Date Published: September 14, 2010
Publisher: Public Library of Science
Author(s): Zoë Matthews, Amos Channon, Sarah Neal, David Osrin, Nyovani Madise, William Stones
Abstract: Andrew Channon and colleagues outline the complexities of urban advantage in maternal health where the urban poor often have worse access to health care than women in rural areas.
Partial Text: As the global urban population surpasses the rural, continuing growth in most developing countries means an inevitable increase in urban births. The majority of births in many countries will not be in remote rural areas, but in towns and cities . Far from being good news for the twin Millennium Development Goals (MDGs) of maternal and child health—neither of which is currently on track for success —high levels of urbanisation are likely to be associated with increased exclusion from care for many mothers in poor countries, and continued high maternal and newborn mortality among the urban poor. Health and social services in urban areas have not kept pace with urban population growth ,. Women in slum communities can find care difficult to access even though a well-functioning health infrastructure is located nearby, and in some cases the urban poor have less access to services than people who live in rural areas –.
Over the last few decades, large-scale migration from rural to urban areas in developing countries has led to a proliferation of slums and informal settlements in many cities and towns. High fertility in urban areas, especially in poorer groups, has further boosted city populations. Cities are not only becoming larger, they are becoming more inequitable, with large impoverished and marginalised settlements springing up often in close proximity to relatively wealthy existing communities. Much of the existing literature has tended to ignore these inequities and focus instead on simple average differences between urban and rural areas, indicating that most nations experience substantially better maternal and neonatal survival in urban than in rural areas –. The urban–rural difference is often explained by the greater access to health care services available to urban residents, and this is indeed supported by a number of studies ,–.
Several patterns or typologies of exclusion from care emerge from the data on health service use. These are characterised not only by inequalities in urban areas, but also by the variability of health service access in the rural areas that feed them. Three different urban scenarios can be distinguished, and are summarised in Figure 2. First, there are countries with a very large exclusion problem, where it is not only the poor who are excluded, but many others as well. These are countries with urban areas where less than 75% of mothers give birth in a health facility. Many countries fall into this “substantial urban exclusion” category, although they show a spectrum of concurrent rural service use: some with almost non-existent rural services, others where the rural rich have more access to services than the urban poor. The second scenario is where there is marginalisation of the urban poor. In these countries a high proportion of urban residents obtain health services, but most of the very poorest group do not. In the third group of countries, the urban population is well served across the socioeconomic spectrum with little inequality, representing a situation moving rapidly towards the gold standard of universal health provision for mothers and babies. Figure 3 shows example countries in each of these three scenarios to illustrate the very different nature of inequality that exists in developing countries.
The choice of strategies to improve coverage of care in the towns and cities of developing countries depends on the pattern of exclusion. Understanding the barriers to care for the urban poor is the first step towards building strategies, although only limited evidence exists to guide policymakers. Countries where substantial exclusion from maternal and newborn care is seen in urban environments are generally suffering from an inadequate urban health infrastructure. Although there is evidence of cultural barriers constraining care-seeking ,, as well as gender factors  and lack of knowledge on the part of women and their families , it is clear that where enough care has been provided to the majority of women it is almost universally accessed in urban areas, even by recent migrants.
Understanding the barriers to access for women and their babies is the first step, but there is little evidence to guide interventions aimed at breaking them down in urban areas. Strategies for breaking through the constraints should be tailored to context and exclusion typology. Setting up outreach or insurance systems for a minority group of poor and marginalised families is a very different proposition from the establishment of services over a wide range of urban population groups. According to the concurrent situation in rural areas, there may be migration streams with different expectations and demands in terms of service availability. Expanding services for the poor who are recent migrants from rural areas where services are totally lacking requires a different approach from service provision for rural migrants who have already attained a level of access in their communities of origin.