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Wellcome Trust Strategic Award

18 April 2008

Anthony Costello and partners Professor Dharma Manandhar, Dr Prasanta Tripathy, Dr Kishu Azad, Dr Armida Fernandez and Dr Charles Mwansambo, have been successful in their application to the Wellcome Trust for a strategic award to continue their work in Nepal, India (Jharkhand and Mumbai), Bangladesh and Malawi.  The overall programme aim is to build the evidence base to improve the survival of women and children in high mortality settings. This aim will be achieved through meeting three primary objectives:

  • To develop a global network of linked surveillance sites in Bangladesh, India, Malawi and Nepal to study population maternal and child health and survival.
  • To translate global network research evidence into policy and practice in partner countries and through international agencies.
  • To strengthen capacity of partner institutions to design, manage and communicate high quality policy-relevant research.

The strategic award will support a programme of research on maternal, newborn and child survival, with a particular emphasis on UN Millennium Development Goals 4 and 5. Administered by the UCL Centre for International Health and Development at the Institute of Child Health, the programme will consolidate a global network of research centres and population surveillance sites in Bangladesh, India, Malawi and Nepal. This is a mature collaboration: each partner has worked on their population maternal and child health research programmes for at least 4 years, and visited the other partners through workshops held in each country.

The development of a formal global network will add great value through:

  • International cohesion for shared research objectives, leadership and problem solving.
  • South-to-south exchange of ideas and experience between sites.
  • Linking Africa and Asia: the expanded programme of three projects (five districts) in central Malawi will benefit from links with successful research programmes in south Asia.
  • Development of local university links and research capacity at each site, and the sharing of successful initiatives in capacity building.
  • Expansion of policy influence nationally and globally: intelligent approaches to the translation of research findings rapidly into policy and practice, learning lessons from different policy and population settings, and sharing success in communications and links with policymakers.
  • Providing a base for large scale new multi-centre trials of interventions, which would expedite research into practice.
  • Sharing and combined analysis of the large population databases at each site, with planning of co-ordinated cohort studies.

History

The network has been developed with country partners and national academic institutions through a shared commitment to population-based maternal, newborn and child health research. The partnership in Nepal began in 1992, in Bangladesh in 2002, and in Malawi and India in 2003/4. The combined population under surveillance is approximately 2.25 million.

We have already established an international network of studies to evaluate community health and nutrition interventions for measurable effects on key maternal, newborn and child health outcomes, including mortality, nutritional status, quality of health service delivery, equity of access to and uptake of services, and longer term neurodevelopmental and anthropometric outcomes. Studies combine measurement of hard mortality and morbidity outcomes with mixed methods evaluation of intervention processes and cost-effectiveness. Methods include cluster-randomised controlled trials, cost-effectiveness and equity analyses, longitudinal cohort studies, audits and quality of care analyses. The implications for incorporation into national policy are central to the questions asked.

Our partnerships have helped to place newborn survival on the international public health agenda. An intuitive expansion from newborn into maternal health followed from the scale of our surveillance sites. We began with clinical studies on neonatal hypoglycaemia, hypothermia and birth asphyxia. At this point it became clear that the burden of disease and mortality was outside the reach of clinical services. We moved beyond the clinical setting to conduct a randomised controlled trial (RCT) of health education for postpartum mothers. Studies on the prevalence and outcomes of low birth weight and exposure to the international debate on community-based intervention, led us to begin intervention studies in poor communities, notably with a double-blind RCT of antenatal micronutrient supplementation. At the same time there was a groundswell of interest in public health and economic research in the evaluation of interventions through community cluster trials. A combination of these two agendas is the platform for our research work: effectiveness evaluation of interventions to improve maternal and newborn survival in poor communities, through cluster RCTs.

The hallmark trial was conducted in Makwanpur district, Nepal, and suggested that community mobilisation through women's groups could substantially reduce mortality (Manandhar et al, 2004). Six further trials are underway in different settings.

Data collection requirements for such large-scale trials have led us to develop expertise in vital registration and surveillance systems, and the active field sites are both a rich source of data and a stimulating locus for sub-studies.