Saving Moms and Babies; What Does the Impact Evaluation Evidence Show?

1. Saving Moms and Babies;What Does the Impact Evaluation Evidence Show? Jeffery C Tanner, Team Leader jtanner@worldbank.org

2. 1. Introduction to Systematic Reviews2. SR on Maternal & Child Mortality3. Results4. Knowledge Gaps5. Summing Up

3. Evidence-Based Decision-Makingthe contribution of Systematic Reviews • “Sum up the best available research on a specific question” (The Campbell Collaboration) • Make strong claims on comprehensiveness of search • Are a form of research • Unit of Analysis: Secondary observations (Studies) • Follow basic steps of research process • Aim to minimize bias and error

4. Why do we need systematic reviews? • Sheer amount and flow of information/ research • Variable quality of research outputs • Need to ‘separate the wheat from the chaff’ • Problems of publication bias • Limitations of single studies

5. 2. SR on Maternal & Child Mortality

6. MDGs 4 and 5 Continue to Lag • MDG5: ¾ Reduction in Maternal Mortality by 2015 • Main Indicator: Proportion of births attended by skilled health personnel • MDG4: 2/3 Reduction in Under-Five Mortality • Knowing what to do is no longer the problem; knowing how to do it remains a challenge

7. Objective of this Systematic Review • Scope: Reviews impact evaluations of interventionsto improve five MCH outcomes (SBA, MM, NM, IM, U5M) and those of SBA as an intervention from scalableprograms in IDA/IBRD countries • Outcome-oriented approach: Include full range of interventions • Aims to answer the following questions: • What interventions demonstrate reductions in maternal and child mortality and increase skilled birth attendance? • What do we know about the effects of increasing skilled birth attendance? • What important knowledge gaps remain on interventions to reduce maternal and child mortality?

8. Frequency of Impact Evaluations by Outcome and Quality • AAA-quality Impact Evaluations: Established Causality • Few, if any, remaining threats to internal validity. • AA-quality Impact Evaluations: Likely Causality • Some identifying assumptions untested or unclear • Consistency Analysis. Key Results driven by AAA-rated IES • External Validity, Construct Validity also considered

9. 3. Results

10. Standardized Effect Size: SBA—Outcome

11. Results: Increasing Skilled Birth Attendance—Outcome • Skilled Birth Attendance rates can be improved through • Conditional Cash Transfers and Vouchers • Interventions that bundle quality improvements with increased accessibility • Solely training health workforce or increasing awareness of safe motherhood was not observed to yield significant results on SBA rates. • Where reported, effects are larger for more disadvantaged households

12. Results: Skilled Birth Attendance – Intervention • No Robust Evidence that solely increasing proportion of births with SBA affects mortality • Only evaluated program is JSY in India: Null results for NM • 2 IEs, AAA and AA quality, both high-powered • No effect even in areas with high (or low) quality of health services • Critical Knowledge gap: Need more IEs on this MDG indicator • SBA “+” Can affect mortality and intermediate outcomes • PLUS=Provision & Utilization: quality of care, knowledge, access • But evidence is mixed across outcomes, even within a given study • Unclear what explains variation in results • Consistent, if thin, evidence on better U5M, Breastfeeding, Family planning, Postnatal visits, Immunization, Anthropometric outcomes

13. Intermediate Outcomes of SBA as an Intervention • SBA PLUS = Provision & Utilization • Quality of care, knowledge, access • Consistent, if thin, evidence that SBA+ results in better • U5M • Breastfeeding • Family planning • Postnatal visits • Immunization • Anthropometric outcomes

14. Results: Maternal Mortality • Few (8) studies exist, concentrated in SA (5) • Most studies underpowered to detect effects in MM • Interventions bundling components of both health care provision and utilization can reduce maternal mortality. • Specifically, bundling health worker training and mothers’ knowledge and information (with and without insurance) • More evaluations are needed • 3 Delay Model, especially transport and referral systems • Family planning, universal health

