Conducting international research in midwifery: ICM Congress workshop, Vienna, April 2002.
A workshop on international research in midwifery was held at the triennial International Confederation of Midwives (ICM) Congress in Vienna, April 2002. The workshop was planned after it was noted in discussions at the ICM Congress in Manila in 1999 that midwives wanted and needed to learn skills necessary to conduct high quality research. The Vienna workshop was facilitated by midwifery researchers from India, Zimbabwe, the UK and the USA. An introductory-level workshop was planned, with the proviso that the agenda could be changed as requested by the participants. As it turned out, the participants were relatively experienced researchers, who generated and agreed upon a new agenda. The resulting workshop focussed on the important issues of how to conduct ethical, collaborative, international research, especially when the partnerships are between researchers from countries of disparate levels of development (1). The exciting and challenging discussion that resulted is summarized below, and recommendations for future follow up on these issues are also given.
The 35 workshop participants were from the USA, UK, Malawi, Japan, Australia, China, Denmark, Germany, India, Israel, Malta and Zimbabwe. Nineteen participants returned evaluation and biographical forms, showing that they included experienced researchers: 16 had research training, 15 had conducted studies, 14 had published their research, and 13 had received research funding.
The new workshop agenda focused on ethical issues in international research, politics, process, power and gatekeeping. It raised the following issues:
* The complexity of collaboration among researchers, care providers and health care users from developing and developed countries
* Gender and power issues in womens' health research
* Using community development approaches and sociocultural perspectives in research in midwifery
* The implications of instrument development and validation in international research
* Priorities for international research in midwifery
A wide-ranging discussion of these topics followed. The main conclusions and recommendations were agreed by the group and are summarised in this paper.
International research relationships and collaboration
All participants shared the desire to be involved in collaborative international research that was of high quality, culturally sensitive, mutually respectful, and that addressed important issues in women's health. Potential problems in meeting this goal were discussed.
When researchers from developed countries enter into collaborative research with developing country partners, the relationship is rarely equal. The research agenda is likely to be defined by those who control the funding, and the questions studied in the developing country may primarily address the health problems of developed countries, while ignoring the problems of the country where the research is conducted. For example, developed countries have a strong interest in prevention of low birthweight, and fund numerous studies on this issue in poor countries. Yet, little research is done on the major causes of maternal mortality in poor countries, such as the prevention and treatment of obstetric haemorrhage or maternal sepsis. Research is similarly lacking on other diseases that disproportionately affect the poor and powerless, such as malaria and multi-drug resistant tuberculosis (Farmer 1999). This disparity in funding priorities is known as the 10/90 gap, because only 10% of global health research funding is targeted to the diseases which account for 90% of the world's disease burden (Global Forum on Health Research 2002). The disparity issue in funding priorities may also arise within one country, for example when researchers fail to study the health problems of minority ethnic groups or families living in poverty.
Mutually beneficial international collaboration means that researchers from developed countries need to pay attention to the insights of their developing country colleagues about local health research priorities. They can advocate with their own funding agencies to encourage the support of an agenda that will not only meet the agency's needs, but will also contribute to better health in the countries where the studies are being conducted.
Research should not be conducted in countries or cultures other than the researchers' own simply because it is easier to collect the data there; the research question should be one that is a priority in that community, too.
Working in other countries and cultures requires a willingness to understand each others' problems, which can only be achieved with time, patience, communication and respect.
An infrastructure is essential to support any ongoing collaboration. This should include researchers, advisors, health care providers, participants and funders. In a developing country context, this offers additional challenges, which can be met in a variety of ways, including newsletters, websites, and publication of progress reports.
Ethical conduct in international research in midwifery
If studies are being conducted in different countries or cultures, the following points should be addressed:
* Research should involve women, their families, and their local health care providers in defining the research agenda and methods. This will help to identify research priorities, ensure an appropriate design and clear communication about the study, and maximise the potential for informed consent. All study materials and communication must be produced in the local language and at an appropriate level for participants to comprehend.
* A prior evaluation of the resources and benefits each party brings to or gains from the study, and the context of the planned study, will help to ensure that everyone understands their roles and responsibilities, and the needs of all involved. This will include the funding agency, the research team, local clinical staff and research collaborators, study participants and potential participants.
* Informed consent should be required at a level that would be demanded in the funding country. All potential participants should be told about the study, given the opportunity to ask questions, assured that they will not suffer any detriment if they choose not to participate, and should be able to withdraw from the study at any point, if they so wish. This process will be especially complex in countries where decisions are not always made at the level of the individual, and where serious inequalities exist in power and status between the sexes. Decisions may rest, for example, at the level of the family, or the community. This is more likely to be the case for women in many societies, making research in midwifery care particularly complex.
* Host country collaborators should be seen as partners in research, without whose special knowledge the study could not take place, rather than simply as data collectors. Their involvement should be given credit, and their participation in the research should provide the opportunity to develop their own career and build their research capacity. Roles, responsibilities and the production of knowledge from the study, including authorship of reports and published papers, should be agreed and acknowledged in the planning stage.
* Study results should be shared with appropriate health professionals, and study participants in the host country, as well as with the funder and developed country colleagues. Policymakers, such as the Ministry of Health, in the host country should be included in any dissemination plan.
* Researchers and funding agencies should consider their contribution to the development of research capacity among midwives and nurses around the world. This could include the support of education and training, and funding for nursing and midwifery researchers.
