Linking political exposures to child and maternal health outcomes: a realist review

Maxwell S Barnish,Rebecca V H Nelson-Horne,Michelle Tørnes,Araz Taeihagh,G J Melendez-Torres,Si Ying Tan

doi:10.1186/s12889-021-10176-2

Abstract

BackgroundConceptual and theoretical links between politics and public health are longstanding. Internationally comparative systematic review evidence has shown links between four key political exposures – the welfare state, political tradition, democracy and globalisation – on population health outcomes. However, the pathways through which these influences may operate have not been systematically appraised. Therefore, focusing on child and maternal health outcomes, we present a realist re-analysis of the dataset from a recent systematic review.MethodsThe database from a recent systematic review on the political determinants of health was used as the data source for this realist review. Included studies from the systematic review were re-evaluated and those relating to child and/or maternal health outcomes were included in the realist synthesis. Initial programme theories were generated through realist engagement with the prior systematic review. These programme theories were adjudicated and refined through detailed engagement with the evidence base using a realist re-synthesis involving two independent reviewers. The revised theories that best corresponded to the evidence base formed the final programme theories.ResultsOut of the 176 included studies from the systematic review, a total of 67 included child and/or maternal health outcomes and were included in the realist re-analysis. Sixty-three of these studies were ecological and data were collected between 1950 and 2014. Six initial programme theories were generated. Following theory adjudication, three theories in revised form were supported and formed the final programme theories. These related to a more generous welfare state leading to better child and maternal health especially in developed countries through progressive social welfare policies, left-of-centre political tradition leading to lower child mortality and low birth weight especially in developed countries through greater focus on welfare measures, and increased globalisation leading to greater child and infant mortality and youth smoking rates in LMECs through greater influence of multinational corporations and neoliberal trade organisations.ConclusionWe present a realist re-analysis of a large systematically identified body of evidence on how four key political exposures – the welfare state, democracy, political tradition and globalisation – relate to child and maternal health outcomes. Three final programme theories were supported.

Highlights

Conceptual and theoretical links between politics and public health are longstanding
Following further assessment against the additional criterion for the realist review – that the studies included at least one child or maternal health outcome – a total of 67 studies were included in the realist review, while the remaining 109 were excluded due to ineligible outcomes, i.e. they did not contain results related to child and/or maternal health outcomes
A more generous welfare state has a beneficial effect on child and A more generous welfare state has a beneficial effect on child and maternal health outcomes including infant and maternal mortality maternal health outcomes including infant and maternal mortality (Outcomes) especially in low- and middleincome countries (LMECs) (Context) by improving the social (Outcomes) especially in developed countries (Context) by conditions especially of those who face deprivation and ensuring improving the social conditions especially of those who face they have what they need, including through progressive child- and deprivation and through progressive social welfare policies family-facing social policies (Mechanism)

Summary

Introduction

Conceptual and theoretical links between politics and public health are longstanding. Despite the existence of formal evidence-based systems for the licensing of medicines and medical devices especially in developed countries, many of the pathways through which influences on population health are generated and diffused are political [4, 5] and the influence of ideology can lead to marked evidence-policy gaps in health policy and other policy relevant to health [6] This may be seen as inevitable in a democracy where ‘politics has primacy’ and decisions can ‘never solely be made on evidence’ but will be informed by ideology, values, public opinion and lobbying [7]. In 2011, Muntaner et al [10] published a systematic review – the first of its kind – synthesising 73 internationally comparative studies linking four key political themes – the welfare state, political tradition, democracy and globalisation – with population health outcomes

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