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Understanding and spotting research gaps through a systematic literature review

2022, IJRISS

Various researchers have established the need for researchers to position their research problem in the research gap of the study area. This does not only indicate the relevance of the study but it demonstrates the significant contribution it would make in the field of study. The purpose of this paper is to conduct a systematic literature review on the concept of research gaps and provoke a discussion on the contemporary literature on types of research gaps. The paper discusses the various approaches for researchers to identify, align and position research problems, research design, and methodology in the research gaps to achieve relevance in their findings and study. A systematic review of the current literature on research gaps might assist beginning researchers in the justification of research problems. Given the acceptable tenet of developing a research agenda, design, and development on a research gap, many early career researchers especially (post)graduate students have difficulties in systematically identifying research gaps as a basis for conducting research work. The significance of this paper is twofold. First, it provides a systematic review of literature on the identification of research gaps to undertake research that would challenge assumptions and underlying existing theories in a significant way. Second, it provides a theoretical discussion on the importance of developing research problems on research gaps to structure their study.

Related Papers

Journal of Research Methods and Strategies

D. Anthony Miles

One of the most prevailing issues in the craft of research is to develop a research agenda and build the research on the development of the research gap. Most research of any endeavor is attributed to the development of the research gap, which is a primary basis in the investigation of any problem, phenomenon or scientific question. Given this accepted tenet of engagement in research, surprising in the research fraternity, we do not train researchers on how to systematically identify research gaps as basis for the investigation. This is has continued to be a common problem with novice researchers. Unfailingly, very little theory and research has been developed on identifying research gaps as a basis for a line in inquiry. The purpose of this research is threefold. First, the proposed theoretical framework builds on the five-point theoretical model of Robinson, Saldanhea, and McKoy (2011) on research gaps. Second, this study builds on the six-point theoretical model of Müller-Bloch and Franz (2014) on research gaps. Lastly, the purpose of this research is to develop and propose a theoretical model that is an amalgamation of the two preceding models and re-conceptualizes the research gap concepts and their characteristics. Thus, this researcher proposes a seven-point theoretical model. This article discusses the characteristics of each research and the situation in which its application is warranted in the literature review The significance of this article is twofold. First, this research provides theoretical significance by developing a theoretical model on research gaps. Second, this research attempts to build a solid taxonomy on the different characteristics of research gaps and establish a foundation. The implication for researchers is that research gaps should be structured and characterized based on their functionality. Thus, this provides researchers with a basic framework for identifying them in the literature investigation.

IRA International Journal of Education and Multidisciplinary Studies

Ragneel Chand

Wang, Wang, Chen, and Yang (2016) defined research gaps as a region where the ability to infer a particular question is constrained by a lack of knowledge. It is an area where the methods and insufficient research data have limited the capacity to get to a fully reliable judgment on a research subject. Therefore, academics need to situate their objectives in the research gap of the subject field. Particularly research gaps are those research questions that have not been addressed properly beforehand. This not only indicates the study's relevancy but also the considerable contribution it could bring to the field of study (Issah, Hamza, & Prosper, 2022). According to Ajemba and Arene (2022) posing questions and finding new research areas based on previous studies are the first steps in doing research. The limitations of the study's design, the use of inadequate instruments, or other factors that the researcher could or could not control led to the development of a research gap...

UNICAF University - Zambia

Ivan Steenkamp

Azeez T Fatimo

Researchers and academia often have difficulties identifying the research gap in literature in various fields of study. Hence, exploring research gap is one of the most arduous tasks for researchers especially those at the preliminary stage. The explicit identification of research gap is an inevitable step in developing a research agenda including decision about funding and the design of informative studies. Thus, to identify the research gap, the researcher needs to prune down his area of interest as identifying research gaps requires a lot of reading and analyzing of materials from various literatures. Hence, this study explores literatures regarding the method of identifying research gaps in management sciences. This was done by extensively examining various literatures on the method of identifying research gaps from previous researchers. However, the study made use of content analysis to identify research gaps in some articles. This study revealed that researchers are focused on a single type of research gap, leaving other research gaps unexplored. Also, there are some methods of research identification that has remained understandable by researchers as there are little or no knowledge about them. Hence, the study recommended among others that the various research identification methods be explored by researchers who intend to engage in studies in this field of management sciences.

Kayode Oyediran

Problem in a research as well as human body calls for perfect diagnosis of illness. This is important to avoid treating the symptoms instead of the actual disease. A research problem could be identified through professional or/and academic efforts. This poses a lot of problems to students, both at the undergraduate and postgraduate levels, as this determines the title of their articles or research works. Many of them have to submit many topics to their supervisors before one could be reframed and approved. At times, students appealed to their supervisors to provide them with researchable topics. This to the supervisor(s) almost writing the dissertations/theses for them. The argument of this paper is to let students understand "problem identification" using an analogy from the Holy Bible. The study employed a conversation analysis methodology, which is empirically grounded, exploratory in process and inferential. This involves using every conversation between two or more parties to explore facts/lesson. It was recommended that seasoned lecturers should explain to students how to identify research problems using what are familiar to them to make them understand this important aspect of research.

Sid Ahmed KHETTAB

A research gap is generally any problem a scientific article, an academic book or a thesis may contain. In the previous article [https://discourse.clevious.com/2019/12/how-to-come-up-with-research-idea.html], based on Dr. Anthony Miles' article on research gaps, I summarized the 7 research gaps into three main categories: theoretical problems, reasoning problems, and empirical problems.

Research issues

Dr. Odera C O N Z A L K Amos Ouma

Research is a fundamental process in academic and scientific endeavors, aiming to extend knowledge, address societal challenges, and inform decision-making. However, the research process itself is multifaceted and often subject to complex challenges and considerations. Understanding the key research issues, such as research theory, triangulation, research gaps, and the role of annotated bibliographies, is crucial for the design, implementation, and evaluation of robust and impactful research studies. The purpose of this study is to critically examine and highlight the significance of various research issues, including research theory, triangulation, research gaps, and annotated bibliographies, in the context of social science and humanities research. Objectives of the study has been to explore the role and application of research theory in informing the conceptual foundations, methodological approaches, and analytical frameworks of research projects; investigate the concept of triangulation and its utility in enhancing the validity, reliability, and depth of research findings; identify and analyze the significance of research gaps, their identification, and the strategies for addressing them in the development of novel and impactful research agendas; and examine the purpose, structure, and value of annotated bibliographies in supporting comprehensive literature reviews and situating research within the broader scholarly discourse. This study has employed a qualitative research approach, drawing on a combination of methods, including literature review, conceptual analysis, and expert interviews. The research design has involved a multi-phase approach, encompassing: a comprehensive review of scholarly literature on research theory, triangulation, research gaps, and annotated bibliographies; conceptual analysis and synthesis to develop a deeper understanding of the key research issues and their interconnections; and in-depth interviews with experienced researchers, methodologists, and research experts to gain insights into the practical application and contextual nuances of the research issues under investigation. The data collected through the literature review and expert interviews has been subjected to thematic analysis to identify patterns, themes, and key findings. The analysis has sought to elucidate the conceptual, methodological, and practical implications of the research issues, as well as their significance for the design, implementation, and evaluation of rigorous and impactful research projects.

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Framework for Determining Research Gaps During Systematic Review: Evaluation [Internet].

Introduction.

The identification of gaps from systematic reviews is essential to the practice of “evidence-based research.” Health care research should begin and end with a systematic review. 1 - 3 A comprehensive and explicit consideration of the existing evidence is necessary for the identification and development of an unanswered and answerable question, for the design of a study most likely to answer that question, and for the interpretation of the results of the study. 4

In a systematic review, the consideration of existing evidence often highlights important areas where deficiencies in information limit our ability to make decisions. We define a research gap as a topic or area for which missing or inadequate information limits the ability of reviewers to reach a conclusion for a given question. A research gap may be further developed, such as through stakeholder engagement in prioritization, into research needs. Research needs are those areas where the gaps in the evidence limit decision making by patients, clinicians, and policy makers. A research gap may not be a research need if filling the gap would not be of use to stakeholders that make decisions in health care. The clear and explicit identification of research gaps is a necessary step in developing a research agenda. Evidence reports produced by Evidence-based Practice Centers (EPCs) have always included a future research section. However, in contrast to the explicit and transparent steps taken in the completion of a systematic review, there has not been a systematic process for the identification of research gaps.

In a prior methods project, our EPC set out to identify and pilot test a framework for the identification of research gaps. 5 , 6 We searched the literature, conducted an audit of EPC evidence reports, and sought information from other organizations which conduct evidence synthesis. Despite these efforts, we identified little detail or consistency in the frameworks used to determine research gaps within systematic reviews. In general, we found no widespread use or endorsement of a specific formal process or framework for identifying research gaps using systematic reviews.

