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Figure 4.2: Causal chain for infant and neonatal mortality Root causes INTERVENTION IMPACT SUSTAINABILITY Lack of training Education Service management Compromised skin barrier Breastfeeding HIV transmission Lack of vaccination Prevention Vaccination Formula Improved care Vitamin intake Audit/review Skin emollients Improved access Cash transfer schemes Reported Neonatal mortality Declined morbidity outcome Not reported Behaviour/ policy change Early weaning Urban settings Poor settings Low cost/ Suitable for low resource settings Sustainability not assessed Synthesis results 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? 50
4.3 Summary of results of causal chain analysis Synthesis results We identified seven high-quality items with evidence of successful interventions in terms of maternal and infant outcomes. The heterogeneity of the successful interventions we report here reflects our deliberately inclusive search and inclusion strategy. There are four studies (Appendix 4.9) where the positive mortality outcome was clearly targeting or, with disaggregation, could be shown to have a beneficial effect for poor urban populations. In keeping with our inclusive approach to addressing this question, however, we also present a second table (Appendix 4.10) to show those high-quality studies (n=3) with positive impact(s) on maternal and infant outcomes that (based on circumstantial evidence, for example the site of intervention) we have every reason to believe addressed a poor urban population, though this was either not stated explicitly or was unclear. Returning to the four studies, generalising from so few is inadvisable, and just one of the papers (Darmstadt et al., 2008) dealt with infant mortality. Notable, however, is that two out of the four involved service (re)organisation in some form for maternal healthcare (Munjanja et al., 1996; Dumont et al., 2006), albeit with rather different recommendations. Munjanja et al.’s (1996) study in Zimbabwe tested whether reducing the number of routine antenatal visits and tests for routine pregnancies might have had a negative impact on mortality outcomes. Their study, using a RCT design, found no significant change in perinatal and maternal mortality. Dumont et al.’s (2006) Senegalese study using before and after study design showed that, when applied to qualified professionals (physicians, midwives, managers), the Maternal Deaths Review (MDR) helped to improve the organisation of care, leading to significant decline in overall mortality over the study’s three year period. 16 The Darmstadt et al. (2008) study in Bangladesh, using a prospective, randomised controlled design, showed significant reductions in neonatal mortality rates for preterm neonates (≤33 weeks) at risk of skin infections who received emollient skin-barrier therapy. A companion paper (Le Fevre et al., 2010) (++)/(+) on the cost-effectiveness of this intervention is reviewed elsewhere in this report. Whilst all of these three interventions showed significant impact on maternal or neonatal mortality, none dealt with the issues involved in accessing the services where the interventions were provided, although the economic evaluation accompanying the last study did look at issues of sustainability. The one study that did deal with issues around accessing health services is that by Lim et al. (2010), which considered the impact of India’s JSY conditional cash-transfer scheme on maternal health outcomes through analyses of the National Family Health Service (NFHS). The claims made for the JSY programme in India by Lim et al. (2010) are not without critique (Das et al., 2010), some of which the authors have acknowledged (Lim et al., 2011), in particular that their analyses of demand-side interventions such as the JSY cannot deal with supply-side issues such as facility readiness. Turning to the studies that did not specifically report on urban areas, the three successful high-quality interventions identified to impact on infant mortality involved four very different kinds of intervention. Studies by Cobra et al. (1997) and Taha et al. (1997) targeted infants in general. The study by Taha et al. (1997) on vaginal cleansing to reduce bacterial infections, which are substantial in many 16 A linked, but separate study by Dumont et al. (2005) using a similar approach is listed in Appendix 4.10 for high-quality, positive interventions, but ones without explicit application to poor urban populations. 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? 51
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Systematic review What are the effe
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Contents List of abbreviations ....
