McPake Barbara, Koblinsky Marge
Institute for International Health and Development, Queen Margaret University, Queen Margaret University Drive, Musselburgh, East Lothian, EH21 6UU, UK.
J Health Popul Nutr. 2009 Apr;27(2):93-107. doi: 10.3329/jhpn.v27i2.3324.
Technical interventions for maternal healthcare are implemented through a dynamic social process. Peoples' behaviours--whether they be planners, managers, providers, or potential users--influence the outcomes. Given the complexity and unpredictability inherent in such dynamic processes, the proposed cause-and-effect relationships in any one context cannot be directly transferred to another. While this is true of all health services, its importance is magnified in maternal healthcare because of the need to involve multiple levels of the health system, multiple types of care providers from the highly skilled specialist to community-level volunteers, and multiple technical interventions, without the ability to measure significant change in the outcome, the maternal mortality ratio. Patterns can be followed however, in terms of outcomes in response to interventions. From these case studies of implementation of maternal health programmes across five states of India, Pakistan, and Bangladesh, some patterns stand out and seem to apply virtually everywhere (e.g., failure of systems to post staff in difficult areas) while others require more data to understand the observed patterns (e.g., response to financial incentives for improving maternal health systems; instituting available accessible safe blood). The patterns formed can provide guidance to programme managers as to what aspects of the process to track and micro-manage, to policy-makers as to what features of a context may particularly influence impacts of alternative maternal health strategies, and to governments more broadly as to the factors shaping dynamic responses that might themselves warrant intervention.
孕产妇保健的技术干预措施是通过一个动态的社会过程来实施的。人们的行为——无论是规划者、管理者、提供者还是潜在使用者——都会影响结果。鉴于这种动态过程中固有的复杂性和不可预测性，任何一种情况下提出的因果关系都不能直接套用到另一种情况。虽然所有卫生服务都是如此，但在孕产妇保健中其重要性更为突出，因为需要涉及卫生系统的多个层面、从高技能专家到社区志愿者等多种类型的护理提供者以及多种技术干预措施，而无法衡量结果（孕产妇死亡率）的显著变化。然而，可以根据干预措施的结果来探寻模式。从印度、巴基斯坦和孟加拉国五个邦实施孕产妇保健项目的这些案例研究中，一些模式凸显出来，似乎在各地都适用（例如，系统未能在困难地区派驻工作人员），而其他一些模式则需要更多数据来理解所观察到的模式（例如，对改善孕产妇保健系统的财政激励措施的反应；建立可获取的安全血液供应）。所形成的模式可以为项目管理者提供指导，告知他们在过程中要跟踪和微观管理哪些方面；为政策制定者提供指导，告知他们哪些背景特征可能特别影响替代孕产妇保健策略的效果；并为更广泛的政府提供指导，告知他们塑造动态反应的因素，而这些因素本身可能需要进行干预。
