a result of eclampsia/pre-eclampsia and Post Partum Haemorrhage (PPH). Only 15.9% and 14.4% of maternal deaths in 2019 and 2020 respectively were reviewed. Perinatal asphyxia accounted for 36.4% and 31.8% of perinatal deaths in 2019 and 2020 respectively, while prematurity resulted in 24.7% and 35.6% of deaths in 2019 and 2020 respectively. The Perinatal Mortality Rates (PMR) were 78.3/1000 births in 2019 and 76.1/1000 births in 2020. Conclusion: Although MMR and PMR have been on a decline in Gombe state from 2018 till date, these figures are still far from achieving the SDG 2030 target. There is therefore the need to revive MPDSR activities in the state and improve emergency obstetric health care services.

Ending preventable maternal deaths: The time is now

Article

Full-text available

Oct 2013

Setting Research Priorities for Preconception Care in Low- and Middle-Income Countries: Aiming to Reduce Maternal and Child Mortality and Morbidity

Article

Full-text available

Sep 2013
PLOS MED

Sohni Dean and colleagues report their CHNRI exercise that developed health research priorities for effective pre-conception care in low- and middle-income countries. Please see later in the article for the Editors' Summary

Setting research priorities to reduce global mortality from preterm birth and low birth weight by 2015

Article

Full-text available

Jun 2012

This paper aims to identify health research priorities that could improve the rate of progress in reducing global neonatal mortality from preterm birth and low birth weight (PB/LBW), as set out in the UN's Millennium Development Goal 4. We applied the Child Health and Nutrition Research Initiative (CHNRI) methodology for setting priorities in health research investments. In the process coordinated by the World Health Organization in 2007-2008, 21 researchers with interest in child, maternal and newborn health suggested 82 research ideas that spanned across the broad spectrum of epidemiological research, health policy and systems research, improvement of existing interventions and development of new interventions. The 82 research questions were then assessed for answerability, effectiveness, deliverability, maximum potential for mortality reduction and the effect on equity using the CHNRI method. The top 10 identified research priorities were dominated by health systems and policy research questions (eg, identification of LBW infants born at home within 24-48 hours of birth for additional care; approaches to improve quality of care of LBW infants in health facilities; identification of barriers to optimal home care practices including care seeking; and approaches to increase the use of antenatal corticosteriods in preterm labor and to improve access to hospital care for LBW infants). These were followed by priorities for improvement of the existing interventions (eg, early initiation of breastfeeding, including feeding mode and techniques for those unable to suckle directly from the breast; improved cord care, such as chlorhexidine application; and alternative methods to Kangaroo Mother Care (KMC) to keep LBW infants warm in community settings). The highest-ranked epidemiological question suggested improving criteria for identifying LBW infants who need to be cared for in a hospital. Among the new interventions, the greatest support was shown for the development of new simple and effective interventions for providing thermal care to LBW infants, if KMC is not acceptable to the mother. The context for this exercise was set within the MDG4, requiring an urgent and rapid progress in mortality reduction from low birth weight, rather than identifying long-term strategic solutions of the greatest potential. In a short-term context, the health policy and systems research to improve access and coverage by the existing interventions, coupled with further research to improve effectiveness, deliverability and acceptance of existing interventions, and epidemiological research to address the key gaps in knowledge, were all highlighted as research priorities.

Setting priorities for development of emerging interventions against childhood pneumonia, meningitis and influenza

Article

Full-text available

Jun 2012

WAcute lower respiratory infections, which broadly include pneumonia and bronchiolitis, are still the leading cause of childhood mortality. ALRI contributed to 18% of all deaths in children younger than five years of age in 2008, and the main pathogens responsible for high mortality were Streptococcus pneumoniae, Haemophilus influenzae and respiratory syncytial virus. In addition, meningitis was estimated to contribute up to 200 000 deaths each year, and influenza anywhere between 25 000 and 110 000. It is widely acknowledged that a major portion of this mortality should be avoidable if universal coverage of all known effective interventions could be achieved. However, some evaluations of the implementation of World Health Organization’s (WHO) Integrated Management of Childhood Illness (IMCI) strategy, which promotes improved access to a trained health provider who can administer “standard case management”, have shown somewhat disappointing results. Only a minority of all children with life-threatening episodes of pneumonia, meningitis and influenza in developing countries have access to trained health providers and receive appropriate treatment. Thus, novel strategies for control of pneumonia that balance investments in scaling up of existing interventions and the development of novel approaches, technologies and ideas are clearly needed.

