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Sex in the City: As Cities Grow, Are We Forgetting the Urban Poor?

Today, 3.9 billion of us live in cities. That’s more than half the world’s population. By 2050, two-thirds of us will live in urban areas.

Today is World Population Day, and this week the United Nations Population Division released the latest version of its World Urbanization Prospects. The 2014 projections show continued population growth and an additional 2.5 billion city-dwellers by 2050—with almost 90 percent of them in Asia and Africa. But while numbers tell a compelling story, it is crucial to ensure that the urban poor do not get lost in the aggregate.

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Click here for an infographic on reproductive health among the urban poor.

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”?

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. This overall figure fails to capture that 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.

The urban poor have high rates of unintended pregnancies, higher fertility, higher risk of sexually transmitted infections, and poor maternal health outcomes. 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.

Slum Characteristics

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.

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

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.