Research Article: Setting Implementation Research Priorities to Reduce Preterm Births and Stillbirths at the Community Level

Date Published: January 4, 2011

Publisher: Public Library of Science

Author(s): Asha George, Mark Young, Abhay Bang, Kit Yee Chan, Igor Rudan, Cesar G. Victora, Mickey Chopra, Craig Rubens

Abstract: Asha George and colleagues from the GAPPS group report the implementation research priorities to address prematurity and stillbirths at the community level that resulted from their recent expert consensus exercise.

Partial Text: It is estimated that 3.2 million stillbirths occur each year globally, 1 million of which happen during birth [1]. In addition, complications from preterm birth (before 37 completed weeks of gestation) are the leading cause of death for newborns, contributing an additional 1 million or 12% of child deaths [2],[3]. In 2009, more than 200 stakeholders attended the International Conference on Prematurity and Stillbirth convened by the Global Alliance to Prevent Prematurity and Stillbirth (GAPPS, The community expert group at the conference included 15 members drawn from technical and funding organizations in addition to program implementers and researchers from around the world (see Acknowledgments section for specific names). In their discussions, the group framed efforts to address preterm and stillbirths within the broader context of maternal–newborn interventions. As most of the evidence supporting these interventions emanates from research projects in controlled settings in specific contexts, the group identified the main challenge being implementing interventions at scale in different contexts. Based on these discussions, the group began a research prioritization exercise for implementation research on community-based maternal-newborn interventions that address prematurity and stillbirths at scale in different contexts. In this paper, we present the results of this exercise.

A number of research prioritization efforts have recently been applied to various health topics and health system themes [4]–[7]. The GAPPS community expert group chose the methodology proposed by the Child Health and Nutrition Initiative (CHNRI) to systematically list and score research questions. The CHNRI methodology was selected because its conceptual framework [8]–[10] has been used in numerous areas by different national and international organizations [11]–[16] (further information on CHNRI methodology, validity, and potential limitations are discussed in Table S1). The group followed three main stages to derive research priorities (detailed in Box 1). Briefly, guided by the CHNRI methodology the group evaluated 55 research questions against five main criteria:

The research question that was highlighted as the most important out of all 55 reviewed was “Evaluate ways to reduce the financial barriers to facility births at the community level—e.g., user fee exemptions, emergency loans, conditional cash transfers, transportation vouchers, etc.” Other research questions among the top five prioritized also addressed equity issues (reaching the poor and marginalized), but also behavioral practices and skills (engaging with social norms, identifying prematurity) and service delivery (measuring and maintaining quality of care provided by community health workers). The remaining top ten research questions (Table 1) include other behavioral skills and practices (thermal care and feeding for preterm babies, birth planning), concerns about how to best motivate and compensate community health workers and their supervisors, and different dimensions of making referrals more effective. Congruent with the priority need to measure and maintain quality of care by community health workers, rational drug use by community health workers and community engagement with regard to audits was also listed among the top 25 research questions that received an overall research priority score (RPS) of 0.75 or greater (Table 2).

The top 25 research questions that have been prioritized span a broad range of issues (Table 2). These implementation research priorities address fostering and sustaining specific behavioral skills and practices at the community level, engaging communities in monitoring service delivery through audits, and improving referral. With regard to service delivery, a host of implementation research questions about the management of community health workers, along with the health system supports they require to function, were stressed. Finally, issues of equity, financing, and referral were highlighted, reflecting how community-based approaches cannot be dealt with in isolation from broader health system concerns.

While important reviews [23]–[28] have helped to spur attention to community-based maternal newborn issues, with intriguing results for specific interventions [29],[30], the implementation research priorities identified in this article will, we hope, help to secure further research attention and financing for this important area. Priority research areas identified include equity concerns (such as removal of financial barriers and responsiveness to the poor and marginalized), specific behavioral skills and practices, and the management of community health workers including referral care. The challenge is now raised; will communities, governments, donors, research institutions, and international organizations respond?



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