Maternal and neonatal mortality in sub-Saharan Africa remains abysmally high ^{1, 2}. The World Health Organization (WHO) reported that Sub-Saharan Africa accounted for around 70% of maternal deaths and 43% of global newborn deaths in 2020 ^2,3.These deaths continue to occur despite the availability of several evidence-based interventions with proven effectiveness in reducing maternal and neonatal mortality and morbidity ⁴.

It is important to note that despite these evidence-based interventions, there is still research to practice gaps ⁵ attributed to an estimated 17-year lag ⁶ before these interventions could pave the way into routine clinical practice. Therefore, for these evidenced-based interventions to be fully integrated into day-to-day clinical practice, it is imperative to identify and address the gap between what we know works and what we do (practice), using implementation science methods to address this gap systematically ⁵.

As defined by the National Institutes of Health, implementation science (IS) is the systematic study of processes and factors designed to promote the “adoption and integration of evidence-based practices, interventions, and policies into routine health care and public health settings” ⁵. IS seeks to understand factors determining why an evidence-based intervention may or may not be adopted ⁶. This could be within specific healthcare or public health settings where this information can be used to develop and test strategies to improve the speed, quantity, and quality of uptake ⁶.Additionally, IS promotes a systematic approach to designing a strategy to facilitate the uptake of an evidence-based intervention ⁷. The systematic approach includes identifying behaviours contributing to the evidence–practice gap, identifying key determinants of current behaviour and the desired behaviour change using a theoretical framework and selecting components of the implementation strategy that target the key determinants ⁷.This persisting trend in poor maternal and newborn health indices may not be unconnected to the non-adoption and full implementations of available evidenced-based practices for improved maternal and neonatal health in Sub-Saharan Africa and Nigeria.

Evidence-practice gaps currently exist in the field of foeto-maternal medicine in sub-Saharan Africa, with a dire need for implementation sciences to translate these research findings into policy and practice. An example of such a gap is the use of tranexamic acid to treat post-partum haemorrhage (PPH), especially in a low-resource setting where it is most needed. As evidenced by an internationally randomised controlled trial, tranexamic acid can reduce death from bleeding in women with PPH with no adverse effects ⁸. Subsequently, the WHO recommended that tranexamic acid be part of the standard comprehensive PPH treatment package ⁹.Unfortunately, this life-saving intervention is yet to receive wide implementation in most healthcare facilities in low-resource settings. However, a scoping review on the use of tranexamic acid to treat PPH in lower-middle-income countries revealed that no studies have yet explored tranexamic acid acceptability from the standpoint of providers, including the implications for health governance and information systems ¹⁰.

Additionally, there was also a paucity of information on how to prepare the health system and services to incorporate tranexamic acid in lower-level maternity care facilities in low-resource settings. The authors recommended that implementation research was critically needed to assist practitioners and decision-makers in establishing a tranexamic acid-inclusive PPH treatment package to reduce PPH-related death and disability.¹¹

Regarding perinatal health, another classic example is the WHO ACTION-I Trial (Antenatal CorticosTeroids for Improving Outcomes in preterm Newborns) on the use of dexamethasone among high-risk women for early preterm birth in low-resource countries ¹². The trial’s findings revealed significantly lower risks of neonatal death alone and stillbirth or neonatal death than the use of a placebo without an increase in the incidence of possible maternal bacterial infection ¹². However, again, this practice is yet to receive the needed wide implementation at the relevant health institutions and support from professional bodies and other stakeholders towards improved neonatal outcomes.

These evidence-to-practice gaps could be identified through IS methods to prevent the non-uptake of interventions by patients, providers, policymakers and the community by taking into cognisance the role of contextual factors as well as facilitators and barriers to the uptake of evidence-based health interventions. Additionally, IS uses behavioural theory to guide the development of implementation strategies and employs rigorous evaluation designs to determine whether and, importantly, why strategies to reverse the gap are effective ⁷.

