Interventions to Reduce Maternal Mortality in Developing Countries: A Systematic Synthesis of Evidence. Systematic Reviews of Evidence, Meta-Analysis and Meta-Synthesis A thesis submitted to the University of Birmingham for the Degree of Doctor of Philosophy by Amie Wilson School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, The University of Birmingham August 2013 i University of Birmingham Research Archive e-theses repository This unpublished thesis/dissertation is copyright of the author and/or third parties. The intellectual property rights of the author or third parties in respect of this work are as defined by The Copyright Designs and Patents Act 1988 or as modified by any successor legislation. Any use made of information contained in this thesis/dissertation must be in accordance with that legislation and must be properly acknowledged. Further distribution or reproduction in any format is prohibited without the permission of the copyright holder. ABSTRACT Background: Every year 287,000 women die from pregnancy related complications. Methods: Systematic reviews of interventions to reduce maternal mortality in developing countries with meta-analysis or meta-synthesis where appropriate. Results: Participatory learning and actions cycles with women’s groups significantly reduce maternal and neonatal mortality, training and supporting TBAs also reduces perinatal mortality. Clinical officers performing caesareans section do not seem to cause any more maternal or perinatal mortalities than doctors. Prophylactic antibiotics reduce infectious morbidity in surgical abortion, yet the effect on miscarriage surgery is unclear. Cell salvage in ectopic pregnancy and caesarean section appear to be a safe and effective alternative in the absence of homologous transfusion. Motivational interviews may have potential to improve contraceptive use short term. Symphysiotomy may be a safe alternative to caesarean section. The anti-shock garment may improve outcomes when used in addition to standard obstetric haemorrhage management. Potential solutions to emergency transport for pregnant women include motorcycle ambulance programmes, collaboration with local minibus taxis services, and community education and insurance schemes. Conclusion: Several interventions reviewed in this thesis can be utilised to aid reduction in maternal mortality, however the level of evidence available within each review varies, some allowing firm inferences with others more tentative. i DEDICATION For every mother who has suffered whilst giving life to their child ACKNOWLEDGEMENTS I would like to sincerely and deeply thank my loved ones and closest friends for their unwavering and untiring emotional support, continual belief and relentless encouragement, particularly Mum, Dad and Abbie. I am greatly indebted to both my supervisors for their support and guidance, Professor Arri Coomarasamy and Professor Christine MacArthur. I would like to thank all co-reviewers featured in this thesis; David Lissauer, Sarah Hillman, Rita Champaneria, Nieves Plana, Javier Zamora, Ioannis Gallos, Hoda Harb, Mikey Rosato, Anthony Costello, Julia Hussein, Audrey Prost, Hoda Harb, Krishnarajah Nirantharakumar, Nadine Steward and Ewa Truchanowicz Finally, I would like to thank all the members at Ammalife for their dedication to making improvements to maternal health care for the world’s poorest women. ii Contents CHAPTER 1: INTRODUCTION ............................................................................................................... 1 CHAPTER 2: METHODS FOR SYSTEMATIC REVIEWS, META-ANALYSIS AND META-SYNTHESIS ....... 30 CHAPTER 3. EFFECTIVENESS OF STRATEGIES INCORPORATING TRAINING AND SUPPORT OF TRADITIONAL BIRTH ATTENDANTS ON PERINATAL AND MATERNAL MORTALITY: META-ANALYSIS ... 46 ABSTRACT .......................................................................................................................................... 46 3.1 BACKGROUND ....................................................................................................................... 47 3.2 METHODS .............................................................................................................................. 49 3.3 RESULTS ................................................................................................................................. 52 3.4 DISCUSSION ........................................................................................................................... 73 3.5 CONCLUSION ......................................................................................................................... 76 CHAPTER 4: WOMEN’S GROUPS PRACTISING PARTICIPATORY LEARNING AND ACTION TO IMPROVE MATERNAL AND NEWBORN HEALTH IN LOW-RESOURCESETTINGS: A SYSTEMATIC REVIEW AND META-ANALYSIS .......................................................................................................... 78 ABSTRACT .......................................................................................................................................... 78 4.1 BACKGROUND ....................................................................................................................... 79 4.2 METHODS .............................................................................................................................. 82 4.3 RESULTS ................................................................................................................................. 84 4.4 DISCUSSION ........................................................................................................................... 94 4.5 CONCLUSION ......................................................................................................................... 98 CHAPTER 5: MATERNAL EMERGENCY TRANSPORT IN LOW AND MIDDLE INCOME COUNTRIES: A SYSTEMATIC REVIEW AND THEMATIC SYNTHESIS OF QUALITATIVE STUDIES .................................... 110 ABSTRACT ........................................................................................................................................ 110 5.1 BACKGROUND ..................................................................................................................... 111 5.2 METHODS ............................................................................................................................ 113 5.3 RESULTS ............................................................................................................................... 115 5.4 DISCUSSION ......................................................................................................................... 130 5.5 CONCLUSION ....................................................................................................................... 135 CHAPTER 6: CAN MOTIVATIONAL INTERVIEWS IMPROVE CONTRACEPTIVE COMPLIANCE AND REDUCE UNMET CONTRACEPTIVE NEED: A SYSTEMATIC REVIEW AND META-ANALYSIS .................. 144 ABSTRACT ........................................................................................................................................ 144 6.1 BACKGROUND ..................................................................................................................... 145 6.2 METHODS ............................................................................................................................ 147 6.3 RESULTS ............................................................................................................................... 151 6.4 DISCUSSION ......................................................................................................................... 165 6.5 CONCLUSION ....................................................................................................................... 169 CHAPTER 7: A COMPARISON OF CLINICAL OFFICERS WITH MEDICAL DOCTORS ONOUTCOMES OF CAESAREAN SECTION IN THE DEVELOPING WORLD: META-ANALYSIS OF CONTROLLED STUDIES .... 180 iii ABSTRACT ........................................................................................................................................ 180 7.1 BACKGROUND ..................................................................................................................... 181 7.2 METHODS ............................................................................................................................ 185 7.3 RESULTS ............................................................................................................................... 187 7.4 DISCUSSION ......................................................................................................................... 199 7.5 CONCLUSION ....................................................................................................................... 202 CHAPTER 8: PROPHYLACTIC ANTIBIOTICS FOR UTERINE EVACUATION: A SYSTEMATIC REVIEW AND META-ANALYSIS .................................................................................................................................. 205 ABSTRACT ........................................................................................................................................ 205 8.1 BACKGROUND ..................................................................................................................... 206 8.2 METHODS ............................................................................................................................ 211 8.3 RESULTS ..............................................................................................................................