Maternal and Perinatal Health Research collaboration, India (MaatHRI): improving outcomes in pregnant women with iron deficiency anaemia

Globally 210 million women become pregnant each year and more than 300,000 women die from preventable complications. India has the highest number of maternal deaths of any country. Every year, about 45,000 pregnant women die in India compared to only 70 in the UK, with some states like Assam being worse. Although Assam has only half the population of UK, 6 pregnant women die every day. In addition to death, around 5 million pregnant women in India suffer a life-threatening complication. It is therefore essential that work is done to investigate these complications to improve maternal health.
A starting point for this is to ensure that maternal deaths and severe complications are identified accurately so they can be researched. I have already tested the feasibility of such work in two teaching hospitals in Assam, where I successfully collected information on over 22,000 women. I will extend this method (Objective 1) to 16 hospitals in Assam and 2 in Maharashtra, which would enable information to be collected on 100,000 deliveries a year. This approach, using a 'research platform' called 'Maternal and Perinatal Health Research collaboration, India (MaatHRI)', will provide a model for examining maternal health in other states in the future.
Anaemia is an important cause of maternal death in India. From my initial work, I found that, over one year, half of the deaths of mothers were due to anaemic heart failure and a third were due to severe bleeding at childbirth with some of the excess risk being related to the management of labour and delivery in anaemic women. Surprisingly, very little is published on maternal anaemic heart failure, so we do not know what individual factors are contributing to it, or why some women die from it whilst others do not. Similarly, we need more information on the safety of inducing and stimulating delivery in anaemic women. As these two areas are the most important, I will start by using MaatHRI to investigate them.
I will (1) compare two groups of pregnant women with moderate and severe anaemia: one group who develop heart failure and another who do not, to look at the clinical features and factors leading to heart failure; (2) I will facilitate expert reviews of a sample of pregnancy care notes of women who suffered from heart failure to identify factors that led to the death of some women and the positive elements that saved the lives of others (Objective 2). I will also examine the safety of inducing and stimulating the process of labour in anaemic women (Objective 3) by comparing the outcomes of induction/ stimulated birth with that of normal vaginal delivery, and examine factors that may be influencing the outcomes. The results will be used to develop guidance for (1) the prevention and management of anaemic heart failure, and (2) the safety of inducing or stimulating birth in pregnant women with anaemia. I will do this by running three workshops in years 4-5. This will be done alongside plans to disseminate results and to encourage scaling up of MaatHRI to other hospitals and states (Objective 4).
Finally, I will develop proposals for research to follow on from this fellowship, using MaatHRI (Objective 5). The role of infectious diseases as risk factors for the health and well-being of mothers and babies will be explored. To this end, a survey of infectious diseases in pregnant women will be initiated in year-4. In addition, I will design studies in other areas identified as problematic in my early work, namely: eclampsia, septicaemia and ruptured womb.
To summarise, this work will (1) set up a much needed research 'platform' to survey key maternal health problems in India; thus enabling (2) studies to understand the reasons for serious complications (starting with anaemic heart failure and safety of induction in anaemic women); leading to (3) the development of guidance and interventions which can be tested and implemented in the future to save the lives of mothers and babies.

India contributes to a sixth of annual maternal deaths globally and over 5 million Indian pregnant women suffer a life-threatening complication. This project aims to establish a UK-India collaborative platform for maternal and perinatal health research (MaatHRI), and use it in the first instance to improve the clinical management and outcomes of pregnant women with iron deficiency anaemia which is a major contributor to maternal deaths in India.
Objective-1 is to establish MaatHRI in 18 hospitals in two states covering ~100,000 deliveries yearly to continue the survey of 6 severe pregnancy complications initiated during the pilot work.
Objective-2 is to investigate the risk factors, clinical characteristics, management and outcomes of anaemic heart failure through an unmatched case-control study using MaatHRI (cases 900 pregnant women with anaemic heart failure; controls 3600 women with anaemia but no heart failure). In-depth review of hospital notes of cases and deaths due to anaemic heart failure will be conducted in each hospital by an expert panel. Lessons identified will be combined with evidence from the case-control study to develop pregnancy care guidance.
Objective-3 is to examine the safety of induction and augmentation of labour in pregnant women with anaemia through a cohort study of 10,800 pregnant women with haemoglobin level <10 g/dl using MaatHRI. Results will lead to guidance and interventions to reduce any risk associated with induction and augmentation of labour.
Objective-4 is to explore the feasibility of establishing MaatHRI in other states by disseminating the study outputs and mapping potential hospitals through workshops.
Objective-5 is to develop studies on the other surveyed complications and follow-up projects from the outputs. Survey of infectious diseases in India that are emerging risk factors for pregnancy complications will be initiated in year-4 to estimate their prevalence and case fatality, and to develop further studies.

Maternal health is not a trivial issue as 210 million women become pregnant each year. The death of a mother is a loss to her children, family and the society. Studies show that the risk of death and severe complications are higher in babies and children whose mothers died compared with those whose mothers did not. The World Health Organisation states that maternal mortality and morbidity have negative effects on the dependency ratio and labour productivity. The Indian Government acknowledges that "the survival and well-being of mothers is not only important in their own right but are also central to solving large broader-economic, social and developmental challenges". The proposed fellowship project endeavours to establish a UK-India collaborative platform to improve maternal and perinatal health and survival [Maternal and Perinatal Health Research collaboration, India (MaatHRI)].
Potential beneficiaries and how they will benefit
1. Pregnant women and babies: The most important beneficiaries are women of reproductive age who are planning a family or are already pregnant, their babies and their families. New evidence generated will improve pregnancy care to prevent and manage severe life-threatening complications, thereby improving maternal and perinatal outcomes.
2. Academics and scientists: MaatHRI aims to create a platform for academics and scientists in India and the UK from various disciplines for conducting large-scale population-based research to improve maternal and perinatal health. Researchers will have access to secondary data collected by the collaboration as well as have the opportunity to collect new data to test specific research hypotheses through the platform.
3. Local collaborating hospitals: During the fellowship, an institutional ethics review board will be set up at the Srimanta Sankaradeva University of Health Sciences. Research staff and clinicians in the 18 collaborating hospitals will be trained to conduct maternal mortality and morbidity reviews, and will be actively engaged in translating the research outputs into policy guidance and implementation plans. This will build research and implementation capacity in the local hospitals and at Srimanta Sankaradeva University of Health Sciences.
4. Research students in the UK and India: The collaborative platform will also be a training platform for UK and Indian students interested in developing skills in conducting research in maternal and perinatal health in a low-middle income country (LMIC) setting.
5. Policy makers and clinicians: New and improved scientific evidence generated by the research outputs will help policy makers and clinicians in India and globally to develop guidance to improve pregnancy care in LMIC settings. Studies that are critical to informing policies and planning to address new and emerging complications in pregnancy (such as adult Japanese Encephalitis) could be quickly and efficiently rolled out through MaatHRI to generate evidence for timely interventions.
6. Society: In the longer term, robust scientific evidence from the research outputs of MaatHRI will contribute towards averting the 45,000 maternal deaths and about 5 million severe maternal morbidities that occur in India ever year, and the related economic costs and societal losses.