Targeted Interventions for Improved Equity in Maternal and Child Health in Low- and Middle-Income Settings: A Systematic Review and Meta-Analysis

BackgroundTargeted interventions to improve maternal and child health is suggested as a feasible and sometimes even necessary strategy to reduce inequity. The objective of this systematic review was to gather the evidence of the effectiveness of targeted interventions to improve equity in MDG 4 and 5 outcomes.Methods and FindingsWe identified primary studies in all languages by searching nine health and social databases, including grey literature and dissertations. Studies evaluating the effect of an intervention tailored to address a structural determinant of inequity in maternal and child health were included. Thus general interventions targeting disadvantaged populations were excluded. Outcome measures were limited to indicators proposed for Millennium Development Goals 4 and 5. We identified 18 articles, whereof 15 evaluated various incentive programs, two evaluated a targeted policy intervention, and only one study evaluated an intervention addressing a cultural custom. Meta-analyses of the effectiveness of incentives programs showed a pooled effect size of RR 1.66 (95% CI 1.43–1.93) for antenatal care attendance (four studies with 2,476 participants) and RR 2.37 (95% CI 1.38–4.07) for health facility delivery (five studies with 25,625 participants). Meta-analyses were not performed for any of the other outcomes due to scarcity of studies.ConclusionsThe targeted interventions aiming to improve maternal and child health are mainly limited to addressing economic disparities through various incentive schemes like conditional cash transfers and voucher schemes. This is a feasible strategy to reduce inequity based on income. More innovative action-oriented research is needed to speed up progress in maternal and child survival among the most disadvantaged populations through interventions targeting the underlying structural determinants of inequity.

研究背景：改善母婴健康的针对性干预措施，被视为减少健康不公平的可行路径，在部分场景下甚至是必要之举。本系统综述（systematic review）的研究目的为，收集针对改善千年发展目标4（MDG4）与千年发展目标5（MDG5）相关结局公平性的针对性干预措施的有效性证据。
研究方法与结果：我们通过检索9个健康与社会科学数据库（涵盖灰色文献（grey literature）与学位论文），纳入所有语言的原始研究。纳入标准为：研究需评估针对母婴健康不公平的结构性决定因素设计的干预措施的效果，因此仅针对弱势人群的一般性干预措施将被排除。结局指标限定于千年发展目标4与千年发展目标5所提出的相关指标。最终共纳入18篇文献：其中15篇评估了各类激励项目，2篇评估了针对性政策干预措施，仅1篇研究针对文化习俗相关的干预措施展开评估。针对激励项目有效性的Meta分析（Meta-analysis）结果显示：产前检查（antenatal care）就诊率的合并效应量为相对危险度（Relative Risk, RR）1.66（95%置信区间（Confidence Interval, CI）：1.43~1.93，共纳入4项研究、2476名受试者）；住院分娩率的合并效应量为RR 2.37（95%CI：1.38~4.07，共纳入5项研究、25625名受试者）。由于其余结局相关的研究数量过少，未对其开展Meta分析。
研究结论：旨在改善母婴健康的针对性干预措施，目前主要局限于通过各类激励机制（如有条件现金转移支付计划（conditional cash transfers）、代金券计划（voucher schemes））缩小经济层面的健康不公平。该策略是缩小收入相关健康不公平的可行路径。未来仍需开展更多创新性、以行动为导向的研究，通过针对健康不公平深层结构性决定因素的干预措施，加快改善最弱势人群的母婴生存状况。