Page 5 and 6: List of abbreviations AIDS Acquired
Page 7 and 8: Executive summary Background Execut
Page 9 and 10: Executive summary be to retrospecti
Page 11 and 12: Background many LICs and LMCs, it i
Page 13 and 14: Background Cross-sectional surveys
Page 15 and 16: Background For some causes of mater
Page 17 and 18: Background informal settlements on
Page 19 and 20: Background review focused on explic
Page 21 and 22: Types of intervention Interventions
Page 23 and 24: Box 2.2: Websites searched AFD (Age
Page 25 and 26: second stage previously described f
Page 27 and 28: using qualitative analysis to attem
Page 29 and 30: Figure 3.1: Filtering of papers fro
Page 31 and 32: Middle East and North Africa (8%) S
Page 33 and 34: Search results access or satisfacti
Page 35 and 36: 4. Synthesis results Summary Synthe
Page 37 and 38: Synthesis results Four studies focu
Page 39 and 40: Drug treatments (including micronut
Page 41 and 42: Synthesis results Training and audi
Page 43 and 44: Synthesis results order to be effec
Page 45 and 46: Synthesis results government admini
Page 47 and 48: HIV/AIDS and Malaria, as well as no
Page 49 and 50: Synthesis results ASSESSING THE COS
Page 51 and 52: and birthing care services, includi
Page 53 and 54: Synthesis results of settings were
Page 55: Figure 4.1: Causal chain for matern
Page 59 and 60: 5. Strengths and limitations Summar
Page 61 and 62: 6. Conclusions and recommendations
Page 63 and 64: Conclusions and recommendations Urb
Page 65 and 66: References Bakr A F, Karkour T (200
Page 67 and 68: References Deschamps M M, Noel F, B
Page 69 and 70: References Lim S, Dandona L, Hoisin
Page 71 and 72: References Shantharam Baliga B, Rag
Page 73 and 74: References Channon A A, Falkingham
Page 75 and 76: References Jowett M (2000) Safe Mot
Page 77 and 78: References Rice J, Rice J S (2009)
Page 79 and 80: Appendices Appendix 1.1: Authorship
Page 81 and 82: Appendix 2.1: Inclusion and exclusi
Page 83 and 84: Appendix 2.2: Search strategy for e
Page 85 and 86: Appendix 2.2 Infant* OR Matern* OR
Page 87 and 88: OR/ 12-13 11 AND 14 Limit 15 to pub
Page 89 and 90: Appendix 2.4: Journals handsearched
Page 91 and 92: POOR PROFILE Is the study populatio
Page 93 and 94: infants (
Page 95 and 96: Appendix 2.5 Intervention (surgical
Page 97 and 98: Appendix 2.5 Intervention (service
Page 99 and 100: MORTALITY OUTCOME TYPES Which morta
Page 101 and 102: positive neutral negative unclear/n
Page 103 and 104: yes no unclear/not stated N/A Study
Page 105 and 106: surveillance system none of the abo
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no SELECTION CHARACTERISTICS Is inf
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Appendix 2.5 QUANTITATIVE DATA ADJU
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RESEARCHER RELATIONSHIP Has the rel
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Were the inclusion/exclusion criter
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person-years). 3.5 Was follow-up ti
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Appendix 2.7 Appendix 2.7: Quality
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triangulation, or for not triangula
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Was the study approved by an ethics
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Item Yes No Not clear 3. The viewpo
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Appendix 2.9: Electronic databases
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Web of Knowledge (including ISI Cit
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Study Setting Intervention type Abo
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Study Setting Intervention type Alw
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Study Setting Intervention type Ben
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Study Setting Intervention type Ble
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Study Setting Intervention type Cob
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Study Setting Intervention type Des
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Study Setting Intervention type Faw
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Study Setting Intervention type Jak
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Study Setting Intervention type Kup
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Study Setting Intervention type Mar
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Study Setting Intervention type Nah
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Study Setting Intervention type Pad
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Study Setting Intervention type Str
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Study Setting Intervention type Zia
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Appendix 3.2 Adam G K, Abdulla M A,
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Appendix 3.2 Balkus J, Bosire R, Jo
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Appendix 3.2 Boerma J T, Stroh G (1
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Appendix 3.2 Chiwuzie J, Okojie O,
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Appendix 3.2 De Alencar A E, Arraes
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Appendix 3.2 Ekman B, Pathmanathan
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Appendix 3.2 Garg R, Omwomo W, Witt
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Appendix 3.2 Gupta R, Sachdev H P,
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Appendix 3.2 Hutton G, Schellenberg
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Appendix 3.2 Khandker S R, Latif M
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Appendix 3.2 Lindblade K A, Eisele
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Appendix 3.2 Menéndez C, Bardají
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Appendix 3.2 Nduati R, John G, Mbor
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Appendix 3.2 O'Rourke K (1995a) The
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Appendix 3.2 Prual A, De Bernis L,
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Appendix 3.2 Sabitu K, Alti-Mu'azu
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Appendix 3.2 Smith J B, Coleman N A
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Appendix 3.2 Van Rheenen P, De Moor
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Appendix 3.2 Xiang X, Wang L, Xu L
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Appendix 3.4 Appendix 3.4: Studies
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Appendix 3.4 International Bank for
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Appendix 3.5 Appendix 3.5: Studies
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Orji (2003) (-)/(-) Shihadeh (2001)
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Chinayon (1998) (+)/(+) Kamilya (20
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Nahar (2004) (-)/(-) Tukur (2007) (
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Ndibazza (2010) (++)/(+) Antiretrov
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Bergstrom (1991) (+)/(+) Women with
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Enakpene (2010) (+)/(-) Etuk (2000a
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Pereira (1996) (-)/(-) Saleem (2007
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Author (year) (IV)/(EV) Joshi (2007
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Author (year) (IV)/(EV) Aaby (2005)
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Author (year) (IV)/(EV) Martins (20
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Author (year) (IV)/(EV) de Muylder
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Author (year) (IV)/(EV) Provider mo
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Appendix 4.4: Included items dealin
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Author (year) (IV)/(EV) Target Popu
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Author (year) (IV)/(EV) Colonna (19
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Author (year) (IV)/(EV) Kuhn (2008)
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Author (year) (IV)/(EV) Target popu
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Author (year) (IV)/(EV) Mswia (2003
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Appendix 4.6: Included items dealin
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Appendix 4.8 Appendix 4.8: Economic
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Author (year) (IV)/(EV) and setting
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Appendix 4.9: Included items identi
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Author (year) (IV)/(EV) Poor urban
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Author (year) (IV)/(EV) Poor urban
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Appendix 4.10: High-quality include
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The authors of this report were sup
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