We developed a framework to systematically identify research gaps from systematic reviews. This framework facilitates the classification of where the current evidence falls short and why the evidence falls short. The framework included two elements: (1) the characterization the gaps and (2) the identification and classification of the reason(s) for the research gap.

The PICOS structure (Population, Intervention, Comparison, Outcome and Setting) was used in this framework to describe questions or parts of questions inadequately addressed by the evidence synthesized in the systematic review. The issue of timing, sometimes included as PICOTS, was considered separately for Intervention, Comparison, and Outcome. The PICOS elements were the only sort of framework we had identified in an audit of existing methods for the identification of gaps used by EPCs and other related organizations (i.e., health technology assessment organizations). We chose to use this structure as it is one familiar to EPCs, and others, in developing questions.

It is not only important to identify research gaps but also to determine how the evidence falls short, in order to maximally inform researchers, policy makers, and funders on the types of questions that need to be addressed and the types of studies needed to address these questions. Thus, the second element of the framework was the classification of the reasons for the existence of a research gap. For each research gap, the reason(s) that most preclude conclusions from being made in the systematic review is chosen by the review team completing the framework. To leverage work already being completed by review teams, we mapped the reasons for research gaps to concepts from commonly used evidence grading systems. Briefly, these categories of reasons, explained in detail in the prior JHU EPC report 5 , are:

Insufficient or imprecise information
Biased information
Inconsistent or unknown consistency results
Not the right information

The framework facilitates a systematic approach to identifying research gaps and the reasons for those gaps. The identification of where the evidence falls short and how the evidence falls short is essential to the development of important research questions and in providing guidance in how to address these questions.

As part of the previous methods product, we developed a worksheet and instructions to facilitate the use of the framework when completing a systematic review (See Appendix A ). Preliminary evaluation of the framework and worksheet was completed by applying the framework to two completed EPC evidence reports. The framework was further refined through peer review. In this current project, we extend our work on this research gaps framework.

Our objective in this project was to complete two types of further evaluation: (1) application of the framework across a larger sample of existing systematic reviews in different topic areas, and (2) implementation of the framework by EPCs. These two objectives were used to evaluate the framework and instructions for usability and to evaluate the application of the framework by others, outside of our EPC, including as part of the process of completing an EPC report. Our overall goal was to produce a revised framework with guidance that could be used by EPCs to explicitly identify research gaps from systematic reviews.

Cite this Page Robinson KA, Akinyede O, Dutta T, et al. Framework for Determining Research Gaps During Systematic Review: Evaluation [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013 Feb. Introduction.
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The energy transition: Where are we, really?

Almost nine years after the landmark Paris Agreement and nearly halfway through what has been called a “decisive decade” for climate change, the world stands at a critical juncture in their transition away from fossil fuels.

About the authors

This article is a collaborative effort by Diego Hernandez Diaz , Humayun Tai , and Thomas Hundertmark , with Michiel Nivard and Nicola Zanardi, representing views from McKinsey’s Global Energy & Materials Practice.

Translating into action the ambitious climate targets that have been put in place by governments and companies depends on accelerating the deployment and adoption of several interrelated technologies. These include renewable energy sources (RES), electrification technologies such as electric vehicles (EVs), and heat pumps—as well as comparatively less mature technologies, such as carbon capture, utilization, and storage (CCUS), green and blue hydrogen, and sustainable fuels.

These decarbonization technologies (alongside many others, such as nuclear, long-term duration energy storage, battery energy storage systems, and energy efficiency investments) are the cornerstone of efforts to reduce greenhouse gas (GHG) emissions in all McKinsey energy scenarios. The period until the end of this decade is a critical one to put in place a trajectory of accelerated adoption to meet 2030 and 2050 targets set by countries and companies.

The technology gap

The gap between what is needed and what has been achieved in the deployment of low-emissions technology is large—to date, only about 10 percent of the deployment of low-emissions technologies globally by 2050 required for net zero has been achieved, mostly in less challenging use cases. Closing the gap would require building a new, high-performing energy system to match or exceed the current one, which would entail developing and deploying new low-emissions technologies, along with entirely new supply chains and infrastructure to support them.

Given the size and complexity of today’s energy system, this is no easy task. The physical challenges that would need to be overcome to successfully transform the energy system are significant and would require concerted action to solve. McKinsey’s recent report, “The Hard Stuff: Navigating the physical realities of the energy transition,” identifies 25 physical challenges across seven domains of the energy system that would need to be addressed for the energy transition to succeed. 1 The hard stuff: Navigating the physical realities of the energy transition , McKinsey Global Institute, August 14, 2024.

Addressing these physical challenges would involve improving the performance of low-emissions technologies, addressing the interdependencies between multiple challenges, and achieving massive scale-ups, even in technologies where a strong track record has not yet been established. And, of course, this is only one side of the equation. To overcome these physical challenges, significant firm investment into low-emission technologies needs to be unlocked.

While significant progress has been made in developing and deploying some of these technologies, notably solar and wind, for which installed capacity has risen sharply over the past 15 years, a significant gap has emerged between the actual results and the expected ones. The at-scale deployment of all these technologies is still not happening as fast as needed to reach 2030 targets (see sidebar “The technology gap”). Moreover, the technologies are at risk of facing raw material and labor shortages and long permitting procedures.

We have identified three major issues that threaten the necessary deployment of capital: first, the business case—that is, the economic returns and policy predictability for developers—often remains weak; second, many technologies are increasingly but not yet cost-competitive for consumers, given the lack of at-scale manufacturing capacity or learning rate driven by deployment; and third, several technologies have not been tested at scale and need multiyear product, project, and supply chain development, thereby creating uncertainty about their effectiveness and efficiency. Ultimately, technology-focused enablers have not yet managed to address the challenges posed by macroeconomic shocks, geopolitics, and what it takes to enable tech ecosystems.

Our analysis

To shed light on the current status of the energy transition and provide a rigorous, fact-based assessment, we conducted an extensive analysis involving several steps.

Scope: We identified the key singular technologies that together account for the bulk of decarbonization potential (onshore and offshore wind, solar PV, clean hydrogen, sustainable fuels, CCUS, electric vehicles, and heat pumps). This means we excluded several other decarbonization technologies, including energy storage and battery energy storage systems (BESS) because these technologies are already in vast supply, with very healthy pipelines, and numerous players not only announcing projects but committing to them. We also excluded energy efficiency, low-carbon thermal generation, and nuclear because these are very fragmented markets with limitations due to regulation.

Data collection: We gathered comprehensive data from various sources, including proprietary and commercial project-tracking databases. This allowed us to obtain up-to-date information on the status of numerous projects across different decarbonization technologies.

Policy and historical capacity review: We reviewed existing policies, historical capacity deployments, and growth trends to understand the broader context and the trajectory of different technologies. This helped us benchmark current progress against historical data and policy targets.

Comparative analysis: We compared stated targets with expected capacity deployments, including project status and historical sales levels for customer adoption-driven technologies, such as EVs and heat pumps. This enabled us to assess the alignment between ambitious climate targets and actual progress on the ground.

Gap assessment: By examining the project status, including those that have reached FID stage, we assessed the gap between target volumes, expected volumes (based on current trends), and volumes that have already reached FID. This analysis highlighted the discrepancies between announced projects and those that are likely to materialize.

Fresh McKinsey analysis of the energy transition landscape, including the uptake of key climate and decarbonization technologies and investment decisions that follow project announcements (see sidebar “Our analysis”), suggests that corporate, public, and private equity investors are hesitating about deploying capital for the reasons described above. Invested capital is behind where it needs to be to ensure deployment targets are met. As it stands, a significant proportion of announced projects have not yet reached the final investment decision (FID) stage at which projects are greenlit, meaning that there is a continuing risk of cancellation or leakage. 1 Final investment decision (FID) is the point at which formal approval from the project developer is given to proceed, marking the commitment to allocate capital resources to the execution of the project. And projects with longer lead times (such as offshore wind) are quickly reaching the stage at which capacity that has reached FID will only come online after 2030.

Facing this hard truth, innovation and policy resets will be needed for the increasing number of country and company net-zero commitments to be achieved in practice and move projects to FID and quickly beyond to subsequent deployment.

Rigorous, fact-based assessment of real-world progress is key to ensuring that momentum is maintained, and the energy transition continues at the necessary pace. In this article—a prelude to our Global Energy Perspective 2024—we seek to provide a detailed, albeit partial, assessment of where the execution of projects stands for specific low-emissions technologies in Europe and the United States. The goal is to answer the critical question: where are we, really, in the energy transition?

