Systematic analysis of research underfunding in maternal and perinatal health
Prof NM Fisk, University of Queensland Centre for Clinical Research, RBWH Campus, Herston, Brisbane, Queensland 4029, Australia. Email firstname.lastname@example.org
Background Little published evidence supports the widely held contention that research in pregnancy is underfunded compared with other disease areas.
Objectives To assess absolute and relative government and charitable funding for maternal and perinatal research in the UK and internationally.
Search strategy, selection criteria, data collection, and analysis Major research funding bodies and alliances were identified from an Internet search and discussions with opinion leaders/senior investigators. Websites and annual reports were reviewed for details of strategy, research spend, grants awarded, and allocation to maternal and/or perinatal disease using generic and disease-specific search terms.
Main results Within the imprecision in the data sets, ≤1% of health research spend in the UK was on maternal/perinatal health. Other countries fared better with 1–4% investment, although nonexclusive categorisation may render this an overestimate. In low-resource settings, government funders focused on infectious disease but not maternal and perinatal health despite high relative disease burden, while global philanthropy concentrated on service provision rather than research. Although research expenditure has been deemed as appropriate for ‘reproductive health’ disease burden in the UK, there are no data on the equity of maternal/perinatal research spend against disease burden, which globally may justify a manyfold increase.
Author’s conclusions This systematic review of research expenditure and priorities from national and international funding bodies suggests relative underinvestment in maternal/perinatal health. Contributing factors include the low political priority given to women’s health, the challenging nature of clinical research in pregnancy, and research capacity dearth as a consequence of chronic underinvestment.
Research and development (R&D) is integral to advances in medical care. Biomedical knowledge has increased exponentially over the past decade as the result of both enabling technologies and record investment. In that time, R&D funding in the not-for-profit government and charitable sectors doubled in leading Western economies.1 Similarly, the pharmaceutical industry, which funds over half health-related R&D in the USA and Europe2,3 trebled its R&D expenditure,4 while public–private investment targeting R&D for low-resource settings rose several fold.5
The largest government funder, both absolutely and as a percentage of gross domestic product (GDP), is the US National Institutes for Health (NIH) with an annual budget of $28.6bn in 2007 (0.21% of GDP).6 This dwarfs national research council spends in other knowledge-based economies,1 like the UK (Medical Research Council [MRC] budget 05/06 £529M [US$1.1bn, 0.05% of GDP]),7 Canada (Canadian Institutes of Health Research 06/07 $C863M ($0.9bn, 0.05% of GDP),8 Sweden (Swedish Research Council and Swedish Agency for Innovation Systems 05 SEK4467M [$0.7bn, 0.18% of GDP]), and Australia (National Health & Medical Research Council 07 $A630M [$0.6bn, 0.07% of GDP]).9 In the UK, applied health services research is funded separately within the National Health Service (NHS) by the Department of Health, with an allocation larger than the MRCs (06–07 £753M [$1.6bn, 0.07% of GDP]). Charities also make sizeable contributions to R&D. Many are disease- or area-specific while the UK’s Wellcome Trust funds over £400M (US$0.8bn) of research across all specialties.10 Charities accounted for 18% of the £5.4bn (US$10.8bn) total UK healthcare-related R&D spend (04/05 financial year)2 and 9% of the much greater US$111bn total healthcare-related R&D spend in the same period.11
R&D into maternal and fetal health has long been considered underresourced compared with other disease areas.1,12–14 In 1992, The Institute of Medicine in the USA detailed relative research underfunding in women’s health.15 In 2006, ‘incredible’ underfunding was the basis of the UK charity Action Medical Research’s Touching Tiny Lives campaign to increase government research funding into preterm birth, pre-eclampsia and other serious conditions affecting expectant mothers and their babies.16 The UKs National Perinatal Epidemiology Unit in noting that maternal and neonatal research is almost entirely from public funds in the presence of minimal industrial/pharmaceutical interest,17 attributed underfunding to a bias towards basic science.12 However, there are few data to support this widely held contention that research into maternal and perinatal disease is underfunded relative to other disease areas or contribution to disease burden.
