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Synthesis results
of settings were also identified as a cause of non-implementation of breastfeeding
and obstetric care. One example of this was the practice in some countries of new
mothers sequestering themselves from most people during a culturally determined
period after delivery, as in parts of India (Lim et al., 2010). Micronutrient shortage
in pregnant women in LICs linked to low birthweight for infants was associated with
morbidity and mortality (Kaestel et al., 2005).
Cultural barriers remain a key determinant to lack of access to services (Lim et al.,
2010) and to the implementation of appropriate health services/interventions
(Jakobsen et al., 2008). Only one study (Lim et al., 2010) highlighted the
inequalities in access to care to explain high rates of maternal mortality.
The root causes of infant and neonatal negative outcomes were identified as
pneumonia and diarrhoea mainly because of delays in vaccination (Martins et al.,
2008), lack of antenatal care (Munjanja et al., 1996), and general lack of guidelines
in breastfeeding for HIV positive women (Becquet et al., 2007; Kumwenda et al.,
2008). Children born prematurely had compromised barrier functions which
increased their risk of infection and of hypothermia (Darmstadt et al., 2008).
4.2.2 Impact on health outcomes
Only 7 out of the 21 studies reported a positive impact on health outcomes (Cobra et
al., 1997; Taha et al., 1997; Dumont et al., 2005; Dumont et al., 2006; Darmstadt et
al., 2008; Richard et al., 2008; Lim et al., 2010), of which five were related to
maternal outcomes and three to infant and neonatal ones. The interventions
included: skin barrier methods (Darmstadt et al,. 2008); death reviews and financial
regulations (Dumont et al., 2005; Dumont et al., 2006; Richard et al., 2008 ); oral
iodine supplementation for infants (Cobra et al., 1997); cash transfer schemes to
improve institutionalised deliveries (Lim et al., 2010); and birth canal cleansing to
reduce infections (Taha et al., 1997). Although we consider Kumwenda et al. (2008)
as an overall neutral study, some of the clinical interventions did result in a positive
impact on postnatal mortality.
The range of interventions and specificity of the settings shows that no general
conclusion can be reached on successful impact on health. Vaccination remains a key
determinant of curbing infant mortality rates in resource poor settings. However
what still needs to be further studied is the timing of vaccination. Martins Cesario et
al. (2008) found no significant reduction in post-natal mortality in infants vaccinated
before 9 months of age in resource-poor settings. However they suggested that an
early two-dose strategy providing Edmonston-Zagreb vaccination (measles) as early
as 4.5 months of age might be used in humanitarian emergencies or during outbreaks
with a high risk of measles infection. A few studies suggested that there was
insufficient evidence that changes in feeding practices did significantly reduce
infection rates, as overall the effects might be counterbalanced (Kuhn et al., 2008) .
However Becquet (2008) stressed that given appropriate nutritional counselling and
care, access to clean water, and a supply of breastmilk substitutes, these
alternatives to prolonged breastfeeding could be safe interventions to prevent
mother-to-child transmission of HIV in urban African settings.
4.2.3 Poverty and impact (sustainability)
One study looked at the sustainability of intervention in low-resource urban settings
(Figures 4.1 and 4.2): one controlled trial in Bangladesh identified a low-cost
intervention that could be funded if necessary through out-of-pocket payments, for
emollient skin barrier therapy, although this still needs further testing (Darmstadt et
al., 2008). Other interventions such as vaginal wash (Taha et al., 1997) were
deemed to be low cost and sustainable, although this study is now over a decade
old.
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? 47