JNMC Women’s and Children’s Health Research Unit’s

JNMC Women’s and Children’s Health Research Unit’s Community Based Research Initiatives for Reducing Maternal and Newborn Mortality in North Karnataka

India contributes to the greatest number of the 2.6 million stillbirths, 3.1 million neonatal deaths and the 342,900 maternal deaths that occur globally every year. The international community and the ministries of health are looking for evidence based health care strategies that can be implemented in low-resource community settings to make a significant impact on this alarming mortality burden. J N Medical College, Belgaum has taken a special initiative for improving the health status of the mothers and newborns in the north Karnataka region. In that noble endeavor, the year 1999 represents a significant landmark. Spurred by the encouragement of Dr Prabhakar Kore, MP, and the visionary Chairman of KLE Society, an academic collaboration was established with the University of Illinois at Chicago, USA. The major emphasis of the collaboration was to strengthen Medical Education as well as develop research capacity and clinical care services in Maternal and Child Health.

The National Institute of Child Health and Human Development of the National Institutes of Health, USA for the first time ever formed a Global Network for Women’s and Children’s Health Research in the year 2001. The objective of the Global Network is to implement community based research studies to improve maternal, neonatal, infant and early childhood health and accelerate the achievement of Millennium Development Goals 4 and 5 (of reducing maternal and newborn mortality) in low and middle income countries across Asia, Africa and Latin America. JNMC has the unique distinction of being selected as one of the sites of the research network. For realizing the Global Network mandate, JNMC established a Women’s and Children’s Health Research Unit in 2001. In fulfilling its mission, the JNMC Research Unit has forged a strong Public Private Partnership with the public sector health care system. Building on the expanded research capacity emanating from Global Network participation, JNMC has forged collaborations with nine Universities of the USA and two from Canada as well as other international not-for-profit organizations.

Over the past twelve years, JNMC’s multi-disciplinary research team has conducted a number of community based research projects with support from other NIH agencies, the World Health Organization, Geneva, the American Academy of Pediatrics, the International Atomic Energy Agency, the Thrasher Research Foundation, the Norwegian Agency for Development Cooperation (NORAD), the Laerdal Medical Foundation and the Bill and Melinda Gates Foundation. The research areas relate to: identifying strategies for preventing excessive bleeding during child birth; optimizing delivery practices of birth attendants; improving the skills of birth attendants for initiating newborn resuscitation in babies who fail to breathe spontaneously after birth; developing a home-to-hospital continuum of Emergency Obstetric and Newborn Care health system model through community participation and improvement of quality of health care services at hospitals; training community health workers like ASHAs to identify pregnant women with increased risk for preterm delivery and facilitating the administration of corticosteroids for reducing mortality among preterm low birth weight babies; promoting optimal childhood growth and development through home based education of families; and testing the effectiveness of nutritional supplementation prior to pregnancy on the growth and development of the baby. The site has pioneered a population based registry for tracking maternal and newborn health outcomes. The overarching intent of these research projects is to develop sustainable service delivery models for informing policy that could be scaled up programmatically by countries to meet MDGs 4 and 5. The results of these insightful research studies have had a profound impact at national and international levels in shaping public health policies.

Misoprostol-tablet, first tested in Belgaum district for preventing excessive bleeding in women after delivery, is now endorsed by the Government of India for community level prevention of postpartum bleeding. The study provided the critical evidence for the inclusion of misoprostol on the World Health Organization’s List of Essential Medicines for prevention of postpartum hemorrhage and stronger advocacy of misoprostol for PPH prevention by the United Nations’ Commission on Life-Saving Commodities for Maternal Health. It also prompted expansion of the registration and use of misoprostol for prevention of postpartum bleeding by the Ministries of Health of 21 countries. However, the skill of birth attendants in conducting delivery and management of the immediate postpartum period is a critical factor in determining the extent of blood loss after childbirth. Studies conducted by the JNMC Research Unit have demonstrated that simplified practices for managing the third stage of delivery, and training birth attendants for adopting them, are capable of improving the health outcomes of mothers.

Failure to breathe spontaneously at birth (birth asphyxia) is one of the leading causes of early newborn mortality. Inappropriate and unscientific resuscitation practices for reviving such babies are prevalent widely and contribute significantly to the high number of stillbirths and newborn deaths witnessed in our communities. Between 2005 and 2008, the ‘Global Network’ launched a major initiative of training community-based birth attendants in Neonatal Resuscitation for reducing early neonatal mortality in developing countries. The results of this “First Breath: Community Based Training and Intervention in Neonatal Resuscitation” research project led to the incorporation of the neonatal resuscitation training curriculum in the Basic Newborn Care & Resuscitation Program called “Navajat Shishu Suraksha Karyakram” (NSSK) program of the Government of India.

While ‘First Breath’ attempted reduction of early newborn mortality from birth asphyxia, it was speculated that the survivors may end up with varying degree of impaired neurological development. The burden on families and the communities assumes greater significance in view of the scarcity of supportive care available to children of rural population. The “Brain Research to Ameliorate Impaired Neurodevelopment: Home-based Intervention Trial (BRAIN HIT)” addressed this concern by testing the feasibility of a home based early intervention program on babies resuscitated from birth asphyxia in improving their physical, mental and social development. The BRAIN-HIT study findings demonstrate that simple home based strategies could be effective in reducing neurodevelopmental disabilities in young children from low and middle income countries.