Although R&D is usually conducted in high-income countries focused on disease burden in such settings, any underfunding of pregnancy R&D will have disproportionate impact in resource poor settings where >98% of the half million maternal and 6 million perinatal deaths occur each year.18–20 The WHO Commission on Macroeconomics and Health identified maternal and perinatal health as second only to infectious disease as a priority for global health research.21 Maternal and perinatal disease is the single largest contributor to the global burden of disease, accounting for more than 6% of disability-adjusted life years (DALYs),20 a figure that would be considerably higher if it included stillbirths,20 and there has been little progress towards meeting the United Nations’ (UN) Millennium Development Goals (MDG4 and MDG5) targets for their reduction.22,23
We previously analysed the drug development pipeline in maternal health to document marked underinvestment by the pharmaceutical industry relative to comparable disease areas.17 To date, there has been no systematic attempt to analyse nonpharmaceutical investment in maternal health R&D. To investigate the priority given to pregnancy disorders both in the UK and internationally, we assessed the absolute and relative allocations of current government and charitable funding to maternal and perinatal health within health-related R&D.
The major research funding bodies and research alliances in health and specifically in pregnancy were identified from (i) discussions with global opinion leaders/senior clinical investigators in obstetrics, maternal, fetal, and neonatal medicine and (ii) an Internet search using the terms research; grants or funding; and one or more of obstetric, pregnancy, fetal, maternal, perinatal, neonatal, labour/labor, and birth. Searches were limited to English speaking (or English reporting) countries.
Their websites and annual reports were then reviewed in November 2007 for the following: current and future strategy; total research spend; grants awarded; allocation to maternal and/or perinatal disease; professional membership of research advisory committees; and the search terms obstetric, maternal, fetal, antenatal, placental, perinatal, neonatal, labour/labor, pre-eclampsia, growth restriction, birth, and postpartum. Expenditure was referenced to US currency at 6 November 2007 exchange rates, uncorrected for purchasing power parity. Where available, the titles of grants awarded were reviewed manually and using the above terms to determine their relevance to maternal health. Because a number of funding bodies pooled maternal and neonatal research together, we used maternal/perinatal as a pragmatic classification to include neonatal research into conditions arising from obstetric pathologies (e.g. prematurity, intrauterine growth restriction, birth asphyxia) but excluded areas typically considered gynaecology, for example contraception, abortion, and developmental biology unrelated to pregnancy outcome. Membership of research advisory boards was reviewed for departmental and specialty affiliations and area of research interest to ascertain the number of individuals with relevant maternal and/or perinatal expertise, either in clinical or in basic science.
Searches in the UK covered research alliances such as the UK Clinical Research Collaboration24 and the Association of Medical Research Charities,25 the main government funders, the MRC,7 and the NHS Research and Development Programme26 and relevant charities including the Wellcome Trust,10 the British Heart Foundation,27 Action Medical Research,28 SPARKS (Sport Aiding Medical Research for Kids),29 Wellbeing of Women,30 and the Tommy’s Campaign.31
Major international funding bodies included the European Union,32 the US NIH,6 and the Centers for Disease Control and Prevention33 with additional searching via the CRISP database of publicly funded research,34 the Canadian Institutes of Health,35 and the Australian National Health and Medical Research Council9 at the government level and the charity March of Dimes.36
Although most biomedical research is performed in developed countries, searches were also conducted of major funding institutions located in or directed towards health problems in the developing world. These included the Indian Council of Medical Research37 and the South African Medical Research Council38 as government bodies, the WHO, UNICEF,39 the UNDP/UNFPA/WHO/World Bank HRP program (Special Program of Research, Development and Research Training in Human Reproduction),40 and UNAIDS41 as key multilateral UN agencies19 and the Bill and Melinda Gates Foundation42 and the Rockefeller Foundation43 as charities.
The MRC allocates just over half (52% in 05/06) of its direct research spend to 3 intramural institutes and 29 MRC units, none of which obviously relates to maternal health. Among the remainder allocated to investigator-led research and training in universities and hospitals, only 11 (1.2%) of 888 extramural research grants between June 2004 to March 2007 related to maternal/perinatal health, accounting for £8.5M ($17.7M) or 1.7% of £495.8M ($1.03bn) awarded. Two of the MRCs six current priorities are relevant, global health and clinical research, but no specific mention is made of maternal health. Pregnancy features in 1 of 55 achievements listed for 2001–2005. Obstetrics is covered by two of the five research boards, Physical Systems & Clinical Sciences and Health Services & Public Health Research. Within the former’s allocation, the two relevant subcategories detailed of reproductive biology and paediatrics/fetal/infant development are confounded by inclusion of other areas, while the subcategories within the latter are generic, precluding derivation of a figure for maternal health spend. These more clinically oriented boards are the smallest and together control only one-quarter of grant expenditure; one and two members, respectively, of their 20 person boards have pregnancy expertise (7.5%).