15. Results: Neonatal Mortality • Health: Knowledge & Information interventions in the sample which change home-based care practices at the community level reduced mortality • Non-health: Interventions in non-health sectors associated with maternal education consistently lowered neonatal mortality • More IEs are needed in • 3 Delay Model, esp. Transportation and Referral Systems • Improvements in Quality and Availability of Health Infrastructure for newborns

16. Infant Mortality • Interventions in non-health sectors consistently reduced IM • Water and Sanitation • Energy • Education • Governance interventions report significant effects in lowering infant mortality • Training health workers to provide continuum of care services within communities can reduce IM • Where reported, households from lower SES benefited more

17. Under-Five Mortality Interventions in non-health sectors consistently report large reductions in under-five mortality. Public Participation, Service Packages may reduce U5M Insecticide Treated Nets are only intervention targeting three main causes of mortality that has IE evidence on U5M

18. 4. Knowledge Gaps

19. Gaps by Region 1 IE 1 MM 1 IM 0 IEs 15 IEs 10 SBA 2 MM 4 NM 7 IM 3 U5 28 IEs 15 SBA 5 MM 18 NM 6 IM 4 U5 15 IEs 3 SBA 1 NM 9 IM 7 U5 9 IEs 5 SBA 3 NM 3 U5

20. Gaps by Severity

21. Other Gaps in Impact Evaluation Evidence • By Outcome • Maternal Mortality: limited number of studies but highly concentrated in South Asia (5 out of 8) • By Intervention Type • 3 Delay Model (especially transport and referral systems) • Governance • Health information systems, infrastructure, financing • Income generating / Labor market interventions • Transportation infrastructure

22. External Validity Implications: Beneficial Impacts are more likely in problematic areas Neonatal Mortality Skilled Birth Attendance Infant Mortality Under-Five Mortality

23. 5. Summing Up

24. Key Messages • There is no IE evidence that increasing skilled birth attendance alone reduces maternal or neonatal mortality: • Importance of EVIDENCE-BASED INDICATORS for post-MDGs • Slow progress on MDGs 4 & 5, but evidence of effective interventions • SBA: vouchers, CCTs, bundled interventions • MM: SBA+ combining provision and utilization elements • NM: knowledge & information, maternal education • IM: Governance, Energy, WASH, Ed; training community health workers • U5: Gov & Participation, WASH, Education; health Service Packages, ITNs • Countries & households with higher burdens may see larger results • Important knowledge gaps remain • Intervention: including SBA, Nutrition, 3 Delays Model (esp transportation) • Evaluation components (subgroup analysis)

25. Thank You! • The Systematic Reviewcan be downloaded from • https://ieg.worldbankgroup.org/Data/reports/mch_eval.pdf • The Database of all IEs is at • https://ieg.worldbankgroup.org/Data/mch/mch_dataset.xlsx

26. General Systematic Review resources and international bodies • Cochrane Collaboration; 1993; www.cochrane.org • Producing high quality information about the effectiveness of health care (> 5000 published online – Cochrane library) • Campbell Collaboration; 2000; www.campbellcollaboration.org • Producing systematic reviews of the effects of social interventions (>200 published online – Campbell library) • International Development Coordinating Group (IDCG); 2010 www.campbellcollaboration.org/international_development • Producing systematic reviews of high policy-relevance focusing on social and economic development interventions in LMICs • International Initiative for Impact Evaluation, 3ie; 2008 www.3ieimpact.org/en/evidence/systematic-reviews • EPPI Centre - An Institute of Education centre focusing on systematic reviews in education, health and social policy • Collaboration for Environmental Evidenceproducing systematic reviews for environmental management

27. Backup Slides

28. Overview Introduction Methods Results Knowledge Gaps Summing Up

29. 1. Introduction

30. MDGs 4 and 5 Continue to Lag • MDG5: ¾ Reduction in Maternal Mortality by 2015 • Main Indicator: Proportion of births attended by skilled health personnel • MDG4: 2/3 Reduction in Under-Five Mortality • Knowing what to do is no longer the problem; knowing how to do it remains a challenge

