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Background: Africa will miss the maternal and neonatal health (MNH) Sustainable Development Goals (SDGs) targets if the current trajectory is followed. The African Academy of Sciences has formed an expert maternal and newborn health group to discuss actions to improve MNH SDG targets. The team, among other recommendations, chose to implement an MNH research prioritization exercise for Africa covering four grand challenge areas. Methods: The team used the Child Health and Nutrition Research Initiative (CHNRI) research prioritization method to identify research priorities in maternal and newborn health in Africa. From 609 research options, a ranking of the top 46 research questions was achieved. Research priority scores and agreement statistics were calculated, with sub-analysis possible for the regions of East Africa, West Africa and those living out of the continent. Results: The top research priorities generally fell into (i) improving identification of high-risk mothers and newborns, or diagnosis of high-risk conditions in mothers and newborns to improve health outcomes; (ii) improving access to treatment through improving incentives to attract and retain skilled health workers in remote, rural areas, improving emergency transport, and assessing health systems’ readiness; and (iii) improving uptake of proven existing interventions such as Kangaroo Mother Care. Conclusions: The research priorities emphasized building interventions that improved access to quality healthcare in the lowest possible units of the provision of MNH interventions. The lists prioritized participation of communities in delivering MNH interventions. The current burden of disease from MNCH in Africa aligns well with the list of priorities listed from this exercise but provides extra insights into current needs by African practitioners. The MNCH Africa expert group believes that the recommendations from this work should be implemented by multisectoral teams as soon as possible to provide adequate lead time for results of the succeeding programmes to be seen before 2030.
The group used the Child Health and Nutrition Initiative (CHNRI) method 10 (first used in 2008) as the scheme for the research prioritization exercise. It is currently the dominant method in health research prioritization. It has been used over 100 times with constant updates 11 to set global 10 , national 12 , and regional 13 research priorities in areas ranging from maternal, newborn 12 , child health and nutrition 14 , in humanitarian settings 15 , sexual health, disability, and dementia 16 . CHNRI uses the principles of the wisdom of the crowds to collect systematically and transparently score research options against pre-set criteria in a particular field 17, 18 . We followed the following steps to undertake this initiative: The Steering Committee constituted by the Grand Challenges Africa programme at the African Academy of Sciences oversaw the CHNRI exercise in 2019 for MNH in Africa. An independent CHNRI expert (KW) provided input on the methodology. The exercise aimed to identify research priorities in maternal and newborn morbidity, mortality, and disability in Africa using the CHNRI exercise. The grand challenge areas for MNH identified from a previous workshop 5 conducted in September 2018 identified four critical ‘grand challenges’ that need addressing, which formed the basis of the research prioritization exercise. These grand challenges were: (i) better care during pregnancy; (ii) better care at birth; (iii) better postnatal care for women and their infants; and, (iv) better hospital care of sick newborns. Each grand challenge was also described under the continuum of research development, namely (i) description, (ii) discovery, (iii) development and (iv) delivery. This proposed framework for systematic listing of research ideas in health research takes into account the listing of health research areas and the depth of the recommended research ideas 17 . Over 700 1 experts, identified through a database held by the AAS, and through a literature review and snowballing, were invited to submit research ideas. Research ideas were submitted via an online survey from 251 experts using Survey Monkey (see Extended data 19 ). Experts were asked to submit up to four ideas each within any of the four grand challenge domains. We received a total of 609 research ideas. The long list of 609 research questions was consolidated into 403 research options by removing duplicates and combining similar ideas. The research team then classified the research options into the 4D categories, ‘discovery, development, delivery, or description’ (defined in Box 1), intended to cover all possible types of research questions 17 . Description – research to assess the burden or risk factors for the problem (e.g. disease). Discovery – research to develop (or discover) new interventions or innovations. Development – research to improve upon existing interventions. Delivery – research to optimize the health status of the population using existing interventions (e.g. operational research, cost effectiveness, policy). Members of the Steering Committee evaluated the consolidated list of research options, refined the wording further, and merged the research options into a list of 281. This list was then scored independently from 1 to 5 (with 1 representing a less important research option, and 5 representing an extremely important research option). An average was calculated, and a cut-off score of > 4.25 was used that selected 46 top research options to be presented for scoring by the larger group of experts (see Underlying data 19 ). As scoring for the CHNRI exercise can be onerous, it was decided to limit the number of research options scored by the larger group of experts in order to maximize response rate and reduce scorer fatigue. A workshop was held in June 2019, which presented the criteria ( Table 1) to stakeholders, including representatives from the public and private sector, donors, civil society organizations, clinicians, and academics. A total of 42 stakeholders determined by availability but balanced by region, discipline, expertise, and gender participated in the weighting exercise. Stakeholders were asked to rank the criteria from 1 to 4 (with 1 being the most important, and 4 being the least important). An average across each criterion was calculated, and converted to a weight using the following formula (demonstrated for criterion 1): weight(criterion 1)= [(∑scores criterion 1ncriterion 1)10/]*4 Weights for each criterion can be found in Table 1. Survey Monkey was used to circulate the list of 46 research questions to the wider group of experts. The experts scored the questions against pre-set criteria, developed by the independent consultant in consultation with the Steering Committee ( Table 1). The criteria were phrased as yes or no questions; experts were given the choice of answering yes, no, or I don’t know, or uninformed. A total of 319 experts from across all regions (North, South, East, and West) in Africa scored the research questions in the 2-hour survey where questions were randomized and presented to scorers in a different order. Invited experts were top publishing authors from each country in MNCH from 2015 to 2019. Table 2 contains individual and demographic characteristics for each scorer, including country of residence, gender, age, and area of specialization. Duplicate responses were removed and scorers included in the analysis if they scored at least one full research question. A total of 195 scorers filled the survey completely (e.g. entered a score for every criterion for each research question). The data team calculated the Research Priority Scores (RPS) and the Average Expert Agreement (AEA) for each research question using Excel (Version 16.45) (Excel for Mac). The RPS, which is a mean score across the number of scorers for each research question, was calculated both weighted and unweighted. In the weighted scores, the RPS was first calculated within each criterion, then the stakeholder weights were applied to the within-criteria RPS, and a final RPS (across criteria) was calculated as an average score across criteria. Scores above 1.0 are therefore possible under the weighted calculations. The AEA is the mode (i.e. the proportion of experts scoring the most common answer) and is calculated on the unweighted scores. We conducted several sub-analyses including research priorities in MNH for East Africa; research priorities for West Africa; research priorities among international experts (e.g., those who do not reside in Africa); research priorities within each ‘grand challenge’ category; and, research priorities within each 4D category.
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