Asking different questions: research priorities to improve the quality of care for every woman, every child
Authors: Holly Powell Kennedy, Sashiyo Yoshida, Anthony Costello, Eugene Declercq, Marcos A Dias, Elizabeth Duff, Atf Gherissi, Karyn Kaufman, Frances McConville, Alison McFadden, Michaela Michel-Schuldt, Nester T Moyo, Kerri Schuiling, Anna M Speciale, Mary J Renfrew
Journal: The Lancet Global Health (2016)

Unacceptably high rates of adverse outcomes persist for childbearing women and infants, including maternal and newborn mortality, stillbirth, and short-term and long-term morbidity.1International Confederation of MidwivesWHOUNFPAState of the World's Midwifery: a universal pathway, a woman's right to health.http://www.unfpa.org/sowmyGoogle Scholar In light of the challenges to achieve the UN Sustainable Development Goals, it is timely to reconsider priorities for research in maternal and newborn health. Are we asking the right questions?2Chalmers I The perinatal research agenda: whose priorities?.Birth. 1991; 18: 137-141Crossref PubMed Scopus (16) Google Scholar Recent evidence indicates the importance of seeking knowledge beyond the treatment of complications, to inform better ways of providing sustainable, high quality care, including preventing problems before they occur.3Souza JP Widmer M Gulmezoglu AM et al.Maternal and perinatal health research priorities beyond 2015: an international survey and prioritization exercise.Reprod Health. 2014; 11: 61Crossref PubMed Scopus (36) Google Scholar The 2014 publication of The Lancet's Series on Midwifery presented a unique opportunity to generate future areas of inquiry by drawing on the most extensive examination to date of evidence on the care that all women and newborn infants need across the continuum from pre-pregnancy, birth, postpartum, and the early weeks of life.4Renfrew MJ McFadden A Bastos MH et al.Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care.Lancet. 2014; 384: 1129-1145Summary Full Text Full Text PDF PubMed Scopus (707) Google Scholar, 5Homer CS Friberg IK Dias MA et al.The projected effect of scaling up midwifery.Lancet. 2014; 384: 1146-1157Summary Full Text Full Text PDF PubMed Scopus (199) Google Scholar, 6Van Lerberghe W Matthews Z Achadi E et al.Country experience with strengthening of health systems and deployment of midwives in countries with high maternal mortality.Lancet. 2014; 384: 1215-1225Summary Full Text Full Text PDF PubMed Scopus (151) Google Scholar The series summarised the evidence base for quality maternal and newborn care in a new framework that focuses on the needs of women, infants, and families and differentiates between what care is provided, how it is provided, and by whom.4Renfrew MJ McFadden A Bastos MH et al.Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care.Lancet. 2014; 384: 1129-1145Summary Full Text Full Text PDF PubMed Scopus (707) Google Scholar These are concepts that are often confused or ignored in existing studies. Midwifery was identified as a cost-effective and fundamentally important element of quality care, with the potential to improve over 50 different maternal and newborn outcomes including mortality and morbidity. However, there are substantive barriers to proper implementation and integration of midwifery into health systems.1International Confederation of MidwivesWHOUNFPAState of the World's Midwifery: a universal pathway, a woman's right to health.http://www.unfpa.org/sowmyGoogle Scholar We adapted the Child Health and Nutrition Research Initiative (CHNRI) methodology to score competing future research topics on quality maternal and newborn care and the contribution of midwifery to that care.7Rudan I Gibson JL Ameratunga S et al.Setting priorities in global child health research investments: guidelines for implementation of CHNRI method.Croat Med J. 2008; 49: 720-733Crossref PubMed Scopus (153) Google Scholar This method has been used to set health research priorities for infant and childhood conditions,8Yoshida S Rudan I Lawn JE et al.Newborn health research priorities beyond 2015.Lancet. 2014; 384: e27-e29Summary Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 9Lawn JE Bahl R Bergstrom S et al.Setting research priorities to reduce almost one million deaths from birth asphyxia by 2015.PLoS Med. 2011; 8: e1000389Crossref PubMed Scopus (91) Google Scholar reduction of maternal and perinatal mortality,2Chalmers I The perinatal research agenda: whose priorities?.Birth. 1991; 18: 137-141Crossref PubMed Scopus (16) Google Scholar and preterm birth and stillbirths.10Bahl R Martines J Bhandari N et al.Setting research priorities to reduce global mortality from preterm birth and low birth weight by 2015.J Glob Health. 2012; 2: 010403Crossref PubMed Google Scholar A team representing expertise in maternal and newborn health research, including authors from The Lancet's Series on Midwifery, contributors from WHO, UNFPA, the International Confederation of Midwives, and a representative of or advocate for service users conducted the work. The team identified 30 research topics based on an analysis of gaps in the evidence presented in the 2014 Lancet Series on Midwifery. Stakeholders were asked to consider the potential research topics in terms of their relevance, significance, and potential future implementation based on five criteria: answerability, community involvement, sustainability, equity, and maximal impact.7Rudan I Gibson JL Ameratunga S et al.Setting priorities in global child health research investments: guidelines for implementation of CHNRI method.Croat Med J. 2008; 49: 720-733Crossref PubMed Scopus (153) Google Scholar The 30 research topics and scoring criteria were distributed in English, French, and Spanish online surveys to 1191 stakeholders, including constituents of the global Partnership for Maternal, Newborn, and Child Health (PMNCH) and representatives from all WHO regions. Stakeholders were asked to score each of the 30 research topics as 1·0 (yes), 0·5 (informed but undecided answer), or 0 (no) on whether they met each of the five criteria. It was possible to omit a score if a respondent did not feel confident to decide on a criterion; these were regarded as missing data and not part of the denominator. Summary scores for each criterion