Richard Horton, Editor-in-Chief, The Lancet
- New evidence: session overview: child survival and nutrition interventions
Betty Kirkwood, Professor of Epidemiology and International Health, London School of Hygiene and Tropical Medicine
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- New evidence: neonatal survival interventions
Joy Lawn, Director Global Evidence and Policy, Saving Newborn Lives, Save the Children
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- New evidence: maternal survival interventions
Fernando Althabe, Director, Department of Mother and Child Health Research, Institute for Clinical Effectiveness and Health Policy, Argentina
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- Implementation research: new evidence and future directions
Anuraj Shankar, Senior Research Scientist, Harvard School of Public Health
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An overview of major recent research findings that answer the question “Is there any major new evidence …thinking?” The session highlighted controversial or novel findings and encouraged discussion of their implications, presenting new evidence on maternal, newborn and child survival since 2008, with a fourth look at Implementation of interventions. The overview was informed by a straw poll of experts.
MODERATOR RICHARD HORTON opened the session acknowledging that research is at times ‘off message’, that it is much more than knowledge and has multiple influences on the subject being discussed. Dr Horton pointed out research offers an opportunity for better reasoning around the political and social messages that determine the messages around women and children. It provides a platform for advocacy, political voice and an opportunity for solidarity amongst us, rather than division…a moment for accountability. There is not a better way to hold each and every one of us accountable than evaluations, he said. Dr Horton concluded: “All of us have an obligation to advocate for better research, so we don’t waste precious resources. Call for more research, do more research and come back in two years!!!”
DR BETTY KIRKWOOD set the scene for the coming session, outlining the history of the Initiative in 2003 and the first Lancet Child Survival Series which examined 23 interventions through to the present, where new interventions and research are being considered and reviewed by a Working Group of the Partnership for Maternal, Newborn & Child Health (PMNCH). “Evidence is not static,” she pointed out.
Dr Kirkwood also spoke to new developments within child survival and nutrition intervention research, where new evidence is leading to the adaptation of existing interventions, the rediscovery of old ones and putting others ‘on watch’. She spoke of new research and trials on HIV and infants, antenatal iron, indoor residual spraying, rotavirus vaccine, pneumococcal conjugate, and PCV7, Vitamin A for newborns, and home fortification. On the horizon, she noted mass distribution of RSV and malaria vaccines, as well as the ‘lab on a chip diagnostic tool’, maternal depression and domestic violence. Kirkwood spoke to major gaps, including research into nutrition interventions geared to the first 2 years of life, and the importance of an evidence base for implementation. “How do we deliver effectively and equitably, at scale and with impact?” she asked.
DR JOY LAWN: “The exciting thing is that we are at the tipping point,” said Dr Lawn, pointing to the recent good news that newborn, child and maternal deaths are coming down. “There are new tools that we can accelerate the progress. Neonate mortality rate is going down globally, but inequitably. But Dr Lawn pointed to the enormous neonatal mortality continues: “ These millions of deaths are more than malaria deaths, more than child AIDS deaths. But it is not something you hear about.“ She spoke to the main killers of the neonate: preterm birth, birth asphyxia and neonatal infections. She also discussed the research into their effective interventions including Kangaroo Mother Care, neonatal resuscitation and chlorhexidine umbilical cord cleansing. She mentioned new technology on the horizon, including cell phone and wind-up powered Doppler fetal heart rate monitors. These she said will be critical to evaluate. Dr Lawn also spoke to community-based care, mentioning the WHO/UNICEF Statement on Postnatal Visits released since Countdown 2008 and ended by calling for more research on context and content of packages.
DR FERNANDO ALTHABE highlighted new research into the major causes of maternal death, post partum haemorrhage and new evidence on how to deliver effective interventions and interventions and delivery strategies, including the use, dosage and delivery of misopostol as well as of prophylactic oxytocin at facility. He also explored new evidence and interventions on pre-eclampsia/eclampsia, maternal and perinatal health, including Vitamin A supplementation, antenatal steroids coverage and research questions on HIV and maternal mortality. Dr Althabe concluded that:
- Effective delivery strategies are urgently needed to increase coverage of beneficial interventions;
- Strengthening health systems will probably not be enough in the short term; and
- Vertical interventions at community and facility level are also needed and should be ready for being tested by next Countdown.
ANURAJ SHANKAR: HARVARD SCHOOL OF PUBLIC HEALTH
“We may know what to do but not always how to do it at scale, “pointed out Dr Shankar spoke of what he called the ‘access and coverage paradox’ and the ‘missing middle’ —missing information on the intervening steps in the results chain involving activities, outputs and services provided, and their outcomes. He called for detailed evidence linking implementation processes to actual health outcomes in the field, research on the barriers and facilitators to implementation which can lead to improved policies, programs and practice. He pointed to research on the use of mobilizing through women’s groups. He called for the urgent research and need to overcome barriers to health facility access, improve facility based care and impact and enhance human resource practices. Dr Shankar also called for research to identify how financial incentives can be effectively used, noting a recent article in the Lancet highlighting the success of a conditional cash transfer program in India. He outlined the needs for successful implement research:
- There is an urgent need to invest in implementation research to identify effective strategies for delivery proven interventions at scale and quantify their impact
- Rigorous methods must be used to assess what enables programs to work best at scale through conventional randomized controlled trials and other approaches;
- Reliable routine monitoring must be established, and data used in programs;
- Paths to success must be based on local health system and context, including human resource practice, quality of care and implementation and sustainability.