Setting Research Priorities to Reduce Global Mortality from Childhood Pneumonia by 2015

Article

Full-text available

Sep 2011
PLOS MED

Igor Rudan and colleagues report the results of their consensus building exercise that identified health research priorities to help reduce child mortality from pneumonia.

Setting priorities for global mental health research

Article

Full-text available

Jul 2009

To set investment priorities in global mental health research and to propose a more rational use of funds in this under-resourced and under-investigated area. Members of the Lancet Mental Health Group systematically listed and scored research investment options on four broad classes of disorders: schizophrenia and other major psychotic disorders, major depressive disorder and other common mental disorders, alcohol abuse and other substance abuse disorders, and the broad class of child and adolescent mental disorders. Using the priority-setting approach of the Child Health and Nutrition Research Initiative, the group listed various research questions and evaluated them using the criteria of answerability, effectiveness, deliverability, equity and potential impact on persisting burden of mental health disorders. Scores were then weighted according to the system of values expressed by a larger group of stakeholders. The research questions that scored highest were related to health policy and systems research, where and how to deliver existing cost-effective interventions in a low-resource context, and epidemiological research on the broad categories of child and adolescent mental disorders or those pertaining to alcohol and drug abuse questions. The questions that scored lowest related to the development of new interventions and new drugs or pharmacological agents, vaccines or other technologies. In the context of global mental health and with a time frame of the next 10 years, it would be best to fill critical knowledge gaps by investing in research into health policy and systems, epidemiology and improved delivery of cost-effective interventions.

Setting Priorities in Global Child Health Research Investments: Guidelines for Implementation of CHNRI Method

Article

Full-text available

Jan 2009
CROAT MED J

This article provides detailed guidelines for the implementation of systematic method for setting priorities in health research investments that was recently developed by Child Health and Nutrition Research Initiative (CHNRI). The target audience for the proposed method are international agencies, large research funding donors, and national governments and policy-makers. The process has the following steps: (i) selecting the managers of the process; (ii) specifying the context and risk management preferences; (iii) discussing criteria for setting health research priorities; (iv) choosing a limited set of the most useful and important criteria; (v) developing means to assess the likelihood that proposed health research options will satisfy the selected criteria; (vi) systematic listing of a large number of proposed health research options; (vii) pre-scoring check of all competing health research options; (viii) scoring of health research options using the chosen set of criteria; (ix) calculating intermediate scores for each health research option; (x) obtaining further input from the stakeholders; (xi) adjusting intermediate scores taking into account the values of stakeholders; (xii) calculating overall priority scores and assigning ranks; (xiii) performing an analysis of agreement between the scorers; (xiv) linking computed research priority scores with investment decisions; (xv) feedback and revision. The CHNRI method is a flexible process that enables prioritizing health research investments at any level: institutional, regional, national, international, or global.

Setting Priorities in Global Child Health Research Investments: Addressing Values of Stakeholders

Article

Full-text available

Nov 2007
CROAT MED J

To identify main groups of stakeholders in the process of health research priority setting and propose strategies for addressing their systems of values. In three separate exercises that took place between March and June 2006 we interviewed three different groups of stakeholders: 1) members of the global research priority setting network; 2) a diverse group of national-level stakeholders from South Africa; and 3) participants at the conference related to international child health held in Washington, DC, USA. Each of the groups was administered different version of the questionnaire in which they were asked to set weights to criteria (and also minimum required thresholds, where applicable) that were a priori defined as relevant to health research priority setting by the consultants of the Child Health and Nutrition Research initiative (CHNRI). At the global level, the wide and diverse group of respondents placed the greatest importance (weight) to the criterion of maximum potential for disease burden reduction, while the most stringent threshold was placed on the criterion of answerability in an ethical way. Among the stakeholders' representatives attending the international conference, the criterion of deliverability, answerability, and sustainability of health research results was proposed as the most important one. At the national level in South Africa, the greatest weight was placed on the criterion addressing the predicted impact on equity of the proposed health research. Involving a large group of stakeholders when setting priorities in health research investments is important because the criteria of relevance to scientists and technical experts, whose knowledge and technical expertise is usually central to the process, may not be appropriate to specific contexts and in accordance with the views and values of those who invest in health research, those who benefit from it, or wider society as a whole.

Setting research priorities to reduce global mortality from low birth weight by 2015

Article