While considerable progress in the energy transition has been made in many countries, this article focuses solely on Europe and the United States, both of which have set explicit 2030 targets. 2 For the analysis in this article, Europe refers to the European Union plus Norway, Switzerland, and the United Kingdom. There may some gaps in the data based on data availability. It should be noted that we are neither modeling nor forecasting future outcomes, but rather seeking to bring to light the facts as best as can be defined to assess how big the gap is and what needs to be done to close it.

Commitments and enthusiasm are up

Recent years have seen a flurry of net-zero commitments and ever-growing enthusiasm for climate action from all parts of society.

On the policy side, all 195 countries that signed the historic 2015 Paris Agreement have put forward so-called Nationally Determined Contributions (NDCs)—climate action plans—and more than 70 countries today have net-zero targets enshrined in law or outlined as a goal in policy documents. 3 “Net Zero Tracker,” accessed June 2024; “Nationally determined contributions under the Paris Agreement, synthesis report by the secretariat,” United Nations Climate Change, November 14, 2023; Net zero stocktake 2023, a joint report by NewClimate Institute, Oxford Net Zero, Energy and Climate Intelligence Unit, and Data-Driven EnviroLab, June 2023. More than 155 countries have signed the Global Methane Pledge to reduce methane emissions by 30 percent below 2020 levels by 2030. 4 “Global methane pledge,” Climate and Clean Air Coalition, accessed June 2024.

Industrial policy in many OECD economies is now anchoring climate technologies as a core pillar and substantial public funds are being earmarked for their development. In both Europe and the United States, emerging industrial policy has centered on building up a competitive cleantech value chain.

In Europe, the European Green Deal, introduced in 2019, aims to make the European Union climate-neutral by 2050, with intermediate Fit for 55 targets to reduce GHGs by at least 55 percent by 2030 compared to 1990 levels. 5 “European green deal,” Council of the European Union, June 17, 2024. In the United States, the Inflation Reduction Act (IRA) of 2022 is the largest climate investment in US history, with total climate-related spending of almost $370 billion over ten years, with the aim of cutting emissions by 40 percent by 2030 from 2005 levels. 6 Building a clean energy economy: A guidebook to the Inflation Reduction Act’s investments in clean energy and climate action , The White House, January 2023. In addition, the Infrastructure Investment and Jobs Act has allocated billions toward modernizing the energy grid, expanding EV infrastructure, and enhancing energy efficiency across sectors. 7 “A guidebook to the bipartisan infrastructure law,” The White House, January 2024.

Together with continued cost improvement, including through innovation, these and other policy initiatives are leading to progress. Globally, between 2010 and 2023, renewable energy installation capacity grew around 20 percent per year, while the adoption of EVs surged, with a compound annual growth rate of around 80 percent (Exhibit 1). 8 Renewable energy installation includes solar photovoltaic, solar thermal, onshore wind, and offshore wind.

From the corporate side, 66 percent of Fortune 500 companies have made climate commitments (either carbon neutral, net-zero, or science-based). 9 “Commitment issues: Markers of real climate action in the Fortune Global 500,” Climate Impact Partners. Overall, more than 5,000 companies globally have joined the Science-Based Targets Initiative (SBTi)—widely considered the gold standard for voluntary climate targets—and have set approved targets compatible with a 1.5° pathway. 10 “Ambitious corporate climate action,” Science Based Targets Initiative, July 2024. Public companies in the European Union and the United States increasingly report on their sustainability impact as part of their financial disclosure requirements. 11 “Corporate sustainability reporting,” European Commission, 2023.

Such developments underscore a broader trend toward cleaner energy and reduced carbon emissions, but are now set against an increasingly complex and uncertain global energy space. Energy security, affordability, reliability, and industrial competitiveness can be challenging to achieve alongside sustainability, and investment is harder to secure. 12 “ An affordable, reliable, competitive path to net zero ,” McKinsey, November 30, 2023.

The challenge of maintaining momentum

The question remains whether the world’s much-needed commitments can be translated to action. McKinsey’s analysis of targets and announcements highlights a potential disconnect between climate ambitions and what is likely to be achieved in practice—at least at current course and speed. Regarding NDCs, for example, the United Nations acknowledges that “quality and ambition vary.” 13 “All about the NDCs,” United Nations Climate Action, accessed July 2024. Where the SBTi is concerned, many of the companies that have signed up have made commitments but have not yet articulated a clear plan to achieve them. 14 SBTI monitoring report 2023 , Science Based Targets initiative, July 2023.

In the United States alone, more than 1,000 green or blue hydrogen projects have been announced since 2015. However, fewer than 15 percent had reached FID at the time of writing, indicating a high risk for project fall-through. 15 Hydrogen Insights Project Tracker, McKinsey. This discrepancy between announced projects and projects realized following FID does not only apply to hydrogen—it is true across most critical energy transition technologies (Exhibit 2).

Indeed, decarbonization technology projects have historically had a high fall-through rate, with only a small percentage of announced projects reaching FID, and an even smaller numbers of projects actually being realized. Our analysis shows that many planned projects for key decarbonization technologies in the European Union and the United States are falling short of announced targets, some significantly so.

The extent of this shortfall varies by technology and region—renewable energy generation technologies, especially solar, are the closest to meeting short-term goals, while electrification technologies have seen periods of rapid growth but are now losing momentum. Many innovative technologies that could be crucial for decarbonizing “hard-to-electrify” sectors have ambitious project pipelines but are not yet deployed at scale. These technologies need to be deployed as electrification is only a partial answer.

Here, we look at the progress of each of these technologies and where they are falling short of targets.

Solar PV and wind: Growth may lose momentum

In the European Union and the United States, renewable energy generation technologies, such as solar PV, onshore and offshore wind, and battery energy storage systems (BESS), have experienced rapid development, driven by supportive policies and increasing private sector investment.

BESS has seen significant technological advancement over the last decade and has scaled rapidly since 2015. In the United States, legislation has supported a robust pipeline and project conversion, especially in states like California and Texas. In Europe, we expect the solar PV project pipeline will in turn attract BESS projects, especially in places like Germany and Spain where colocation is favorable. All in all, battery production capacity appears healthy, leading us to believe there is less risk of a supply gap (and therefore why we excluded BESS from this analysis).

However, our analysis of offshore wind and solar PV shows that not all renewable pipelines are on track to meet 2030 targets and short-term deceleration is threatening the existing pipeline further (Exhibit 3). System bottlenecks need to be resolved faster to ensure deployment scales at the required rate.

Solar PV has experienced significant growth in both Europe and the United States, with around 180 gigawatts (GW) and 120 GW of solar PV capacity added since 2015, respectively. 16 “Renewable capacity statistics 2023,” International Renewable Energy Agency, March 2023.

Despite this growth, Europe’s solar pipeline is not on track to meet 2030 capacity targets of 600 GW: less than 390 GW of capacity is planned to be online by end of the decade, leaving a gap of approximately 200 GW. Moreover, of the approximate 114 GW of additional solar capacity expected to come online over the next five years, less than 20 percent has reached FID. A catch-up is still possible: in contrast to wind, additional solar capacity could be delivered rapidly, within 18 months, and the pipeline between now and 2030 could increase and become firmer.

In the United States, according to our analysis, annual solar PV capacity additions will slow down after 2028, at about 220 GW of capacity (operational and FID), because of a lack of firm longer-term commitments. Of the announced capacity to come online before 2030, around 60 percent is still pending FID, putting a significant proportion of planned solar at risk. However, again, here we would acknowledge that the nature of solar installation is such that the pipelines could indeed materialize in time.

Offshore and onshore wind

In wind, power projections vary significantly by geography and technology. Wind projects typically have longer lead times, too, which can make project pipelines less secure. In Europe, the wind energy pipeline is broadly on track to meet 2030 targets, while in the United States, the pipeline appears to be less secure.

Europe currently has approximately 240 GW of onshore wind capacity in operation, with an additional 106 GW in the pipeline. If fully realized, this would exceed the target of 314 GW of onshore wind capacity. However, this pipeline is not yet committed, with only 17 GW (16 percent) of planned capacity having reached FID. The United States faces a more challenging situation, with only 39 GW of onshore wind capacity expected to come online after 2025, and just 16 GW (41 percent of the total pipeline) having secured FID.

Offshore wind development in Europe has a gap of only 18 GW remaining to meet its overall 2030 target of 176 GW. This should be achievable despite approximately 65 percent of the announced 124 GW of offshore wind capacity in the European pipeline is still pending FID.

The United States currently has about 1 GW of installed offshore wind capacity—far off its national targets, which aim for 30 GW by 2030. The 17 GW of offshore wind capacity that has been announced to come online by 2030 still only represents 60 percent of this goal—of which, 90 percent are still in the pre-FID phase.

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Electric vehicles and heat pumps: momentum has slowed when it most needs to pick up.

