Bringing Sexual and Reproductive Health in the Urban Contexts to the Forefront of the Development Agenda: The Case for Prioritizing the Urban Poor

Population growth challenges underlie virtually all millennium development goals (MDGs) [1‐5]. There is consensus that the MDGs are difficult or impossible to achieve with prevailing levels of population growth in the least developed countries and regions. Following the overwhelming evidence on the importance of population growth is the global consensus that promoting sexual and reproductive health (SRH) through voluntary family planning is critical for the achievement of development goals [3, 4]. Besides its ability to contribute to the achievement of more clearly related goals, such as poverty reduction, maternal and child survival, and women’s empowerment through alleviating pressures caused by over-reproduction, the promotion of family planning is also linked to the attainment of less obviously salient objectives, such as environmental stability and access to natural resources, which are inextricably linked to population stabilization [2].

Since the 1994 ICPD conference, various mechanisms for monitoring and action frameworks have been enacted by various national, international and regional bodies to attain the SRH goals developed by this seminal conference. Consequently many countries in sub-Saharan Africa (SSA) have developed reproductive health policies and provided frameworks to guide implementation of SRH programs [6]. However, the notion that SRH is just health sector argument prevents many SSA countries and its leadership from adequately allocating resources to fund SRH programs, including inconsistent FP commodity supplies, has hindered the full realization of their commitments. Overall, although there has been progress in the policy space surrounding SRH in SSA countries, the implementation of SRH programs, especially those impacting the most vulnerable groups, remains problematic.

The heightened calls around repositioning of population issues in development agendas, policies, and programs, particularly in the context of SSA in recent years [7] and the current shift of discourses in the development sectors towards the post-MDGs agenda, provides a window of opportunity to highlight the importance of focus of new development goals on SRH in urban contexts across the global south, particularly in the SSA region. This commentary summarizes key policy, programmatic, and research priorities identified from (1) discussions with population experts, doctoral students, and policy makers and (2) an extensive review of published and grey literature on population dynamics, urbanization, and sexual and reproductive health.

The year 2007 marked the world’s transition from a primarily rural sphere to a largely urban domain. Despite its status as the world’s least urbanized region, SSA currently has the fastest rate of urban growth in the world at between 3 and 4 % per annum, with urban population in the region projected to increase from 37 % in 2011 to about 57 % by 2050 [8]. Unless there are remarkable shifts in governance and economic growth, a large proportion of the urban population in SSA will live in dire poverty. In the face of increasing urbanization of poverty, it is estimated that approximately 70 % of all urban residents in the region will be living in slums or in slum-like environments [9, 10].

The growth of slums, which are characterized by overcrowding, social and economic marginalization, poor environmental conditions, insecurity, and little or no basic social services, has been linked to appreciable deterioration of key urban health and social indicators and reversals in favor of rural areas [10‐13]. In particular, the new face of urban poverty has been linked to adverse SRH outcomes for the urban poor such as high rates of unwanted pregnancies, higher fertility, sexually transmitted infections (STIs), and poor maternal and child health outcomes. Evidence from Nairobi, the capital city of Kenya, shows that the fertility rate in the city’s informal settlements was higher than the Nairobi average (4.7 vs. 2.6). Similarly, child and infant mortality as well as disease prevalence, unemployment and poverty rates are higher than the city average [14, 15]. Nairobi slum residents exhibit significant disadvantages with respect to living conditions, morbidity, access to health services including family planning services, mortality, sexual violence and risky sexual practices relative to other population sub-groups, including rural residents [15‐19]. Living in urban slums has been found to limit women’s ability to control their fertility and implement their fertility preferences. For example, in Korogocho and Viwandani slums in Nairobi city, almost half (47 %) of the pregnancies are unintended. Also, for about a quarter (28 %) of postpartum months where the risk of another pregnancy is high, no contraceptive method was used by women in the two slums [20]. Moreover, maternal mortality rates in the urban slums are almost double the national average, with 706 maternal deaths to 100,000 live births estimated, compared to 488 per 100,000 live births for all of Kenya [15].

Studies in several countries have yielded similar results with indicators such as child mortality rates being higher among the urban poor than among the rural population in several countries [9]. In the slums of Ibadan, Western Nigeria, Adedimeji et al. [21] found that 65 % of 1,600 youth aged 15–24 reported unprotected sex in the 3 months prior to the study. Although the sexually-active respondents demonstrated basic knowledge of HIV/AIDS and high risk perception of infection, risky behavior was common and protective behavior was poor. About 48 % of 505 males and 12 % of 537 females had multiple partners. Similarly, 29 % of males and 38 % of females were engaged in transactional sex, and only 14 % of males and 5 % of females used any form of protection, resulting in the high rates of STIs reported by 27 % of males and 10 % of females. The level of risky behavior observed against a background of high risk perception, suggests significant levels of constraint to adopting protective behaviors, with implications for high rates of STIs and the spread of HIV/AIDS. These constraints are rooted in the pervasive poverty and socioeconomic disparities that prevent many in the urban slums from practicing protective behaviors [22].

Building on the backdrop of the foregoing discussion and in the context of the more recent definition of reproductive health as complete well-being in sex and reproduction, highlighting not only family planning, conception, and birth, but also the imbalances in decision making autonomy between men and women, the possibilities of coercion and violence in relationships and exposure to difficult health risks [23, 24], the reproductive health disadvantage of the urban poor has become a key challenge in SSA. Consequently, the importance of a renewed focus in addressing the SRH challenges faced by the urban poor cannot be overstated. In fact, the point is made that many of the worst human problems, including poor health, play out together in city slums. The positive implications of effective SRH programs for maternal and child survival, morbidity and mortality outcomes have been well documented [25]. Effective SRH programs have provided a win–win solution not only on the improved welfare of individual women and children but also on national economies and the physical environment [26, 27].

Today, as the development sectors lobby for their own piece of the post-MDGs pie, it is vitally important that the post-2015 global development agenda includes focus on SRH in urban contexts. Building on our wide consultations with experts across the global north and south and triangulation of theoretical and empirical literature, we highlight key sexual and reproductive health priority areas for policy, programs, and research.

A comprehensive strategy of SRH policy, programs and research focused on the urban poor apart from its direct implications for improved SRH outcomes among urban and peri-urban dwellers, has the potential to diffuse to rural areas to which most urban dwellers are linked [32, 33]. Addressing poor SRH outcomes among the urban poor is critical, particularly because urban slums provide an expansive population—a fact which holds immense potential for making a large and much-needed impact. For example, there is a large market for contraceptives among this population due to lower desired family size than rural areas and the high number of unwanted births, meaning that there is also an opportunity to have a significant impact in the short term. As a corollary, family planning on its own, as a single intervention will have minimal impacts on the health of women and children, especially that of the urban poor. Extant literature posits that the integrated provision of family planning and maternal and child health services has implications for not only poverty reduction in resource poor settings, but significant declines in the maternal and child mortality rates [34]. Integration of family planning and maternal and child health services in urban informal settings therefore holds a great potential for significant impacts on the health of the mother and child, quality of services received and a long term impact on the overall wellbeing of families and their respective communities [35]. Finally, the significant role of poverty in the adverse SRH outcomes of the urban poor cannot be overlooked in policies and programs. To this effect, we argue that the SRH of the urban poor needs to be looked at both from a development perspective, as well as from a health sector and service delivery perspective. The need for multipronged approaches that include behavior change, job and wealth creation remains essential to addressing the SRH needs of the urban poor. Similarly, research efforts linking all these pillars, and documenting impacts, what works and identifying new and innovative approaches will be an important part of the process.