Most of the stillbirths that occur around the world are among women who live in low- and middle-income countries. Some 2.5 million women suffer the heartbreaking loss each year.

Yet determining the causes and prevention of stillbirths has largely been ignored as a global health priority — the incidence not even included in the WHO Millennium Development Goals.

Stanford Health Policy’s Rosenkranz Prize Winner, Ashley Styczynski, MD, MPH, discovered the alarmingly high level of stillbirths while working in Bangladesh as a 2019-2020 Fogarty Fellow, studying antimicrobial resistance in newborns in the hospitals there.

The $100,000 Rosenkranz Prize is awarded to a Stanford researcher who is doing innovative work to improve health in the developing world.

“I was surprised to learn that the rates of stillbirths were comparable to sub-Saharan Africa and that in many cases they had no idea of the cause,” Styczynski said in a Skype call from Dhaka, where she has been living for eight months while conducting her antimicrobial resistance research.

The South Asian nation is among the top 10 countries with the highest number of stillbirths, with an average of 25.4 stillbirths per 1,000 births. Studies have implicated maternal infections as the cause; one ongoing study in Bangladesh has recovered bacteria from blood samples in stillborn babies in whom no prior maternal infection was suspected.

Styczynski believes intrauterine infections may be an underrecognized factor contributing to the excess stillbirths in Bangladesh. She intends to perform metagenomic sequencing on placental tissues of stillborn babies, a process that will allow her to examine the genes in the organisms of those tissues and evaluate the bacterial diversity.

“The alternative hypothesis would be that stillbirths are caused by non-infectious etiologies, which I will be assessing through interviews,” Styczynski wrote in her Rosenkranz application.

Those interviews will be with mothers to evaluate for frequency of infectious symptoms during pregnancy, including fever, rash, cough, dysuria and diarrhea, as well as possible toxin exposures. She will compare the findings with the metagenomic sequencing results to determine how frequently potential pathogens may be presenting as subclinical infections.

“By applying advanced technologies and software platforms, this research will not only enhance our understanding of causes of stillbirths in Bangladesh, but it may also provide insights into causes of early neonatal deaths," Styczynski said.

Bangladesh, one of the poorest and most densely populated nations in the world, offers a rich variety of emerging and known diseases that go undetected.

“The panoply of infections that could contribute to stillbirths is really unknown,” Styczynski said. “That’s why metagenomics is a great tool here. It just hasn’t been accessible here because of the expense. Now this tool will begin to unpack what’s causing these stillbirths.”

The Rosenkranz Prize was started and endowed by the family of the late Dr. George Rosenkranz, who devoted his career to improving health-care access across the world and helped synthesize the active ingredient for the first oral birth control pill.

“No one is more deserving of the Rosenkranz Prize than Dr. Ashley Styczynski”, said Dr. Ricardo Rosenkranz. “Because of her tenacity, originality and focus, Dr. Styczynski exemplifies the ideal Rosenkranz Prize recipient. She has chosen an often overlooked adverse outcome that may prove to be mitigated by her findings. As a neonatologist interested in health disparities, I fully realize the potential relevance and urgency of her work and am excited to see it come to fruition. As the son of George Rosenkranz, for whom this prize is lovingly named, I know that my father would appreciate Dr. Styczynski’s pioneering spirit as well as her desire to affect global positive change by improving medical outcomes in vulnerable communities. We can’t wait to celebrate her work back at Stanford in the near future."

Sheltering in Place

Styczynski spoke from her flat in Dhaka, where she has been confined for three weeks as the world’s third-most populated city prepares for the onslaught of the coronavirus. The country is on lockdown; no international flights in or out.

As of Thursday, there were 1,572 cases in Bangladesh and 60 deaths, according to the widely used Johns Hopkins Coronavirus Map.

But Styczynski believes that’s about 1% of the actual disease activity in the country because testing was so slow to start. She said there is great stigma in the country over testing — red flags are put on the homes of those who have been diagnosed with COVID-19 — because it breaks up the unity of families and the surrounding community. Health-care workers are being kicked out of apartments by frightened landlords and people are afraid to use the health-care system for fear of infection.

“So, the hospitals are quite empty — more so than they’ve ever been,” she said.

Styczynski likened it to waiting for the tsunami that you know is coming.

“That’s why I wanted to jump in to stave off the morbidity and mortality that will be inundating one of the most populated countries in the world,” she said. Some 165 million people are packed into 50,250 square miles — a land mass about the same size as New York State, which has some 19.5 million people.

The Centers for Disease Control and Prevention (CDC) has a small team of four people working in Bangladesh. Having spent two years as an Epidemic Intelligence Service Officer at the CDC, Styczynski has now joined its Bangladesh team and is also working with the infection prevention and control team of the International Centre for Diarrhoeal Disease Research, Bangladesh.

“Many people here in Dhaka live in high-density apartments with six to 12 people living in the same room,” she said. “How do you isolate when you have a one-room home?”

Ninety percent of the population are daily wage earners, Styczynski noted, who say they’d rather take their chances with coronavirus than die of starvation.

They take those chances at great risk. There is one ventilator for every 100,000 people in Bangladesh and the district hospitals have maybe one to two days of oxygen supply, Styczynski said.

They started out training military hospitals on medical triage, quarantine and isolation, and infection prevention strategies.

“We’ve also been going to some district hospitals to assess some of the challenges they are facing and to identify some of the gaps in preparedness so that we can communicate back to the Ministry of Health how they can better support these district hospitals,” she said.

