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(Philips et al., 2004) was available to assess the quality of economic evaluations
based on a synthesis of effectiveness data from a range of papers and the
construction of different forms of economic evaluation (Appendix 2.8).
2.3.2 Overall approach to and process of synthesis
The approach to synthesis was driven by the research question, the types and quality
of studies and the data included in the review. Heterogeneity of study design,
population and intervention precluded statistical meta-analysis. The most
appropriate approach – a textual narrative synthesis – was conducted. Because our
review question involves two linked but distinct populations – mothers and infants –
we have structured our review accordingly. For a subset of high-quality items, we
conducted a causal chain analysis, also separated according to whether the outcome
was maternal or infant mortality.
2.3.3 Selection of studies for synthesis
The narrative synthesis includes all eligible studies on the basis of the
inclusion/exclusion criteria. The causal change analyses are restricted to studies
identified as high quality.
2.3.4 Selection of outcome data for synthesis
Outcomes included maternal and infant health outcomes: maternal, infant,
neonatal, perinatal, post-neonatal mortality, and still-birth; and severe acute
maternal morbidity (SAMM) (haemorrhage, dystocia, hypertension, sepsis,
incomplete abortion, Caesarean section (CS), hysterectomy and blood transfusion)
(World Health Organization, 2011b).
This review focuses on maternal and infant mortality outcomes. Process indicators,
such as skilled care at birth, are often used as substitutes for mortality outcomes
whose measurement poses considerable challenges. However, mortality outcomes
are not necessarily improved where gains in individual process indicators are not
accompanied by broader changes (Koblinsky et al., 1999). A focus on mortality
outcomes is thus crucial, particularly in areas where the mortality burden is high
(Campbell and Graham, 2006; Bhutta et al., 2008; Lawn et al., 2009).
2.3.5 Synthesis of evidence
All eligible studies were included within the qualitative analysis to establish a
detailed picture of the available evidence. We first analysed the data using EPPI-
Reviewer 4 and generated comprehensive tables for each code. All tables were then
exported and merged in Excel 13 to produce a unique results table.
Narrative synthesis was the principal approach used. Eligible studies were grouped
into type of interventions – broadly grouped into clinical and non-clinical – as
described later on in the report. Findings were analysed within each category for the
two main target populations: mothers and infants, including neonates. While most
systematic reviews focus on synthesising evidence on effectiveness from quantitative
research, we wanted to develop the contribution that can be made by different
types of evidence, including that involving qualitative data.
In addition, causal chain analysis was performed on included studies identified as
high quality to allow the extraction and illustration of the casual path emerging from
our review, linking reasoning for intervention, with experience, implementation and
sustainability. We used an approach based on White’s (2009) theory-based impact
evaluation, and drawing on the realist review approach of Pawson et al. (2005),
13 http://office.microsoft.com/en-us/excel/
Methods
What are the effects of different models of delivery for improving maternal and infant health
outcomes for poor people in urban areas in low income and lower middle income countries? 20