Local and foreign authorship of maternal health interventional research in low- and middle-income countries: systematic mapping of publications 2000–2012

Researchers in low- and middle-income countries (LMICs) are under-represented in scientific literature as a whole, and in fora such as editorial boards of journals [1‐7]. Even within fields particularly pertinent to LMICs, such as tropical medicine, only around five percent of articles are written exclusively by authors from countries with a low human development index, and an equally low percentage of editorial and advisory boards for journals in this field include people from these countries [1]. The proportion of studies in LMICs where the lead author is affiliated with an institution in a high-income country (HIC) does, however, vary considerably between research fields. For example, HIC authors led 50–52 % of studies done on international epidemiology, psychiatry and tropical medicine in LMICs [1, 5, 8], while they led only about 10 % of publications on orthopaedics [9] or on tuberculosis and lung disease in LMICs [10]. Reviews of publishing patterns at country level also demonstrate deficiencies in representation of LMIC authors. In Fiji, for example, in the period from 1965 to 2002, only 13.5 % of publications on health in the country had a Fijian first author [11]. By contrast, under one percent of studies in HICs included an LMIC author, and a similar proportion of scientists affiliated to an institution in one LMIC led articles reporting the findings of research done in another LMIC [8, 9].

For an individual, ownership of study results – based on active participation and research leadership – provides a powerful incentive for securing local dissemination and application of those results [12, 13]. Authorship also boosts one’s career prospects, motivation and opportunities for research funding. For institutions and countries, their capacity to lead research might reflect their ability to drive a local research agenda, tailored to the priorities of the country [12, 14]. These priorities might well differ from the interests of foreign researchers or external donors [15].

This study maps authorship of research outputs on maternal health in LMICs, and temporal shifts in authorship between LMICs and HICs. By examining the proportion of articles where the lead author is affiliated with an institution in the same country as the study, together with the characteristics of the articles, we aim to identify factors associated with data ownership, and the capacity to analyse and articulate research findings in LMICs. Based on the patterns identified, we also make inferences about the extent to which the considerable investment in North–south collaborations in recent decades has impacted on scientific leadership in LMICs. The data presented were extracted from full text articles included in a large systematic mapping of literature on maternal health interventions in LMICs. Mapping allows for a more comprehensive assessment than is done in classic bibliometric studies, which only summarise the data fields contained within databases such as Medline. The field of interventional research in maternal health was investigated given the continued high levels of maternal mortality in LMICs and the funding constraints for research on this topic [16, 17].

The analysis assessed authorship of 2292 articles, of which 49.1 % (1126) were led by an author affiliated at an LMIC institution, 43.4 % (995) by an HIC affiliate, and the remaining 7.5 % were authors who held affiliations at both an LMIC and HIC institution (171). The total number of papers led by an author affiliated with an LMIC institution (a measure of LMIC research capacity) rose from 45.0/yr in 2000–2003 to 98.0/yr in 2004–2007, but increased only slightly thereafter to 113.1/yr in 2008–2012. Comparing the first and last time periods, increments in numbers of locally-authored articles per year were particularly marked in the fields of HIV (15.0 to 42.8) and health systems (12.0 to 40.5), and in studies using qualitative methods (1.0 to 8.4) or systematic review (1.5 to 9.4, Table 1).

The study details marked deficiencies in lead authorship in many countries and on several research topics. This suggests deficits in local ownership of data in the field of maternal health interventional research within LMICs, as well as in the capacity to analyse and articulate research findings. The figure of about 60 % of research on maternal health interventions in LMICs being led by authors affiliated with an LMIC institution is higher than research in the fields of tropical medicine [1] and international epidemiology [8], but much lower than in studies of orthopaedics [9] or tuberculosis in LMICs [10]. In our study, it is striking that HIC researchers lead two thirds of articles in journals with an Impact Factor above 5, and even higher proportions of systematic review and modelling studies. The capacity of countries to advance their own maternal health research agendas appears to vary markedly: only a quarter of countries led more than 75 % of their research, while another quarter led under 25 %. Aside from Brazil and the Middle East, North Africa region, no other countries or geographical regions increased the proportion of articles led over time. Finally, the rate of increase in number of publications by LMIC authors diminished from 2008 onwards. This might indicate a change in funding patterns for maternal health, different pressures to publish on HIC country researchers, or perhaps that many LMIC institutions had reached a ceiling in their capacity to publish findings of maternal health research.

The study demonstrates the presence of many North–south research collaborations in maternal health. North–south collaborations take many forms, including the partnering of northern and southern institutions [25], who then write joint research proposals, share mentoring of post-graduate students [26] and have staff exchanges, for example. Other initiatives entail the development of international databases and consortia who generate and analyse large databases, such as in the International Epidemiologic Databases to Evaluate AIDS (IeDEA) network [27]; and specific efforts to strengthen capacity in southern countries, such as in research ethics [28]. In contrast with well-developed North–south relations, the negligible number of LMIC authors who hold affiliations or lead work in another LMIC, suggests that South-South partnerships in maternal health are poorly developed [3, 29]. Genuine research partnerships are clearly important for creating and sustaining research in LMICs; through offering efficiencies by the transfer of technologies between countries, economies of scale and productivity, and broadening the visibility of a project [30]. The concept of research partnerships and authorship practices within such partnerships seemingly varies considerably, as illustrated by the marked discrepancies in authorship practices across funders and HICs [31, 32]. Interestingly, several large global malaria partnerships began around 2000 (see, for example, [33, 34]), likely accounting for the rise in number of publications on malaria. This was, however, accompanied by a drop in the proportion of locally led articles on the topic, possibly indicating that such partnerships might undermine data ownership. Conversely, hypertension publications are predominately locally led, but the total number of these papers rose only slightly over time, and we could not identify any high-profile global partnerships focused on hypertension in pregnancy.

