ANDARI WURI ASTUTI., S.SIT., MPH., PHD Research to Improve Quality of Maternal and Newborn Care in Low-Middle-Income Countries (LMIC’s) ANDARI WURI ASTUTI., S.SIT., MPH., PHD

Does it really matter?

Objectives Introduction Research related to maternal and newborn care in LMICs Challenges for conducting research in LMICs Conclusion

Introduction Every day, approximately 830 women die from preventable causes related to pregnancy and childbirth. 99% of all maternal deaths occur in LMICs. Maternal mortality is higher in women living in rural areas and among poorer communities Young adolescents face a higher risk of complications and death as a result of pregnancy than other women.

Contd…. Skilled care before, during and after childbirth can save the lives of women and newborn babies. Between 1990 and 2015, maternal mortality worldwide dropped by about 44%. Between 2016 and 2030, as part of the Sustainable Development Goals, the target is to reduce the global maternal mortality ratio to less than 70 per 100 000 live births (WHO, 2017)

The major complications 75% contribute to maternal deaths: severe bleeding (mostly bleeding after childbirth) infections (usually after childbirth) high blood pressure during pregnancy (pre-eclampsia and eclampsia) complications from delivery unsafe abortion

Global Strategy WHO responses: Increasing research evidence, providing evidence-based clinical and programmatic guidance, setting global standards, and providing technical support to Member States However there are vary of national responses amongst countries Vary on the topics being researched

Framework to improve quality of maternal and newborn care

Global research related to maternal and newborn care Before 2000, research has often targeted management of critical situations that contribute to high mortality, such as haemorrhage, hypertensive disorders, obstructed labour, preterm birth, and sepsis Current trends: moving towards a focus on prevention (WHO, 2016)

Research in LMICs Studies on malaria and HIV dominated the field, with hypertension, haemorrhage and Sexual Transmitted Infections (1/3 clinical conditions) 70% of LMIC studies addressed issues relating to women during pregnancy and much fewer included postpartum women 50 % studies led by an LMIC author Increasingly encompassed the application of qualitative research and systematic review (Chersich and Martin, 2017)

ICM 2017 Future investment in maternal and newborn should be focused on “right care”. Care is tailored to individuals, weight benefit and harm, person-centred, works across the whole continuum of care, advance equity, and is informed by evidence including cost effectiveness.

Identify global priorities of research agenda

Midwifery key research agenda improving provision of effective family planning reducing rates of preterm birth provision of high-quality care for all women and babies promoting sustainable health systems and reducing the use of unnecessary interventions (Kennedy, 2014)

No Research Priority 1 Evaluate the effectiveness of midwifery care and the contributions of its’ components, when compared with other models of care across various settings, particularly on rates of maternal/ fetal/ infant death, preterm birth, and low birthweight hand on access to and acceptability of family planning services What are features of models of care that provide optimal clinical outcomes and positive antenatal, intrapartum, postnatal, and early life experiences for women and newborns across all resources settings and within specific sociocultural context and how can these be replicated or scale up? What are the shorts and longer term outcomes of different models of midwifery, including midwifery led care continuity of care in LMICs? In all resources settings, what are the unique berries or facilitators to implementing midwifery models of care including midwife led continuity of care? What strategies could be used to upskill midwifery work forces to provide the full scope of midwifery, including midwife led continuity of care across settings through improvement and implementation science as determined by distinct context? What kind of community birth places are optimal for healthy women and newborns and how should these be embedded in the wider health system to ensure right sizing and appropriate delivery of obstetric resources? 2 Identify and describe aspects of care that optimise, and those that disturb, the biological/ physiological processes for healthy childbearing women and fetus/newborn infants and for those who experience complications What are biological, physiological, psychological, sociological and cultural features of physiology pregnancy, labour and birth, postnatal, breastfeeding and the newborn period (hereafter refferred to as the childbearing continuum) and how are they influences across care settings and models of care? What specific practice, attitudes and behaviour optimise or disturb biological and physiological processes across the childbearing continuum in range of health system, sociocultural, geographic and commercial context? How do organisational and birth environment factors including settings, architecture, artifacts, policies and access to care optimise or disturb biological and physiological processes accross childbearing continuum? How do providers’ attitudes and behaviours optimise or disturb biological and physiological processes across childbearing continuum, and how are they influenced by disciplinary training and norms, experience, philosophy and preparation? How do the attitudes, behaviours, and prebirth preparation activities of women, their partners and families optimise or disturb biological and physiological processes across the childbearing continuum? What are critical lifetime reproductive, life course and inter-generational outcomes that are influenced by optimisation or disturbance of naturally occurring biological and physiologic processes across the childbearing continuum? 3 Determine which indicators, measures and benchmarks are most valuable in assessing quality maternal and newborn care across setting, including the views of women; and develop new ones to address identified gaps. Can a culturally, linguistically and socially relevant minimum data set be created to evaluate the different questions? How do we create and make more widely available an item bank of existing, validated measures and indicators in the framework? How do we best evaluate existing models of care, including short and longer term health outcomes and cost effectiveness? How do we best assess gaps in measured and indicators and support targeted development of new ones to capture all component in the framework across the childbearing continuum and in the first week of life in all resource settings? How can we best ensure and support community-led design, development and validation of new measures of the impact of the lived experience of care on quality and safety as defined by the person? How can these measures be used most effectively to support quantifiable improvements in both clinical indicators and maternal experiences? Are they more applicable to research, evaluation, or quality assurance/ quality improvement programs in existing form, or do they have cross-cutting value?

(Souza et al, 2014)

Challenges for conducting research in LMICs Lack of Training: It is a big problem faced by researchers in LMICs countries. Repetition: Research studies overlapping one another are carried out in many cases for want of adequate information. Lack of Interaction: You will find inadequate interaction between the university research department, on one side and business establishments, government departments and research institutions, on the other.

Contd…. Illiteracy: This has affected the appreciation of the value of research findings by the vast majority of the people Lack of Code of Conduct: There doesn’t exist a code of conduct for researchers and inter-University and inter-departmental rivalries are also quite common. Shortage of Resources: For performing a quality research sufficient funds are not provided. 

Contd… Absence of Coordination: There exists lack of coordination among various organizations responsible for performing research. Problem of Conceptualization: Many a time problems of conceptualization and problems concerning the procedure for data collection and related things crop up leading to frittering of resources. Scanty Information Base: This narrows down the volume and quality of literature accessible to a researcher.

Conclusion Challenges of research in LMICs including creating an increased pool of well trained professionals, providing the resources needed, improving and appreciating of the researchers, making the availability of research materials and strengthening the nations’ infrastructure. Apart from direct financial and technical support from the government and other organisations, there is still a need for international assistance through the provisions of fellowships, fieldtrips, visiting researchers, and establishing facilities for research studies

TERIMAKASIH