31. Role of IEG • Independent Evaluation in the World Bank Group • Impact Evaluations in the World Bank Group • Why this Systematic Review • Are we doing the right things to achieve MDGs? • Compare Causal evidence vs Bank Portfolio • Compare stock vs need of evidence, regionally

32. 2. Methods

33. Search Process • 3 Search Rounds • Electronic, “hand” and snowball search strategies • Review and coding into 300+ fields • 7,000  62 studies • Quality ratings by Internal Validity • Elements of Construct and External Validity also considered

34. Challenges and Cautions for Systematic Reviews • Representativeness of Interventions—non-random selection • Overrepresentation of easily evaluable interventions • Focus on “reduced form” studies excludes those with intermediate outcomes • Lack of evidence does not imply no effect • Representativeness of Impact Evaluations • Includes only existing studies • Publication bias (file drawer bias) • Interpretation of Results • IEs measure partial equilibrium; general equilibrium may be different • Null results must be interpreted carefully—we never “accept” zero • External validity—changes to time, place, or scale may affect results

35. Standardized Effect Size: Maternal Mortality

36. Standardized Effect Size:Neonatal Mortality

37. Search Criteria • Impact Evaluations • Experimental or Quasi-Experimental design • Counterfactual • Completed 1995 – Present • Effectiveness / Policy / Field studies • (Rather than bio-medical and efficacy trials) • Low and Middle-Income Countries • Representative Sample of population of interest • Peer Review • Report impacts on at least 1 outcome of interest • Skilled Birth Attendance, Maternal Mortality • Neonatal, Infant, Under-five Mortality

38. What of Nutrition? • No studies on nutrition explicitly; some “bundling” • Mortality Outcomes • Effectiveness, not clinical/efficacy • 18/93 studies mentioned “nutrition” or supplements (or variants) • 3 AAA—Intervention: Supplements to moms/kids • 2 on Progresa CCT in Mexico—Impacts on IM; not significant for NM, SBA • 7 AA, only 3 Interventions (4 Outcomes) • Bangladesh—Converted nutrition workers to Kangaroo Care; not significant for NM, IM • Bangladesh—Family planning through Community Health Workers; highly significant for U5 • Vietnam—Provided training in child malnutrition; not significant for SBA • 6/93 with Breastfeeding: 3 AAA (all India), 3AA (India, Pakistan, Bangladesh) • 5 Bundled Interventions—all reduced NM, none improved SBA • CHW in India also reduced IM • Women’s Group in India not significant for MM

39. Standardized Effect Size:Infant Mortality

40. Standardized Effect Size:Under-Five Mortality

41. IEs of World Bank Funding and Projects: Mortality No significant results for maternal or neonatal mortality Significant, but often small effects on infant mortality. Larger for U5.

42. IEs of World Bank Funding & Projects:Skilled Birth Attendance (Outcome) SBA often significant, but small effect size Of 15 IEs on World Bank, 11 from 3 countries SBA & IM IEs concentrated in regions with 2nd –lowest burden

43. Specific Knowledge Gaps • SBA: no robust evidence that solely increasing proportion of births with SBA affects mortality • Mortality: • Maternal Mortality: limited number of studies but highly concentrated in South Asia (5 out of 8) • Child Mortality: needs attention to IE quality and intervention details • More high quality evaluations are needed • Family planning, universal health • Improvements in quality and availability of health Infrastructure for newborns • “3 Delay” models (especially Transport and Referral Systems)

44. What makes a systematic review ‘systematic’? • Scoping: defining answerable question, methods set out in study protocol • Rigorous search to identify published and unpublished sources, in any language • Application of study inclusion criteria (PICOS) • Critical appraisal of study quality, to assess how reliable is the evidence • Data extraction and organisation • Synthesis of evidence (outcomes along causal chain) • Interpreting results (policy and practice, research recommendations) • Improving and updating reviews as new evidence emerges