It is noteworthy to mention that there are currently some already completed and ongoing implementation science research in feto-maternal medicine in Nigeria like the Early Detection of Postpartum Haemorrhage and Treatment Using the World Health Organisation MOTIVE (E-MOTIVE) Trial, Intravenous versus oral iron for iron deficiency anaemia in pregnant Nigerian women (IVON) trial, Intravenous Versus Oral Iron-Postpartum IVON-PP Trial, Intravenous Versus Oral Iron-Implementation Study (IVON-IS) etc. These efforts are highly commendable. However, there is still a dire need for more coordinated efforts to bring implementation science to the fore in the field of foeto-maternal medicine towards eradicating preventable maternal and neonatal morbidity and mortality in sub-Saharan Africa.

All hands must therefore be on deck towards making implementation science a continuous conversation in foeto-maternal medicine towards attaining Sustainable Development Goal (SDG)³.

References

1. Musarandega R, Nyakura M, Machekano R, Pattinson R, Munjanja SP. Causes of maternal mortality in Sub-Saharan Africa: A systematic review of studies published from 2015 to 2020. J Glob Health. 2021;11:04048.

2. Tiruneh D, Assefa N, Mengiste B. Perinatal mortality and its determinants in Sub Saharan African countries: systematic review and meta-analysis. Matern Health Neonatol Perinatol. 2021 Dec;7(1).

3. World Health Organization. Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. 2023 [cited 2023 Mar 18]; Available from: https://www.who.int/publications-detail-redirect/9789240068759

4. Robert E Black, Ramanan Laxminarayan, Marleen Temmerman, Neff Walker. Reproductive, Maternal, Newborn, and Child Health 2 VOLUME DISEASE CONTROL PRIORITIES • THIRD EDITION [Internet]. 2016 [cited 2023 Mar 30]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK361907

5. Ashrafzadeh S, Metlay JP, Choudhry NK, Emmons KM, Asgari MM. Using Implementation Science to Optimize the Uptake of Evidence-Based Medicine into Dermatology Practice. Vol. 140, Journal of Investigative Dermatology. Elsevier B.V.; 2020. p. 952–8.

7. Handley MA, Gorukanti A, Cattamanchi A. Strategies for implementing implementation science: A methodological overview. Vol. 33, Emergency Medicine Journal. BMJ Publishing Group; 2016. p. 660–4.

8. Li B, Miners A, Shakur H, Roberts I. Tranexamic acid for treatment of women with post-partum haemorrhage in Nigeria and Pakistan: a cost-effectiveness analysis of data from the WOMAN trial. Lancet Glob Health. 2018 Feb 1;6(2):e222–8.

9. Shakur H, Roberts I, Fawole B, Chaudhri R, El-Sheikh M, Akintan A, et al. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. The Lancet. 2017 May 27;389(10084):2105–16.

10. Tran NT, Bar-Zeev S, Schulte-Hillen C, Zeck W. Tranexamic Acid for Postpartum Hemorrhage Treatment in Low-Resource Settings: A Rapid Scoping Review. Vol. 19, International Journal of Environmental Research and Public Health. MDPI; 2022.

11. Oladapo OT, Vogel JP, Piaggio G, Nguyen MH, Althabe F, Gülmezoglu AM et al. Antenatal Dexamethasone for Early Preterm Birth in Low-Resource Countries. N Engl J Med. 2020 Dec 24;383(26):2514-2525. doi: 10.1056/NEJMoa2022398

12. Oladapo OT, Vogel JP, Piaggio G, Nguyen MH, Althabe F, et al. WHO Collaborators, Antenatal Dexamethasone for Early Preterm Birth in Low-Resource Countries. New England Journal of Medicine [Internet]. 2020 Dec 24;383(26):2514–25. Available from: http://www.nejm.org/doi/10.1056/NEJMoa2022398