Full Report - Research for Development - Department for ...

Background
many LICs and LMCs, it is now crucial to establish evidence-based ways of
improving models of service delivery and access to and uptake of maternal and
infant care in order to improve maternal and child outcomes.
Levels of infant mortality are often lower in urban areas than in rural at the
aggregate level (UNSD, 2008). However recent trends have shown mortality
improvements in the rural areas and increases in the urban areas with the
exception of a few South Asian countries (UNSD, 2008). Central American and
central Asian countries often show a higher level of mortality in urban areas than
rural. This is possibly due to the rapid urbanisation, which often occurs without
appropriate planning for infrastructure and health services. The differences
become even more striking when we consider the gap between the poor and the
rich. While we have a more even distribution in rural areas, the inequality within
urban areas is often striking. A recent study in sub-Saharan African (SSA) countries
(Anyamele, 2011) showed a considerably higher level of infant mortality in rural
areas, but also a high level of variation within urban areas when considering level
of wealth. However, data on maternal mortality by residence is very hard to
estimate due to the small numbers. One recent study by Matthews et al. (2010)
shows how the urban advantage is almost non-existent when we account for wealth
levels within areas. In urban areas, they remark that this is mainly due to poverty
marginalisation, which prevents access to care.
Despite growing evidence of poor maternal and infant health outcomes and
inequalities within urban areas of low income countries, a systematic analysis and
synthesis of evidence as to effective models of service delivery is lacking. The aim
of our study was to conduct a robust systematic review to address the question:
What are the effects of different models of delivery for improving
maternal and infant health outcomes for poor people in urban areas in low
income and lower middle income countries?
Through the systematic review we aim to provide important information and draw
out key recommendations for policy makers at international, national and subnational
levels.
1.2 Definitional and conceptual issues
1.2.1 The urban poor: who and where? 2
Urban growth – including the absolute and relative number of urban dwellers and
the physical expansion of urban areas – is ‘reshaping’ population health,
particularly among the urban poor (Commission on Social Determinants of Health,
2008, p.4). By 2050, there will be an estimated 6.4 billion urban dwellers,
compared to 3.4 billion in 2009 (UNHABITAT, 2010), and the global future has been
described as a ‘planet of cities’ (Angel et al., 2011).
By 2050 it is estimated that seven out of every ten people will live in a city, with
almost all of this growth taking place in developing countries. It is estimated that
one in three urban dwellers lives in a slum, meaning that an estimated 828 million
people are currently living in informal settlements, producing so-called ‘hidden
cities’ (UNHABITAT, 2010). More than 90 percent of slums are located in cities in
developing countries, and those cities that are the fastest growing are most likely
to have informal settlements. In sub-Saharan Africa, it is estimated that more than
60 percent of city dwellers inhabit slums (UNHABITAT, 2010).
2 Unless stated otherwise, all data are drawn from United Nations Department of Economic and Social
Affairs (2010) and UNHABITAT (2010).
What are the effects of different models of delivery for improving maternal and infant
health outcomes for poor people in urban areas in low income and lower middle income
countries? 5