Of course, RES and BESS do not alone hold the answer to the energy transition. Decarbonization also involves replacing fossil fuel-powered processes with electric alternatives in areas such as transportation and residential and commercial heating. 17 To achieve true zero-carbon status, these electric alternatives must be powered by green electricity—putting even more pressure on the European Union and United States to meet their targets.

Historically, EVs and heat pumps have seen strong growth. Since the Paris Agreement, the adoption of EVs and heat pumps has surged in both the European Union and United States; however, particularly for EVs, this momentum has slowed precisely at the time when acceleration is needed, requiring action to put EVs back on track to meet targets (Exhibit 4).

Electric vehicles

For the European Union to meet its target of 30 million EVs by 2030, it would need to add almost twice as many EVs as it currently has on the road (around 11 million) over the next five years. 18 IEA Global EV Data Explorer. A similar scale-up rate is required in the United States, which is targeting 26 million EVs by 2030, but has only 5 million EVs on the road today. Even with the ground still to be made up, based on FID commitments, the momentum in Europe is stronger than that in the United States.

Despite optimistic forecasts for EV deployment, lackluster sales figures over the past two years suggest a continued US slowdown in EV growth to 2030. 19 IEA Global EV Data Explorer. A lack of charging infrastructure is one of the challenges that will still need to be overcome, to increase consumer confidence in EVs.

Heat pumps are seeing a similar mixed picture, creating a challenge to the successful decarbonization of residential heat in both regions. Heat pumps have seen continued growth since 2016 due in part to policy action such as the EU Green Deal, which targets a 55 percent reduction in natural gas imports by 2030, and financial incentives in the United States to lower the upfront costs of heat pump installation. 20 “European green deal,” Council of the European Union, June 17, 2024; “Inflation reduction act overview,” US Environmental Protection Agency, January 2023.

While European heat pump sales are still on a positive trajectory, the high cost of capital, among other factors, may impact this progress. In the United States, heat pump sales declined in 2023, and, if this trend continues, the United States could see a marked slowdown in heat pump additions before 2030. 21 “AHRI releases December 2023 US heating and cooling equipment shipment data,” AHRI, February 9, 2024.

CCUS, hydrogen, and sustainable fuels: Interdependencies put progress at risk

Some sectors are, by their nature, hard to decarbonize. Their successful decarbonization relies on the deployment of electrification technologies, combined with renewable technologies and newer technologies, such as CCUS and hydrogen.

For the most part, these technologies remain largely untested at scale and have the lowest levels of FID among all decarbonization levers. Project delays or cancellations here could hinder the development of sustainable fuels and other critical components of the energy transition, with knock-on effects for energy transition targets. Further, the challenge with some of these value chains is that they require the development not just of a singular technology (for example, capture trains) but an entire value chain that coincides with the deployment of projects—further complicating the issue.

Carbon capture, utilization, and storage

CCUS has emerged as a key decarbonization lever across Europe and the United States. Project pipelines are full and ambitious, with around 60 times and nine times the amount of current CCUS capacity in Europe and the United States to be available, respectively, over the next six years. However, while announced capacity is high, the vast majority of projects are still lacking FID and hence are at high risk of not materializing (Exhibit 5). Regulatory approvals can also be lengthy. Approximately 15 percent of the announced projects are in more conventional segments (for example, gas processing) while the rest is in new(er) segments, such as cement and hydrogen.

Clean hydrogen has also attracted significant attention as a critical energy source, with both Europe and the United States setting ambitious targets for clean hydrogen production. 22 Clean hydrogen includes both green hydrogen (hydrogen produced from the electrolysis of water using renewable energy sources) and blue hydrogen (produced using steam methane reforming or gasification with CCUS). The European Union aims for 20 megatons (Mt) of clean hydrogen supply by 2030, with 10 Mt produced domestically and 10 Mt imported. 23 “Hydrogen,” European Commission. The United States is targeting 10 Mt of clean hydrogen production by the same year.

The data suggest that there is a long way to go in both regions. To meet 2030 targets, clean hydrogen production needs to increase approximately 25-fold in Europe and 20-fold in the United States over the next five years. Current project pipelines are projected to meet about 90 percent of European and 70 percent of US targets, but only around 11 percent of Europe’s and 15 percent of US announced project pipelines have reached FID. And, while Europe’s clean hydrogen project pipeline anticipates steady capacity addition until 2030, the US project pipeline already shows a sharp decline after 2028 (Exhibit 6).

Sustainable fuels

Biobased sustainable fuels are also uncertain, largely due to the unsettled hydrogen project pipeline, given hydrogen’s role as a critical input for sustainable fuels production. This may slow the impetus for sustainable fuels following policy developments, including ReFuelEU and the US sustainable aviation fuels (SAF) “Grand Challenge.” 24 Grand Challenge refers to the combined work of US DOE, DOT, USDA, and other federal government agencies working to scale up the Sustainable Aviation Fuel value chain.

The current European and US announced pipelines include around 21 million tons per annum (mtpa) and 33 mtpa of sustainable fuel capacity, respectively, with the vast majority of this being in hydrotreated vegetable oils (HVO) and hydroprocessed esters and fatty acids (HEFA). 25 HVO/HEFA, advanced middle distillate and methanol. Although the production of HVO and HEFA is largely on track, achieving these goals would entail more than quadrupling current European SAF production and tripling that of the United States over the next five years.

The SAF project pipeline—while ambitious—is largely not yet firm, with only around 25 percent and 30 percent of capacity until 2030 having achieved FID in Europe and the United States, respectively.

Factors affecting market performance

Accelerating action to meet climate goals

Make no mistake—a lot of progress has been made since the 2015 Paris Agreement. New policy initiatives combined with progressive corporate attitudes (spurred on by ever-increasing public pressure) mean the world is moving in the right direction where climate action is concerned.

At the current pace, however, Europe and the United States risk missing important 2030 climate targets across critical technologies. The interdependent nature of these technologies means that delays could have cascading effects, hindering the development and successful deployment of subsequent innovations and putting 2050 net-zero goals at risk.

Nevertheless, there is still a window of opportunity for governments and companies to deliver the growth needed to meet net-zero ambitions. To do so, reevaluating existing strategies in the light of changing global conditions may be necessary. Many current decarbonization strategies assumed a different economic and policy landscape than the one that exists today.

With this clear view of current progress in hand, now is the time for stakeholders across the energy value chain to revisit decarbonization plans and assess if these plans are still sufficient to achieve their climate goals.

Companies will need to adjust portfolio focus, given the rapid evolution of policies and government targets. Those with more experience in specific technologies could hold a significant advantage. But, they will also need to avoid getting too far ahead in regions and markets with low pipeline firmness or small pipelines.

Relevant government stakeholders could prioritize project- and market-enabling policies to improve project economics and to drive demand from the market for new products and solutions. For the former, options include financing schemes (for example, tax credits such as the 45Q in the United States). For the latter, policymakers may want to consider carbon pricing, product mandates, or other demand drivers.

After revising their portfolio strategy, stakeholders could actively derisk critical developments integral to the company’s strategy, for instance, by:

Forming partnerships: industrial OEMs and engineering, procurement, and construction (EPC) players face the challenge of delivering increasingly complex technologies at lower costs. Forming industrial partnerships could provide better visibility into product development and help maintain a network of trusted EPCs and partners.
Engaging actively: with policies and subsidies becoming more complex, stakeholders could actively engage in discussions and highlight the challenges, bottlenecks, and enablers that are needed to advance the net-zero transition. This engagement could help ensure that policies provide strong signals for investors and enable positive returns.
Addressing offtakes and infrastructure needs: given that the possible reduced availability of specific technologies may affect the demand/supply balance, stakeholders could proactively seek offtake agreements, understand green premiums, and address infrastructure needs.
Staying on top of developments: as the changing market landscape impacts the attractiveness of merchant strategies, stakeholders can adjust these strategies based on the latest market intelligence and sector developments.

By revising their portfolio strategies and actively derisking critical developments, stakeholders may be better able to navigate the uncertainties of the evolving market landscape, ensuring sustained growth to reach their climate goals.

Diego Hernandez Diaz is a partner in McKinsey’s Geneva office; Humayun Tai is a senior partner in the New York office; Thomas Hundertmark is a senior partner in the Houston office; Michiel Nivard is a consultant in the Amsterdam office; and Nicola Zanardi is an alumnus of the Munich office.

The authors wish to thank Corina Ai-Hua Lo, Eva Mühlebach, Marco Barbaro, Patrícia Ovídio, Sophie FitzGerald, and Tobias Esswein for their contributions to this articl.

