Improving Maternal and Child Health in the Urban Context

Keynote statement by Dr. Natalia Kanem, UNFPA Executive Director, at the 14th International Inter-Ministerial Conference on Population and Development, Technical Session on "Improving Maternal and Child Health in the Urban Context: Sustainable Cities, Human Mobility and International Migration", Yogyakarta, Indonesia.

 

Mr. Chair,
Distinguished panelists and guests,
Ladies and gentlemen,

Good afternoon! It is a pleasure to be here with all of you for this discussion on improving maternal and child health in the urban context. And this is closely linked to migration, which often is movement towards cities.

First, however, I’d like to zoom out a bit and look at some of the challenges related to reproductive and maternal health more generally. Then I will delve into the particularities of the urban and migration contexts.

The world has made vast strides over the past few decades.

The number of maternal deaths has dropped from over 500,000 in 1990 to around 303,000 today.  The chances of a woman dying due to pregnancy and childbirth complications have fallen by about 45%. 

For the first time in history, more than 670 million women and girls in developing countries are using modern contraceptives. As a result, more than 307 million unintended pregnancies are averted every year.

But this progress does not tell the whole story. In most developing countries, the poorest women have the least power to decide whether, when or how often to become pregnant. The poorest women also have the least access to quality care during pregnancy and childbirth.

As a result, reproductive health problems remain a leading cause of death and disability for women and girls in the developing world.

In the poorest communities, women’s status, maternal death, and child marriage rates have seen very little progress in the past 20 years. In fact, in some instances, gains are being reversed.

Becoming a mother should be a joyful event for every pregnant woman. It should not be a death sentence. There is still much more that can be done to save the more than 800 women who die every day.

For every woman who dies in childbirth, 20 to 30 more suffer disease, infection or injury, such as fistula – a hole in the birth canal caused by obstructed labour. Women with the condition often suffer incontinence, and as a result, often face social isolation and stigma.

In many places, adolescent girls and young women lack access to the education, including comprehensive sexuality education, that is so fundamental to their health.

They lack agency and autonomy over their own bodies, which prevents them from claiming their human rights. The facts underline the importance and urgency of addressing their needs and protecting their rights.

Complications from pregnancy and childbirth are the leading cause of death for 15- to 19-year-old girls worldwide.

While the number of new HIV infections overall has stabilized, we see a troubling increase in new infections among adolescent girls and young women in Africa.

The poorest women and adolescent girls have the least power to decide whether, when or how often to become pregnant. Contraception is often out of reach for the poor, especially adolescent girls.

About 214 million women in developing countries lack modern family planning. It is essential that contraceptive commodities are accessible to all women at the right time, at the right place and importantly, of the right quality.

Family planning is a fundamental human right, and essential to achieving the world’s sustainable development goals.

Let’s turn now to the urban context.

Urbanization is a global trend with far-reaching implications for health, education, the environment and the future of our planet.

In 1950, only 30 per cent of the world’s population lived in urban areas. Yet today a majority are urban. And it is projected that around two-thirds of the world’s population will live in urban areas by 2050.

The individual experience of these macro demographic trends is something UNFPA has thought a lot about, as we combat conventional wisdom on the challenges of population, and speak to the importance of investing in the dignity, human rights and capabilities of all people.

Urbanization presents a great opportunity for improving reproductive, maternal and child health.  Many of the challenges faced by rural populations are less severe in urban areas:

• Urban dwellers generally have easier physical access to health facilities and health care providers than many rural dwellers.
• The availability of contraceptives, life-saving drugs and necessary medical equipment is generally greater in urban areas.

But the opportunities presented by increasing urbanization do not always translate into major improvements in health outcomes.

• The face of inequality is increasingly an urban one. Too many urban residents grapple with extreme poverty, exclusion, vulnerability and marginalization.    
• Poor people often reside in remote or peripheral parts of cities, often in dense informal settlements or slums.
• Many people in slums lack ready access to health facilities. Others rely on paying private, unregulated providers for health services that are free in rural areas.
• In some urban slums, poor women have fertility rates closer to those of rural women. The urban poor often face risky and unhealthy living conditions, such as heavy pollution or high vulnerability to disasters.

Adolescents and young people, who are disproportionately represented among migrants to cities, may benefit from urbanization, but also face many of the challenges just described.

Urbanization can bring heightened risks of gender-based violence, including sexual exploitation and abuse, particularly for poor women and girls living in communities with little security or infrastructure.

Yet cities also offer opportunities for social mobilization and women’s empowerment. For many young people, especially young women, moving to cities is an opportunity to escape traditional patriarchy and experience new freedoms.

Urban areas offer greater access to education and health services, including sexual and reproductive health care, promoting women’s empowerment and the realization of their reproductive rights. This contributes to significantly reduced fertility in urban areas, changing the trajectory of overall population growth.

What is UNFPA doing in urban areas?

UNFPA works:

• to support sexual and reproductive health in urban slums,
• to build the capabilities of young people in urban areas,
• to promote gender equality and the elimination of gender-based violence
• to support data-gathering about the needs and vulnerabilities of women and young people in urban settings.

Let’s turn now to migration – both internal and across borders.

There over 750 million internal migrants and around 250 million international migrants, roughly 40% more international migrants than in 2000.

And again, migration and urbanization are tightly linked since cities are major migration hubs, whether at home or abroad. 

Young people often move first into urban hubs in their own country, and move abroad if urban opportunities fail them at home.  

The world today is increasingly globalized. More people have greater access than ever before to information about prospects and options in new places -- something previous generations lacked.

