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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