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Details of included studies Executive summary The searches returned 9,025 potentially relevant items of evidence, including 9,010 from database searches and 15 from handsearches. Of these papers, 98% were excluded after reviewing titles; the abstracts of the remaining 114 studies date from 1989 to 2010. Our search strategy was limited to LICs and LMCs, and certain countries were prominent in the resulting database of evidence. A quality assessment was made on all items including the evaluation of both internal and external validity by means of standard tools. Internal validity concerns the accuracy of results; for example results could be inaccurate if samples were not selected randomly. External validity concerns the generalisability of the findings to the population. Synthesis results There are few published studies looking at interventions that specifically target the urban poor’s access to and use of maternal and child health (MCH) services, and even fewer that use mortality indicators as one of their outcomes. No items were found that explicitly assessed the effectiveness of different models of service delivery to reduce maternal and infant mortality among poor urban populations. However it should also be acknowledged that studies that have been excluded from this analysis because they do not specifically focus on urban, poor populations will contain evidence on the effectiveness of different intervention models that could potentially be targeted at the urban poor. It is important to consider the extent to which these interventions could be applied to our target population. Of the items returned, 56% were classified as individual clinical interventions, leaving 44% in the non-clinical category. Of the ‘non-clinical’ interventions, most consisted of systemic interventions such as provider models, information, audits, investment and scaling up, and financial protection. Of the non-clinical items, 26% included established groups of non-clinical interventions such as Kangaroo Mother Care and nutrition approaches such as breastfeeding promotion. Most of the studies that concerned purely clinical interventions – although pertaining to urban populations – are applicable in rural areas. Interest in our review focused mainly on the non-clinical findings – as these are judged to be closer to the wider conceptualisation of ‘models of delivery’ which has been key to implementation but less of a focus among researchers. Conclusions and recommendations Our analyses form a convincing case that there is a need for high-quality evidence on maternal and infant interventions that specifically target the urban poor. The existing evidence base is minuscule compared to the rapidly growing and large urban poor population. Much of the existing evidence is of poor quality, with little emphasis on baselines and follow-up studies, and almost no qualitative (how? why?) evidence to complement the limited quantitative (what?) data. This small evidence base is out of step with the growing interest in urban poor people and the size of this population. Interventions supported by the review are already present in existing WHO guidelines. However, there is a need for research that specifically addresses the effectiveness of different models of service delivery, including how sub-populations (e.g., urban poor) are targeted. Although the evidence base appears limited, there are in fact a number of ways in which it might be strengthened in the short term. We suggest one way of strengthening the evidence base on the cost-effectiveness of different strategies to promote better access and use of maternal and infant health services. This would 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? 2
Executive summary be to retrospectively make use of data looking at the uptake and effectiveness of actions that help increase uptake from papers identified in this review, then estimate the costs of implementation, including their impact on the future use of health services or on other economic costs if mortality (and morbidity) were avoided. 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? 3
Page 1 and 2: Systematic review What are the effe
Page 3 and 4: Contents List of abbreviations ....
Page 5 and 6: List of abbreviations AIDS Acquired
Page 7: Executive summary Background Execut
Page 11 and 12: Background many LICs and LMCs, it i
Page 13 and 14: Background Cross-sectional surveys
Page 15 and 16: Background For some causes of mater
Page 17 and 18: Background informal settlements on
Page 19 and 20: Background review focused on explic
Page 21 and 22: Types of intervention Interventions
Page 23 and 24: Box 2.2: Websites searched AFD (Age
Page 25 and 26: second stage previously described f
Page 27 and 28: using qualitative analysis to attem
Page 29 and 30: Figure 3.1: Filtering of papers fro
Page 31 and 32: Middle East and North Africa (8%) S
Page 33 and 34: Search results access or satisfacti
Page 35 and 36: 4. Synthesis results Summary Synthe
Page 37 and 38: Synthesis results Four studies focu
Page 39 and 40: Drug treatments (including micronut
Page 41 and 42: Synthesis results Training and audi
Page 43 and 44: Synthesis results order to be effec
Page 45 and 46: Synthesis results government admini
Page 47 and 48: HIV/AIDS and Malaria, as well as no
Page 49 and 50: Synthesis results ASSESSING THE COS
Page 51 and 52: and birthing care services, includi
Page 53 and 54: Synthesis results of settings were
Page 55 and 56: Figure 4.1: Causal chain for matern
Page 57 and 58: 4.3 Summary of results of causal ch
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5. Strengths and limitations Summar
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6. Conclusions and recommendations
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Conclusions and recommendations Urb
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References Bakr A F, Karkour T (200
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References Deschamps M M, Noel F, B
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References Lim S, Dandona L, Hoisin
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References Shantharam Baliga B, Rag
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References Channon A A, Falkingham
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References Jowett M (2000) Safe Mot
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References Rice J, Rice J S (2009)
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Appendices Appendix 1.1: Authorship
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Appendix 2.1: Inclusion and exclusi
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Appendix 2.2: Search strategy for e
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Appendix 2.2 Infant* OR Matern* OR
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OR/ 12-13 11 AND 14 Limit 15 to pub
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Appendix 2.4: Journals handsearched
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POOR PROFILE Is the study populatio