The NHS R&D program spends more on research than the MRC but determining a percentage for maternal health is problematic for two reasons: (i) funds are often allocated for research models across many areas (e.g. primary care, nurse support, teamwork) and (ii) the constant state of flux as the program changed first from a themed commissioning structure then to concentrate on health technology assessment and service delivery and now a National Institute of Health Research.44 The relatively small sum of £7.4M ($15.4M, <1% of current annual budget) was spent on commissioned research under the National Mother and Child Health Program between 1995 and 2001, with only 10 of 33 awards being maternal. Of the 400 completed reports commissioned by the Health Technology Assessment program, 3% involved maternal/perinatal health.
Between 2000 and 2005, the Wellcome Trust, the world’s second largest medical charity, allocated £1.4bn ($2.9bn) for research grants at UK universities, trained 700 and gave fellowships to a further 1000 scientists, and spent £500M ($1.04bn) on core facilities. Although there is no breakdown of grants by discipline, none of the 34 principle research fellows, 69 senior research fellows in basic science, or 36 senior research fellows in clinical science listed on the Wellcome website worked in maternal health. One study costing £4.5M ($9.4M) of the £90M spent on longitudinal studies was relevant to pregnancy outcome, but none of the 30 ‘Showcase’ grants funded since 1996. Abroad, 1 of the 91 international senior research fellows (whose subject is HIV in pregnancy) and 1 of 11 international collaborative research grants (£0.5M [$1.04M] of the £6M [$12.5M]) related to pregnancy. The Trust’s substantial investment in its five clinical research facilities, its four major overseas programs, and its special initiatives in genomics facilities and consortia may be of some relevance to maternal health, although none is mentioned. The Trust highlights saving premature babies through antenatal steroids as one of its ten major achievements, but this was in the early 1970s. Only two members of the seven funding stream committees have any relevant maternal health background, although neither is an obstetrician.
The Association of Medical Research Charities mapped expenditure for small–medium charities by research type,25 with 94% of their funds directed to disease-specific research rather than generic research. Four charities focused on maternal health. The Tommy’s Campaign’s entire £0.9M ($1.9M) annual spend goes on research into causes and prevention of problems in pregnancy. Wellbeing of Women focuses on women’s health, but is even smaller, with only 33.1% of £1.5M ($3.1M) in grants awarded between 04 and 06 related to pregnancy or birth. Two charities have broader portfolios, Action Medical Research (prevention and cure of disabling conditions, annual spend £4M [$8.3M]), with 16.3% of 269 current or recent grants in maternal/perinatal health, and SPARKS (conditions affecting babies and young children), with 23.3% of £1.3M ($2.7M) awarded in 2006 in maternal/perinatal health. These two have 3/11 and 3/12 research advisory board members, respectively, with maternal/perinatal expertise. The British Heart Foundation (annual spend £53.5M [$101.1M]), for which pre-eclampsia is relevant as a cardiovascular disease, spent only 1.2% on maternal health in 06/07, but at £0.7M ($1.5M), this exceeded all minor charities except the Tommy’s Campaign.
The EU underpins networks of collaborating researchers supported by small–medium enterprises, usually at less than full cost. Despite searching the 820M page Community Research & Development Information Service database, obtaining a breakdown of health spend by specialty was problematic, as these were nonfixed contracts with costs negotiated annually. Two maternal/perinatal projects totalling €1.9M ($2.8M) represented 3% of the €64M ($92.7M) budget allocated to rare diseases under the framework 5 program in 1998–2002. Only one project (costing €12M [$17.4]) retrieved in searching the lifesciences, genomics, and biotechnology for health section (€2.5bn [$3.6bn]) of framework 6 dealt entirely with pregnancy, although 4 others of 85 did in part. In framework 7 planned for 2007–2013, €6.1bn ($ 8.8bn) of the €50.5bn ($73.1bn) total will go to health with a biotechnology and translational focus across a range of six disease areas that do not include maternal/perinatal health.
In the USA, the budget of the relevant NIH institute, the National Institute of Child Health & Human Development (NICHD), is huge at $1.26bn in 2007, despite being only 4.4% of the NIH total budget. Nineteen percent goes on intramural research among laboratories organised along basic science themes, although one is the Perinatology Research Branch focussing on preterm labour. Most maternal/perinatal research is extramural, within the Pregnancy & Perinatology Branch’s annual budget of $93.4M (2004). Although relative allocations are not calculable for intramural research, data for the Pregnancy & Perinatology Branch’s five themes show that after subtracting the infant death category, 91.1% of this budget is in the area of maternal/perinatal health, while further excluding neonatology means that 64.6% is in maternal health. The NIH as a whole produces figures for actual spend, intramural and extramural and across all its institutes, broken down into 215 diseases/conditions. However, these are not exclusive, which precludes summating the six pertinent categories as does the fact that the largest women’s health ($3.5bn in 2006) covers gynaecology as well. Notwithstanding this, expenditure on the single area of ‘conditions arising in the perinatal period’ was $407M in 2006.
