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Maternal mortality researchers are going the extra mile

29 October 2008, 13:31

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Burkina Faso villages have been laughing and crying at theatrical performances written by scientists, and played by comedians, on saving mothers and infants in childbirth – the inspired result of the Immpact research programme on maternal and infant mortality. Maurice Yaogo in Ouagadougou, and Véronique Filippi, Sue Fairburn and Wendy Graham of Immpact tell Robert Walgate the story and its implications.

Les villageois du Burkina Faso ont ri et pleuré en assistant aux pièces de théâtre écrites par des scientifiques et jouées par des comédiens, expliquant comment sauver la vie des mères et des bébés au cours de l’accouchement – pièces inspirées par le programme de recherche Immpact sur la mortalité maternelle et infantile. Maurice Yaogo de Ouagadougou, et Véronique Filippi, et Sue Fairburn d’Immpact parlent à Robert Walgate du programme et de sa portée.

>RealHealthNews: Véronique, how did scientists get to be writing a comedy?

VÉRONIQUE FILIPPI, researcher with Immpact and Towards MDG 4+5 at the London School of Hygiene and Tropical Medicine: What happened is that there was a very nice, competent communication officer in Burkina Faso called Hilaire Dadjo, who wrote a play with Rasmané Ganaba, with help from Issiaka Sombié, with messages about the how the husband needs to look after his wife and people need to put money aside and things like that.

He found a theatre group with actors who are very well known in Burkina Faso, even outside Burkina. They are often on TV. They do sketches to make people laugh. Even one of the Beninese who was there told me that she knew them – she had seen them on TV in Benin.

>RHN: Had Hilaire and his colleague had any experience of play
writing before?

VF: No, they hadn’t. I also thought about the main message that we wanted to convey, and then wrote it up and sent it to the actors, who commented on it and changed it, etcetera. So there was a process of comments, and revision, and the actors adapted the play.

SEE BOX: The play in English: ‘To be a woman isn’t easy’"

Then they went to a small town where we had worked [in Dougou in North West Burkina] and we invited all the women who had been part of our cohort study, and they gathered, and the play was presented. At the end of the play people from the crowd – the husbands were also invited but they tended not to come – made comments or asked to say something that they find interesting in the play. It was an opportunity to make the message stronger.

VOIR ENCADRE: La pièce en Français: ‘Etre femme c’est pas facile’"

>RHN: What do you mean by your ‘cohort study’?

VF: It means that you follow a group of persons across several months. So there make several interviews with the same women to see what happened in their life. There were 1000 women in all.

>RHN: What results were you communicating?

VOIR ENCADRE: Même la première dame

VF: What we were doing was a study showing that women who had had complications in childbirth continued to suffer for a long time from this complication, even though they are released from hospital because at that time they were paying very high user fees to get a Caesarean section, for example.

So often all their savings were being used up, they had to go into debt to get more money. They may have lost their baby, and of course there may be some social implications, and also they often are not as healthy as they used to be. So we tried to document this by comparing women who had very, very severe complications with a group of women who had given normal childbirth.

We showed that the women who had complications were more likely to die up to one year post partum, their babies were more likely to die up to one year post partum, there was more depression, etcetera.

>RHN: Even after they had come home?

VF: Yes. But the message that we gave was not like that. It was more describing the story of a woman who has complications and how it was dealt with by her husband and family. So the husband doesn’t really want to spend the money, then she loses her baby, then he goes with another wife and all these things. So it was more telling a story, and then at the end of the story when it was finished being told, then we discussed what the messages were that came through and it was like you need to save money, you need to act quickly when there is bleeding, these types of things.

At the same time that we were doing that, we were going to each hospital where we worked and presented our more scientific findings. There were people in the hospital and district medical officers. They were invited if they wanted to go to the play, but I don’t think many did, to be honest.

>RHN: So you said you were presenting this to your cohorts and their husbands. So what you were doing really was you were taking the people you had done the research with and you were telling them the results of the research.

VF: Yes, we were trying to do that.

>RHN: That’s brilliant. That happens so infrequently.

