Progress in achieving maternal health goals and reducing maternal deaths from individual conditions varies considerably across low— and middle-income countries (LMICs). Overall, considerably smaller reductions have occurred in deaths from haemorrhage and hypertension, than from HIV, for example. In principle, the research agenda in each country and region should closely reflect variations in outcomes and tackle the factors responsible for local inequities. Setting such an agenda and marshalling the resources to implement it does, however, require strong capacity at country level, and an alignment between a country’s priorities and the interests of foreign researchers and donors.
The MASCOT/MHSAR study (Multilateral Association for Studying health inequalities and enhancing North–south and South-South Cooperation; Maternal Health and Health Systems in South Africa and Rwanda) sought to build a clearer picture of this global research agenda by mapping interventional research in maternal health across LMICs from 2000 to 2012. It summed the topics covered, research methodologies applied, research funding landscape and the trends in authorship attribution between LMIC and high-income country (HIC) researchers. The study contrasted patterns in health systems and health promotion research with those in research on clinical conditions, specifically haemorrhage, hypertension, malaria, HIV and other sexually transmitted infections (STIs).
To our knowledge, this is the largest mapping of maternal health research, in terms of size, breadth of scope and extent of international collaboration. The mapping team involved 15 reviewers, drawn from 8 countries across 5 continents. Together they screened 35,078 titles and abstracts independently in duplicate, then assessed 4175 full text articles for eligibility, and extracted data from 2292 papers on 17 variables. The LMIC study was complemented by a mapping of literature on community-based interventions on maternal health in HICs, which located 119 studies on the topic. This commentary focuses on the LMIC study, but draws a few comparisons between the findings of the LMIC and HIC mappings. The study procedures in both mappings, similar to a ‘scoping review’, did not involve an evaluation of the quality of the included studies, or the extraction of data on the outcomes of interventions. It thus synthesizes a body of literature, as opposed to an evaluation of literature, as in a systematic review.
In this commentary, we sum the findings of the series of articles on the LMIC mapping and some implications thereof. Over the twelve years reviewed, the total number of publications in this field rose several-fold, with the largest rise occurring from 2004 to 2007. The range of research methods also broadened considerably, and increasingly encompassed the application of qualitative research and systematic review. Overall, articles on malaria and HIV dominated the field, with hypertension, haemorrhage and STI research making up less than a third of all papers on the clinical conditions. Most especially, in several parts of sub-Saharan Africa, a very high proportion of research addressed HIV. For example, in Cote d’Ivoire, almost 95% of studies in this period addressed HIV. Similarly, only 1 in 30 publications in South Africa was on haemorrhage in pregnancy. HIV research was two-fold more likely to apply qualitative methods than other clinical conditions, but, as compared to haemorrhage research, it was half as likely to include a health systems component in the intervention being studied. The number of publications per 1000 maternal deaths from hypertension was almost double that of haemorrhage.
Scant attention was placed on research about equity in the LMIC review. By contrast, the mapping of health promotion in HICs found that a third of studies targeted vulnerable groups, such as poor women, adolescents, and black and ethnic minorities. The timing of interventions studied also varied between LMICs and HICs. Two thirds of the HIC studies focused on the postpartum period, mostly addressing breastfeeding assistance and promotion, preventing and treating post-natal depression, or interventions to support and build capacity around parenting and child care. By contrast, 70% of LMIC studies addressed issues relating to women during pregnancy and much fewer included postpartum women.
Health system and health promotion articles increased over the review period at a faster rate than those on other topics, but were less likely to be evaluated in a trial, summarised in a systematic review, or published in high-impact journals. Studies in South Asia had a substantially greater focus on health systems or health promotion research than other regions. Research on STIs other than HIV, however, progressively diminished over time. The number of studies on STIs, malaria, hypertension and haemorrhage were very similar in 2000–2003, but diverged markedly thereafter. Merely 3.5% of studies addressed STIs in 2008–2012, and many of these were reviews, rather than empirical research.
In about ten countries, maternal health interventional research made up more than five percent of all health publications in the country. By contrast, in nearly twenty other countries, studies on maternal health contributed less than one percent to the overall research done in the country. In India, of note, maternal health research formed only 0.25% of all health publications from the country and there were only 0.13 publications per billion USD GDP. Many countries in Latin America and several large countries like China and Russia also had very few papers per billion USD GDP.
In terms of funding sources, the National Institute of Health, the US Agency for International Development, and the Bill and Melinda Gates Foundation together made up 40% of funder acknowledgements. For all types of funders, but especially for Global Health Initiatives, the most common topic studied was HIV and the most common region supported was sub-Saharan Africa. Few studies were funded by national governments, though this has slightly risen over time. Importantly, the two main causes of maternal mortality — haemorrhage and hypertension — had a high proportion of papers without any funder mention, as did STI articles. This suggests that researchers have continued their work in these critical areas, even in the absence of adequate support from funders. Funding patterns are quite different within HICs, where national governments were the largest funding source in the papers reviewed, followed by not-for-profit organisations.
The number of LMIC lead authorships, used as a measure of research capacity, rose substantially in the mid-2000s, but slowed thereafter. Findings on data ownership and a country’s ability to advance its own research agenda (as measured as the proportion of articles led by authors affiliated with an LMIC institution) were concerning. Only about half the papers across the review period were led by an LMIC author, with a further 8% having a dual HIC and LMIC affiliation. And, only a quarter of countries led more than 75% of their research, while another quarter led less than 25%. Very few countries increased the proportion of articles led over time; in some it even decreased.
Authors affiliated with institutions in the United States and United Kingdom together accounted for a third of all publications. Authors from these two countries were four times less likely than those from institutions in mainland Europe to also hold an affiliation in a LMIC. Of note, few authors held affiliations in more than one LMIC. Two thirds of studies funded by USAID and the European Union were led by HIC researchers, twice as many as that of Wellcome Trust and Rockefeller Foundation. Even in studies acknowledging funding by national governments in LMICs, only about 70% had an LMIC lead. Strikingly, the median Impact Factor was 3 · 1 for papers led by a HIC author and 1 · 8 for those from LMICs. In fact, HIC researchers lead two thirds of articles in journals with an Impact Factor above 5, and even higher proportions of systematic review and modelling studies. Sub-Saharan Africa had the lowest overall proportion of locally-led publications of all geographical regions.