Present internationally-agreed authorship criteria provide little, if any, recognition for the ‘technical tasks’ of research, even though these require considerable scientific skills and expertise [12]. The funding that LMIC researchers receive from international research partnerships is predominantly for these ‘technical tasks’ (such as running clinical research sites, participant recruitment and retention, community partnership and local dissemination), rather than for developing their own research ideas, analysing data and completing publications. Also, the dominance of United States and United Kingdom authors may partly be explained by the substantial linguistic challenges faced by non-Anglophone authors when drafting and critically revising an article in English [35]. These considerations might explain why fewer locally-led studies in Latin America were published within journals with a high Impact Factor. Finally, local researchers may even prefer a better-known HIC counterpart to be the first author, in the belief that this raises prospects of publication and future citation [8].

Journals themselves have made some efforts to address the above concerns, including waiving publication fees for LMIC authors, devoting space to local research from specific regions and providing editing assistance to non-English speakers [35]. In a similar spirit, research collaborations might adopt strategies such as alternating first authorship between HIC and LMIC researchers, or publishing as a collective. The intent of such initiatives is, in part, to redress capacity deficits or past discrimination, and to place LMIC and HIC researchers on a more equal footing.

The methods employed in this research extend other bibliometric means of measuring authorship of publications [29, 30], by using data from full text articles to investigate a broader range of factors that might explain authorship patterns. While the indicator ‘lead author’ provides a proxy measure of data ownership and research leadership, assessing affiliations of all authors of an article would have allowed for a more comprehensive evaluation. Authors with multiple affiliations were categorised as being locally affiliated if they held an affiliation in the country of study, and the direction of bias introduced by this classification is hard to ascertain. It is likely that the authorship practices and research contributions of researchers holding a dual HIC and LMIC affiliation vary considerably, making it difficult to interpret this variable. Researchers, from LMICs and HICs alike, may increasingly be highly mobile and affiliations shift rapidly over time. It is possible, for example, that LMIC nationals live and conduct research in their country, while holding an affiliation in a HIC. Classifying those individuals as HIC authors would mean that the proxy measure ‘lead author’ used in this study underestimates the actual research capacity of LMIC countries. As a further limitation, the study only measures one component of research capacity (ability to analyse and articulate findings), and cannot comment on the other elements thereof. Furthermore, importantly, the number of articles is a reflection of the level of external funding for a topic, not only of data ownership and research capacity. The analysis also does not assess whether a relatively small group of authors at LMIC institutions account for most papers in an LMIC [29], which might explain the slowing of increases in number of papers, as research institutes reach a maximum size. Finally, assessments, similar to the one presented here, repeated over time, might serve to monitor changing trends in scientific capacity and data ownership of LMICs [14].

Health challenges in LMICs remain grievous, as again demonstrated by the Ebola outbreak. Substantial advances were made in the number of LMIC lead authorships in the mid 2000s, but increments slowed thereafter. This suggests that different approaches might now be required to achieve further gains in research capacity; with approaches tailored to the specific constraints in different settings. Steps taken might include mentorship on leading complex research projects, improved research infrastructure and specific funding for academic writing [36]. Increased investments by LMIC governments for strengthening research capacity at all levels may also further raise research skills and infrastructure.

The proxy for data ownership, the proportion of articles led by authors affiliated to LMIC institutions, rose slowly, if at all, in most categories assessed. Gaps in systematic review expertise in LMICs are especially concerning [3], given the importance of these skills for evaluating and synthesizing locally-relevant evidence to inform policy decisions. South-South collaborations appear weak, with few joint LMIC cross-country authorships or joint affiliations identified. This might reflect limited funding for South-South work.

More stringent oversight of authorship attribution may accelerate gains made in local authorship and counter any residual inequities between LMIC researchers on the one hand, and their more prominent HIC counterparts or funding agencies on the other. Revision of international authorship guidelines (e.g. ICMJE [37]) may be warranted, with specific recommendations to guide authorship attribution between LMIC and HIC researchers. For example, for papers where the first author is not affiliated with an institution in the country of study, journals could require authors to state why it was not possible for a local author to lead the paper. Already, some journals do not publish articles that do not include an author from the study country [38]. This issue has also gained political traction among policy leaders in Africa, such as the Rwanda health minister Agnes Binagwaho, who have argued that no research or article about a low-income country should be published without joint authorship from that country [39]. If not addressed, continued low levels of LMIC authorship may demoralise the increasingly experienced local researchers in LMICs and undermine global health research collaborations in this vital field of work. More importantly, stronger research leadership in LMICs will help ensure that a country’s research agenda is aligned with its knowledge needs, and not merely with the research interests of HIC scientists. Non-alignment can have substantial negative impacts on population health.

HIC, high-income country; ICMJE, International Committee of Medical Journal Editors; IQR, inter-quartile range; LMIC, lower middle income country