The other sizeable US funder, the Centers for Disease Control and Prevention, had an annual budget of $8.6bn in 2006, 85% of which is allocated through grants and contracts and 72% extramurally. Much of this goes on generic tools, surveillance and public health initiatives rather than disease-specific research, but $44M went to safe motherhood and $38.5M to birth defects and developmental disabilities.
It was not possible from the Canadian Institutes of Health website or annual reports to derive disease- or specialty-based funding from the 06–07 allocation of C$487M (US$531M) for open competition research. The most relevant of the institutes, the Institute of Human Development, Child and Youth Health, is a virtual institute with an annual budget of around $8M. However, searching the funding database revealed 254 maternal/perinatal awards of all types funded in 06/07 totalling $C25.5M ($27.6M), which represents almost 3% of the Canadian Institutes of Health’s budget.
Data from the Australia’s National Health and Medical Research Council allowed ready calculation of the relative allocation between ten disease areas. The maternal conditions/fetal development/neonatal disorders category accounted for 4.9% of 1159 awards and 4.1% (A$25M US$23.4M) of the A$615M ($572M) awarded in 2007. The larger relative allocation compared with other funders may reflect ‘a healthy start to life’ being one of four priorities, with 25% of the national spend. Nevertheless, maternal conditions/fetal development/neonatal disorders was still the smallest category.
The March of Dimes mission is to improve the health of babies by preventing birth defects, premature birth, and infant mortality, mainly in the USA but with some global activity. It spends only 19% of its annual expenditure ($227M in 2006) on research, but this is still a sizeable $43M. No precise figures are available to derive a maternal/perinatal allocation. However, their annual report does indicate that $27M went on research into the developmental biology of birth defects and other causes of death and disability in newborns, and one-third of their research spend goes on research into prematurity and its consequences. In line with their remit, this suggests that the large majority of their research spend is on maternal and perinatal health.
Equity of funding
Little information exists on the equity of distribution among disease areas or specialities by developed world funders. Two recent reports in the UK mapped allocation by UK disease burden. The first looked at R&D spend on health research by government and the three largest health research charities (Wellcome, Cancer Research UK, and British Heart Foundation),45 while the second used the same methodology on 29 small–medium health charities.25 These suggest that the 1.6% allocated by the smaller charities to ‘reproductive health’ almost precisely parallels disease burden, whereas the corresponding 2.8% from the larger funders’ allocation exceeds an equitable allocation. However, the ‘reproductive health and childbirth’ category used includes fertility, contraception, abortion, in vitro fertilisation, mammary development, menstruation, and menopause, which given their greater ease of study and the basic science focus of major funders, may not necessarily reflect maternal health spend. Also disease burden data do not yet include numerically important stillbirths.46
Funding in resource poor countries
The Indian Council of Medical Research lists Maternal and Child Health as one of its nine ‘thrust areas’ and subcategorises this into basic, clinical, health services, and community research priorities. Intramural research within 22 institutes accounted for 22.2% of budget (52.2M Rs [$1.3M] of the 235.4M Rs [$6.0M]), but the only potentially relevant institute, the National Institute for Research in Reproductive Health, appears to have an entirely fertility-based agenda. Of 1054 extramural grants between 2002 and 2007, only 14 (0.1%) pertained to maternal/perinatal health, with no details of award amounts. Only 10 (0.5%) of 204 extramural grants awarded under the reproductive health and nutrition theme in 05/06 pertained to maternal/perinatal health, the vast majority instead pertaining to fertility control and assisted reproduction. This belies the thrust areas, and indeed of the three Maternal & Child Health projects detailed in the 05/06 Annual Report, two were gynaecological.
The South African Medical Research Council (annual expenditure R423M [$64.5M]) similarly appears to prioritise maternal health, with Women’s and Child Health as one of six national programs. However, this is the smallest of the six and only one of the four constituent units is maternal/perinatal. The publicly available information does not allow breakdown by disease area or specialty. The strategy for 2005–2010 does not mention maternal health, although HIV is a priority (30% of pregnant women are HIV positive), as is translational medicine.
