Examining the “Urban Advantage” in Maternal Health Care in Developing Countries

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 [1]. 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 [2]—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 [3,4]. 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 [5–7]. This Policy Forum article investigates the ‘‘urban advantage’’ to determine whether the urban poor in a range of different countries really do have an advantage over rural populations in health and access to services. It also quantifies the gap between the urban poor and other residents of towns and cities. We investigate whether the urban rich–poor gap is a feature of all cities, or whether there are some countries whose urban environments are more equitable than those of others. Using nationally representative Demographic and Health Survey data from 30 developing countries in Africa, Asia and Latin America (representing approximately 47% of developing country populations), we look at maternal and newborn service use among groups with different levels of poverty. Most previous studies have not distinguished between poverty groups in urban settings and those in rural areas, categorising the poor as mainly rural. Our study takes into account the different nature of deprivation in urban areas, and identifies health access indicators among the urban poor separately from the equivalent indicators for rural populations. It also shows patterns of inequalities within cities in different countries, and explores the ways that urban and rural inequalities interlink. By identifying patterns of unequal access to services for mothers and babies, we pinpoint barriers to access in these different contexts, and conclude by suggesting evidence-based policy solutions where documented.