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Open access
Published: 03 September 2024

Preterm birth, low birth weight, and their co-occurrence among women with preexisting chronic diseases prior to conception: a cross-sectional analysis of postpartum women in a low-resource setting in Ghana

Ruth Nimota Nukpezah ORCID: orcid.org/0000-0002-4560-3329 1 ,
Emmanuel Akolgo Abanga 2 , 3 ,
Martin Nyaaba Adokiya ORCID: orcid.org/0000-0003-0167-5512 2 ,
Gifty Apiung Aninanya ORCID: orcid.org/0000-0002-5654-2445 4 ,
Lovett Olaedo Odiakpa ORCID: orcid.org/0009-0001-2021-5215 5 ,
Nura Shehu ORCID: orcid.org/0009-0000-7292-1958 6 ,
Ngozi Mabel Chukwu ORCID: orcid.org/0009-0008-6839-9122 7 ,
Abraham Bangamsi Mahama ORCID: orcid.org/0009-0003-3698-4515 7 &
Michael Boah ORCID: orcid.org/0000-0002-5660-2292 2 , 8

Maternal Health, Neonatology and Perinatology volume 10 , Article number: 18 ( 2024 ) Cite this article

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The incidence of chronic diseases, which are significant contributors to maternal deaths and adverse new-born outcomes, is increasing among women of reproductive age in northern Ghana. This emerging health issue raises serious concerns about the potential exacerbation of adverse birth outcomes in this setting, given that it is one of the regions in the country with a high incidence of such outcomes. We investigated the risks of preterm birth (PTB), low birth weight (LBW), and concurrent PTB and LBW among women with preexisting chronic conditions prior to conception in the Tamale Metropolis of northern Ghana.

A facility-based cross-sectional study was conducted among 420 postpartum women randomly selected from five public health facilities. Information was collected electronically on participants’ self-reported experience of chronic conditions, namely, hypertension, diabetes, asthma, heart disease, and sickle cell disease, prior to their most recent pregnancy. Information on gestational age at delivery and birth weight was also collected. Regression modeling was used to quantify the risk of adverse newborn outcomes among women who reported preexisting chronic conditions prior to pregnancy.

Chronic diseases affected 31.2% of our sample. Of these, 28.6% had a single chronic condition, while 2.6% had comorbid chronic conditions. The prevalence of PTB was 24.0% (95% CI: 20.2, 28.4), 27.6% (95% CI: 23.5, 32.1) of the newborns were born LBW, and 17.4% (95% CI: 14.0, 21.3) of the pregnancies resulted in both PTB and LBW. Compared with those without chronic conditions, women with chronic conditions prior to conception had a greater risk of PTB (aOR = 6.78, 95% CI: 3.36, 13.68), LBW (aOR = 5.75, 95% CI: 2.96, 11.18), and the co-occurrence of PTB and LBW (aOR = 7.55, 95% CI: 3.32, 17.18).

Conclusions

We observed significant rates of PTB, LBW, and the co-occurrence of PTB and LBW among women who were already aware that they had preexisting chronic conditions prior to conception. Our findings highlight a potential gap in the quality of prenatal care provided to these women before delivery. Preconception care may offer an opportunity to address preexisting chronic conditions in women before pregnancy and potentially improve maternal and newborn health outcomes.

Preterm birth (PTB) and low birth weight (LBW) represent significant public health challenges, that exert substantial impacts on the health and well-being of newborns worldwide. Recent estimates indicate that nearly 10% (13.4 million) of infants are born preterm, and approximately 15% (21.0 million) experience low birth weight annually on a global scale [ 1 , 2 ]. Notably, the sub-Saharan African (SSA) region, which ranks second only to Asia, bears a substantial burden of PTB and LBW. The literature reports that a variety of factors, either directly or indirectly, influence birth outcomes, including maternal age, level of education, marital status, obstetrical factors like gravidity and parity, medical conditions like hypertensive disorders of pregnancy, healthcare, and behavioural factors like smoking and antenatal care use [ 3 , 4 , 5 , 6 ]. Scholars have also identified that PTB and LBW are related, with data showing that newborns born prematurely are more likely to have a low birth weight [ 7 , 8 , 9 ].

Noncommunicable diseases (NCDs), also referred to as chronic diseases, impact individuals across diverse backgrounds and geographical regions globally. This category of health conditions continues to be the primary contributor to the highest disease burden, accounting for 74% of global deaths in 2019 [ 10 ]. The prevalence of chronic diseases poses a significant concern, particularly in SSA, where existing health systems in many countries face challenges such as fragility, fragmentation, inadequate resources, and limited infrastructure and capacity to address the rising burden of these conditions and have historically prioritised the management of infectious diseases and maternal, neonatal, and child health [ 11 , 12 , 13 ]. The increasing recognition of the challenges presented by chronic diseases is apparent in global initiatives such as the UN Sustainable Development Goals. Among these goals is a target to reduce premature deaths attributed to major NCDs by 30% by the year 2030, alongside a focus on promoting mental health and overall well-being [ 14 ].

Despite global improvements in healthcare, chronic diseases such as hypertension, diabetes, cardiovascular conditions, and chronic respiratory issues significantly impact maternal health and can detrimentally influence pregnancy outcomes. The scientific literature suggests that the burden of adverse birth outcomes, such as premature delivery and low birth weight, is notably higher among women with preexisting chronic diseases, especially in resource-constrained settings [ 15 , 16 ]. Perinatal mortality has also been observed among these women in severe situations [ 17 ]. Systematic reviews and meta-analytic studies have shown that babies who are born early or with a low birth weight have a greater chance of developing long-term conditions such as metabolic syndrome and cardiometabolic disorders as adults [ 18 , 19 , 20 ]. This interconnected relationship between chronic conditions and adverse birth outcomes creates a potentially vicious cycle.

The relationship between chronic diseases and adverse birth outcomes involves intricate interactions among biological, economic, social, and healthcare factors. Nevertheless, maternal health management of chronic diseases, particularly in low- and middle-income countries (LMICs), is often neglected: a systematic review of studies revealed a significant gap in LMICs, as most guidelines focus on high-income countries [ 21 ]. Furthermore, the existing guidelines in high-income countries neglect the multimorbidity of chronic diseases in pregnant women by focussing on single conditions. In Ghana, NCDs contribute 43% of all-cause mortality, including major diseases such as heart disease, stroke, diabetes, cancer, and respiratory disease [ 22 ]. However, the capacity to address chronic conditions at the primary healthcare level is limited due to issues such as poor policy awareness, coordination, funding, and intersectoral engagement [ 23 , 24 ].

Chronic diseases are on the rise among women of reproductive age in northern Ghana, a region characterised by socioeconomic disparities and inadequate healthcare infrastructure [ 25 ]. This emerging health issue raises serious concerns about the potential exacerbation of adverse birth outcomes in this population, given that it is one of the regions in the country with a high burden of such outcomes, as indicated by existing studies [ 26 , 27 , 28 ]. Moreover, earlier research on adverse birth outcomes in the region has overlooked this important aspect [ 26 , 28 , 29 , 30 ]. For example, Hussein et al., in their prospective cohort study, investigated prenatal malaria exposure and its association with adverse birth outcomes [ 28 ]. Similarly, Boah and colleagues assessed the risk of adverse birth outcomes among women who experienced physical and psychological intimate partner violence during pregnancy [ 30 ]. Thus, there is a pressing need to deepen our understanding of how preexisting chronic conditions might impact the risk of adverse birth outcomes in this setting.

This study aimed to assess the prevalence of preexisting chronic conditions among women prior to conception and to investigate any potential associations between these conditions and the risk of PTB and LBW, as well as the co-occurrence of PTB and LBW within the Tamale Metropolitan Area of the northern region of Ghana.

Study setting and design

This facility-based cross-sectional study was conducted in the Tamale Metropolitan Area of the northern region of Ghana. The Tamale Metropolitan Area is among the 261 Metropolitan, Municipal, and District Assemblies in Ghana and one of the 16 MMDAs located in the Northern Region. It was upgraded to the status of a metropolis in 2004, with Tamale serving as the capital. The area has a population of 374,744 according to the most recent 2021 population and housing census [ 31 ]. Three public hospitals, eight health centres, more than ten private hospitals, a hospital run by the Christian Health Association of Ghana (CHAG), and more than 20 private clinics all provide care for the local population. Health centres provide primary healthcare services such as antenatal care (ANC), immunisation, family planning, and basic treatments for common illnesses.

Sample size and sampling strategy

Our study employed a multiple sampling approach to select both health facilities and study participants. We purposefully chose health facilities because they offered advantages in terms of convenience and access to the target population. Five health centres were randomly selected from the available eight in the metropolis using the lottery technique. The sample size for the study was then determined using the Taro Yamane formula for estimating proportions in finite populations, expressed as follows:

where $n$ denotes the desired sample size, e represents the desired precision, and N represents the estimated cumulative number of deliveries from the five selected health facilities for the year 2022. Assuming 5% desired precision and an estimated 8489 deliveries, the minimum sample size required for the study was 382 women. To account for possible nonresponse, we adjusted the sample size to 420 and allocated it to each of the facilities based on their proportion of deliveries.