Although WHO spends a considerable proportion of its $3.3bn annual budget (2006–2007) on public health, policy and health systems planning in areas relevant to maternal and perinatal health, teasing out a figure for targeted research in this area is problematic. A further confounder is cofunding with partner or constituent UN agencies. UNICEF focuses its R&D program on child rights and policy implementation issues rather than targeted perinatal research. Preventing mother to child transmission of HIV is a priority for UNAIDS, yet no figure for this is available from their annual report or budget ($406M in 2006–2007), in keeping with their role as a catalytic rather than primary funder.47 The multiagency HRP covering R&D in human reproduction allocated 11.1% ($4.3M) of its 2006–2007 budget ($38.8M) to maternal and child health, with 62.3% ($4.1 of 6.6M) of research allocations involving leveraged funding in maternal and perinatal trials, mainly in preventing mother to child HIV transmission.40
The Bill and Melinda Gates Foundation, the world’s biggest charity, had by March 2007 spent $7.9bn on global health. Its global health strategy aims to prioritise disease and health conditions that cause widespread sickness and death in the developing world yet receive little attention. One of its ten areas of activity is reproductive and maternal health and another is child health. Although most spend goes to infectious disease, $110M was allocated to newborn health via Save the Children’s Saving Newborn Lives42 initiative. This largely went on service provision and training 13 000 healthcare providers, and although the focus was neonatal, at least half the care package delivered is antenatal or intrapartum. The Foundation also awarded $57M to Columbia University to improve access to obstetric care in developing countries.
The Rockefeller Foundation, with $3.5bn in assets, lists global health as one of its five areas of focus but allocated <$0.4M to maternal health, chiefly to networks, conferences, and appropriate technology.
This is the first systematic attempt to document nonindustrial R&D expenditure in maternal/perinatal health. The picture that emerges is necessarily approximate and incomplete, reflecting both limitations in the publicly accessible data and variations between funders in the time periods and grant classifications used. In particular, absence of longitudinal data makes it difficult to ascertain changes in level and distribution of funding for maternal/perinatal health, both in absolute terms and relative to other priority areas. In addition, the breadth of research in maternal/perinatal health renders it more difficult to classify expenditure than for a single disease or infection as performed for tuberculosis.48 Notwithstanding this, it suggests relative underfunding of R&D in maternal/perinatal health and supports the generally held view12,15,16 and the unanimous view of researchers interviewed.
The available UK data from the MRC and relevant small/medium charities suggest an annual spend on maternal/perinatal health in the region of only £5.5M ($11.6M), from a total government and charity spend on directly funded peer reviewed research of considerably more than £950M ($2bn)49 if the small–medium charities are included. This figure contrasts with a ministerial response in Hansard that the MRC alone spends £4M ($8.3M) per year on premature birth,50 although the latter was acknowledged as including large cohort studies where the birth component was only minor. However, the £5.5M ($11.6M) numerator above is likely also to be an underestimate, as no figures could be derived from the available NHS R&D or Wellcome Trust data. Notwithstanding this, there is little evidence of a commitment to maternal health from either body, the Wellcome Trust having none of its 139 senior research fellows working in this area, while it can be estimated that NHS R&D spent <£0.4M ($0.8M) per year on maternal health during its 6 year National Mother & Child Health program.
Internationally, the limited European data suggest only modest EU funding for R&D activity in maternal/perinatal health. This contrasts with US investment, which is more than an order of magnitude greater for a population five times that of the UK. Again, it is easier to quantify the extramural NIH allocation, which within the NICHD equates to $60.4M annually on maternal health alone, or $85.1M including neonatology. Nevertheless, the latter figure, which excludes intramural and non-NICHD spend, represents only 0.3% of the total NIH budget or 0.6% of NIH annual research project grant funding. A considerably larger figure is suggested by the 2006 spend on perinatal conditions alone, $407M in 2006, although this is nonexclusive so may only be peripherally related. Charitable spend is similarly high in the USA, with most of the March of Dimes $43M research spend going on maternal/perinatal health. These figures dwarf the equivalent UK expenditure of $11.6M, even if doubled to allow for the Wellcome and NHS R&D contribution. The European and Canadian data were consistent with the 1–3% spend seen elsewhere. Australia fared better with a 4.1% allocation from government funders, which for one-third of the population seems more in both relative and absolute terms than in the UK.
