Today, 3.9 billion of us live in cities. That’s more than half the world’s population. According to a new report released by the United Nations Population Division, by 2050, approximately 66 percent of the globe’s population will live in urban areas. Rapid urbanization is often associated with increased access to information, education, economic opportunities and health services—and by extension greater access to sexual and reproductive health services. This idea is based on the assumption that proximity to services and opportunities means they are evenly distributed among urban populations. However, this ignores inequities that exist within cities. Not all urban dwellers are the same. How real is the “urban advantage?”
While numbers can tell a compelling story, it is crucial to ensure that the urban poor do not get lost in the aggregate. How does urban poverty affect sexual and reproductive health? The urban poor have high rates of unintended pregnancies, higher fertility, higher risk of sexually transmitted infections, and poor maternal health outcomes. When looking only at averages, urban centers often demonstrate improving health outcomes. For example, the Nigerian Urban Reproductive Health Initiative (NURHI) found the contraceptive use rate of modern methods by women with partners to be 31.9 percent in Abuja. However, women in the poorest wealth quintile had a modern contraceptive use rate of only 18.4 percent. Similarly, in Kenya the maternal mortality rate in urban slums—706 maternal deaths per 100,000 live births—was almost double the national average of 488 maternal deaths per 100,000 live births. A range of factors that characterize urban poverty contribute to these poor reproductive health outcomes: unemployment, unsanitary and overcrowded living conditions, inadequate access to formal health services, gender-based violence and limited autonomous decision-making for women.
U.N. Habitat has estimated that more than 70 percent of sub-Saharan Africa’s urban dwellers live in slums. Asia boasts the highest absolute number of slum dwellers at 380.3 million. These slums and other informal settlements typically lack public health facilities. This means that a significant number of Asians and the vast majority of Africans in urban settings may actually be excluded from formal public services, including reproductive health services.
The urban poor often have to travel beyond their immediate neighborhood to obtain contraceptive information, services and supplies from the public sector. This raises a serious opportunity cost: spend extra time to travel for a low-cost or free public service or pay more for a potentially lower-quality service from a nearby private sector provider? With both time and disposable income in short supply, it is understandable that many urban residents living in poverty simply do not access quality reproductive health services. The urban poor therefore face vulnerabilities that can put them at the disadvantage compared to their rural counterparts.
The “Last Mile” Now Leads Back to the City
In recent years mature family planning programs have emphasized reaching “the last mile”—disadvantaged groups who do not have equitable access to contraceptive information, services and supplies. In many cases, the focus has been on geographically isolated or rural populations. When considering underserved populations, we must not disregard shifting population dynamics in the developing world and forget the urban poor.
An analysis of 26 sub-Saharan African countries by the African Population and Health Research Center showed that in many countries urban poor women were more likely to have a higher unmet need for family planning than rural women. In 12 countries, urban women in the poorest wealth quintile had higher rates of unmet need than rural women in the same wealth quintile.
Addressing the reproductive health needs of the urban poor and rural communities requires a holistic approach and increased financial investment and political commitment. In many sub-Saharan African countries, the urban poor are the fastest growing sub-population. Today alone, 120,000 people were added to the populations of Asian cities. The reproductive health needs of the millions of urban poor cannot be ignored. Governments need to expand access to formal health services as well as think beyond state-sponsored options. These include:
- Budget and expend adequate funding for sexual and reproductive health services in all sizes of cities
- Effectively utilize community health workers and community-based organizations to expand access to reproductive health information and services in slums and informal settings
- Support urban poverty alleviation by investing in economic empowerment programs to improve the education and economic opportunities for women – ultimately improving their sexual and reproductive health
Rapid urbanization poses many challenges. Luckily however, urban population density has some advantages. The expanded provision of quality reproductive health information and services in these settings is often more cost-effective and can reach more people. Today’s urban centers are often characterized by poverty in plain sight. Many of the urban poor now experience poorer health—including sexual and reproductive health—outcomes than rural populations. New urban realities require new solutions and an increased focus on meeting the sexual and reproductive health needs of all urban dwellers, not just the easy-to-reach.