1. 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

2. 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

3. 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.

4. 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

5. 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)

6. 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

7. 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.

8. 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

9. 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

10. 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)

11. 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

12. 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

13. 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

14. 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