The drug drought in maternal health: an ongoing predicament

L-Arginine and L-Citrulline for Prevention and Treatment of Pre-Eclampsia: A Systematic Review and Meta-Analysis

BACKGROUND

Evidence suggests L-arginine may be effective at reducing pre-eclampsia and related outcomes. However, whether L-arginine can prevent or only treat pre-eclampsia, and thus the target population and timing of initiation, remains unknown.

OBJECTIVES

To evaluate the effects of L-arginine and L-citrulline (precursor of L-arginine) on the prevention and treatment of pre-eclampsia.

SEARCH STRATEGY

MEDLINE, Embase, CINAHL, Global Index Medicus and the Cochrane Library were searched through 7 February 2024.

SELECTION CRITERIA

Trials administering L-arginine or L-citrulline to pregnant women, with the comparison group receiving placebo or standard care, were included.

DATA COLLECTION AND ANALYSIS

Meta-analyses were conducted separately for prevention or treatment trials, using random-effects models.

MAIN RESULTS

Twenty randomised controlled trials (RCTs) (2028 women) and three non-randomised trials (189 women) were included. The risk of bias was 'high' in eight RCTs and showed 'some concerns' in 12. In prevention trials, L-arginine was associated with a reduced risk of pre-eclampsia (relative risk [RR] 0.52; 95% confidence interval [CI], 0.35, 0.78; low-certainty evidence, four trials) and severe pre-eclampsia (RR 0.23; 95% CI, 0.09, 0.55; low-certainty evidence, three trials). In treatment trials, L-arginine may reduce mean systolic blood pressure (MD -5.64 mmHg; 95% CI, -10.66, -0.62; very low-certainty evidence, three trials) and fetal growth restriction (RR 0.46; 95% CI, 0.26, 0.81; low-certainty evidence, two trials). Only one study (36 women) examined L-citrulline and reported no effect on pre-eclampsia or blood pressure.

CONCLUSIONS

L-arginine may be promising for pre-eclampsia prevention and treatment, but findings should be interpreted cautiously. More trials are needed to determine the optimal dose and time to commence supplementation and support clinical decision-making.

Factors Influencing Pregnant Women's Participation in Randomised Clinical Trials in India: A Qualitative Study

OBJECTIVE

To explore factors affecting participation of pregnant women in randomised clinical trials in Belagavi, Karnataka, India.

DESIGN

A qualitative study using semi-structured in-depth interviews and focus group discussions as data collection methods.

SETTING

Primary, secondary and tertiary health facilities and their community catchment areas in Belagavi district.

SAMPLE

Thirty-three in-depth interviews with health workers and previous participants of a pregnancy-focused trial, and 12 focus group discussions with currently pregnant women who had not previously participated in a clinical trial, family and community members, and accredited social health activists.

METHODS

Inductive thematic analysis with a team-based approach to interpretation in the study context.

RESULTS

Pregnant women were often unable to distinguish between maternal health programmes and trial interventions. Among previous trial participants, expectations of higher quality care were a key motivation for trial participation. Household gendered power relations and trust in the health workforce influenced decisional dynamics regarding participation. Health workers vouched for trial safety, once they assessed the intervention as acceptable. Trial Implementation by the health workforce required understanding and navigating pregnancy-related beliefs and practices in communities.

CONCLUSION

Anticipated health benefits, improved healthcare access, and trust in health workers are facilitators of trial participation. Engaging primary decision-makers is essential due to household gender dynamics. Trials must integrate strategies that clarify the distinct goals of research versus clinical care.