For participant selection, a systematic random selection method was utilised. The postnatal register at each health facility served as a sampling frame and provided a list of women who had given birth within the past twelve months. The sampling interval was determined by dividing the total number of eligible women by the minimum sample size required from the facility. Starting with a random selection from the first ten names in the sampling frame, respondents were then chosen using the sampling interval until the desired sample size was achieved.

Data collection tool and procedures

The study utilised a semistructured questionnaire to collect data electronically via Google Forms on Apple phones running iOS software. A pilot test was conducted with 42 women from healthcare facilities outside the study area to ensure the reliability of the questionnaires in gathering the needed information. Modifications were made where applicable to unclear questions to enhance clarity.

Information was collected from respondents covering various aspects, including their background characteristics, obstetrical history, ANC utilisation during their most recent pregnancy, and the self-reported presence of preexisting chronic conditions prior to their most recent pregnancy. Information on their birth outcomes, such as birth weight and gestational age at delivery, was also gathered. Maternal and child record books were used to retrieve information on ANC, birth outcomes, and certain obstetrical information. Five trained research assistants conducted the data collection, ensuring adherence to the research protocol and ethical guidelines. The interviews were conducted with the women when they visited the facility to receive postnatal care or child welfare services. The data were collected throughout August and September 2023.

Dependent variables

Three outcome variables were considered in the present study, namely PTB, LBW, and concurrent PTB and LBW. These outcomes were defined according to international classifications [ 32 ]. Preterm birth is when a baby is born too early, before 37 weeks of pregnancy have been completed. On the other hand, LBW occurs when a baby is born with a weight less than 2500 g, regardless of gestational age. Concurrent or co-occurrence of PTB and LBW was defined as a baby being born prematurely and having a low birth weight at the same time. The gestational age at delivery was established using the last menstrual period and ultrasound.

Main independent variable

The main independent variable in this study was the self-reported presence of preexisting conditions. In this study, the following conditions were considered: hypertension, asthma, diabetes, sickle cell disease, and heart disease. These conditions are commonly diagnosed at health facilities in Ghana [ 22 ]. Furthermore, these conditions are frequently included in studies involving chronic diseases among pregnant women globally [ 33 ]. Information regarding the presence of these conditions or otherwise before their most recent pregnancy was obtained from respondents using two questions. These questions are as follows: 1) “Have you ever been told by a doctor or other health worker that you have [name of condition]?” 2)”Before your recent pregnancy, were you taking any drugs (medication) for [name of condition]?” The response options for both questions were “yes” or “no.” These questions have been employed in standard WHO STEPS surveys to gather information on NCDs and their risk factors [ 34 ]. Respondents who answered “yes” to any of the conditions were classified as having a preexisting chronic condition.

While the main interest is in understanding the relationship between preexisting chronic conditions and the selected outcomes, studies conducted in low-resource settings have indicated that various sociodemographic, obstetric, and healthcare-related factors and interventions may influence these birth outcomes [ 3 , 4 , 5 ]. Therefore, factors such as the age and education of the woman, the number of pregnancies (gravidity) and births (parity) she has had, and healthcare-related factors, including healthcare facility, antenatal care utilisation, and interventions such as iron and folic acid supplementation, drugs against helminth parasites, and malaria prophylaxis, were considered potential confounding factors during the analysis. This was done to ensure that the results were accurately interpreted and that potential confounding factors were isolated. Gravidity was used in its continuous form for analysis.

Statistical analysis

All analyses were performed in Stata 15/IC for Windows (StataCorp LLC, Texas, USA). We used both descriptive and inferential statistics. The descriptive statistics explored the distribution of study respondents by their background characteristics, the percentage distribution of chronic conditions existing among respondents prior to pregnancy, and the prevalence of the study outcomes, PTB, LBW, and concurrent PTB and LBW. We used crude logistic regression models to investigate the relationship between each chronic condition and the outcomes. We used adjusted binary logistic regression models to quantify the associations between the main exposure variable, as an aggregate exposure, and the outcomes. However, only the results of the adjusted analyses are presented as adjusted odds ratios (aORs) with their corresponding 95% confidence intervals. Statistical significance was set to a probability value less than 0.05 in two-tailed tests. We used the Hosmer–Lemeshow goodness-of-fit test to evaluate the fitness of our models; all models indicated a good fit ( p > 0.05).

Ethical considerations

The current investigation was conducted in accordance with the ethical guidelines specified in the Declaration of Helsinki regarding research with human beings [ 35 ]. Specifically, this study received approval from the Ghana Health Service Ethics Review Committee (GHS-ERC 101/07/2023). Moreover, prior to participation, the respondents provided both verbal and written informed consent after being briefed on the study's objectives, procedures, potential benefits and risks, their right to withdraw at any stage, and the guarantee of confidentiality and anonymity throughout the research process.

Background characteristics of the respondents included in the present study

Table 1 presents information on the background characteristics of the respondents, including their demographic and obstetrical characteristics, health-seeking behaviour, and ANC interventions received during their most recent pregnancy. The results showed that a higher percentage of the respondents were in the 25 – 34- year-old age group (52.6%), had received basic education (33.6%), were in a relationship (89.8%), and were employed (69.3%). Furthermore, less than half (42.9%) of the respondents made at least eight ANC visits before delivery and booked their first visit in the first trimester. Moreover, a greater percentage reported receiving iron and folic acid supplements (77.6%) and IPTp (88.6%) during pregnancy.

Prevalence of preexisting chronic diseases among women of reproductive age prior to conception

The percentage distribution of preexisting chronic diseases among women prior to pregnancy is summarised in Table 2 . According to the findings, hypertension was the most prevalent chronic condition reported by women, accounting for 12.4% of cases. Diabetes affected 7.6% of the respondents, while sickle cell disease affected 4.8%. Conversely, heart disease was the least frequently reported condition among the surveyed population, affecting 1.9%. In total, chronic diseases affected 31.2% of our sample. More specifically, 28.6% of respondents had a single chronic condition, while 2.6% had comorbid chronic conditions (see Fig. 1 ).

Prevalence of preexisting chronic conditions among women of reproductive age prior to conception

Burden of preterm birth, low birthweight, and the co-occurrence of preterm birth and low birth weight in women with preexisting chronic diseases prior to conception

The rates of PTB, LBW, and the co-occurrence of PTB and LBW are illustrated in Fig. 2 . According to the information presented in Fig. 2 a, the prevalence of PTB was 24.0% (95% CI: 20.2, 28.4). Similarly, 27.6% (95% CI: 23.5, 32.1) of the newborns were born with a low birth weight (Fig. 2 b). Furthermore, 17.4% (95% CI: 14.0, 21.3) of pregnancies resulted in both PTB and LBW, as shown in Fig. 2 c.

Rates of preterm birth, low birth weight, and concurrent preterm birth and low birth weight among women with preexisting chronic diseases prior to conception

Risk of preterm birth, low birth weight, and the co-occurrence of preterm birth and low birth weight in pregnant women with preexisting chronic diseases

We analysed the relationship between each chronic condition and PTB, LBW, and the co-occurrence of PTB and LBW. Table 3 presents the results of this crude analysis. Each of the three outcomes had a statistically significant relationship with hypertension, heart disease, and sickle cell disease. Only preterm birth was significantly associated with asthma, while diabetes was not associated with any of the outcomes. Overall, among variables that were associated with the outcomes, women who self-reported the existence of chronic conditions had increased odds of the outcomes. We analysed the crude association between the preexisting chronic conditions and the birth outcomes. For this analysis, we aggregated the exposures by combining the chronic conditions that showed significant associations with birth outcomes, excluding diabetes mellitus. The results showed that women with preexisting conditions had increased odds of delivering prematurely (cOR = 7.80, 95% CI: 4.72, 12.88), having a low-birth-weight baby (cOR = 6.16, 95% CI: 3.80, 9.99), and experiencing both PTB and LBW (cOR = 6.58, 95% CI: 3.83, 11.31).

Table 4 presents the results of the regression analysis on the risk of PTB, LBW, and concurrent PTB and LBW among pregnant women with any preexisting chronic conditions, after accounting for potential confounding factors, including demographic and economic variables, obstetric factors, health-seeking behaviour, and ANC interventions. For this analysis, we used only the aggregated exposure variable. The findings revealed a strong association between preexisting chronic conditions in women before pregnancy and the risk of PTB, LBW, and concurrent PTB and LBW. Specifically, women with preexisting chronic conditions had significantly greater odds of delivering prematurely (aOR = 6.78, 95% CI: 3.36, 13.68), having a low-birth-weight baby (aOR = 5.75, 95% CI: 2.96, 11.18), and experiencing both PTB and LBW (aOR = 7.55, 95% CI: 3.32, 17.18).

