How did you get started in your career?

Dr. Shiyam Sunder’s second son got a severe illness in the 1990’s when he was less than 1 years old. Thankfully at this time, Shiyam was in medical school and knew his son needed immediate medical care. His son got admitted and the disturbing experience during his stay in the hospital shattered Shiyam’s world yet turned his path towards pediatric care and research. After completing his medical degree, he started his career with the National Institute of Child Health in Karachi as a resident medical officer. He was later given the opportunity to work in the Department of Pediatrics & Child Health, Aga Khan University (AKU) under the mentorship of Professor Anita Zaidi. He later went back to school at AKU to get his Masters in Epidemiology and Biostatistics funded by National Institute of Health’s Fogarty International Center. Throughout the years, Dr. Sunder realized that “newborn health cannot be seen or perceived as an isolated entity because the mother’s health is also important. If the mother is healthy, the baby born has less chances of getting sick later in life and developmentally better compared to those who are born sick.” This realization is what drove Dr. Sunder to continue in his career in maternal and child health.

How did you get involved with the Global Network?

Dr. Sarah Saleem recognized Dr. Sunder’s interests and onboarded him onto her Department of Community Health Science at AKU in 2015 as a site coordinator for the Global Network’s MNH Registry. His involvement with Dr. Saleem’s studies, Dr. Sunder was able to experience firsthand the impact of nutrition in women who live in rural areas through the Global Network’s Women’s First study which solidified his belief that mothers health directly correlates to neonatal health. From the MNH registry it was identified that proportion of neonatal mortality rate is highest in Pakistan and one of the major causes of neonatal mortality is prematurity and low birth weight. The Global Network then launched the ASPIRIN study to gain more information on the uses of low-dose aspirin to alleviate chances of neonates being born prematurely. As years have progressed, Dr. Sunder has been able to work in various clinical research roles such as a coordinator and monitor. His recent accomplishment is representing the Pakistan site as the Principal Investigator for the ASPIRIN Neurodevelopment Follow-up (ASPFU) study that enrolled babies of mothers enrolled in the ASPIRIN study. Dr. Sunder’s knowledge and gratitude are largely contributed to the work he has been able to conduct with an “enormous group of scientists” who always inspiring him to continue seeking to fill the gap in research. Such motivation pushed him to successfully publish two papers as lead author! He thinks back to a previous professor who encouraged him to follow the research pathway, as he agrees even to this day that he is “not a clinical guy, but a research guy!”

What is the most impactful thing you have experienced while working with the Global Network?

Dr. Sunder felt that the work of the Global Network impacts his country in multiple ways. One of the impacts he felt most passionately about was the ability for the Global Network to train country coordinators and field administrators how to collect data and conduct proper follow-up. In the MNH Registry training, he has been able to witness the evolution of their data collection methods. The administrator’s capacity has been built over time, for example, the Global Network’s First Look study trained the administrators basic obstetric ultrasound techniques that can be completed in the home with the proper equipment. While impactful and important for the community to have, the site has tried to share the results with key healthcare providers with no progress. This is a challenge his site recognizes and works to overcome with future research and publications. Dr. Sunder expressed how the “rate of stillbirth from 2008 until now is markedly declined, however, the neonatal mortality and morbidity rate has remained unchanged from 2008 to now.” This is extremely frustrating to researchers like Dr. Sunder who want to develop simple interventions and reduce these rates. With that said, the Global Network is providing more and more opportunities and simple interventions that are readily available in areas similar to Pakistan. Dr. Sunder hopes that the Global Network continues to provide these opportunities in hopes of furthering the impact and promote change in his country.

In your opinion, what has been the most rewarding experience while working within the Global Network?

