Professor Deborah Baker Preventative Interventions to Reduce Maternal and Child Health Inequalities: Where is the evidence? Dr Helen Prosser Professor Deborah Baker Centre for Social Justice Research University of Salford, UK

Context Inequalities in health and access to health care is associated with low socio-economic status and ethnicity Emphasis in recent policy documents on the crucial role of preventative action as well as treatment for ensuring best possible child health Paramount in deprived areas where child poverty translates itself into social disadvantage and lower access to health care

Aim To review international literature on the effectiveness of healthcare interventions to improve child health in 3 public health areas that display clear inequalities: the initiation and continuation of breastfeeding smoking cessation in pregnancy the identification and treatment of postnatal depression.

Design Review focused on interventions delivered in health care settings Included evidence from systematic reviews, RCTs, Case Control studies and Cohort studies from 1990 onwards Searches done separately on populations of pregnant mothers and women with a child <24 months, teenage mothers (13-19) and by ethnic group

Findings: Breastfeeding International review of evidence found only 12 studies (7 RCTs and 5 cohort studies) that focused specifically on socio-economically disadvantaged populations Majority of studies conducted in the US (only 2 UK studies)

Findings: Breastfeeding Population interventions that work No recommendations could be made from the evidence Population interventions that may work Peer counselling /support (for low income Latino and African American women) Professional support e.g. lactation counselling/breast feeding clinics Hospital based initiatives e.g. Baby Friendly Initiative increase initiation but not duration Population Interventions that do not work Support from NCT/professional counsellors (UK study) Health education delivered by nurse/midwives Written literature alone or in combination with formal education

Findings: Smoking cessation Only 6 smoking cessation intervention studies were identified that recruit substantially from disadvantaged groups and that also include biochemical validation of self-reported smoking cessation. It was rare for studies to include information on child health outcomes - only one study included birth weight as an outcome measure Low income women can be of younger age than the norm or from Black or Hispanic ethnic groups - difficult to disentangle the independent effects of these socio-economic and demographic characteristics in smoking cessation interventions.

Findings: Smoking cessation Population interventions that work No recommendations could be made from the evidence Population interventions that may work interventions that take account of the social and psychological circumstances of low income women may have some limited effect in reducing smoking, e.g, those that include counseling for stress and depression or have some element of social or peer support. Population Interventions that do not work Self help information booklets Motivational interviewing by health professionals

Findings: Postnatal Depression Only 8 studies (incl. 1 pilot study) that focused specifically on socio-economically disadvantaged populations. Characteristically trials conducted with small samples - difficulty of recruiting and retaining disadvantaged groups, particularly for trials that involve a sustained period of treatment. Heterogeneity of research design, thus recommendations about efficacy problematic

Findings: Postnatal Depression Population interventions that work No recommendations could be made from the evidence Population interventions that may work Interpersonal therapy - incorporating components that augment social support and solve interpersonal problems linked to depression (for ethnically diverse, low income women) Population interventions that do not work Antenatal educational intervention (African American women) Home-visiting, postpartum support provided by trained individuals or health professionals (African American adolescents or low income women in UK)

Conclusions Given the emphasis on reducing health inequality in a global context, surprisingly little evidence about effective interventions for disadvantaged women to improve child health outcomes No international studies examining the effect of interventions on reducing inequalities between affluent and deprived groups Deficit of large-scale intervention studies that are sufficiently robust or have been replicated in enough settings to assess generalizability

Evidence base difficult to synthesise Significant heterogeneity between the type of intervention, the outcome variables and the populations targeted. Low SES women can be of younger age than the norm or from Black or Hispanic ethnic groups. It is difficult to disentangle the independent effects of these socio-economic and demographic characteristics in interventions in order to show what is effective for a particular group. Interventions vary according to the content and range of components, the type of provider, the mode, timing, intensity and duration of delivery and the outcomes measured. Lack of standardisation in defining and measuring outcomes

What works: Implications for Practice Peer Support Smoking cessation; breastfeeding - low income & minority ethnic women Multifaceted interventions (e.g. education, information, advice, counselling, professional/peer support) PND – low income women Breastfeeding - low income & minority ethnic women Psychosocial elements (small group-based or individual interpersonal psychotherapy) PND, low income mothers Written materials or self-help literature have little effect in isolation

Implications for Research Development of the evidence base Robust evidence not only about what works for different disadvantaged groups, but also what works to reduce inequalities between rich and poor areas Process evaluations and description of the content and delivery of an intervention and its control comparison Qualitative evidence about the services people need and more insight about determining factors underlying health related behaviours Development of evidence base for community-based as well as health care based initiatives