Advancing maternal and perinatal health through clinical trials: key insights from a WHO global consultation

Pregnant and lactating women have long been excluded from participation in clinical research. This exclusion has resulted in the absence of high-quality evidence on the effectiveness and safety of medical products (medicines, vaccines, and other biological or biomedical products) during pregnancy and lactation, and fragmented health policies and practice recommendations. Based on the discussions at the inaugural WHO Global Clinical Trials Forum in November, 2023, a rapid review of key global, regional, or national ethical and regulatory documents, and previous expert consultations, this paper aims to summarise obstacles and suggest opportunities for appropriate inclusion of pregnant and lactating women in clinical trials. The main challenges identified relate to issues of: trial design; inconsistent interpretation and implementation of ethical, regulatory, and legal guidance; high costs of trials and low return on investments; insufficient research capacity and funding opportunities; misinformation; and insufficient community engagement. Appropriate inclusion is necessary and possible through: multi-stakeholder coordination; alignment with governance bodies to streamline ethical, regulatory, and legal processes for trial conduct; advocacy to prioritise investments in research; stronger focus on capacity strengthening; and good participatory practice that includes women and communities. A paradigm shift towards more inclusive and integrated research methodologies is urgently needed. This shift extends beyond pregnancy to transform the overall trial ecosystem and prioritise the health and wellbeing of all women and their infants everywhere, to truly achieve equitable access to health and innovations and leave no one behind.

Lactate accumulation from HIF-1α-mediated PMN-MDSC glycolysis restricts brain injury after acute hypoxia in neonates

Fetal intrauterine distress (FD) during delivery can cause fetal intrauterine hypoxia, posing significant risks to the fetus, mother, and newborns. While studies highlight the role of polymorphonuclear myeloid-derived suppressor cells (PMN-MDSCs) in neonatal diseases and tumor hypoxia, their specific involvement in newborns experiencing fetal distress during delivery (FDNB) is not well understood. Here, we found elevated PMN-MDSC activation, increased glycolysis, enhanced lactate production, and upregulated HIF-1α expression in the blood of FDNB neonates compared to healthy newborns (NNB). Importantly, PMN-MDSC levels were inversely correlated with neuron-specific enolase (NSE), a marker for neurological injury. In neonatal mice subjected to acute hypoxia, a 48-h exposure led to a shift from exacerbation to amelioration of brain damage when compared with a 24-h period. This change was associated with a reduction in microglial activation, a decrease in the expression of inflammatory factors within the microglia, alongside increased peripheral PMN-MDSC activation. Depleting PMN-MDSCs led to heightened microglial activation and aggravated brain injury. Mechanistically, enhanced activation of PMN-MDSCs promotes HIF-1α accumulation while enhancing glycolysis and lactate release, thereby mitigating neonatal brain injury. Notably, lactate supplementation in hypoxic mice rescued brain damage caused by insufficient PMN-MDSC activation due to HIF-1α deficiency. Our study clarifies the role of lactate in peripheral PMN-MDSCs after acute hypoxia and its effects on microglial activation and subsequent brain injury.

Opportunities to Advance Maternal Immunization Research

In the last decade, there has been a notable surge in efforts to address longstanding obstacles to the conduct of clinical trials during pregnancy. This brief report draws attention to recent initiatives in vaccine and pregnancy-related research and highlights opportunities for researchers and clinicians to advance maternal immunization research, benefiting the health of pregnant women, fetuses and neonates.

A Tale of Two Medicines: The Need for Ownership, End-to-End Planning and Execution for Development and Introduction of Maternal Health Medicines

Postpartum hemorrhage (PPH) persists as the leading direct cause of maternal mortality in low- and middle-income countries (LMICs) and is a major global health challenge. Following favorable evidence from pivotal efficacy clinical trials, the World Health Organization (WHO) recommends the use of heat-stable carbetocin to prevent PPH as a viable substitute in settings where maintaining a cold chain for thermosensitive uterotonics is compromised, and tranexamic acid as an adjunct therapy for PPH treatment. However, the implementation of these drugs has been hindered by several challenges, such as decentralized and disorganized procurement, poor quality assurance, inadequate supply chain management, and limited access in many LMICs. While including maternal health drugs in the essential medicines list and adopting updated global recommendations are necessary steps forward, they are not enough to guarantee access unless there is end-to-end (E2E) thinking, planning, and execution for essential maternal health commodities. We describe distinct access challenges between the two drugs, both having compelling safety and efficacy data and normative recommendations around the same time; one patent protected and owned by a pharmaceutical company and another with multiple generic manufacturers. We highlight the need for coordinated action to facilitate access to evidence-based maternal health commodities.