Every day more mothers give birth in urban areas, often in informal settings. More than a billion people will live in slums and informal settlements by 2020 in the developing world, according to UNFPA. These high numbers of urban poor coupled with emergence of high-density informal settlements will challenge governments who wish to provide effective coverage of essential services to achieve their Sustainable Development Goals.
Ref: Save the Children. State of the World’s Mothers 2015, The Urban Disadvantage.
While there may be proximity to standard services in urban areas, access to them by the poor and migrants is compromised. Techniques that have proven successful in rural systems are not always applicable in urban contexts. The vagueness of urban health service delivery, especially for the poor, leaves women and children vulnerable, unable to obtain appropriate care or required services. Sustainable and scalable approaches to reach pregnant women and newborns by frontline workers, tracking cases, community engagement, and referral services need to be customized to address the needs of each city, and these approaches will almost certainly differ from those that work successfully in rural areas. Despite the great needs, there are not many examples that provide us concrete guidance on how to approach this problem.
A few cities, however, like Addis Ababa, Manila, Cairo and Nairobi suggest positive directions. Over the past decade these cities, despite their national challenges, were able to significantly reduce the number of deaths of children under age 5. Various approaches targeted to urban poor communities helped to increase awareness and use of services. According to Save the Children’s State of the World’s Mothers 2015 report, the most successful strategies these cities used included: 1) better care for mothers and babies before, during and after childbirth; 2) increased use of modern contraception to prevent or postpone pregnancy; and 3) effective strategies to provide free or subsidized quality health services for the poor. Unlike in rural areas, service delivery systems vary from city to city in a country. Therefore, it is crucial to understand the needs of the community to formulate effective and sustainable strategies.
Despite these successes, inequities abound: 94% of mothers in the richest quintile receive skilled care at birth in Addis Ababa, but only 68% receive the service in the poorest quintile; these numbers are 77% and 6% in Dhaka. Addressing these inequities demands multi-sectoral participation in developing innovative models that can ensure adequate capacity, proper sanitation and cultural appropriateness in delivering quality services.
There is a dearth of information on the health needs and aspirations of the urban poor. Survey methods need to be adjusted to obtain data representative of the actual population in areas with rapidly changing boundaries, because urban averages do not provide insight into the equity gaps. This demands disaggregated data to understand the disparities across socioeconomic groups within a city to develop policies and target effective coverage.
Building on its extensive experience in working with communities and in generating evidence-based innovative strategies to improve maternal and newborn survival, Save the Children is partnering with governments, academics, donors, NGOs and, most importantly, communities to advance the status of health among mothers and their newborns living in poor urban settings. A concerted and sustained effort is essential to reach the most deprived.