Connecting the dots: Adoption of maternal, newborn and child health research evidence in policy and practice.

India's concerted efforts to provide accessible and quality maternal and newborn health services has translated into impressive gains in maternal and neonatal health outcomes. Examples include a decreased maternal mortality ratio (from 130/100 000 live births in 2015–2016 to 97/100 000 live births in 2018–2020)1 and neonatal mortality rate (from 24/1000 live births in 2016 to 20/1000 live births in 2020).2 This improvement is partly attributed to adoption of policies that are based on research evidence. Examples include misoprostol use for prevention of postpartum haemorrhage (PPH)3 and Helping Babies Breathe (HBB) training of birth attendants for reducing neonatal deaths.4 However, despite these interventions and improvements, maternal and neonatal deaths remain high in India, requiring continuous efforts to attain sustainable development goals. Leveraging the best available evidence to improve effectiveness, efficiency and equity of health policies and interventions should enhance the optimal use of scarce public resources, and increase the transparency and accountability of policies and interventions.5 However, not all relevant published evidence is translated into effective health policy and improved practices. Investments in research should be reflected in societal benefits and therefore, though challenging, bridging this gap between research and policy and practice is crucial. The III International Conference on ‘Maternal, Newborn and Child Health; Translating Research Evidence to Practice’ held in Belagavi, Karnataka, India, in November 2022 facilitated a dialogue between a host of international and national organisations and individuals (research funders, researchers, professional societies, development agencies, healthcare providers, academicians) to understand the perspective of these diverse stakeholders on the critical steps needed to synthesise research evidence and accelerate its inclusion in both policy framework and practice. This article provides a summary of this discussion and its key recommendations. Early and ongoing engagement between the researchers and policymakers/implementors, not only at the time of research priority setting but throughout the process, was identified as a key element. Understanding research needs and identifying context-specific national and regional health issues that are rooted in the federal and state governments’ policies can lead to designing and implementing more effective projects, programmes and policies. Research aligned with the country's needs ensures early ‘buy-in’ and accelerated uptake of evidence by policymakers. Given India's diversity, with varying health indices and services across states and districts, the priority issues for research are expected to be contextual and different across regions. Having policymakers onboard during study design and execution will acquaint them with ongoing research and its impact on pregnant women and the health of their offspring. The quality of the relationship and collaboration between researchers and policymakers before, during and after research was the single most mentioned facilitator in a systematic review.6 Interactions between researchers and policymakers increased the prospects for translating evidence into policy, Hence, credible advocacy and support from these experts as ‘champions’ would leverage policy translation, while individual negative attitudes towards research and lack of skills decrease it.7 Such interactions were, however, limited and mostly informal.8 Most researchers either do not have access to, or are not familiar or not comfortable working at the policy interface. The individual or institutional incapacity to forge personal contact or a collaborative relationship with policymakers/implementors leads to research–policy–practice gaps. Platforms wherein researchers and policymakers can interact and be sensitised regarding ongoing research, evidence generated and its policy implications need to be established. Government institutions with a mandate to promote and support health research and its policy translation should facilitate and support this type of collaboration and dialogue. Multi-stakeholder engagement throughout the research project's lifecycle would ensure that the trial implementation is acceptable, relevant and trusted. Alongside policymakers, other stakeholders such as programme implementers, patient and community groups, advisory boards, professional societies and healthcare providers should be given balanced and objective information about the project, the problem being addressed and alternative solutions. Their feedback should be integrated whenever possible and appropriate. Participatory research was considered an important component of the evidence to policy ecosystem. Regardless of the research evidence, community perception about the usefulness of any intervention determines its uptake. For instance, iron supplementation uptake is still low during pregnancy despite high-quality evidence for its positive impact on maternal and perinatal morbidity and mortality and it being included in the health programme for decades.9 Community engagement to include the end users’ needs and perspectives in framing the research question, study design and its robust execution could be important elements leading to community trust and intervention uptake. Researchers should use communication, dissemination and engagement strategies tailored to potential users at each stage of evidence creation, thus placing the community at the centre and considering the end user's needs, demands, barriers and concerns. Ideally, this interaction should occur prior to initiation of studies so that end points and protocols can take into account patients’ wishes, preferences and fears. India's private healthcare delivery sector has a large footprint. Knowledge translation should percolate to all levels of public and private healthcare providers, resulting in more evidence-based practice, and be reflected in changes in professional behaviours and quality indicators. However, evidence–practice gaps exist with even proven interventions. In a cross-sectional observational study across 56 facilities in India, uterotonic administration after delivery was administered correctly to only 31% women.10 Conversely, because of this evidence–practice gap, patients may get care that is either not needed or that could potentially be injurious,11 exposing them to unwanted risks of iatrogenic harm. Strengthening intersectoral linkages and partnerships can bridge this evidence–practice gap. Professional societies can play a pivotal role in disseminating knowledge adapted to the country context, serving as training hubs and monitoring the ‘knowledge to translational losses’ and distortions through audits and informative feedbacks. Capacity building should be accomplished at individual levels through tailored interactive workshops with goal-focused mentoring and promoting cross-sector team activities.12 Collaboration and co-production of knowledge between researchers, policymakers and civil society has the potential to improve policy and health