October 6, 2015
Critical maternal health knowledge gaps in low- and middle-income countries for the post-2015 era
Written by Tamil Kendall, research fellow, Women and Health Initiative, Harvard T.H. Chan School of Public Health
Between June and October 2014, the Maternal Health Task Force at the Harvard T.H. Chan School of Public Health consulted 26 international maternal health researchers to gather perspectives on the most critical and neglected areas for knowledge generation to improve maternal health in low- and middle-income countries.
- Respondents prioritized implementation research for health systems strengthening to deliver existing evidence-based interventions with high-quality and at scale.
- Respondents emphasized evaluating effectiveness, feasibility, and equity impacts of health system interventions to increase the quality and utilization of maternity services.
- The priorities identified were comprehensive, including not only the prevention of direct obstetric deaths, but contraception, abortion, morbidities, non-communicable diseases, and the need for knowledge generation to address social determinants of maternal health.
- Several of the respondents called for a paradigm shift away from causal linearity towards systems thinking. This shift needs to be reflected in measurement tools, health information systems, and the design of implementation research and evaluation.
- Respondents noted the need to overcome narrow specializations in maternal health and to conduct interdisciplinary research. They also called for thinking strategically about evidence for policy advocacy.
- Finally, the respondents consulted observed that persuading donors and researchers of the value of rigorous evaluation and implementation science is crucial to support progress towards eliminating preventable maternal mortality and morbidity and promoting women’s health.
Priorities for Research and Knowledge Generation
The Maternal Health Task Force asked respondents to identify research and evaluation priorities in three broad areas: 1) persistent and critical knowledge gaps that need to be filled to accelerate reductions in maternal mortality and morbidity in low-and middle income countries; 2) crucial maternal health issues that have not been given adequate attention by research and donor communities; and 3) new situations and emerging challenges that require research to improve maternal health outcomes.
- Persistent and critical maternal health knowledge gaps: The respondents interviewed emphasized that strengthening health service delivery needs to be the primary focus for knowledge generation. Health systems research questions were oriented towards identifying models that can deliver what is known to be effective to prevent and treat the main causes of maternal death at scale in different contexts and to sustain coverage and quality over time. The second most commonly mentioned priority area for knowledge generation was 6 improvement of quality of care. Other specific topics frequently mentioned were increasing the availability and quality of information about maternal mortality; women’s empowerment; contraception; and abortion. The one departure from the focus on health systems and implementation research was identification of the need for basic research and randomized controlled trials to develop and test new treatments for major causes of maternal mortality (pre-eclampsia/eclampsia and obstetric hemorrhage)
- Crucial issues in maternal health that have not received adequate attention from donors and researchers: The health workforce was the most frequently mentioned topic considered not to have received adequate attention from donors and researchers. Respondents identified the need for implementation research to improve distribution and retention of healthcare workers, facilitate task shifting, transform training to improve “hands-on” skills and promote evidence-based practice, and increase managerial capacity at different levels of the health system. Other specific topics frequently mentioned as having been relatively neglected were: over-medicalization of birth; prevention and elimination of disrespect and abuse; demand generation; and the measurement, prevention and treatment of maternal morbidities.
- New situations and emerging challenges that affect maternal health: Respondents identified the following as the key factors that will shape the landscape of maternal health over the next decade: increasing burden of non-communicable diseases among pregnant women and women of reproductive age; the persistence of social and economic inequality and vulnerability; and urbanization. With respect to new opportunities, the most frequently mentioned was the potential for information and communication technologies to enhance decision-making by women, healthcare providers and policymakers. Several respondents identified the need to translate the growing evidence about the developmental origins of health and disease, specifically how women’s health prior to conception and the uterine environment influence the long-term health outcomes of their children, into policy, programs and health information systems. The need to attend to geopolitical determinants of maternal health, such as climate change and food insecurity, the proliferation of conflict and humanitarian crises, and the rise of religious fundamentalism, was also mentioned.
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