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infants (
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Appendix 2.5 Intervention (surgical
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Appendix 2.5 Intervention (service
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MORTALITY OUTCOME TYPES Which morta
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positive neutral negative unclear/n
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yes no unclear/not stated N/A Study
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surveillance system none of the abo
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no SELECTION CHARACTERISTICS Is inf
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Appendix 2.5 QUANTITATIVE DATA ADJU
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RESEARCHER RELATIONSHIP Has the rel
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Were the inclusion/exclusion criter
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person-years). 3.5 Was follow-up ti
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Appendix 2.7 Appendix 2.7: Quality
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triangulation, or for not triangula
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Was the study approved by an ethics
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Item Yes No Not clear 3. The viewpo
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Appendix 2.9: Electronic databases
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Web of Knowledge (including ISI Cit
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Study Setting Intervention type Abo
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Study Setting Intervention type Alw
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Study Setting Intervention type Ben
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Study Setting Intervention type Ble
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Study Setting Intervention type Cob
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Study Setting Intervention type Des
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Study Setting Intervention type Faw
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Study Setting Intervention type Jak
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Study Setting Intervention type Kup
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Study Setting Intervention type Mar
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Study Setting Intervention type Nah
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Study Setting Intervention type Pad
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Study Setting Intervention type Str
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Study Setting Intervention type Zia
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Appendix 3.2 Adam G K, Abdulla M A,
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Appendix 3.2 Balkus J, Bosire R, Jo
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Appendix 3.2 Boerma J T, Stroh G (1
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Appendix 3.2 Chiwuzie J, Okojie O,
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Appendix 3.2 De Alencar A E, Arraes
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Appendix 3.2 Ekman B, Pathmanathan
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Appendix 3.2 Garg R, Omwomo W, Witt
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Appendix 3.2 Gupta R, Sachdev H P,
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Appendix 3.2 Hutton G, Schellenberg
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Appendix 3.2 Khandker S R, Latif M
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Appendix 3.2 Lindblade K A, Eisele
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Appendix 3.2 Menéndez C, Bardají
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Appendix 3.2 Nduati R, John G, Mbor
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Appendix 3.2 O'Rourke K (1995a) The
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Appendix 3.2 Prual A, De Bernis L,
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Appendix 3.2 Sabitu K, Alti-Mu'azu
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Appendix 3.2 Smith J B, Coleman N A
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Appendix 3.2 Van Rheenen P, De Moor
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Appendix 3.2 Xiang X, Wang L, Xu L
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Appendix 3.4 Appendix 3.4: Studies
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Appendix 3.4 International Bank for
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Appendix 3.5 Appendix 3.5: Studies
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Orji (2003) (-)/(-) Shihadeh (2001)
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Chinayon (1998) (+)/(+) Kamilya (20
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Nahar (2004) (-)/(-) Tukur (2007) (
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Ndibazza (2010) (++)/(+) Antiretrov
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Bergstrom (1991) (+)/(+) Women with
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Enakpene (2010) (+)/(-) Etuk (2000a
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Pereira (1996) (-)/(-) Saleem (2007
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Author (year) (IV)/(EV) Joshi (2007
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Author (year) (IV)/(EV) Aaby (2005)
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Author (year) (IV)/(EV) Martins (20
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Author (year) (IV)/(EV) de Muylder
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Author (year) (IV)/(EV) Provider mo
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Appendix 4.4: Included items dealin
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Author (year) (IV)/(EV) Target Popu
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Author (year) (IV)/(EV) Colonna (19
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Author (year) (IV)/(EV) Kuhn (2008)
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Author (year) (IV)/(EV) Target popu
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Author (year) (IV)/(EV) Mswia (2003
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Appendix 4.6: Included items dealin
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Appendix 4.8 Appendix 4.8: Economic
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Author (year) (IV)/(EV) and setting
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Appendix 4.9: Included items identi
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Author (year) (IV)/(EV) Poor urban
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Author (year) (IV)/(EV) Poor urban
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Appendix 4.10: High-quality include
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The authors of this report were sup
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