Several potentially confounding variables, including maternal age, the number of ANC visits prior to birth, iron and folic acid supplementation, and intermittent preventive treatment of malaria during pregnancy (IPTp), exhibited significant associations with the outcomes. Compared to women aged 15–24 years, those aged 25–34 years and 35–49 years had lower incidences of PTB, LBW, and concurrent PTB and LBW. Similarly, women who had at least eight ANC visits prior to childbirth had a reduced risk of PTB, LBW, and concurrent PTB and LBW. Additionally, women who received IPTp were less likely to experience PTB, LBW, and concurrent PTB and LBW than were those who did not receive IPTp. Individuals who received deworming treatment, on the other hand, were less likely to experience PTB or have a child with concurrent PTB and LBW. The analysis also showed that women who booked their first ANC visit in their third trimester had increased odds of having LBW babies compared to those who booked in their first trimester of pregnancy (aOR = 5.85, 95% CI: 1.40, 23.97). An increase in the number of pregnancies increased the odds of experiencing concurrent PTB and LBW (aOR = 1.39, 95% CI: 1.03, 1.85). We have presented the marginal analysis (delta-method) of the predicted probability of the outcomes based on the covariates as supplemental material (see Additional file 1).

The aim of the present study was to assess the prevalence of preexisting chronic conditions among pregnant women and investigate any potential associations between these conditions and the risk of PTB and LBW, as well as concurrent PTB and LBW, in a setting characterised by socioeconomic disparities, inadequate healthcare infrastructure, and a high burden of adverse newborn outcomes. According to our study, more than three out of ten women in the sample (31.2%) had at least one chronic disease, with more than a quarter (28.6%) having a single chronic condition and approximately 3% presenting with comorbid chronic conditions. Hypertension was the most prevalent condition among the examined conditions, followed by diabetes and asthma. Sickle cell disease was less common, with heart disease being the least reported condition.

Our analysis, utilising chronic conditions as an aggregate exposure, limits direct comparisons with studies that did not use this approach. Nevertheless, consistent with our findings, a study identified hypertension as the most common chronic condition among more than 1000 conditions found in pregnant women [ 36 ]. Despite the difference in approach, the overarching message remains consistent: chronic conditions pose a substantial challenge for pregnant women, impacting their health and potentially influencing pregnancy outcomes [ 37 , 38 ]. For example, a study in Haiti reported that 7.1% of pregnant women had diabetes only, 12.6% had hypertensive disorders of pregnancy, and 4.2% had both diabetes and hypertensive disorders of pregnancy [ 17 ]. Similarly, a study from a low-resource setting found that about 1% of pregnant women had cardiovascular disease [ 15 ].

According to our study, nearly a quarter (24.0%) of the babies were born prematurely, and more than a quarter (27.6%) had a low birth weight. Furthermore, nearly one in every seven (17.4%) newborns was both premature and had a low birth weight. The rates of PTB and LBW in the present study are higher than those reported in both the SSA region (10% and 13.7%, respectively) and the world on an annual basis (10% and ≈15%, respectively) [ 1 , 2 ]. Furthermore, analyses of pregnant women and their babies in rural communities across six LMICs found a combined preterm birth and LBW rate of 5.5% [ 3 ]. The most recent Ghana demographic and health survey revealed that 11% of newborns in Ghana are born with a low birth weight [ 39 ]. We attribute the higher rates of adverse newborn outcomes reported in the current study compared to the existing studies to the fact that adverse newborn outcomes are relatively more prevalent among women with chronic conditions than among healthy women [ 16 , 36 , 40 ].

Our analysis provides evidence of a significant association between preexisting chronic conditions, such as hypertension, asthma, sickle cell disease, and heart disease, and a greater risk of PTB, and LBW and the co-occurrence of PTB and LBW in the northern region of Ghana, which is consistent with previous studies [ 15 , 17 , 40 , 41 ]. However, our study also contributes to the literature by examining the co-occurrence of PTB and LBW in this population, providing valuable insights into the complexity of pregnancy complications in women with chronic diseases.

Chronic conditions such as hypertension, asthma, sickle cell disease, and heart disease can potentially contribute to adverse newborn outcomes such as PTB, LBW, or both through various mechanisms. Moreover, it is also worth noting that each of these conditions may have different mechanisms and levels of association with adverse newborn outcomes. We postulate that one of these mechanisms involves genetic predispositions associated with certain chronic conditions, which may also play a role in increasing the risk of preterm birth and low birthweight in infants [ 42 , 43 , 44 , 45 ].

In addition to genetics, placental insufficiency also represents a potential central link between chronic conditions and adverse newborn outcomes. This insufficiency manifests through various mechanisms, including vascular complications and impaired oxygen transport. Chronic conditions such as hypertension, asthma, and sickle cell disease can affect pregnancy outcomes by reducing blood flow to the placenta, leading to inadequate oxygen and nutrient supply to the fetus [ 46 , 47 ]. Indeed, it has been established that the efficacy of the placental glucocorticoid barrier, which protects the fetus from excess intrauterine glucocorticoid exposure, is compromised in pregnancies complicated by maternal asthma, reducing oxygen and nutrient supply to the fetus [ 48 , 49 ]. This disruption can result in decreased oxygen and nutrient supplies to the fetus, resulting in PTB and LBW as the fetus fails to receive enough nourishment and oxygen for proper development.

Additionally, managing chronic conditions during pregnancy can be stressful for the mother and increase cortisol levels [ 50 ]. High cortisol levels, in turn, can reduce lymphocyte sensitivity to glucocorticoids by binding to glucocorticoid receptors [ 51 ]. This diminished sensitivity may impair the body’s ability to regulate inflammation and immune responses, potentially impacting both maternal and fetal health during pregnancy. Moreover, chronic conditions, when not controlled, can increase the risk of maternal complications during pregnancy, such as preeclampsia in the case of hypertension or gestational diabetes, further increasing the risk of PTB and LBW [ 52 , 53 , 54 ].

Our study also identified additional significant factors influencing adverse birth outcomes alongside chronic conditions, which was our primary focus. We observed that an increased frequency of ANC visits and the receipt of essential ANC interventions, namely iron and folic acid supplements, dewormers, and IPTp, were associated with a reduced chance of adverse birth outcomes. These findings align with population-based studies that have emphasised the potential significance of ANC in improving birth outcomes and reducing child mortality and malnutrition in the longer term [ 3 , 55 ]. Conversely, late booking for ANC was associated with an increased likelihood of LBW. We propose discussing these factors together rather than independently, as they all fall within the ANC framework.

Regular ANC attendance allows for the timely identification and management of maternal health conditions and pregnancy complications that have the potential to increase the risk of adverse birth outcomes. Consistent visits enable healthcare providers to monitor fetal growth, assess maternal health status, and provide necessary interventions or referrals as needed [ 56 ]. Iron and folic acid supplementation during ANC contributes to optimal maternal nutrition, which is essential for fetal development and growth, thus reducing the risk of LBW [ 57 , 58 ]. Similarly, dewormer administration and IPTp during pregnancy can prevent parasitic infections and their associated consequences, including anaemia, which are known to increase the risk of adverse birth outcomes, consequently reducing the incidence of PTB and LBW [ 28 , 59 , 60 ]. Additionally, early initiation of ANC allows for timely initiation of interventions and monitoring, while late booking may limit the effectiveness of interventions and increase the likelihood of adverse outcomes.

Implications of the study’s findings for policy and practice

Maternal mortality is commonly attributed to direct obstetric causes, but a significant proportion of deaths, approximately 15%, are due to preexisting medical conditions. Our study highlights the burden of chronic conditions, particularly noncommunicable diseases such as hypertension and diabetes, which are increasing in prevalence, among women prior to conception [ 11 ]. Managing these conditions during pregnancy will pose further challenges to our already constrained healthcare system [ 23 ]. Addressing the needs of pregnant women with preexisting medical conditions requires targeted interventions, including strengthening health systems, integrating chronic disease management into maternal health services, and improving access to medications and support [ 61 , 62 ].

The high burden of PTB and LBW and the co-occurrence of PTB and LBW in the study setting suggest that a substantial number of new-borns are likely to face challenges not only in early childhood but also throughout adulthood. These challenges may include developmental delays, cognitive impairments, chronic health conditions, and socioeconomic disadvantages [ 18 , 20 , 63 , 64 ]. Moreover, there is a potential for a complex, vicious cycle in which females born preterm or with low birth weight tend to develop chronic conditions later in life and subsequently deliver children with adverse birth outcomes, thus perpetuating the intergenerational transmission of adverse birth outcomes and chronic conditions. Addressing the underlying factors contributing to PTB and LBW, such as those identified in our study, is crucial for improving the long-term health and well-being of these vulnerable newborns.

