| BackgroundResearchers will encounter potential problems of incomparability and non-standardized intervention when evaluating community based large scale health program. Non-standardized intervention generates different intervention subgroups in different sites and the direct comparison of the indicators with combined subgroups is unreasonable, which will cause biased and even false conclusion. It is necessary to put the data of sub-groups together with technical methods. One of the methods is called prospective Meta-analsysis, which has been applied to evaluate multisite large scale social program for a few years abroad while there are few similar study in China.ObjectivesThe overall objective is to explore if prospective Meta-analysis can be used to evaluate large scale community based health program. Evaluation of CHIMACA project on the quality of hospital delivery services was taken as an example. Specific objectives are to evaluate the effectiveness of CHIMACA projects in three provinces respectively with routine statistical methods; to apply prospective Meta analysis to evaluate the impact of intervention on the quality of hospital delivery services; to explore the impact of context variables such as residence registration and family planning policy on hospital delivery services.Data and Methods(1)Data sources:The CHIMCACA project was conducted in Anhui, Chongqing and Shaanxi,2 counties in Anhui,2 counties in Shaanxi and 1 county in Chongqing. In Anhui,30 townships from 2 counties were covered, which included 6 townships for clinical skill training,8 for health education training,6 for economic intervention and 10 for control; In Chongqing, 20 townships from 1 county were covered, which included 6 townships for clinical skill training,7 for health education training and 7 for control; In Shaanxi,53 townships of the 2 counties were covered, which included 21 townships for clinical skilling training,10 for health education training,12 for economic intervention, and 10 for control. The' intervention of CHIMACA project lasted for one year starting from the end of 2007. All the townships of CHIMACA project were covered by the post-intervention interview, from which 1/3 villages per township were sampled, and all the women who gave birth during Jan 1st 2008-Dec 31st 2008 in these villages were interviewed by structured questionnaire, which included pregnant women's demographic data, data on prenatal care, delivery care and postnatal care.(2) Indicators for evaluation:The indicators include hospital delivery rate, CS rate, whether the doctor gave advice on staying in hospital before and after delivery, compliance of pregnant women, women's satisfaction with quality of the care, hospital environment and providers'attitude towards them, whether the women gave advice to other pregnant women to give birth in the same hospital et al.(3) Statistical analysis:The adjustedχ2 test was used to analyze the data of individual province in order to meet requirement of the cluster randomized design; Prospective Meta-analysis was used to analyze data of three provinces together with aggregate and individual analysis respectively.Results(1) Results of individual sites:The hospital delivery rate in all the groups of Anhui was up to 100%; and the CS rate was more than 65% in all the groups, the CS rate in health education training group was 82.4%. Health education training on professionals promote the doctors to give advice to women on staying in hospital before (OR=1.462) and after delivery (OR=4.528); women in the economic intervention group showed better compliance (OR=1.846); The women's satisfaction on quality of care, delivery environment, midwives's attitude towards women et al were not improved by any intervention.The hospital delivery rate in all the groups of Chongqing was more than 96%. The rate reached 100% in clinical skill intervention group; the average CS rate was about 40%, and the CS rate in intervention groups were higher than control, but without statistical significance; Interventions did not promote the doctors to give advice to women on staying in hospital before and after delivery, and there is no difference between intervention groups and control on women's compliance; women in clinical intervention group showed higher satisfaction than control on quality of care, but no difference on the satisfaction in delivery environment, midwives'attitude towared women et alThe hospital delivery rate in all the groups of Shaanxi was more than 96.5%, The rate reached 99.3% in economic intervention group; CS rate in all the groups stayed in a reasonable range and economic intervention and health education training well controlled CS rate (OR=0.306 and 0.593 respectively); economic intervention promoted the doctors to give advice on staying in hospital before and after delivery, besides, clinical skill training showed similar effect on staying in hospital after delivery; clinical skill straining and economic intervention improved women's compliance (OR=2.289 and 6.932 respectively); economic intervention improved women's satisfaction on quality of care (OR=1.863), delivery environment (OR=4.936) and behavior intention (OR=7.896).(2)Overall evaluation by Meta-analysis:individual data analysis showed that none of the interventions improved the hospital delivery rate while unapproved birth reduced hospital delivery rate (OR=0.4967). There was a association between the distance of women's home to village clinics and hospital delivery rate.Aggregate data analysis did not showed any effect of intervention on CS rate; however, individual data analysis showed that economic intervention reduced the CS rate (OR=0.4989); CS rate was higher in the groups of unapproved birth and was lower in the Groups of lower education (＜6 years) (OR=1.428 for unapproved birth and OR=0.7650 for lower edcuation).Individual data analysis showed that economic intervention and health education training promoted the doctors to give advice to women on staying in hospital before delivery (OR=1.965 and 1.746 respectively), besides. Individual data analysis showed that economic intervention improved women's compliance (OR=7.050); in contrast, lower educated women's compliance was low (OR=0.6975).Neither aggregate data nor individual data analysis found that intervention improved women's satisfaction with quality of care, delivery environment or midwives'attitude towards woemen.Individual data analysis showed that economic intervention (OR=2.983) and health education straining (OR=1.901) promoted women to give advices to other pregnant women to give birth at the same hospital. The distance between women's home and township hospital was a factor influencing women's intention to give advices on choosing delivery hospital (OR= 1.0566). Migrant women were less willing to give the advices to other women on choosing delivery hospital (OR=0.5823).Conclusion:Prospective Meta-analysis shares the same theory as tranditional retrospective Meta-analysis while the former overcomes the shortcomings of retrospective Meta-analysis such as publishing bias. Prospective Meta-analysis is an appropriate method for the overall evaluation of multisite large scale health program. Acording to the overall evalution of CHIMACA Project by prospective Meta-analysis, we got the conclusion on whether the interventions work. It was hard to get a clear conclusion on the level of individual site when some sites showed effect but some others did not. Clustered randomization, intervention groups more than 2 and heterogeneity should be carefully handled. In this care individual data analysis is the choice.CHIMACA project has some impact on the quality of hospital delivery, which was generally contributed by economic intervention; the impact of clinical skill straining and health education training was not strong enough. Improving the rate of hospital delivery is no longer the first priority in the areas where the economic level has been developed; Controlling CS rate in a reasonable range, improving the quality of delivery services as a whole should be carefully considered.
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