National research priorities for maternal and newborn health in The Gambia: a stakeholder-led prioritisation exercise

Technical Summary: National Research Priorities for Maternal and Newborn Health in The Gambia

Problem Statement
Despite expanded coverage of essential maternal and newborn health (MNH) interventions in The Gambia, mortality rates remain high, and progress toward Sustainable Development Goals 3.1 and 3.2 has stalled. While the 2013–2020 period saw a reduction in maternal mortality, neonatal mortality rates increased, and intrapartum stillbirths remain a significant, under-recognized burden. The persistence of these deaths is attributed not to a lack of effective technologies, but to bottlenecks in delivery, quality of care, referral systems, workforce capacity, and equity. Furthermore, the research agenda in low- and lower-middle-income countries is often shaped by external funders and high-income institutions rather than national health system needs, creating a mismatch between the local burden of disease and the research questions being pursued. With the National Reproductive, Maternal, Neonatal, Child and Adolescent Health (RMNCAH) Policy (2017–2026) nearing its end, there is an urgent need for a nationally owned, evidence-based research agenda to inform the successor plan and align partner investments.

Methodology
The study employed a stakeholder-led research prioritisation exercise using an adapted Child Health and Nutrition Research Initiative (CHNRI) method. The process was conducted in October 2023 in The Gambia and involved 46 participants, including Ministry of Health policymakers, programme managers, clinicians (obstetricians, paediatricians, midwives, nurses), researchers, and development partners.

The methodology followed these key steps:

1. Question Pool Development: A starting set of 50 questions was compiled, comprising 46 from the 2019 African Academy of Sciences (AAS) continental MNH prioritisation exercise and four from The Gambia's 2021 National Health Research Agenda.
2. Refinement and Expansion: Through facilitated plenary and small-group discussions, the starting pool was reviewed, contextualised, and expanded to a final list of 61 research questions. These were classified by MNH "grand challenge" areas (e.g., better care during pregnancy, better postnatal care) and CHNRI research domains (description, discovery, development, delivery).
3. Scoring Criteria: Four weighted criteria were established in advance:
   • Potential to reduce maternal and newborn disease burden (Weight: 0.69).
   • Answerability and feasibility in the Gambian context (Weight: 1.39).
   • Potential impact on policy, practice, and equity (Weight: 0.89).
   • Deliverability within The Gambia's health system (Weight: 1.00).
4. Independent Scoring: Participants independently scored each of the 61 questions against the four criteria using a "yes," "no," or "informed but unsure" response format.
5. Analysis: Weighted research priority scores were calculated for each question. The questions were ranked from highest to lowest score to generate the national priority list. Descriptive comparisons were made with the AAS continental and West African subregional rankings.

Key Contributions and Results
The exercise produced a ranked list of 61 MNH research priorities, with scores ranging from 0.92 (highest) to 0.63 (lowest). The results highlight a distinct national focus on implementation and health systems research:

• Dominance of Delivery Research: 49 of the 61 questions (80%) fell within the "delivery" research domain, indicating a strong stakeholder preference for research on how to implement existing interventions effectively rather than on discovery or new product development.
• Top Priorities: The five highest-ranked priorities were:
  1. Strategies to improve early management and stabilisation of obstetric emergencies at referring facilities before transfer to the national referral hospital (Score: 0.92).
  2. Effective strategies for attracting and retaining a trained health workforce (Score: 0.90).
  3. Levels of neonatal resuscitation competence at peripheral hospitals and improvement strategies (Score: 0.89).
  4. The effect of empowering mothers to recognise newborn danger signs on care-seeking and outcomes (Score: 0.88).
  5. Strategies to increase community uptake of kangaroo mother care (Score: 0.87).
• Context-Specific Divergence: While several priorities aligned with continental rankings (e.g., workforce retention, maternal recognition of danger signs), the national exercise identified unique, high-priority questions not prominent in broader regional lists. Most notably, the management of obstetric emergencies before transfer was the top national priority but was not a top continental or subregional priority. Similarly, questions regarding preterm birth prevalence, stillbirth risk management, and the implementation of the WHO postpartum haemorrhage bundle were highly ranked nationally but lacked direct comparators in the AAS rankings.

Significance and Claims
The paper positions this exercise as the first national MNH research priority-setting effort in The Gambia. Its primary significance lies in providing a coherent, nationally owned evidence base to inform the successor RMNCAH plan and guide research commissioning and partner alignment.

The authors claim that the exercise demonstrates the necessity of national-level prioritisation even when continental or subregional rankings exist. While broader exercises can identify shared challenges, only national processes can determine which bottlenecks are most urgent within a specific health system context. The findings suggest that for The Gambia, the most immediate path to reducing mortality lies in addressing implementation gaps—specifically in referral systems, workforce retention, and the quality of care at peripheral facilities—rather than in technological innovation alone. The paper concludes that these priorities offer a practical framework for linking research to routine planning, budgeting, and partner investment, thereby increasing the likelihood that research findings will translate into policy and practice.