Dr. Sunder narrowed his most rewarding experiences to two, one on a larger scale and one from a personal perspective. Firstly, he expressed his joy of working with his community understanding their dynamics and willingness, or lack of willingness, to participate in studies. He understands that his community typically does not allow males to enter their homes but he has experienced a new openness. The pivot in dynamics has allowed him to educate his community on the importance of participating in research which is very important to him and is confident will help his community long term. Secondly, he has learned he enjoys data sampling and developing new techniques to better the sites data quality. He was able to help develop an essential tool called Lot Quality Assurance Sampling ( LQAS). The LQAS tool is used to “calculate the coverage rate, accumulated coverage, and collection of study specific variables via survey to better understand the sites quality of data.” LQAS has been extremely helpful for the Pakistan site to ensure the data they collect is of the highest quality. It has also enabled the site to continuously monitor which is thought to be a large success. Both actively being involved in the research and learning new ways to collect the data has been Dr. Sunder’s most rewarding experiences so far.

What do you want the rest of the world to know about maternal and child health in your country?

Dr. Sunder felt it was important to recognize that accessibility is limited in his research area. The Pakistan site is only focused on one of four districts in the country. The Pakistan site is only capturing a small portion of the total population. Even in this small area, the access to healthcare is difficult due to transportation issues and lack of education to seek care. Lack of road networks make it extremely difficult for the site to reach many. Dr. Sunder hopes that research continues to educate midwives and members of the community in hopes of reducing the mortality rate in women by neutralizing accessibilities.

What do envision the impact of the Global Network in the next 10 years?

Dr. Sunder is confident that the Global Network will provide basic, simple, and cost-effective interventions that women could take or implement in their daily lives. For example, women in Pakistan are undernourished. The site has hired a nutritionist who developed a menu that provides ideas for meals and snacks the women can make with foods easily available in their communities. It would be helpful if policies were enacted to counsel women how to cook foods available to them to ensure they are well nourished. Additionally, he hopes that the government helps all health facilities invest in good quality ultrasound equipment as the machines are available but need to be maintained properly. If provided or required in all health facilities, sonologists and other health staff need to be well trained so that the technology can be used successfully. Overall, Dr. Sunder is confident that Pakistan and global health can improve with simple interventions and methodologies provided through research in the Global Network in the next 10 years.

We thank Dr. Sunder for his insights into the life of an investigator in Pakistan.

How did you start your journey as a Data Manager?

I was selected as a data manager by the KSPH (Kinshasa School of Public Health) for AFRINEST, a WHO study on simplified antibiotic regimes for treatment of severe bacterial infection in newborn babies. This was the first time I worked on a neonatal mortality and morbidity clinical trial, and I saw first-hand the great potential to increase access to maternal and neonatal healthcare, especially in a country like the DRC with such limited access. This is what led me to continue my studies to receive my degree in Project Management and be qualified enough to join the Global Network as the Data Manager for the MNHR in 2013.

What has been the most rewarding part of working with the Global Network?

The most rewarding part of working with the Global Network is the extensive training given to staff before the start of the study. This training helps providers gain applicable knowledge and become greater assets to the health system. Even after GN studies conclude, the workers maintain their skillset to continue to provide higher quality healthcare to the community. Community Health Workers give quality care through community house-to-house surveillance and encouraging women to start ANC as early as possible through pregnancy and making referrals to health facilities in a timely manner. At health centers, staff provide health education on identifying major signs of pregnancy and sensitization on the benefits of delivering at the hospital. All this capacity building has decreased maternal and neonatal mortality in our regions.

How many GN facility sites are in your country? What areas of your country does the Global Network cover? What are the demographics of people living in these areas?

In DRC there are 10 regional clusters. Activities are focused in rural areas of North and South Ubangi provinces. The sites are 700 miles from Kinshasa, the capital of the DRC and accessible by commercial aircrafts. People live in huts made from natural resources like clay and many do not have running water or electricity. Most people are farmers and have not received good quality education or cannot even go to school due to lack of resources; many women work in the field even when they are pregnant. People here produce field crops but their diet is not diversified as they like to eat casava leaves and casava itself (called kwanga), a mashed casava in leaves which can be kept for multiple days. While farmers will produce rice, peanuts and beans, they will sell these foods rather than eating them which results in severe malnutrition in our areas.