In spite of both India’s and South Africa’s research councils identifying maternal and perinatal health as priorities, overall R&D investment by both governments was small, even when converted using 2006 World Bank purchasing power parity rates into international dollars ($55.2M and $175.8M, respectively). India in particular allocated <5% of its grants in reproductive health and nutrition to maternal/perinatal health, the data instead revealing a focus on infertility, which might be seen as perverse in a developing country of more than 1bn inhabitants. The Gates Foundation’s contribution to maternal and neonatal health is substantial, albeit representing only 1.3% of their global health spend. However, this is for health service provision and not R&D. Similarly, the Rockefeller Foundation’s modest contribution to date has largely been facilitatory not for R&D.
The variability in the available data sets essentially precludes comparison of relative spends by disease area. Even if it did not, it is not clear what disease area or specialty would be a suitable control, in particular whether it should be chosen on the basis of population affected, inpatient stay, finished consultant episodes, or disease burden. Reproductive health was not identified as one of the areas underfunded relative to disease burden in the UK,49 but no analysis was performed for maternal health, nor were stillbirths included. The Cooksey report acknowledged calls for increased funding in maternal health among other areas,1 but noted that both public sector and total research spend in the UK were fairly evenly distributed in relation to disease burden, with two exceptions, neither of which included maternal and perinatal health.49 Any future analysis against UK disease burden would need to include NHS R&D and Wellcome Trust spend in maternal health to be meaningful.
These data suggest that the competitive approach to nonring-fenced R&D funding has failed for maternal health. The experts interviewed stated that the usual response when underfunding was raised with major grant bodies was that they fund high-quality applications regardless of area but do not receive as many high-quality applications as from other branches of medicine. Rather than any inherent bias, this suggests deeper issues as the root cause. There are a number of possible explanations.
First, gender inequalities persist, with low political priority given to women’s health, in part because of the less visible disease burden born by mothers and babies and in part because funding has historically been determined by men.51 Despite more than half medical students now being women, there remain relics of a glass ceiling in academic medicine.52 Indeed, MDG3 specifically calls for the promotion of gender equality and empowerment of women.53 Against this, however, breast cancer research seems well funded.
Second, clinical research in maternal–fetal medicine is challenging because of the relative inaccessibility of the human fetus, the charged ethical situation with two patients (mother and fetus), and the heavy service load of clinicians in craft specialities.54
Third, the chronic underfunding has now resulted in limited research capacity,12 with a shortage not only of academic departments and facilities but also of clinical academics and clinical scientists in obstetrics. The rarity of role models has a self-perpetuating effect with lack or academics to train budding researchers.55 This is a particular concern at this time when the focus is shifting back from basic science to translational medicine and campaigns with funding are underway to revitalise academic medicine.56,57
Finally, it may reflect the basic science bias over the past decade of major funders and universities driven by external research assessments, which gives less importance to clinical research, as reflected in lower bibliometrics like journal impact factors55 and the paucity of maternal/perinatal clinicians on research funding boards. Indeed, basic research unrelated to clinical outcomes accounts for the majority of funding, for example 55% of NIH expenditure and 69% of the UKs total nonindustrial health-related R&D spend in 04/05.49
Just as there is minimal industrial R&D in maternal health,17 nonindustrial academic research is similarly underfunded, which not only contributes to fewer new drugs for commercial translation but also retards development of diagnostic methods, devices, and nondrug therapies. Empirically, obstetrics is a mainstream specialty with significant potential for adverse outcomes; it not only involves the most common surgical operation in the world (caesarean), the second most dangerous day of one’s life (the day one is born), a 1 in 50 chance of having a child with a major congenital abnormality, and a 1 in 200 chance of stillbirth, but the lifelong consequences to the offspring are increasingly recognised of cardiovascular/metabolic programming from aberrant pregnancy nutrition and fetal growth, and of perinatal brain injury from prematurity and birth asphyxia. Investment in biomedical R&D has been shown to deliver a five-fold return to the economy,58 and there is no valid reason to suspect that targeted investment in maternal health would not do the same. Indeed, given the lack of progress towards meeting MDG4 and MDG5, the effect could arguably be greater.
Increasing R&D funding in this area will require combined efforts of academics, clinicians, professional societies, and patient groups in sustained advocacy to raise awareness of the R&D funding gaps as well as greater engagement of clinical scientists involved in obstetrics/perinatal research in R&D priority setting to ensure greater equity. This will also require stewardship and coordination, although the source of this stewardship is not immediately obvious, and be a priority for the maternal/perinatal health community.