The high rates of adverse birth outcomes among the women with preexisting chronic diseases in our sample who received antenatal care may be attributed to various factors. These factors include the severity of the chronic condition, individual variability, and complications during pregnancy. However, it also raises questions about the comprehensiveness, timeliness, and effectiveness of the care provided to these women during pregnancy. This highlights potential gaps in the healthcare system’s ability to adequately support high-risk pregnancies, given that these women were already aware of their condition prior to becoming pregnant. Studies suggest that preconception care, including counselling, has reduced adverse birth outcomes in women with preexisting chronic conditions [ 65 , 66 ]. By focussing on this crucial period before conception, healthcare providers can empower women with chronic conditions to enhance their health, thereby reducing the likelihood of complications during pregnancy and improving outcomes for both mothers and children. Preconception care programmes may include preconception health screening to identify and address any existing chronic conditions or risk factors that may affect pregnancy outcomes, as well as comprehensive counselling and support services.

Strengths and limitations

Our study is cross-sectional in design, limiting our ability to establish causality. Although we identified an association between preexisting chronic conditions and adverse birth outcomes, we cannot definitively conclude that these conditions directly caused these outcomes.

Furthermore, it is important to note that participants in facility-based studies may not fully represent the entire population, as they are typically those who seek healthcare services. This could result in an over-representation of women with access to healthcare or those with more severe health conditions. Moreover, we acknowledge that we relied on participants’ self-reports of their preexisting condition prior to becoming pregnant. We cannot rule out the possibility for some participants to unintentionally forget certain conditions, thereby resulting in underreporting of such conditions. However, existing evidence indicates high validity for self-reported maternal chronic conditions during the periconception period, including diabetes and hypertensive disorders [ 67 ].

There are confounding variables that were not accounted for in our analysis, such as women’s autonomy, birth intervals, malaria infection status, gestational anaemia status, and water and sanitation [ 6 , 68 , 69 , 70 ]. As a result, our findings should be interpreted with caution. Despite these limitations, the findings of your study have direct clinical relevance. Since we collected information on the presence of chronic conditions before pregnancy, we can reasonably infer that these conditions preceded the birth outcomes, establishing a direct association between the two factors. This insight can inform healthcare providers about the potential risks associated with preexisting chronic conditions during pregnancy, leading to improved patient care and management strategies.

Our study has highlighted a significant problem regarding preexisting chronic conditions and their impact on adverse newborn outcomes in terms of PTB, LBW, and the co-occurrence of both PTB and LBW. The findings indicate a high prevalence of chronic conditions among women prior to pregnancy and a significant burden of adverse pregnancy outcomes among these women in the study setting. Considering that these women were already aware of their condition(s) before conception, our findings highlight a potential gap in the quality of prenatal care provided to them before delivery. Preconception care may offer an opportunity to address preexisting chronic conditions in women before pregnancy and potentially improve maternal and newborn health outcomes.

Availability of data and materials

The minimal dataset that would be necessary to interpret, replicate and build upon the findings reported in the article are contained within the publication.

Abbreviations

Adjusted odds ratios

Antenatal care

Christian health association of Ghana

Intermittent preventive treatment of malaria during pregnancy

Low- and middle-income countries

Low birth weight

Noncommunicable diseases

Preterm birth

Sub-Saharan Africa

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Nukpezah, R.N., Abanga, E.A., Adokiya, M.N. et al. Preterm birth, low birth weight, and their co-occurrence among women with preexisting chronic diseases prior to conception: a cross-sectional analysis of postpartum women in a low-resource setting in Ghana. matern health, neonatol and perinatol 10 , 18 (2024). https://doi.org/10.1186/s40748-024-00188-2

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Gap analysis consists of four steps: (1) identifying key needs of the present situation, (2) determining the ideal future or desired situation, (3) highlighting the gaps that exist and need to be ...
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Gap Analysis for Literature Reviews and Advancing Useful Knowledge 1. Figure 1: Abstract example of a causal map of a theory. There are really three basic kinds of gaps for you to find: relevance ...
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A research gap develops as a result of the design of the study's constraints, the use of poor tools, or external influences that the study could or could not control. Research needs can be viewed ...
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Framework for literature reviewing (vom Brocke et al. 2009, p. 8) Thus, identifying research gaps forms part of the last step (phase V) of von Brocke et al.'s framework. It is important to note that the process of identifying research gaps is different from the process of literature analysis and synthesis (phase IV).
PDF Methods for Identifying Health Research Gaps, Needs, and Priorities: A
Research needs are knowledge gaps that significantly inhibit the decisionmaking ability of key stakeholders, who are end users of research, such as patients, clinicians, and policymakers. Research priorities are research gaps or needs that are ordered by selected criteria (e.g., potential value, importance to stakeholders).
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BACKGROUND. Well-defined, systematic, and transparent methods to identify health research gaps, needs, and priorities are vital to ensuring that available funds target areas with the greatest potential for impact. 1, 2 As defined in the literature, 3, 4 research gaps are defined as areas or topics in which the ability to draw a conclusion for a given question is prevented by insufficient evidence.
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Hence, exploring research gap is one of the most arduous tasks for researchers especially those at the preliminary stage. The explicit identification of research gap is an inevitable step in developing a research agenda including decision about funding and the design of informative studies.
PDF Understanding and spotting research gaps through a systematic
This systematic review included studies that provide relevant information on the identification of research gaps in literature and the classification of research gaps. Literature reviews on specific topics not related to research gap identification through literature were excluded from the study. However, studies from all disciplines such as ...
(PDF) Understanding and spotting research gaps through a systematic
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Gap Analysis Gap analysis consists of (1) listing of attributes, competencies, and/or performance levels of the present situation ("what is"), (2) cross listing factors required to achieve the future objectives ("what should be"), and then (3) highlighting the gaps that exist and need to be filled.
Frameworks for Determining Research Gaps During Systematic Reviews
Systematic reviews, in addition to summarizing the evidence, generally also discuss needs for future research. However, in contrast to the methods of the systematic review, future needs are not identified systematically. There is limited literature describing organizing principles or frameworks for determining research gaps. We developed and pilot-tested a framework for the identification of ...
PDF QUICK TIPS HOW TO CONDUCT A GAP ANALYSIS
as.2STEPS IN CONDUCTING A GAP ANALYSISA gap analysis is a very thorough appro. etermining that a gap does exist.Step 3Clarify the gap/ discrepancy between Step #1 and St. p #2 - these are the health care issues. Are these gaps related to k. , skills, attitudes or practices?Step 2Define the "Gold Standard" - or what is defined as.
(Pdf) Mind the Gap: Exploring Effective Strategies for Conducting Gap
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A Gap Analysis is: A gap analysis can be defined as the determination of the difference between current knowledge/practices (what we are doing) and current Evidence Based Practices (what we should be doing). Gaps can occur in knowledge, skills or practice. Steps to Performing a Gap Analysis: 1. Find the need- through conducting a Needs ...
Introduction
The identification of gaps from systematic reviews is essential to the practice of "evidence-based research." Health care research should begin and end with a systematic review.1-3 A comprehensive and explicit consideration of the existing evidence is necessary for the identification and development of an unanswered and answerable question, for the design of a study most likely to answer ...
PDF Gap Analysis
Gap Analysis . A . Gap Analysis. is similar to a . Needs Assessment, but it allows for a more standardized process of determining what the gap-in-knowledge (or need) is. It is important to perform a Gap Analysis to justify the necessity for the educational activity and to guide you to select the appropriate teaching and evaluation methods.
(PDF) Framework for Identifying Research Gaps for Future Academic Research
Research gap analysis is essential to every research effort as it helps identify areas where further study is necessary to close knowledge gaps and encourage evidence-based practice.
The reality gap in achieving net zero
Gap assessment: By examining the project status, including those that have reached FID stage, we assessed the gap between target volumes, expected volumes (based on current trends), and volumes that have already reached FID. This analysis highlighted the discrepancies between announced projects and those that are likely to materialize.
Preterm birth, low birth weight, and their co-occurrence among women
Background The incidence of chronic diseases, which are significant contributors to maternal deaths and adverse new-born outcomes, is increasing among women of reproductive age in northern Ghana. This emerging health issue raises serious concerns about the potential exacerbation of adverse birth outcomes in this setting, given that it is one of the regions in the country with a high incidence ...
(PDF) Gap Analysis
PDF | A comparison of the objectives and the expected business outcomes usually leads to a performance gap between the two. Gap analysis is concerned... | Find, read and cite all the research you ...