Has your site played any unique roles in previous Global Network projects?

The GN02 DRC site is unique because we conduct research in areas with very low socioeconomic status: there are no good roads, network coverage, running water, electricity, or transportation as compared to the other sites in the GN. It is important to have these types of sites in the GN because if an intervention can improve health in the DRC sites, then it’s feasible to implement in other LMIC areas without abundant access to resources and still have good results.

How has working with the Global Network influenced Maternal and Child Health Care at your site or in your country?

Intervention protocols like the management of neonatal infection has been improved since the APLUS study. Community Health Workers who make home visits to look for pregnant women and signs of morbidity actively refer women to health facilities from the MNHR Registry work. Women are now encouraged to give birth in the health facility and receive US exams in a way they were not previously. All of this leads to improvement in Maternal and Child Health Care in the DRC.

What has your sites’ biggest success with the Global Network been?

Women First study was our biggest success with the GN. This trial ensured the nutritional intervention was taken by women at a scheduled interval, and women wanted to be in Arm 1 (≥ 3 months preconception) or Arm 2 (12-14 weeks gestational age). For women within these arms there was high compliance in adhering to the intervention, showing an important shift in women being invested in their ANC care.

What would you like the rest of the world to know about Maternal and Child Health in your country?

I would like everyone in the DRC and the rest of the world to know that change must begin with human development, which is made possible by constantly improving the health of mothers and children. A country loses its reason for being a nation when its women consistently die while giving birth and newborns die before five years old due to lack of access to healthcare. Unfortunately, that is being seen in the DRC as mothers and babies are almost abandoned because people without money are left behind by the healthcare system. These overall lack of efforts by the government are not acceptable.

What do you believe the impact of collaborating with sites around the world in conducting Maternal and Child Health Care trials has been to the Global Network’s success?

I see collaboration between various global sites as the primary strength of the Global Network. Sharing of knowledge, experiences and realities in various countries has resulted in robust and comprehensive research protocols. Additionally, the results of studies from various countries strengthens data quality coming from distinct vulnerable communities.

What do you envision the impact of the Global Network will be in the next 10 years? In the next 20 years?

In next 10-20 years, the Global Network will be a model and reference for improving mother and child health. Some of the strongest qualities of the Global Network are trainings led by context-expert PIs, electronic data collection, and on-going data quality and monitoring. These pillars will broaden the impact and strength of the Global Network studies around the world.

Ever since he was young, Lester Figueroa knew that he wanted to be the “guy who delivers babies”. In the social services component of his OBGYN residency, Lester worked in a remote area in Northern Guatemala. This was Lester’s first experience witnessing the lengths women in his country had to go to access maternal healthcare. He once delivered a baby for a woman who had walked 2 hours to the hospital with the hand of the baby outside of her body. He rushed this woman into a C-Section and was heroically able to save both mother and baby. Lester knew from his time working in rural Guatemala that he wanted to save the lives of mothers and babies in these hard-to-reach parts of his country.

Global Network Coordinator was Lester’s first job out of residency. His residency thesis was about preterm delivery and used this experience to obtain the job as the ACT coordinator, a trial focused on improving identification of women at risk of preterm delivery.

Working with the Global Network provided Lester the opportunity to see how health systems work around the world. While all GN sites follow the same protocol, each site develops individual strategies for implementation in their existing infrastructures which are commonly shared across the Network. He sees huge value in comparing the GN results obtained across various countries as it emphasizes that there is not always a universal solution to many issues, but a need to adapt solutions to a specific country and context for it to work. Lester believes that the feasibility of implementing the interventions the Global Network is studying in Guatemala and other LMIC both gives value to the studies and encourages their staff to strive to provide higher quality healthcare.