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Examining the “Urban Advantage” in Lagos, Nigeria: Geographic Disparities in Maternal Mortality

By: Sarah Hodin, Project Coordinator II, Women and Health Initiative, Harvard T.H. Chan School of Public Health

While urban residence has generally been considered a protective factor for maternal health, recent studies have offered a more nuanced perspective on the so-called “urban advantage,” illustrating that many women living in cities across the globe do not have increased access to high quality care. Additionally, a deeper analysis of national-level maternal mortality data often reveals underlying disparities in women’s risks of dying from pregnancy or childbirth-related causes.

Erin Anastasi and colleagues recently published a paper in PLOS One titled, “Unmasking inequalities: Sub-national maternal and child mortality data from two urban slums in Lagos, Nigeria tells the story,” exploring these issues. The Maternal Health Task Force (MHTF)’s Sarah Hodin interviewed Dr. Anastasi about her team’s findings and implications.

SH: Let’s start with you telling me about the aim of the study.

EA: The aim of the study was to estimate maternal, perinatal and child mortality in two marginalized, urban populations in the slums of Lagos, Nigeria where Médecins Sans Frontières (MSF) was working. MSF started working there because the people living in those slums weren’t accessing and benefiting from the health services in the area, so MSF wanted to explore maternal and child health in those areas.

SH: Which methods did you use to estimate maternal mortality?

EA: We looked at a few different methods for measuring maternal mortality, which is difficult to measure since it’s a relatively rare event. You typically need a large sample size to detect maternal deaths, so there have been other methodologies that have been developed over the years to measure maternal mortality in smaller sample sizes. We chose to use the sisterhood method – we interviewed people in almost 4,000 households in Makoko Riverine and Badia East about whether or not they had a sister who died during pregnancy or childbirth. We tried to ensure the accuracy of our data with extensive training and supervision of the interviewers and also by translating the instrument into different local languages.

SH: What were your key findings?

EA: The major finding—and the primary outcome of interest—was the maternal mortality ratio (MMR) in these two slums, which we calculated to be a shocking 1,050 deaths per 100,000 live births. This figure is much higher than the average MMR of Lagos State, which is 545 deaths per 100,000 live births, as well as Nigeria’s national MMR, which is 814 deaths per 100,000 live births. Women in Makoko Riverine and Badia East have a lifetime risk of maternal death of one in eighteen, which is also significantly higher than the average lifetime risk in Lagos State and Nigeria overall. In many ways, I think these are invisible populations. Our findings exemplify that national statistics often mask inequalities, whether the disparities are geographic, socioeconomic, ethnic, etc.

SH: What do you think are the implications of these findings?

EA: Even though this paper is about two slum communities in Lagos, the principles apply more broadly. If there’s a certain group that is marginalized or suffering more than others, it’s important to identify contextual challenges, work collaboratively with communities and use a tailored approach. This study also illustrates the importance of data disaggregation for monitoring progress and making decisions about resource allocation. I love that the vision of the Sustainable Development Goals (SDGs) is to “leave no one behind.” It’s a lofty goal, and if we’re going to achieve it, countries need to figure out who is being left behind and how best to reach different marginalized or vulnerable groups.

The views expressed in this post are individual and do not necessarily reflect the views of any affiliated organizations or partners.

Read the full open access paper in PLOS One.

Check out papers from the MHTF-PLOS Collection, “Neglected Populations: Decreasing Inequalities & Improving Measurement in Maternal Health.”

Browse the March 2017 MHTF Quarterly, “Maternal Health in Urban Settings.”

Learn more about the global and national maternal mortality targets under the SDGs.

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