Maternal and newborn health for the urban poor: the need for a new mental model and implementation strategies to accelerate progress

Abstract

BackgroundUrbanization challenges the assumptions that have traditionally influenced maternal and newborn health (MNH) programs. This landscaping outlines how current mental models for MNH programs have fallen short for urban slum populations and identifies implications for the global community. We employed a three-pronged approach, including a literature review, key informant interviews with global- and national-level experts, and a case study in Bangladesh.Main bodyOur findings highlight that the current mental model for MNH is inadequate to address the needs of the urban poor. Implementation challenges have arisen from using traditional methods that are not well adapted to traits inherent in slum settings. A re-thinking of implementation strategies will also need to consider a paucity of available routine data, lack of formal coordination between stakeholders and providers, and challenging municipal government structures. Innovative approaches, including with communications, outreach, and technology, will be necessary to move beyond traditional rural-centric approaches to MNH. As populations continue to urbanize, common slum dynamics will challenge conventional strategies for health service delivery. In addition, the COVID-19 pandemic has exposed weaknesses in a system that requires intersectoral collaborations to deliver quality care.ConclusionPrograms will need to be iterative and adaptive, reflective of sociodemographic features. Integrating the social determinants of health into evaluations, using participatory human-centered design processes, and innovative public-private partnerships may prove beneficial in slum settings. But a willingness to rethink the roles of all actors within the delivery system overall may be needed most.

Neonatal and perinatal mortality in the urban continuum: a geospatial analysis of the household survey, satellite imagery and travel time data in Tanzania

“…The analysis of 22 large African cities also showed variable levels of essential care elements (>99% of babies born in health facilities were weighed but only half of babies initiated breast feeding within an hour of birth) and high levels of early discharge from health facilities following both vaginal and caesarean section births in Dar es Salaam. Further, literature shows that poor women, especially those living in informal settlements, might also receive poorer quality of care, encounter stigmatising attitudes and disrespectful care in health facilities 31–33. Our additional analysis on the timing of deaths showed that a comparatively low percentage of neonatal deaths in core urban areas occurred on the day of birth compared with semi-urban and rural areas.…”

“…Further, literature shows that poor women, especially those living in informal settlements, might also receive poorer quality of care, encounter stigmatising attitudes and disrespectful care in health facilities. [31][32][33] Our additional analysis on the timing of deaths showed that a comparatively low percentage of neonatal deaths in core urban areas occurred on the day of birth compared with semi-urban and rural areas. Interpretation is difficult, but one explanation may be better access to emergency obstetrical care including neonatal resuscitation in core urban compared with rural areas.…”

Caesarean delivery and neonatal mortality: evidence from selected slums in and around Dhaka city, Bangladesh- A prospective cohort study

“…A systematic review pooled 22 studies and found that around 57% of the neonatal deaths occurred during the first 3 days of life, as neonatal mortality due to asphyxia, prematurity, and malformations were mostly caused during these first 3 days of life [ 46 ]. These high rates, along with our study, demonstrate the lack of evidence-based interventions beginning in the antenatal period, which is relatively low among urban slum mothers [ 46 – 48 ]. Relatively lower mortality for caesarean delivery than vaginal on the 1st day of life could be due to the care received by the mother and newborn from the hospital, as the caesarean-delivered mother had to stay for a longer time at the hospital [ 2 , 49 – 52 ].…”

Interventions addressing maternal and child health among the urban poor and homeless: an overview of systematic reviews

“…Moreover, with the global expansion of towns and cities, there has for some time been a trend of urbanization of poverty [4]. The convenience of living in cities (shorter distances, accessibility of services, social networks) benefits a small percentage of population with millions of urban-dwellers being excluded [3]; which in turn has implications for maternal [5] and child health [6]. A study drawing from Demographic and Health Surveys in Least Developed Countries showed significant inequalities in children's nutritional outcomes, with higher inequalities in the most rapidly urbanizing countries [7].…”

“…A study of 22 African cities showed disruptions in the maternal continuum of care, characterized drop offs in antenatal care, childbirth and postpartum care, with varying reliance on public and private sector use, and use of hospitals across cities [8]. Another study, drawing on data from seven cities in LMICs highlighted issues relating to availability, accessibility, quality of MCH services as well as delayed care-seeking [5]. In a study on 30 developing countries, it was noted that the urban poor did not have better access to maternal healthcare despite proximity to healthcare services [9].…”