Erosion of the Capital City Advantage in Child Survival and Reproductive, Maternal, Newborn, and Child Health Intervention Coverage in Sub-Saharan Africa

Abstract

The place of residence is a major determinant of RMNCH outcomes, with rural areas often lagging in sub-Saharan Africa. This long-held pattern may be changing given differential progress across areas and increasing urbanization. We assessed inequalities in child mortality and RMNCH coverage across capital cities and other urban and rural areas. We analyzed mortality data from 163 DHS and MICS in 39 countries with the most recent survey conducted between 1990 and 2020 and RMNCH coverage data from 39 countries. We assessed inequality trends in neonatal and under-five mortality and in RMNCH coverage using multilevel linear regression models. Under-five mortality rates and RMNCH service coverage inequalities by place of residence have reduced substantially in sub-Saharan Africa, with rural areas experiencing faster progress than other areas. The absolute gap in child mortality between rural areas and capital cities and that between rural and other urban areas reduced respectively from 41 and 26 deaths per 1000 live births in 2000 to 23 and 15 by 2015. Capital cities are losing their primacy in child survival and RMNCH coverage over other urban areas and rural areas, especially in Eastern Africa where under-five mortality gap between capital cities and rural areas closed almost completely by 2015. While child mortality and RMNCH coverage inequalities are closing rapidly by place of residence, slower trends in capital cities and urban areas suggest gradual erosion of capital city and urban health advantage. Monitoring child mortality and RMNCH coverage trends in urban areas, especially among the urban poor, and addressing factors of within urban inequalities are urgently needed.

Keywords: Capital cities; Child mortality; Intervention coverage; Place of residence; RMNCH; Urban health.

Fig. 1

Neonatal and under-five mortality rates by place of residence and country (latest DHS or MICS survey, 5-year rates)

Fig. 2

Trends in under-five mortality by residence and sub-region in sub-Saharan Africa

Fig. 3

Under-five and neonatal mortality by wealth quintile comparing the group of countries with highest mortality in the capital city to others

Fig. 4

Composite coverage index by place of residence by country in sub-Saharan Africa (latest DHS/MICS survey), ordered by sub-region and coverage level

Fig. 5

Predicted trends in composite coverage index (CCI) by sub-region in sub-Sahara Africa

Fig. 6

Median and interquartile range for the composite coverage index (CCI) for richest urban, poorest urban and rural by sub-region in sub-Saharan Africa

Fig. 7

Composite coverage index for richest urban, poorest urban, and rural population by country