outcomes, as well as enhance research quality and relevance.5 Individual studies, by themselves, rarely provide sufficient evidence to drive practice and policy changes; additional forms of research may be needed. Systematic reviews support policymakers in decision-making by synthesising evidence and identifying gaps. They may further de-risk a decision by limiting suspicions of the policymaker prioritising a single research source or pharma.13 For India and similar low- to middle-income countries (LMICs), cost-effectiveness studies through economic evaluations and modelling help to determine whether the intervention is worth including in policy, given limited resources. Health technology assessment (HTA) can facilitate the process of transparent evidence synthesis leading to informed decision-making. The HTA in India (HTAin) collates and, where needed, generates evidence on clinical effectiveness, cost-effectiveness, and safety of medicines, devices and health programmes.14 India's clinical, social and infrastructural context is different from the global north. Hence, feasibility studies in the local context can evaluate the acceptability of an intervention by end users and healthcare providers, inform on its demand or uptake, and the extent to which it can be delivered under existing means, resources and circumstances. Through behavioural research, strategies that would facilitate behaviour change among users and providers and sustain change in them may be identified. Investing in implementation research was strongly underlined. Policymakers often want to know the barriers and strategies needed for effective on-the-ground implementation. Informing them about implementation issues would make the transition from research, including demonstration project research, more feasible to the wider expansion and institutionalisation that is entailed in scaling up implementation. As India is a large and diverse country, implementation research may need to be undertaken across different geographies, health sector governance and performance settings to understand the contextual and intervention-specific bottlenecks. This approach will allow for the development of strategies to find solutions (e.g. educational programmes, necessary equipment, impact on staffing) within existing resources to achieve effective and high-quality coverage of evidence-based interventions. A pilot project on ‘Community-based Advance Distribution of Misoprostol’ programme in India successfully provided a scalable model for effective implementation with important implications in reducing the incidence of PPH and maternal mortality during home deliveries.15 Demonstration projects are effective mechanisms for forging partnerships between public, private and community sectors, working together and generating visible results on the ground. Scalability and sustainability go hand-in-hand and mechanisms for sustainability should be built into the demonstration project at the outset. Equity considerations should be incorporated at all levels of the evidence-to-policy ecosystem and the inclusivity of vulnerable and marginalised groups factored in during project design. A study of carbetocin, an innovative room temperature-stable uterotonic for PPH prevention, is ongoing at various levels of public health settings to determine its acceptability and implementation issues. The evidence generated will be valuable for policy consideration and to scale up its appropriate use in public health facilities. Effective communication strategies link evidence generators to users. Apart from the primary publication, research results should be communicated in a tailored manner to target audiences including policymakers, organisational leaders, professionals and end users.16 Lack of relevant, reliable and clear research findings, and poor access to results restrict policymakers’ use of evidence.6 Often, policymakers are not adequately research-literate or are too preoccupied with other responsibilities to go through publications; hence, easy-to-read, concise and precise policy briefs that harness key research findings, can support decision-making. In doing so, quality, local applicability, and equity considerations should be accounted for.13 Such briefs can assist policymakers and stakeholders in determining whether and how available evidence is in harmony with their own beliefs, interests, political goals and strategies. Frameworks and tools such as target policy profile (TPoP)17 and others5, 13 are available to guide researchers in bringing evidence into the policy discussion towards translation. Armed with this knowledge, researchers can maximise the likelihood that studies generate optimal policies in an efficient way. Research evidence should be disseminated at educational events such as conferences, symposia and training sessions for fostering knowledge uptake. Subject experts, researchers, healthcare providers and academicians have an opportunity to deliberate on the costs, benefits, opportunities and challenges of the intervention at such events. Policymakers often rely on the tacit knowledge of the subject experts or trusted providers. Hence, credible advocacy and support from these experts as ‘champions’ would leverage policy translation. Clinical practice guidelines should be prepared by interdisciplinary teams of professionals and researchers, and their endorsement by international bodies such as WHO, NICE, FIGO and national professional societies can influence the likelihood of the evidence being translated into policy and practice. Reporting research findings in print and electronic media is another important way of sharing information with the public, health professionals and policymakers. Although its impact is difficult to measure, mass media can influence individual health behaviours, levels of healthcare utilisation, healthcare practices and policy. Social media with its wide reach can serve as knowledge dissemination and advocacy platforms; harnessing its full potential through blogs, infographics and informative messaging can be a highly effective communication tool. Generating high-quality evidence on interventions that positively impact maternal and perinatal outcomes alone is not enough. Its translation to public policy and scaling-up is critical. The following steps will enhance informed decision making and accelerated uptake and implementation of research evidence into practice: (1) effective advocacy and communication of research evidence, (2) government institutionalised platforms for knowledge synthesis and transfer directed at policy development and implementation; (3) communication between researchers, policymakers, and end- users; (4) proactive collaboration of all stakeholders to mobilise resources and influence systems to change policies, programmes and practices. SSG, NC, RMS, AK, MSS conceptualised the idea. NC wrote the first draft with inputs from SSG, AK, MSS and RMS. All the authors have approved the article. The author would like to thank Dr Hetal Shah for her support in editorial review of the paper. This paper was funded by the internal resources of Jawaharlal Nehru Medical College, Women's and Children's Health Research Unit, Belagavi, India. None declared.