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Synthesis results
government administration, regional or national levels, and as such include rural and
urban populations.
One study focused entirely on an urban population (Bashir et al., 1995) (-)/(-). A
combination of low-cost services or free services for deserving cases, obstetric flying
squad services, training for TBAs, antenatal check-ups and intensive community
education had a positive impact on maternal mortality levels in a major city in
Pakistan. A key to the uptake and success of services such as the flying squad was
the community events and radio education campaigns highlighting their availability.
Three studies published over the last decade focused on evaluation of Safe
Motherhood or Mother Care interventions as a whole. These complex programmes
involved many different types of interventions which present particular challenges
for evaluation. Studies in Egypt and Tanzania assessed the impact of national
programmes on maternal mortality, and found that reductions in mortality over time
were evident (Mbaruku and Bergstrom (1995) (-)/(-); Mswia et al., 2003 (+)/(++);
Alwen et al., 2005 (-)/(+); Campbell et al., 2005 (+)/(+)), although attributing
causality was poor. In Nigeria, Okaro et al. (2001) (-)/(-) showed that the Safe
Motherhood Initiative had not succeeded, with the MMR increasing fivefold since its
start. This was attributed to a deterioration in general living standards which had
wiped out any improvements due to better maternal health care. This highlights that
health sector investment alone is unlikely to reduce maternal deaths.
Two further studies have considered how interventions at a national or state level
may have contributed to declining maternal mortality over time. Padmanaban et al.
(2009) (-)/(+) outlined the interventions that were judged to have contributed to the
significant decrease in maternal mortality in the Indian state of Tamil Nadu. The
MMR in the state reduced from 380 to 90 per 100,000 live births in the period from
1993 to 2007. The paper drew on the observations of the authors, based within the
Ministry of Health and Family Welfare, as well as secondary data and literature
where available. The paper described wide-ranging interventions from improvements
in availability of human resources; availability of key drugs, blood and supplies;
improved management capacity; and better surveillance and analysis of maternal
deaths. It is not possible from the paper to quantify the effect of the interventions
directly but it does highlight the importance of political will and leadership, and
engagement of directorates across governments, not just health. For China, Yan
(1989) (-)/(-) showed how improved training and services under a national
programme had helped to reduce maternal mortality in the country since the 1950s.
Starting with training of TBAs, then with referral systems in 1952, up to recruitment
and training of midwives and obstetricians alongside TBAs, the Chinese MMRs
declined sharply in the 1950s and 1960s. However, no specific reference is made in
this study to specific interventions in poor urban areas.
4.1.6 Complex interventions: infant mortality outcomes
Only three papers focused on complex interventions for infant mortality (Appendix
4.6). Section 4.1.5 showed that the complex interventions for maternal mortality
focused mainly on national or large scale programmes. Two of the complex
interventions for infant mortality focused more closely on addressing a specific area
of clinical care through a package of interventions. The areas of focus were special
care for infants (Borulkar et al., 1998) (-)/(-) and management for mothers with
diabetes during pregnancy and labour (Mirghani and Saeed, 2000) (-)/(-).
The study by Borulkar et al. (1998) (-)/(-) in India reported on the development of a
model for the special care of newborns at a community hospital in a predominantly
tribal block in an urban area. The key interventions included: adequate warmth;
prompt resuscitation; proper feeding; and oxygen administration when necessary.
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? 39