Research and Learning Priorities for a Surgical Obstetrics and Family Planning Project Implementing in Low- and Middle-Income Countries: Results of an Expert Consultation

Strengths and Limitations

This process adapted an approach and criteria previously developed and applied by a comparable global project to generate a focused priority learning agenda and develop a research portfolio targeting the identified priorities.¹¹ The experience and strong engagement of the expert group, comprehensive rating criteria, and iterative nature of the process represent strengths of this consultation. The group of international experts held expertise spanning research and evaluation, clinical practice, and development assistance and implementation across the 4 focus technical areas. The rating criteria enabled the identification of topics where need for further investigation is greatest yet whose investigation could be done practically in the LMIC context. Moreover, the criteria definitions gained additional precision from discussions with the expert group; for example, recommendations resulted in sustainability being included in the criteria definition of potential for impact. The use of a virtual format enabled greater representation of LMIC participants and avoided travel-related emissions. The process enabled expeditious prioritization, enabling the project to focus on pursuing research activities and generating evidence.

However, the approach utilized also featured several limitations. First, as implemented, the representation of the expert group was limited with respect to affiliation. Representation was largely from international organizations and 4 African universities; no Ministry of Health officials participated, nor did women, families, or communities. Second, we did not collect data on gender, geographic location, or occupation (including experience performing focal surgical procedures). Third, although 39 individuals engaged in the rating survey, some attrition was observed (e.g., only 23 responses to the fistula topics), and fewer than 10 people engaged in each of the technical area-specific small group discussions. Fourth, the family planning topics emerging from this process (as designed and implemented) did not generate priorities on voluntary surgical contraceptive methods. It is possible that any of these limitations, including the small group composition, could have introduced bias, especially at the rating stage where small changes in rating could have resulted in any given topic being included or excluded from discussion during the ranking stage. We acknowledge that the composition of topics (both included initially and prioritized) could have been different if any of these design factors were altered (e.g., foregoing a discussion group-based model in favor of a survey-based model that could have accommodated many more participants).

These findings should be interpreted, therefore, as research priorities for a project that was working in LMICs, not an agenda comprehensively applying to all LMICs. As the surgical obstetrics and family planning evidence base continues to grow, we also acknowledge that new lines of inquiry will emerge and that research topics will need to be re-prioritized. Several lessons from this process can inform future prioritization efforts (Box 2).

We believe that the deficit of topics on voluntary surgical contraceptive methods reflects an overall lack of attention paid to permanent family planning methods. That said, we intentionally set the scope of the prioritization to cover LARCs and permanent methods both because these were the project’s technical areas of focus and because they are procedure-based methods using surgical instruments. However, the topic we included in the initial list on trends and enabling factors in global vasectomy availability and uptake was not rated highly enough to warrant discussion during the ranking stage. This could have been because the expert group was multidisciplinary in nature and was mandated with approximating priorities in the overall landscape of surgical obstetrics and family planning. Had the rating process been restricted to participants exclusively involved in the family planning community of practice, it is possible that this topic could have been rated more highly. It is also important to note that a recently published review sheds some light on global vasectomy trends and enabling factors in uptake, as well as persistent barriers to this method receiving advocacy and attention,³³ and that voluntary surgical contraceptive programming can be studied through the lens of the cross-cutting safe surgery topics prioritized through this process. We nevertheless acknowledge that our approaches could have been adjusted to increase the curation of topics relating to vasectomy and tubal ligation.

Implications for Research and Practice

It is impossible to avert a significant proportion of maternal morbidity and mortality in LMICs without access to high-quality surgical services delivered to the right patient at the right time. In many parts of the world, however, access to surgery is limited,³ referral systems for emergency obstetric conditions remain weak,³⁴ preventable perioperative complications persist,^6,35 and postoperative care needs reinforcement.³⁶ From a human resources for health standpoint, increasing the density of surgeons, obstetricians, and anesthesiologists is correlated with a decline in the maternal mortality ratio, especially in settings with less than 20 specialists per 100,000 population.^2,37 Where it is not possible to easily scale up the number of specialists, surgical task sharing to nonspecialist physicians and nonphysician clinicians has been implemented for a variety of procedures in many settings.^38,39 In parallel, the number of cesarean deliveries, already the most frequently performed surgical procedure worldwide, has increased in recent years, and is expected to continue increasing.⁴⁰ Therefore, strengthening the provision of safe essential surgery in settings with fragile health systems through obstetric, fistula, and family planning programming can both prevent maternal and newborn morbidity and mortality and serve as a framework for strengthening the entire surgical ecosystem and the ensemble of surgical services provided by health facilities.