Health care systems in many developing countries struggle to provide safe delivery by skilled birth attendants and necessary emergency obstetric and newborn care. While the Misoprostol study and First Breath project focused on reducing maternal and newborn deaths from specific causes, community-participatory approaches and health system strengthening are essential if the maternal and newborn mortality has to be reduced drastically. The Emergency Obstetric and Newborn Care study implemented by the JNMC Research Unit tested an integrated package of these strategies for improving pregnancy outcomes. The strategies included creating awareness in the communities for birth planning and hospital transport, birth attendant training for early recognition of pregnancy and newborn complications, and hospital staff training in the management of obstetric and neonatal emergencies. Although, this comprehensive, large-scale, multi-sector intervention did not result in the anticipated impact on pregnancy outcomes, the results were encouraging. Lessons learnt from this project suggest that achieving improvement in pregnancy outcomes in these settings will require substantially more obstetric and newborn care infrastructure and provider training and community mobilization alone will not be sufficient.

Recently, the Research Unit has completed two more major research projects aimed at reducing newborn mortality in Belgaum and Bagalkot districts. While the Antenatal Corticosteroid Trial involved training community health workers in over 150 villages to identify women at high risk for preterm delivery and reduce newborn mortality, the Helping Babies Breathe project trained over 1,200 birth attendants working in 25 public sector (District Hospital, Belgaum, 7 Taluka hospitals, 2 Community Health Centers and 15 Primary Health Centers) and 8 private sector hospitals of Belgaum district for newborn resuscitation. The strategies used in the research studies to-date have demonstrated positive impact on maternal and neonatal outcomes. It is hoped that these will be incorporated by the Ministry of Health for improving the health outcomes of mothers and newborns throughout the country.

Additionally, three new research projects have been initiated by the JNMC Research Unit during the year 2013. The PRE-EMPT Initiative of the Bill & Melinda Gates Foundation is implementing community level interventions for reducing maternal and new-born mortality from hypertensive disorders during pregnancy all over the world. J N Medical College, Belgaum is collaborating with S Nijalingappa Medical College, Bagalkot and University of British Columbia, Vancouver, Canada for implementing this project in Belgaum and Bagalkot districts. Dr Prabhakar Kore, Chancellor of KLE University and Chairman, KLE Society inaugurated the research project in Delhi on November 12, 2013. The inaugural function was attended by more than 100 leading public health researchers in the area of maternal health from 13 countries. Representatives of WHO, Geneva and ICMR, New Delhi were also present at the Inaugural Function. The second project – “Women First: Stree Sanjeevini” – study supported by NICHD Global Network and the Bill and Melinda Gates Foundation is aimed at assessing the effect of nutritional supplementation prior to pregnancy on newborn growth. A third research project funded by Thrasher Foundation – the Clindamycin Trial – focuses on the use of antibiotics for treating infection during pregnancy for reducing preterm births in rural areas. The results of these trials will likely have implications in shaping public health policy nationally and internationally.

Ms Kathleen Sebelius, Secretary of Health, heading the Department of Health and Human Services of the USA visited J N Medical College, Belgaum to observe the research activities conducted at the village level. Congratulating the JNMC research team for the outcomes in community based studies focused on women’s and children’s health, she lauded KLE for its commitment to improve the health status of rural India. On this glorious occasion, she lauded the leadership of Dr Prabhakar Kore and his encouragement to community based research for the benefit of rural women and children. She also gave a special invitation to the Hon’ble Chancellor Dr Prabhakar Kore and the members of the JNMC Research Unit to participate in a meeting of the Global Network in Washington held in June 2012. Acknowledging the outstanding research contribution of the research team, she reaffirmed the continued support of US Government for the next five years through 2018.

In order to strengthen the health care services in the north Karnataka region, the JNMC Research Unit has networked with S Nijalingappa Medical College of BVV Sangha, Bagalkot and Sri B M Patil Medical College of BLDE University, Bijapur. The Research Unit’s activities now encompass over 700 villages spread over the districts of Belgaum, Bijapur and Bagalkot and cover a population of over 20 lakhs. The scientific productivity of the research unit has been phenomenal. Over the past 12 years the Research Unit scientists have authored more than 50 scientific papers that have been published in internationally reputed biomedical journals like the Lancet, the New England Journal of Medicine and Pediatrics.

In conclusion, the JNMC Research Unit has made a humble effort at fulfilling its social responsibility towards improving the health of our mothers and children. But, it recognizes that a lot more needs to be done in the years to come if we have to ensure a safe childbirth and a healthy newborn in our communities. It earnestly desires that the entire community will join hands with it in this earnest endeavor.

Dr Shivaprasad S Goudar MD MHPE
Professor of Physiology &
Research Coordinator, Women’s and Children’s Health Research Unit,
KLE University’s J N Medical College, BELGAUM 590010 Karnataka India
E Mail: sgoudar@jnmc.edu
Tel (Work): +91 831 244 4194
Fax: +91 831 247 2891
Mobile: +91 94481 26371