VF: I don’t think many people do communication with the community, but when you do studies like ours where you speak to the same women maybe six times, and population surveys, we take a lot of time from these ladies. It’s important to tell them what we have found. We have created a relationship between ourselves and them – the interviewers in particular sometimes become very close to the women. So, it’s like giving back really.

I think it’s part of our ethical duty. I mean, we say that usually in our ethical clearance that we will present the findings to everyone. We wanted to do a study as well because we have a similar study in Benin which we haven’t yet disseminated, and we thought there is much less money in Benin for the study.

SUE FAIRBURN, Immpact Knowledge Manager: We’re completely overwhelmed. I think it’s an ultimate opportunity, but just in terms of the cycle of Immpact, we’re just at a point where we have very few bodies on the floor, and we’re all doing double duty in terms of everything. And that’s the funny thing; everybody’s making do with such few people that, I think people’s perceptions are that everybody’s well resourced.

I think the biggest challenge to knowledge transfer is understanding who needs how much information, and when, and that’s something we’re also coming to terms with. Who, exactly, do we need to prioritise, in terms of our responses, right now, and in what ways can we be pro-active? We’re looking for these evidence opportunities, and, then, once we’ve identified them, trying to be really savvy about what we can do with the resources we have.

>RHN: What solutions are you communicating? I mean are you proposing an upgrade of health facilities to take care of complications in pregnancy?

SF: Well, there are over-riding Immpact messages that relate to quality facility delivery, quality facility births, yes. However, in specific countries, like Burkina, we were looking at what strategies they already had in place. Burkina covers 80% of the costs, for each birth, so it isn’t completely free. That was a policy put in place, I think, in late 2006.

We then developed messages – but they haven’t been officially released – on free delivery, meant to totally free women from the financial barriers, and all barriers of delivery, of accessing a quality delivery…

So Immpact met with the government about that, reviewed that strategy in light of Immpact findings, and provided guidance on what more could be done. So we have had fairly good involvement there, fairly good contacts at the ministerial level, and have been invited in to those discussions.

The difficulty, I guess, in Burkina, was how to also build accountability from the ground up, sort of a two-pronged approach.

>RHN: So it’s a very comprehensive communications approach that Impact is taking? This is not academics publishing papers and gaining citation points, and moving on to the next appointment. How come?

SF: It’s an example, I think, of funder feedback, and having to take that on board. I think we’ve had a very good relationship with our funders, and they’ve been able to be quite frank and say, OK, Immpact has all along been recognised as this global opportunity to generate the evidence and respond to these
gaps, but what, then, is going to be done once you have the evidence, and how are you going to do that? It’s something that the UK’s DFID has taken a very active approach on, and it’s something that the Gates Foundation has taken a very active approach on, just in the last 12 months, in fact.

>RHN: And Gates, which from the outside is often treated as only being interested in ‘magic bullets’. has been pushing on Immpact, has it, to increase the impact of Immpact?

SF: Yes, that’s it. I don’t know if you’re aware, but for all the health-related initiatives Gates have funded, they have conducted communication strategy workshops, where they’ve brought in support to try to help researchers broaden their skills, and re-skill them into story telling, re-skill them into areas of developing messaging framework, all of that, to varying degrees of success.

>RHN: Interesting. I’ve also been getting the response from some scientists that this kind of work is, actually, a risk to our career – because we end up working with the politicians, we spend a lot of our time on this, and on communications and all of that, but these do not create publications for our portfolio.

SF: Well, I think it’s a balance between the two. At Immpact we’ve maintained our publication output. Some journals are more receptive to what I would call fringe research, with a
human rights-based framework.

For example The Lancet has certainly been very receptive to this, but we’re finding more and more journals are too. There’s a new journal that has just come out, Global Health Action, in Sweden, which is quite receptive.

So I would say that while researchers are finding the demand or the pull for responding to the need to convey evidence in a different way to a broader network, they’re also finding outputs and outlets for doing that in a way that still meets the Research Academy’s expectations.

>RHN: So there’s a shift of culture.

SF: There’s a shift of culture; the question is how far does that go?