This learning agenda contributes to efforts at reducing maternal morbidity and mortality through programmatic and clinical learning across the safe surgery ecosystem, which encompasses processes involved in seeking, reaching, and receiving quality surgical care as well as the linkages after surgical care. High-impact SBC strategies for LARCs/permanent methods and fistula prevention and care, TOLAC/VBAC, and enhancing intrapartum/midwifery care practices to reduce unnecessary cesarean delivery represent learning priorities that aim to prevent complications necessitating surgical care or improve women’s seeking of surgical care when needed. Several topics explore the provision of surgical care, including strengthening the perioperative environment (e.g., anesthesia supplies, blood, oxygen), surgical team capacity building, respectful surgical care, tools for strengthening decision-making, and task sharing for LARC removal procedures. Lastly, several prioritized topics touch upon strengthening continuity of care after surgery, including the use of post-discharge visits, monitoring of postoperative outcomes, integration of mental health care skills in surgical procedures, and gaps in the provision of holistic fistula care. Referral for surgical and emergency obstetric and newborn care is underrepresented in this agenda; however, a significant amount of research has been done on this topic and a recently published systematic review of referral interventions for obstetric emergencies proposes a logic model for “studying, understanding and improving” such processes.³⁴

Because the research priorities emerging from this process are programmatic and clinical in nature, this agenda neglects topics that may be a few steps removed from service delivery but may, nevertheless, be crucial for strengthening surgical systems in the long term. For example, this agenda does not cover policy questions, such as the generation of political support for safe surgery,⁴¹ or effective strategies for developing and implementing National Surgical, Obstetric, and Anesthesia plans in more LMICs. This outcome, though unintended, may be the result of strong representation of implementing partners in developing this agenda and because the rating criteria, specifically feasibility and potential for impact, may have contributed to prioritization of topics whose pursuit could achieve the most impact with the fewest resources. However, this agenda is not intended to stand alone, but rather to complement other existing learning agendas at the global and national levels, including on maternal health, family planning, safe surgery in LMICs (e.g., general, pediatrics, orthopedics), and health systems and policy research.

Implementation of the Research and Learning Agenda

The MOMENTUM Safe Surgery in Family Planning and Obstetrics project used this learning agenda to guide its research and learning strategy, including a series of activities involving special studies and targeted literature reviews (Table 8). Whereas some of these activities were initiated at the global level, others were launched in response to research priorities established by national and local stakeholders. Examples of the latter include the measurement of postsurgical complications before and after the implementation of a peripartum surgery diploma in Mali and the Robson classification study in Senegal. Indeed, one of the benefits of the broad nature of many of the learning agenda topics is that they offer opportunities for alignment with research priorities established at the national and subnational levels. In addition, we also supported Ministries of Health in generating evidence for topics that were local priorities but that fell outside the learning agenda’s scope.

Opportunities for the Broader Reproductive and Maternal Health Community

Although this agenda was primarily developed for a global project working in LMICs, a time-bound, donor-funded project can only undertake a limited level of learning on such a diverse set of priorities. Evidence on the topics prioritized in this collaborative learning agenda can be advanced by domestic and donor agencies, research institutions, and implementing partners supporting maternal and reproductive health service strengthening.

Indeed, priorities at the national and sub-national levels may not necessarily align with priorities at the global level. As such, research prioritization and evidence generation efforts at the national and subnational levels ought to be led by Ministry of Health officials as well as their partners (e.g., academia, implementing partners, civil society, the private sector, and community-based organizations). As mentioned above, this agenda was primarily developed as a project’s learning agenda and does not intend to substitute national/subnational efforts, but rather to complement them. The topics prioritized in this agenda may, however, support national and subnational stakeholders in identifying potential lines of inquiry to prioritize or interventions to study.

Although the vertical nature of most traditional development assistance for health presents a challenge for learning resource mobilization given the integrated or horizontal nature of safe surgery systems,⁴¹ large-scale donor-funded health programs may want to consider adopting these topics when developing their evidence generation strategies. Stratifying this learning exercise by obstetrics, fistula, family planning, and cross-cutting safe surgery topics can enable implementing partners to consider topics that align with their programmatic mandates, whether vertical or integrated. A maternal health program may, for example, consider investigating the obstetrics topics. As basic and essential surgery is increasingly being recognized as a key component of primary health care,⁴³ an integrated primary health care program working across several technical areas may consider designing implementation research studies with these topics in mind. Many of the cross-cutting topics identified in this agenda can be studied even through the lens of vertical interventions. For example, client definitions of respectful care or strategies for surgical team capacity building can be studied in the context of cesarean deliveries, permanent family planning methods, and/or fistula repair.

That said, the prioritization of topics in this agenda that inherently build on and overlap with each other further emphasizes the integrated nature of the common ecosystem that support surgeries across different technical areas (e.g., cross-cadre surgical teams, safe blood and oxygen systems, and monitoring of postsurgical outcomes) and suggest opportunities for funding research and programming that can be conducted and applied to a range of services. Given the relative newness of global safe surgery as a global public health priority, we view the development of this agenda as a starting point, not an end point, for a dialogue across communities of practices working at different levels (e.g., academics, funders, and implementers).