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?
Published in: 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? (London: Department for International Development, 2012)
The burden of maternal and infant deaths falls disproportionately on low income countries (LICs) and lower middle income countries (LMCs1) and among the poorest within these countries. The causes of maternal and infant mortality and morbidity are well established, yet knowledge on effective management of conditions has not been translated into significantly improved outcomes because of a lack of resources and effective models of service delivery. Urban populations are often assumed to have better access to health care than those living in rural areas. However, urban health systems in many LICs and LMCs have a weak to non-existent public health structure and lack uniform implementation of strategies and necessary infrastructures. Given rapid urbanisation in many LICs and LMCs it is now crucial to establish evidence-based approaches to improving access to and uptake of maternal and infant care models in urban areas and improving quality of services in order to improve maternal and child outcomes. Whilst the medical solutions for preventing maternal and infant mortality are known, delivering these solutions is a considerable challenge in proximity to urban slums. OBJECTIVES: This systematic review addresses the question: 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? METHODS: Our systematic review focused on explicit evaluations of interventions aimed at improving health outcomes for poor people in urban areas. The review focused on maternal, infant, neonatal, perinatal and post-neonatal mortality outcomes, but also included maternal and infant health outcomes. Our review team, including information scientists and information retrieval experts, developed a search protocol and search terms that were subject to external peer review. Our search includes major databases that cover literature on this topic; these cover both English and non-English language material, including specialist health and development databases, as well as those focusing on specific geographical areas. A comprehensive search was conducted of published and unpublished materials. The search followed the study protocol, which set out the search strategy and selection methods. The study used multiple approaches to data analysis (including: narrative; cost-effectiveness; understanding links between the cause, approaches, outcomes and sustainability of change as part of a causal chain analysis) to assess not only which interventions are effective (or not), but how and under what circumstances. Quantitative and qualitative data were collected from and coded for included items, and each item was coded for a range of variables. Interventions were grouped into clinical and non-clinical categories. We collected qualitative evidence on contextual factors and causal pathways that may help to explain why interventions were (in)effective. Details of included studies The searches returned 9,025 potentially relevant items of evidence, including 9,010 from database searches and 15 from handsearches. Of these papers, 98% were excluded after reviewing titles; the abstracts of the remaining 114 studies date from 1989 to 2010. Our search strategy was limited to LICs and LMCs, and certain countries were prominent in the resulting database of evidence. A quality assessment was made on all items including the evaluation of both internal and external validity by means of standard tools. Internal validity concerns the accuracy of results; for example results could be inaccurate if samples were not selected randomly. External validity concerns the generalisability of the findings to the population. SYNTHESIS RESULTS: There are few published studies looking at interventions that specifically target the urban poor's access to and use of maternal and child health (MCH) services, and even fewer that use mortality indicators as one of their outcomes. No items were found that explicitly assessed the effectiveness of different models of service delivery to reduce maternal and infant mortality among poor urban populations. However it should also be acknowledged that studies that have been excluded from this analysis because they do not specifically focus on urban, poor populations will contain evidence on the effectiveness of different intervention models that could potentially be targeted at the urban poor. It is important to consider the extent to which these interventions could be applied to our target population. Of the items returned, 56% were classified as individual clinical interventions, leaving 44% in the non-clinical category. Of the "non-clinical" interventions, most consisted of systemic interventions such as provider models, information, audits, investment and scaling up, and financial protection. Of the non-clinical items, 26% included established groups of non-clinical interventions such as Kangaroo Mother Care and nutrition approaches such as breastfeeding promotion. Most of the studies that concerned purely clinical interventions -- although pertaining to urban populations -- are applicable in rural areas. Interest in our review focused mainly on the non-clinical findings -- as these are judged to be closer to the wider conceptualisation of "models of delivery" which has been key to implementation but less of a focus among researchers. CONCLUSIONS AND RECOMMENDATIONS: Our analyses form a convincing case that there is a need for high-quality evidence on maternal and infant interventions that specifically target the urban poor. The existing evidence base is minuscule compared to the rapidly growing and large urban poor population. Much of the existing evidence is of poor quality, with little emphasis on baselines and follow-up studies, and almost no qualitative (how? why?) evidence to complement the limited quantitative (what?) data. This small evidence base is out of step with the growing interest in urban poor people and the size of this population. Interventions supported by the review are already present in existing WHO guidelines. However, there is a need for research that specifically addresses the effectiveness of different models of service delivery, including how sub-populations (e.g., urban poor) are targeted. Although the evidence base appears limited, there are in fact a number of ways in which it might be strengthened in the short term. We suggest one way of strengthening the evidence base on the cost-effectiveness of different strategies to promote better access and use of maternal and infant health services. This would be to retrospectively make use of data looking at the uptake and effectiveness of actions that help increase uptake from papers identified in this review, then estimate the costs of implementation, including their impact on the future use of health services or on other economic costs if mortality (and morbidity) were avoided.