I think, in Immpact’s situation, we’re still, primarily, a research project, so while you say that we’ve committed ourselves to the communications side, I would say that we’ve done that in a percentage, with a percentage of our resources.

There’s still pure research happening. We’re still committing ourselves to understanding the issues of maternal mortality, and measurement of maternal mortality, and the financing of appropriate strategies etc., but we’re trying to, I guess, encourage better uptake of the findings that do arise out of that.

>RHN: So what fraction of your budget are you spending on the communications?

SF: I would say it’s higher than the DFID 10%; I would put it at closer to, probably, a quarter to a third, right now. You, essentially, have to look at a significantly higher proportion when you have our kind of findings.

>RHN: And it’s pioneering too, so there can be research to do on the communications, no?

SF: And that’s exactly what we’re proposing for our next phase, which is the science of translation, you know, let’s look at this and the effectiveness, and try to inform ourselves as we go along.

It’s a bit uncharted but bodies like DFID and NORAD, very large government bodies, political bodies that have whole communication departments, are seeking ideas on how to do this, are seeking guidance, and have turned to us in some cases, and are turning to others, so I don’t know who knows the best way to go about this.

And I’m not sure whether it should be driven from the North or whether it should be much more of an initiative from the South, so we sit back and take guidance from there.

WENDY GRAHAM, Director of the Immpact project: In the six or seven years of our work on maternal and infant mortality, the audience for evidence has got much broader, and of course all those audiences need rather different packaging.

>RHN: Broader in which direction?

WG: Parliamentarians, advocates, NGOs… the idea of research into policy which assumed a two-community model of researchers and policy makers, is now occupied by a lot of middle ground. There are now lots of groups who want to be, and need to be, in the position of holding governments to account, and they feel the need to do so in an evidence-based way.

>RHN: Are you saying that civil society activity has grown in developing countries?

WG: Of course civil society engagement has always been important – but I would say it used to be more at the end of setting priorities than holding governments to account. Interacting with government I think has changed.

By civil society I mean everything that’s not government in the broadest sense, so NGOs, parliamentarians, advocates, academics, health professionals, any group that can operate independently of government. Parliamentarians, through the countdown to 2015, have got much more engaged in issues around MDG4 and 5. I think the field is changing.

But if you are a researcher whose work is directly relevant to policy programmes and practice, there has been for a long while an uncertainty about how far researchers could and should go in terms of research uptake. Where does our duty end? I think it’s a big question.

An NGO called Women and Children First was asking me about the researcher’s role, and my words were, going the extra mile.

I think it’s something researchers need to take a position on, certainly in safe motherhood. This is a volatile environment. For example, in my case at Immpact, my concern as a Principal Investigator is to ensure value for money out of what we did – which means that putting the evidence in the hands of those who can make best use of it.

Now, those hands, as I said, have broadened, but the air of uncertainty for researchers is we’re not always the best communicators. We don’t always know the smart and nuanced the ways to present our evidence. Of course we’re very familiar with journals, but we’re not always that familiar or trained in that communication side, or the translational step, which is crucial for our evidence to make a difference.

>RHN: Immpact’s work was done mainly Burkina and Ghana and Indonesia – what differences did you find? Were there useful lessons?

WG:The common features were high levels of maternal mortality. In some ways, putting them together, what they show is that in many countries partial solutions are being sought for addressing maternal mortality.

In our case we were looking at different strategies taken up in really rather different countries in terms of skilled care at delivery.

So, in Indonesia the difference there was that the government decided to take the care to the community, bringing the providers, i.e. midwives, closer to the mothers in the community. What we found there, however, is that the cost barrier still wasn’t addressed so poor women still couldn’t afford these providers.

Also there was a deterioration in the standard of training of these midwives. They were often put in the middle of somewhere where they weren’t supported by supervisors and unable to easily refer women on, so women did not have confidence in them, and so did not use them. And any provider would still need to refer on [in case of complications], and the backup of quality services was not in place.

We know that for reducing maternal mortality, and affecting newborn survival as well, you need to address the demand side and the supply side. The response in Indonesia was to think the demand side was crucial so put the care closer to women, but it wasn’t backed up by the right supply, i.e. properly qualified midwives and emergency referrals that really worked.