There are a number of specifically targeted activities that should be considered. One obvious step to stimulate public sector research is to boost funding from the major grant awarding bodies. However, this is unlikely to increase the relative or even absolute amount allocated to obstetric R&D unless ring fenced, because of the dearth of human and infrastructural research capacity in maternal health that has arisen as a consequence of underfunding, against the competitive strength of better funded areas. Government funders are reluctant to ring-fenced R&D funding in the absence of political dictat, and usually only do so for new scientific avenues, or areas with potential intellectual property returns. The MRC for instance prides itself on preserving its extremely high standards, such that there is a history of targeted initiatives remaining unspent. High-profile public awareness campaigns will be required to achieve protected funding. Experience to date, however, in maternal and perinatal health is not encouraging, the Touching Tiny Lives campaign having largely fallen on deaf ears.16 Advocacy is also needed with international philanthropic bodies to make the case for R&D, not just service provision, having a major impact on disease burden, particularly in resource poor settings.
Although there has been considerable work on global maternal and child health,59,60 an area now attracting significant new funds from governments and philanthropic organisations, the focus has been on implementing existing interventions rather than developing new ones. In contrast, there has been little priority setting for maternal/perinatal research, as is now warranted. Initiatives to promote R&D in maternal health also require coordination. The plethora of funding streams for public sector research in some developed nations has contributed to the unevenness of coverage in contrast to the more coordinated planning approach in the USA. In this light, new national oversight bodies are welcome, such as the UK’s Office for Strategic Co-ordination of Health Research, which aims to translate research more efficiently through better coordination and more coherent funding arrangements, in particular a single integrated health research strategy developed in partnership with the NHS and MRC.1,44 A stewardship priority will be ensuring greater transparency and accountability via a reliable framework for data collection to overcome the paucity of R&D expenditure detail highlighted herein.
This systematic review of research expenditure and priorities from national and international R&D funding bodies was hampered by imprecision in the data sets and lack of transparency, indicative of weak accountability. Within these limits, ≤1% of health R&D spent in the UK was on maternal/perinatal health, with little evidence of research capacity building. Other countries fared better with up to 1–4% investment, although nonexclusive categorisation may render this an overestimate. R&D funders in the developing world rightfully focused on infectious disease with visible success, but in the process made only a token contribution to maternal health. Contributing factors to underinvestment in maternal/perinatal health R&D include the low political priority given to women’s health and the challenging nature of clinical research in pregnancy, exacerbated by a vicious cycle of research capacity dearth as a consequence of chronic underinvestment. Turning this around will require lesson learning from the successful experience in substantially boosting R&D funding for infectious diseases in developing countries. This will entail high-profile advocacy with traditional not-for-profit grant bodies to build the case for ring-fenced funding and with international philanthropic bodies to foster R&D as well as service provision to reduce disease burden in resource poor settings.
Disclosure of interests
Both authors are academics with a vested interest in accessing research funding in this area.
Contribution to authorship
R.A. and N.M.F. conceived the initial idea, interpreted the data, and jointly wrote and approved the final manuscript. N.M.F. collected and analysed the data and as corresponding author had full access to the study data and acts as guarantor.
Approval was not required.
This work was supported by the Institute of Obstetrics and Gynaecology Trust, UK registered charity number 292518. N.M.F. acknowledges salary support from the UK National Institute of Health Research Biomedical Research Centre funding scheme.
The authors are grateful to the numerous colleagues with expertise in clinical and basic investigation in perinatal health and research funding, with whom this issue was discussed. This formed part of N.M.F.’s MBA Thesis, which was awarded the Imperial College Business School’s 2008 Executive MBA project prize.
Commentary on ‘Systematic analysis of research underfunding in maternal and perinatal health’
Funding in maternal and perinatal global health
In this century, we have seen an increasing concern in the public health and health research community on maternal and perinatal health towards global health. Unfortunately, this concern has not been reflected in adequate funding. In a comprehensive analysis, Fisk and Atun (BJOG, 2009:116;347–355) have shown the scarcity of funds devoted to maternal and perinatal health research regardless of the fact that maternal and perinatal disease is the single largest contributor to the global burden of disease. Still, more than 500 000 mothers and 4 million babies from poor countries are dying each year and little or no improvements have been shown in the past 15 years. Inadequate funding for research in the area is likely to be a major contributor to the current situation (Roseboom et al., Heart 2000;84:595–8).
Main priorities have already been identified. Interventions that would reduce a large proportion of the maternal deaths and 41–72% of the neonatal deaths are already known, but not routinely used in low- and middle-income countries (LMICs) (Campbell and Graham, Lancet 2006;368:1284–99; Darmstadt et al., Lancet 2005;365:977–88). Dissemination and implementation research are needed to develop and evaluate interventions to scale up those beneficial practices.