and an overall score were then computed as the sum of the scores divided by the number of actual scorers. Responses were received from all WHO regions, with a total response rate of 23% (n=271). Most (83%) responses were submitted in English, 13% in French, and 4% in Spanish. The highest proportion (24%) of those who provided demographic information came from the Western Pacific Region and the lowest (2·6%) from southeast Asia. Over a quarter (26%) came from the academic, research, or training institution sector of the PMNCH constituents. Of the 199 respondents who identified themselves as health professionals, 168 (84%) were in roles associated with maternal and child health. Our goal was to identify the top 10 priorities; however, two scored equally, and so the top 11 are presented in the table. The stakeholders prioritised research that would increase knowledge about ways to prevent complications and reduce unnecessary interventions, strengthen women's own capabilities, and optimise biological, social, and cultural processes. They also identified the importance of examining the role of midwifery in providing quality care for all women and infants. Stakeholders also identified research to improve skilled, knowledgeable, and compassionate care provided by an appropriate workforce that ensures timely referral when complications arise. The top two priorities indicate the fundamental importance of effective family planning services and of quality care to reduce rates of preterm birth, low birthweight, stillbirth, and perinatal mortality. Evidence indicates that midwifery care can be a key intervention to improve these outcomes, but more research is urgently needed to determine clinically and cost-effective models of care in diverse settings, especially in low-resource areas.11Sandall J Soltani H Gates S Shennan A Devane D Midwife-led continuity models versus other models of care for childbearing women.Cochrane Database Syst Rev. 2015; 9 (CD004667)Crossref PubMed Scopus (381) Google Scholar A focus on new measures and indicators of care components that have not traditionally been well examined will enable new benchmarks to be set for developing systems of care that meet the needs of all women and newborns.TableRanking of research topics by overall research priority scoreResearch prioritiesResearch priority score1Evaluate the effectiveness of midwifery care across the continuum in increasing access to and acceptability of family planning services for women90·42Evaluate the effectiveness of midwife-led care when compared to other models of care across various settings, particularly on rates of fetal and infant death, preterm birth, and low birthweight89·83Determine which indicators are most valuable in assessing quality maternal and newborn care89·74Identify and describe aspects of care that optimise, and those that disturb, the biological/physiological processes for healthy childbearing women and fetus/newborn infants and those who experience complications89·35Evaluate the effectiveness of midwifery care in providing culturally appropriate information, education, and health promotion (eg, nutrition, substance use, domestic violence, and mental health)89·16Identify and describe enabling factors from examples of successful implementation of evidence-based maternal and newborn care across a variety of settings897Describe and evaluate the effectiveness of midwives working with others (such as health professionals, community health workers, and traditional birth attendants) in achieving quality maternal and newborn care including, but not limited to: Timely transfer of women to appropriate level/site of careManagement of emergency situationsMaximal use of skills and competenciesShared decision-making and accountability898Assess the views and preferences of women and families across a variety of settings about their experiences of maternal and newborn care including, but not limited to, care providers and sites of care (eg, place of birth, antenatal care)88·89Develop setting-specific benchmarks to assess measurable progress on implementation of quality maternal and newborn care88·310Identify and describe aspects of maternal and newborn care that strengthen or weaken women's psychosocial wellbeing and mental health88·011Assess whether new measures of morbidity are needed to more effectively evaluate outcomes of maternal and newborn care88·0 Open table in a new tab The priorities identified reveal broad knowledge domains rather than individual research questions. Research funding in the past has often targeted management of critical situations that contribute to high mortality, such as haemorrhage, hypertensive disorders, obstructed labour, preterm birth, and sepsis.12Were WM MacLennan C et al.TuncalpQuality of care for pregnant women and newborns-the WHO vision.BJOG. 2015; 122: 1045-1049Crossref PubMed Scopus (500) Google Scholar The priorities identified in this study do not eschew the importance of complication management, but potentially restore balance by moving towards a focus on prevention. Studying ways of providing such care has the potential to improve the provision of quality care for all, enhance women's and infants' own capabilities, and maximise the health promotion potential of midwives. The Global Strategy for Women's, Children's and Adolescents' Health 2016–2030 is designed to help women, children, and adolescents survive, thrive, and transform.13World Health OrganizationThe Global Strategy for Women's, Children's, and Adolescent's Health (2016-2030). World Health Organization, Geneva2015Google Scholar The concepts of thriving and transforming particularly resonate with the research priorities identified in this exercise. Importantly, this new knowledge could contribute to achieving Sustainable Development Goal 3, for healthy lives and wellbeing for all people. Investment in these innovative priorities has the potential to enable the rights of women and children to life and to health, and help women, infants, and families to survive and thrive. It would be transformative for families, communities, and science. We declare no competing interests. Funding from the Bill & Melinda Gates Foundation and NORAD was used to support author meetings, data collection and analysis, and editing.