Then some of our work in Ghana, Burkina Faso and Indonesia points to the importance of overcoming financial barriers. Now, some of that involves big macro level changes like abolition of user fees and free delivery and all that sort of thing. You can point to the evidence and the benefits of doing that but the ability to influence the actual change is really quite limited.

But, there are other groups who can make that research voice heard, or the research evidence used, and I think that’s where it is about linking up with either activists or knowledge brokers who are charged.

For example, there is a knowledge brokering group that runs out of Kenya, Uganda and Tanzania called REACH which is about giving policy makers timely relevant information that comes out of an evidence base but is packaged and responsive to a policy maker’s needs and wishes. I think there could be much more of that to bridge this Venus and Mars that can sometimes exist between us.

>RHN: When you talk with the activists and you’re talking about getting a civil society movement in this direction, does that not offend some of the politicians? Does that not make it more difficult to talk to the policy makers?

WG: It depends on how it’s couched. It’s true that some of the emphasis from civil society groups acting in an accountability role does of course cause some aggravation, but we shouldn’t see the community and the supply sides as opposite ends. I think the important about civil society engagement is to do that in a constructive way.

>RHN: Also, there are things the community can do for itself quite independent of government of funding.

WG: Absolutely. The way to improve the measurement in maternal mortality is to empower communities to want to and be able to do it themselves.

What you count is what you do. You need to get that counting right the way down to communities who want to act, and need to act, as well as act upon the higher levels that needed to act in a rather different way. I think empowering communities through measurement and counting and knowing, birth and death, is very, very important.

>RHN: Just let me ask a personal question here. You’re turning from being a researcher to an activist, aren’t you?

WG: Am I? I don’t know. I think it’s fair to say like many researchers who work at this policy interface or action interface, I suppose, it is potentially a confusing and uncertain phase for us all. We publish in journals still and yet we also know, increasingly, that those journal articles don’t touch the parts that can make a difference, and so we need to interact in different ways with different media and different dialogue.

It’s something I take very seriously because I can see, having been the PI and having to take the responsibility for Immpact making a difference, for me it is important I go that extra mile as much as I can, not that I’m trained in any of these areas. It’s learning by doing, but I certainly see the need for it.

I think one of the big issues, it seems to me, is that there is no model worked out yet. Is it, for example, for researchers to interact with knowledge brokers, for example, who are skilled rather differently but also know how to say it? Obviously with us researchers there remain areas of uncertainty that, frankly, many policy makers don’t want to know about, but if we, as scientists, can’t be open and upfront about certainty and uncertainty in evidence, then we’re in a very difficult position.

However, for certain types of roles and certain types of audiences the uncertainty/certainty is not an issue. I think there is an issue about whether researchers need to go a certain distance and meet part way with knowledge brokers that can be very effective in their communication.

>RHN: How would you define knowledge brokers exactly?

WG: I mean groups who perhaps come from a communication background, or indeed policy maker, people like Sam Adjei, for example, who have been researchers, policy makers and communication activists, people who have worked in a mixed world, as it were, that know how to package the information and make it very effective, what to say to whom and when, and be credible. They take the evidence and they synthesize the evidence.

I think the other big challenge is that when you are a researcher you do your own research, and of course you have to take notice of what others say, but of course you always know your own research better. But a policy maker doesn’t want to hear about just one piece of research, they want to know what the body of knowledge of is telling them. So there is a bit of an immediate conflict.

When you’re funded you’re encouraged to speak about your own research that someone has funded but, as I said, the real issue is policy makers don’t want that. They actually want the synthesized knowledge, so there is a bit of a conflict of interests.

Do you promote your own research or, more importantly, do you put your own research in the broader body of knowledge? You are, however, always going to know about your own research and can nuance it differently than anybody else’s research.

So, again, I think if we’re going to take policy making and uptake of research and, indeed, other groups, civil society, seriously we have to work up those venues and mechanisms that can deliver in a timely way… Researchers are also very slow. We work on different time scales to policy-makers.

>RHN: There are political moments, aren’t there?

WG :There are political moments, and you need to grasp them.

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