We still do not know what the causes are and how to prevent or treat major maternal and perinatal diseases that like pre-eclampsia and preterm birth are major contributors to maternal and perinatal mortality and morbidity. Basic and clinical research is still needed to contribute to ameliorate the high rates of deaths and to improve the quality of life of mothers and their progeny. Additionally, more research focused on expectations, beliefs, barriers and knowledge of women and their families to design and tailor interventions for health improvement and population empowerment is needed.
Finally, strong, sustainable and independent research centres of excellence are needed in LMICs, capable of designing and evaluating original, feasible and culturally appropriated interventions targeted to these priorities.
How can we attain a strong global health research community devoted to improve global maternal and infant health? Is it more an issue of rationale reallocation of existing funds rather than an increase in overall funds assigned to research? How we researchers will afford this issue? We consider that a concerted action among funding agencies, stakeholders and researchers is needed. A critical evaluation about the amount of funds available and how funding agencies establish their priorities may be a first step on this process. Funding agencies need to involve researchers from LMICs in their policy and decision boards. Decision should be based on priorities and on activities that have shown or are expected to have the major impact on the most deprived population within LMICs. We need to attain transparency, independence, rationale and justified allocation, and evaluation of global funds assigned for research since a change on the current health situation of maternal and perinatal health on LMICs is imperative.
JM Belizán, F Althabe
Department for Mother and Child Health Research, Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
In the accompanying article, ‘Systematic analysis of research under funding in maternal and perinatal health’, Professors Fisk and Atun attempt to quantify the percentage of research dollars devoted to the study of pregnancy and its outcomes. It is difficult to arrive at exact numbers but a generous estimate would be that 2–4% of research dollars are directed towards understanding pregnancy-related problems. The question to be asked, ‘Is this enough?’
A strategy employed to answer this question is to consider equitable funding to be related to the ‘disease burden’. The article cites a statement from the Association of Medical Research Charities in the UK that the 1.6% of research dollars provided for studies of reproductive health ‘almost exactly parallels disease burden’. I am not sure how this estimate was determined but 1.6% seems like a very small estimate of the impact of abnormal pregnancy on mothers, infants and society. Prematurity is a leading cause of neurological impairment ranging from cerebral palsy to learning disabilities. Growth restriction affects offspring not only at birth but is increasingly recognised as relevant to adult obesity, diabetes and cardiovascular disease. Although not as well established, it should not be surprising that the intrauterine environment is suggested as a contributor to schizophrenia, immune disorders, bipolar disorders and other adult disorders. Furthermore, the similarity of the pathogenesis and risk factors of pre-eclampsia to later life cardiovascular disease and its association with increased risk of cardiovascular disease suggests a target for both understanding and preventing later life disease in women. Not to be ignored is the large number of maternal deaths in developing countries with their devastating impact on entire families and society. The 1.6% estimate seems to ignore at least some of these factors. The 2–4% of the research budget directed to pregnancy seems ridiculously small.
The authors address the question as to why there is so little funding for pregnancy research and provide some reasonable suggestions. Certainly, the issue of advocacy must be considered. As the authors point out, there are very few pregnancy investigators on the governing boards of most funding agencies and women of reproductive age are only beginning to achieve positions where they could influence policy. Another factor is the almost self-fulfilling prophecy that if a research area is poorly funded it is doomed to be noncompetitive with better funded research areas and will continue to be poorly funded. This is especially problematic in times when funding is limited. Investigators are savvy enough to avoid poorly funded areas. Additionally, the quality of research will be inferior with fewer of the most talented investigators in this area with consequent inability to compete for reduced funds.
Are there answers? Certainly increased funding would have an enormous impact. Not only is 2–4% of a larger number greater, but investigators are more willing to take chances as reviewers and investigators in this setting. This increases the likelihood that the importance of pregnancy research will be sufficient to balance a history of limited funding. Also, training programmes such as those in the USA directed at improving the research base of obstetrics by targeting support to young investigators will also help improve the quality of research. Improved investigators will eventuate in higher profile pregnancy research. It is especially distressing that pregnancy research in developing countries, the site of most maternal and infant deaths are low not only in dollars but in the proportion of dollars. This issue will only be solved through collaborations of developed and developing countries. Finally, the issue of advocacy is extremely important. The 9 months of intrauterine life dictate lifelong health, and effects on the mother’s health during this time influence her future health and that of her family. Somehow, we must all work to get this message across to the general public and decision makers.
Professor Obstetrics Gynecology and Reproductive Sciences (Magee-Womens Research Institute) and Epidemiology University of Pittsburgh, Pittsburgh, PA, USA