Editor's Note:
Save the Children's 16th annual State of the World's Mothers report examines the devastating health disparities between the rich and poor living in major cities around the world. The report reveals that these cities can be home to both the wealthiest and healthiest people as well as the poorest and most marginalized families. It assesses the well-being of mothers and children in 179 countries, and provides a ranking of the best and worst places in the world to be a mother.
Medscape spoke with Bina Valsangkar, MD, MPH, newborn technical advisor at Save the Children, about the report's findings and main messages for healthcare providers everywhere.
Focus on the Urban Disadvantage
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Image courtesy of Save the Children |
Medscape: This year's report noted that child mortality rates are at least twice as high among poor urban children compared with their richer counterparts—a gap that is growing. Yet some countries have addressed the health needs of these families better than others. What factors have been effective in these communities?
Dr Valsangkar: The report provides a few specific examples. Some of the cities that are doing a good job of reducing the gap are in developing countries, so it isn't only the developed countries that have reduced the gap. Some of the most striking gaps we see are in developed countries. The cities that have been able to reduce their gap have increased access to basic maternal newborn and child services, and they have raised awareness about the issues. They have made care more affordable and accessible to the poorest families.
Two cities that have done a great job are highlighted in the report: Addis Ababa in Ethiopia and Kampala in Uganda. Addis Ababa has seen tremendous economic growth over the past several years, which is helpful for improving health indicators. In terms of narrowing the gap, they have also increased their use of contraception. They have addressed the unmet need for contraception over the years and have increased the use of and access to prenatal care, as well as vaccination rates.
They have done this in part by growing their healthcare system so that they have more hospitals, and they are providing more services in those hospitals. They have just trained and employed more nurses, so they have beefed up their health services and made sure that more women and children are reached.
When you look at the gap in Addis Ababa, all of these actions have benefited the poor in the city more so than the rich. They were deliberately targeted to address the poor.
We saw a similar devotion to addressing that gap in Kampala, Uganda, but they took a different approach. In Kampala, they took the health services and the health information to the communities that need them. They went to the point of care and held family health days in churches and places of worship. They did radio shows. They had village health teams that went out into the communities. This was a different approach from that of Addis Ababa, but they achieved similar results in that they were able to narrow that gap because they were targeting the poor.
In these two examples, the important thing to highlight is that narrowing the gap is not a luxury limited to the large, wealthy cities. It can be done in developing countries and poor cities, too.
Medscape: More than one half of the world's population live in cities, and urbanization is not going away. Recognizing that both developed and developing countries have limited resources, what one area would provide the biggest bang for the buck for government investment to improve child and maternal health?
Dr Valsangkar: Our biggest bang for the buck is to increase access to maternal care before pregnancy, during pregnancy, and after pregnancy. That can take shape in many different ways, but better access to prenatal care, to quality care during labor, and to essential newborn care right after delivery—really focusing on the time around labor and delivery—can give us a lot of bang for our buck. That is highlighted at the global level in Every Newborn, an action plan to end preventable deaths.
Addressing the entire continuum of care is important, but if we are talking about an intervention with a potentially large impact, we should focus on a time when many people are accessing the healthcare system, and the time of birth is a logical focal point.
Medscape: Does this have to take place in a hospital setting? Is there any evidence to show that women who deliver outside of the hospital under clean (not aseptic) conditions can have good outcomes?
Dr Valsangkar: Clean, skilled delivery is important. We are striving for facility delivery, but only in places where facility deliveries are cleaner and safer. If facility deliveries are not cleaner and safer than what is happening elsewhere, they offer no significant advantage.
We do want facility deliveries, because the facility is a place where you bring together the expertise and all the supplies you need, with access to an operating room, blood products, and other supplies that you don't have out in the communities. However, you can't always take for granted that these resources are available in the facility. The facility has to be able to provide that kind of care. We want to see facility care, but it must be quality facility care.