TThis presentation was given by Helen de Pinho of Averting Maternal Death and Disability (AMDD) at Columbia University.

This presentation, given at the First Global Symposium on Health Systems Research, outlines the complexity of public health interventions and provides guidance and advice for using a realist evaluation approach.

This is the first of seven articles from a preterm birth and stillbirth report. Presented here is an overview of the burden, an assessment of the quality of current estimates, review of trends, and recommendations to improve data.

‘Capacity building’ is the objective of many development programmes and a component of most others. However, satisfactory definitions continue to elude us, and it is widely suspected of being too broad a concept to be useful. Too often it becomes merely a euphemism referring to little more than training. This paper argues that it is more important to address systemic capacity building, identifying a pyramid of nine separate but interdependent components. These form a four-tier hierarchy of capacity building needs: (1) structures, systems and roles, (2) staff and facilities, (3) skills, and (4) tools. Emphasizing systemic capacity building would improve diagnosis of sectoral shortcomings in specific locations, improve project/programme design and monitoring, and lead to more effective use of resources. Based on extensive action research in 25 States, experience from India is presented to illustrate how the concept of the capacity building pyramid has been put to practical use.

Efforts to achieve the Millennium Development Goals (MDGs) to improve maternal and child health can be accelerated by addressing preterm birth and stillbirth. However, most global health stakeholders are unaware of the inextricable connections of these adverse pregnancy outcomes to maternal, newborn and child health (MNCH). Improved visibility of preterm births and stillbirths will help fuel investments and strengthen commitments in the discovery, development and delivery of low-cost solutions globally. This article addresses potential barriers and opportunities to increasing global awareness and understanding.

The efficacious interventions identified in the previous article of this report will fail unless they are delivered at high and equitable coverage. This article discusses critical delivery constraints and strategies.

No mother, anywhere in the world, should have to risk her life and that of her baby by going through childbirth without expert care. But every year 48 million women give birth without someone present who has recognised midwifery skills. More than 2 million women give birth completely alone, without even a friend or relative present to help them, making these some of the most dangerous moments of their lives.

 

The global shortage of 350,000 midwives means that many women and babies die from complications that could easily be prevented by a health worker with the right skills, the right equipment and the right support. There are 358,000 maternal deaths annually, and more than 800,000 babies die during childbirth each year. Millions more newborn lives are lost in the first month of life. If births were routinely attended by midwives and skilled birth attendants with the right training and support, the lives of 1.3 million newborn babies a year could be saved.

Interventions directed toward mothers before and during pregnancy and childbirth may help reduce preterm births and stillbirths. Survival of preterm newborns may also be improved with interventions given during these times or soon after birth. This comprehensive review assesses existing interventions for low- and middle-income countries (LMICs).

This paper offers a model of research synthesis which is designed to work with complex social interventions or programmes, and which is based on the emerging ‘realist’ approach to evaluation. It provides an explanatory analysis aimed at discerning what works for whom, in what circumstances, in what respects and how.The first step is tomake explicit the programme theory (or theories) -- the underlying assumptions about how an intervention is meant to work and what impacts it is expected to have. We then look for empirical evidence to populate this theoretical framework, supporting, contradicting or modifying the programme theories as it goes. The results of the review combine theoretical understanding and empirical evidence, and focus on explaining the relationship between the context in which the intervention is applied, the mechanisms by which it works and the outcomes which are produced. The aim is to enable decision-makers to reach a deeper understanding of the intervention and how it can bemade to work most effectively.