International migration, which continues to increase in scope, scale and complexity, is a key feature of globalization in the 21st century, and an important enabler of inclusive sustainable development.

Economic, social, demographic and technological transformations have fueled the increase in population mobility across borders worldwide. Virtually all countries in the world are affected by international migration, whether as countries of origin, destination or transit.

Today’s adolescents and youth are the most mobile generation of young people in history. More than 600 million young people aged 10-24, a group larger than the entire population of the European Union, live in fragile and conflict-affected settings.  And more than half of the world’s refugees today are less than 18 years old. These young people are facing the challenges of displacement at a time of intense cognitive, physical and social development.

One of the most significant changes in migration patterns in the last half century is that more women are migrating on their own than ever before. Women now constitute almost half the international migrant population, and in some countries, as much as 70 or 80 per cent.

Since women migrants frequently end up in low-status, low-wage production and service jobs, and they often work in gender-segregated and unregulated sectors of the economy, such as domestic work, they are exposed to a much higher risk of exploitation, violence and abuse.

Many youth migrants leave their homes not only to flee persecution and violence, but also to seek educational, economic and life opportunities. The vulnerabilities they experience in transit need more detailed attention in order to understand and address their needs.

Sexual and reproductive health can be compromised during the journey, not only due to inaccessibility of information and services, but also because of risks and potential exploitation en route to their destination.

What is UNFPA doing in Migration?

At UNFPA, we are committed to protecting the safety, dignity, human rights and fundamental freedoms of all migrants, regardless of their migratory status, at all times. While we focus a great deal on protecting those in transit, the ultimate goal is to ensure that people are choosing, rather than being forced, to migrate.

In keeping with the values of the International Conference on Population and Development Programme of Action, UNFPA promotes a people-centred, humane, dignified and gender-responsive approach to the treatment of all persons in their countries of origin, transit and destination.

We work at global, regional and country level in three major areas relevant to migration: by addressing the drivers of migration, especially for adolescents and youth, through our development work and leadership on the demographic dividend; by providing protection to those in transit through our humanitarian work; and by advocating for including core migration census questions in the 2020 census round to ensure better estimates of those in transit.

In all contexts, UNFPA works to ensure safe birth, safety from fear and sexual violence, and access to contraceptive services.

We have set our sights on achieving three transformative goals by 2030:

• An end to preventable maternal deaths,
• An end to unmet demand for family planning, and
• An end to violence and harmful practices against women and girls.

What is UNFPA doing to help prevent maternal deaths?

UNFPA works at all levels to promote universal access to sexual and reproductive health care and rights, including by promoting international maternal health standards and providing guidance and support to health systems.

Our Maternal Health Thematic Fund supports 39 countries with a high burden of maternal death. Since it started in 2008, this work has helped prevent 92,000 maternal deaths in those countries.

Our programmes emphasize capacity development in maternal care, especially the strengthening of human resources and emergency obstetric and newborn care facilities and networks. Since 2009, UNFPA has supported more than 600 midwifery schools, educating more than 80,000 midwives in countries with high rates of maternal death. These midwives could help more than 14 million women give birth safely each year.

UNFPA also supports the implementation of maternal death review and response systems, which help officials understand how many women are dying, why, and how to respond.

The UNFPA-led Campaign to End Fistula currently provides more than half of all fistula repairs globally. UNFPA has supported more than 85,000 repairs since 2003, with more than 15,000 surgeries in 2016 alone.

What is UNFPA doing to end unmet demand for family planning?

UNFPA works with communities to understand their needs and ensure service delivery is appropriate. Further, engagement with local communities and religious leaders ensures a positive environment for family planning.

UNFPA is the biggest provider of donated, quality-assured contraceptives worldwide. UNFPA adheres to WHO prequalification standards for quality reproductive health commodities.

In many of the priority countries where we work, our UNFPA Supplies programme is the only, or one of very few, external sources of support for procurement of contraceptives.

In 2016, contraceptives provided by UNFPA had the potential to prevent 11.7 million unintended pregnancies, 3.6 million abortions, and 29,000 maternal deaths.

Leaving no one behind

When we speak of reaching those left furthest behind, women and girls affected by conflict, displacement or violence are among the most compelling examples of who we are talking about.

Rohingya refugees fleeing into Bangladesh have reported horrific stories of sexual violence, and UNFPA-supported safe spaces and mobile clinics are providing lifesaving medical services, psychosocial counselling and other services.

In South Sudan, poor pregnant and breast-feeding women who barely had any access to life-saving maternal health care suddenly found themselves with no care at all as deadly clashes near the Ugandan border drove tens of thousands of people from their homes earlier this year. Across the border, a UNFPA-supported clinic provided a range of life-saving reproductive health services and access to antenatal care, safe delivery services and postpartum care.

Gender-based violence and harmful practices, such as child marriage and female genital mutilation, are human rights violations that rob women and girls of their futures and undermine their health and well-being.

Responding to violence against women in development and humanitarian settings, urban or migration contexts, is a priority for UNFPA. Our programmes promote the right of all women and girls to live free of violence and abuse.

In a community on the outskirts of Cairo, for example, a UNFPA-supported programme helps vulnerable women stand up for themselves.  They learn to use their voice as a weapon, to defend themselves and to step outside with confidence.

“Don’t be afraid or hesitate,” the instructor Amany Abdel-Aal tells them. “It is your right.”

The right to a world of safety and dignity is theirs, too.

That is the world UNFPA and our partners are working to build.