Her pandemic travels to the district hospitals and preparedness work has allowed her to gather contextual data for her colleagues back at Stanford who are working to address the lack of personal protective equipment (PPE) in low-resourced countries.

“We hope we can generate some evidence very quickly so that we can share some of this information to better protect health-care workers in other low-resource countries,” she said.

Despite her research being temporarily sidelined, Styczynski is upbeat.

“This is what I signed up for as a Fogarty fellow, to help build local capacity,” she said. “But I am also an infectious disease specialist, and these are the types of situations we run towards rather than away from. We build our career for moments like these.”

Fourteen Stanford researchers addressing global poverty through a range of academic disciplines are receiving a total of $4.6 million in awards from the university-wide Global Development and Poverty (GDP) initiative.

Their projects, which are the first to be funded by the GDP, deal with challenges of health, violence, economics, governance and education in the developing world.

“GDP seeks to transform scholarly activity and dialogue at Stanford around the topic of global poverty, so that the university may have a greater impact on poverty alleviation in developing economies,” said GDP faculty co-chair Jesper B. Sørensen. “By focusing on placing a small number of big bets, GDP encourages researchers to think big, and to move beyond the conventional way of doing things. We are thrilled by the inaugural set of awardees, as they demonstrate the creative, inter-disciplinary approaches that will make Stanford a leader in this area.”

The GDP initiative is part of the Stanford Institute for Innovation in Developing Economies (SEED) and is administered in partnership with Stanford's Freeman Spogli Institute for International Studies (FSI). The GDP is co-chaired by Sørensen, the faculty director for SEED and the Robert A. and Elizabeth R. Jeffe Professor of Organizational Behavior at the Graduate School of Business; and Mariano-Florentino Cuéllar, senior fellow and director of FSI and the Stanley Morrison Professor at Stanford Law School.

SEED, which seeks to alleviate poverty by stimulating the creation of economic opportunities through innovation, entrepreneurship and the growth of businesses, was established in 2011 through a generous gift from Robert King, MBA '60, and his wife, Dorothy.

Through complementary areas of focus, GDP funding and other SEED research initiatives will stimulate research, novel interdisciplinary collaborations and solutions to problems of global poverty and development. GDP research aims to pursue answers to crucial questions that are essential to an understanding of how to reduce global poverty and promote economic development. That includes governance and the rule of law, education, health, and food security – all of which are essential for entrepreneurship to thrive. By contrast, other SEED research focuses on innovation, entrepreneurship, and the growth of businesses in developing economies.

Since 2012, SEED’s Entrepreneurship and Innovation in Developing Economies Award program also has doled out 22 awards and seven PhD fellowships to help support and scale businesses in developing economies. Among the $1 million in funded projects were studies of how to improve the livelihoods of small-holder cacao farmers throughout the tropics; how to identify startups with high job- and wealth-creating potential in Chile; how political accountability affects the ability to attract investment in Sierra Leone; and how managerial practices affect trade entrepreneurship in China.

First GDP Awards

The first 14 GDP award recipients are professors of economics, political science, law, medicine, pediatrics, education and biology, and senior fellows from FSI, the Woods Institute, and the Stanford Institute for Economic Policy Research (SIEPR).

“Each of these projects cuts across disciplines, reflects innovative thinking, and has the potential to generate crucial knowledge about how to improve the lives of the poor around the world,” Cuéllar said. “These projects, along with a variety of workshops engaging the university and external stakeholders, will help us strengthen Stanford’s long-term capacity to address issues of global poverty through research, education and outreach.”

Among the award recipients is Pascaline Dupas, an associate professor of economics and senior fellow at SIEPR. Dupas, along with faculty from the Center for Health Policy and Center on Democracy, Development and the Rule of Law, will launch the Stanford Economic Development Research Initiative using GDP funds.  This initiative will focus on collecting high-quality institutional and individual-level data on economic activity in a number of developing countries over the long term, and making these data available to scholars around the world.

Beatriz Magaloni, an associate professor of political science and senior fellow at FSI, is receiving an award to lead a team focused on criminal violence and its effects on the poor in developing economies, and the practical solutions for increasing security in those regions.

Douglas K. Owens, a professor of medicine and FSI senior fellow, was awarded an award to help him lead a team that will develop models to estimate how alternative resource allocations for health interventions among the poor will influence health and economic outcomes.

Stephen Haber, a professor of political science and history and a senior fellow at the Hoover Institution, received an award to bring together Stanford researchers interested in examining the long-term institutional constraints on economic development. Their goal will be to provide policymakers with a framework for determining the conditions under which particular innovations are likely to have positive payoffs, and the conditions under which resources will likely be wasted.

Other projects will address the educational impacts of solar lighting systems in poor communities; identifying interventions to improve the profits and safety among poor, smallholder pig farmers in Bangladesh and China; the role of law and institutions in economic development and poverty reduction; and how to rethink worldwide refugee problems. Awards are also being provided to researchers focused on microfinance, online education and teacher training.

The project proposals were reviewed by an interdisciplinary faculty advisory council chaired by Cuéllar and Sørensen. 

“We were very encouraged by the impressive number of project proposals from a wide range of areas and are looking forward to introducing several new capacity and community-building activities in the fall,” Sørensen said.. “This wide range of research initiatives will form a vibrant nucleus for Stanford’s growing community of scholars of global development and poverty.”