It is of interest that these points, arising from the direct experience of the workshop participants, are similar to those raised at a conference at the WHO in 1990 (Sleep, 1991). Guidelines for epidemiological (Bankowski et al., 1991) and biomedical (Bankowski et al, 1993) research were developed from that and a subsequent conference. It is of concern that workshop participants described experiencing many of the problems that these guidelines were intended to prevent, suggesting that guideline development is a necessary, but not sufficient, part of any plan to work towards the more ethical conduct of research.
The role of the ICM in international research
The discussion turned to the role that the ICM might play in supporting international research, and the involvement of midwives. The workshop participants concluded that:
* Research on the midwifery model of care, across countries and cultures, is imperative. For example, the rapidly rising rate of interventions in labour in many developed as well as developing countries demonstrates that it is essential to examine basic midwifery care and its relationship with outcomes.
* Midwives need to develop the ability to engage in multidisciplinary research, in collaboration with international organisations such as the World Health Organisation (including the multi-agency Safe Motherhood programme), UNICEF, and bilateral and non-governmental funding agencies.
* Midwifery care affects maternal and infant morbidity and mortality. Research into midwifery care should examine the range of influences on these outcomes. In addition to clinical research, topics should also include the determinants of health, such as socio-economic factors. Research studies should therefore inc-lude a community development perspective, and the examination of gender issues, poverty and conflict to maternal child health.
* Close links need to be developed with policy makers at multiple levels, to enhance the potential for research findings to have an impact.
To support effective international research, the midwifery profession will require development in several areas: career development, to offer midwives the opportunity to develop roles in which the conduct of high quality research is truly possible; education, to support the development of a knowledgeable, empowered midwifery profession; capacity development, to support the training of midwives in the conduct of high quality research, and enable them to gain funding to support relevant, appropriate research.
The ICM staff and Council have an important role in supporting international midwifery research. The Research Standing Committee of the ICM organises a research midwives' network, for example (email@example.com). Work could be developed further to use ICM's influence with international and national organisations. The organisation of regional ICM Research Workshops would provide training in research methods and statistics. They could also support partnerships among universities, funding agencies and midwife researchers, and the development of a distance learning module for research training.
The African Midwives Network (AMRN) has demonstrated a successful modal for regional research workshops. With support from the Swedish Development Agency, African midwives are sponsored to attend a series of workshops on research methods and statistics, while they are developing and carrying out their own research study. Each research cycle ends with a conference at which the new researchers present their study methods and findings. AMRN can be contacted at Tanzania.firstname.lastname@example.org.
Towards an international midwifery research agenda
The following priority areas for future international midwifery research were agreed:
* Defining midwifery and midwifery care
* The prevention of Caesarean birth and other interventions
* Preventing maternal and infant mortality and morbidity
* Infant feeding
* Violence against women
* Workforce planning--recruitment, education and retention of midwives
This list of priorities could be used in several ways; to guide the ICM in lobbying for support for international research, to influence research donors, and to guide midwife researchers to focus on topics for which support for large collaborative studies might be available. It was noted that research priorities would need regular updating, to ensure that all current issues are addressed.
Summary and recommendations
Recognising the fundamental importance of high quality, appropriate, relevant maternal-infant research to the health and well being of women, infants and families, recognising the essential contribution that midwives can make to such research; and acknowledging the early stage of development of skills among midwives to conduct such research, the following actions are recommended:
1. Development of guidelines and a code of ethics for the conduct of international research, relevant to research in which midwives are involved, which can be adopted by the ICM organisations.
2. That the ICM and national midwifery organisations continue to actively support research, and further develop that support. In addition to the ICM research network, they could support education and capacity building for research at basic and continuing education levels.
3. Identification of research priorities for collaborative international studies. An initial list was agreed, which should be regularly reviewed and updated.
(1) No current terminology to describe disparities among countries; eg rich/poor, developed/developing, fully captures the complexities of those differences. We use the terms 'developed' and 'developing' because they are in current use. We do, however, recognise that they do not reflect the positive contribution that can be made by countries considered to be 'developing'.
Bankowski Z, Bryant JH, and Last JM (eds). 1991. Ethics and epidemiology; international guidelines. Proceeedings of the 25th CIOMS conference. WHO, Geneva.
Bankowski Z and Levine RJ (eds). 1993. Ethics and research on human subjects: international guidelines. Proceedings of the 26th CIOMS conference. WHO, Geneva.
Farmer P, 1999. Infections and inequalities; the modern plagues. Unversity of California Press, California
Global Forum on Health Research. 2002. The 10/90 report on health research 2001-2002. Geneva, Switzerland.
Sleep J. 1991. Development of international ethical guidelines for epidemiological research and pratice. Report of the proceedings of the 25th Council for the International Organisation of Medical Sciences (CIOMS) conference, WHO headquarters, Geneva, Switzerland, November 1990. Midwifery 7 (1) 42-4.
Mary J Renfrew, Professor and Director, Mother and Infant Research Unit, University of Leeds, UK. E-mail: email@example.com
Jeanne Raisler, University of Michigan School of Nursing, USA E-mail: firstname.lastname@example.org
Holly Powell Kennedy, Assistant Professor, Department of Family Health Care Nursing, University of California, San Francisco, USA E-mail: email@example.com
Christina Mudokwenyu-Rawdon, Women's University in Africa, Harare, Zimbabwe. E-mail womunica@africaonline
M. Prakasamma, Director, Academy for Nursing Studies, Hyderabad, Andhra Pradesh, India. E-mail: firstname.lastname@example.org