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Women, adolescents, and children are three of the world’s most vulnerable populations. According to a report published by Every Woman Every Child, 7.4 million young people under the age of 25 died of preventable causes in 2019, and every hour 33 women did not survive childbirth.   

One of the reasons for these staggering numbers is that women, adolescents, and children are often disenfranchised and underrepresented in scientific research and healthcare.

“There are more health issues and issues of access that affect these three populations, but they’re often the last to benefit from research advances,” said Grace John-Stewart, a professor of global health and co-director of the Global Center for Integrated Health of Women, Adolescents, and Children (Global WACh) at the University of Washington. “Historically, there's been less advocacy from both the policy and leadership standpoint for people from these groups,””

Founded in 2012 by three UW departments – Global Health, Obstetrics and Gynecology, and Pediatrics – Global WACh envisions a world in which communities recognize the value of women, adolescents, and children by assuring them access to quality health services. To support this mission, Global WACh conducts original research to inform policies, programs, and interventions aimed at these populations. In 2020, the center had 62 active grants in 11 countries and 80 publications.

Whereas many global health organizations view women, adolescents, and children as three independent populations, Global WACh sees them as interconnected through the lifecycle. With this unique perspective comes a unique approach to problem-solving: focusing on critical windows where healthcare interventions can have combined, long-term benefits for two or more of these groups.  

Specializing in randomized control trials and mixed-methods approaches, Global WACh emphasizes research and innovation in three domains critical to women, adolescents, and children: family planning decision support, gut health and child survival, and infectious diseases in pregnancy.

Family Planning Decision Support

Global WACh has been at the forefront of evaluating the impact of short message system (SMS) communications on family planning. In 2014, center researchers partnered with the UW Department of Computer Science and a phone company in Kenya to develop the Mobile WACh Mobile Health System. Through this platform, health care workers in low- and middle-income countries can send tailored messages to patients through mobile phones, enhancing the access and reach of crucial health service interventions and improving health outcomes.

In a recent study published in PLOS Medicine, a team of researchers led by John-Stewart adapted Mobile WACh to reach pregnant and postpartum women living with HIV at six clinics in Kenya. While the study determined that receiving two-way interactive and one-way SMS messages did not improve HIV outcomes, it did find that mobile strategies were associated with improved initiation of postpartum contraception. Collaborators on the study included Dr. Keshet Ronen, an acting assistant professor of global health at UW, and Dr. John Kinuthia of Kenyatta National Hospital.

Gut Health and Child Survival

The period after hospital discharge is a time marked by high rates of morbidity and mortality and is  unaddressed by current interventions. In sub-Saharan Africa, where over 5 million children younger than 5 years die annually, primarily from infectious diseases, the oral antibiotic azithromycin is being considered as a potential child-mortality prevention tool for this vulnerable period.

However, a study published in The Lancet Global Health determined that a 5-day course of azithromycin administered at hospital discharge failed to reduce the risk of death and rehospitalization in Kenyan children younger than 5 years. 

“This trial highlighted that azithromycin is not going to be a magic bullet for reducing morbidity and mortality among Kenyan children who were recently hospitalized,” said study director Patricia Pavlinac, an assistant professor of global health and co-director of the Gut Health and Child Survival scientific priority area of Global WACh. “Addressing the high risk of death and re-hospitalization in the post-discharge period will likely require a package of interventions to address the complex, and multi-facetted reasons why children do not do well during this critical period.”

The study observed that underlying immunocompromising conditions – such as sickle-cell disease, HIV, and malnutrition – and financial hardship are two complicating factors that increase the likelihood of poor outcomes in the post-discharge period, said Pavlinac.

Infectious Diseases in Pregnancy

Infectious diseases can be more severe if the initial infection occurs during pregnancy. To better understand the impact of the SARS-CoV-2, the virus that causes COVID-19, on pregnant people and their infants, Alison Drake, a UW assistant professor of global health, and Sylvia LaCourse, a UW assistant professor of global health and of medicine, led a study of SARS-CoV-2 prevalence, household transmission, and antibody responses among 1,500 pregnant people and their household members in the greater Seattle metropolitan area.

In addition to evaluating the health outcomes of pregnant women infected with SARS-CoV-2, the study is characterizing antibody immune responses and durability in pregnancy. This data will help researchers better determine the role of natural infection, and vaccination, on maternal and neonatal protection against SARS-CoV-2.

“Although the recommendation is that pregnant people can be safely vaccinated, it’s really important for us to know what happens in the setting of natural infection and also what happens in the setting of vaccine,” said LaCourse.

Funded by both the CDC and Merck, this study is unique in that it includes people with previously unknown infection, thereby providing a more complete picture of the rate of infection and risk factors for transmission. In fact, researchers determined that nearly half of pregnant people who tested positive for SARS-CoV-2 antibodies during routine antenatal screening reported no known prior COVID-19 diagnosis or symptoms

The Path Forward

As the new year approaches, Global WACh already has two groundbreaking research studies underway with the potential to improve health outcomes for women, children, and adolescents worldwide.

Patricia Pavlinac is coordinating principal investigator of the Enterics for Global Health (EFGH) Shigella surveillance study, funded by the Bill & Melinda Gates Foundation. This study will estimate the burden and consequences of a leading cause of childhood diarrhea, Shigella, in children under 3 years of age within seven country sites across the world. Through this multi-country surveillance network, and associated clinical and laboratory standardization activities, selected EFGH sites will be ready to quickly implement rigorous and efficient Shigella vaccine trials, accelerating the time to vaccine availability and uptake among children in low- and middle-income countries.

Dr. Keshet Ronen is leading a project in Kenya to design and evaluate community-based digital communication support to improve neonatal health. Funded by the National Institutes of Health, the study will develop an interactive intervention that remotely connects mothers with community health volunteers (CHVs) and integrates SMS messaging into CHV workflows. Collaborators on this study include Drs. John Kinuthia (Kenyatta National Hospital), Isaac Holeman and Beatrice Wasunna (Medic Mobile), and Jennifer Unger (Women and Infants’ Hospital, Brown University).

In addition to maintaining its ambitious research agenda, Global WACh managing director Kate Rankin said the center also plans to convene experts in the field to think big and boldly about research strategies, as well as to incorporate experience in implementation science to translate research into policy outcomes.

“There's still so much we don't know about woman, adolescent, and child health and there's still so much work to be done in terms of ensuring that this population enjoys the same health and wellbeing as other populations,” said Rankin. “The science that we're doing matters and can have real world application and impact.”

By Amy Frances Goldstein