Peer-reviewed article
Erosion of the Capital City Advantage in Child Survival and Reproductive, Maternal, Newborn, and Child Health Intervention Coverage in Sub-Saharan Africa
Agbessi Amouzou, Dessalegn Y. Melesse, Fernando C. Wehrmeister, Leonardo Z. Ferreira, Safia S Jiwani et al. ·
Summary
Written by AI, not yet AICS's view · claude-haiku-4-5-20251001This study analyzes child mortality and reproductive, maternal, newborn, and child health (RMNCH) service coverage across 39 sub-Saharan African countries from 1990 to 2020. The research found that the traditional advantage of capital cities in child survival is eroding, with rural areas making faster progress than urban areas. The gap in under-five mortality between rural and capital city areas narrowed from 41 deaths per 1,000 births in 2000 to 23 by 2015. While inequalities by place of residence are declining overall, capital cities and urban areas are losing their health advantage, particularly in Eastern Africa.
Key points
- Under-five mortality gap between rural and capital cities decreased from 41 to 23 deaths per 1,000 live births between 2000 and 2015
- Mortality gap between rural and other urban areas reduced from 26 to 15 deaths per 1,000 live births over the same period
- In Eastern Africa, the under-five mortality gap between capital cities and rural areas closed almost completely by 2015
- Rural areas experienced faster progress in child mortality reduction and RMNCH coverage than capital cities and other urban areas
- Capital cities show slower trends in reducing child mortality and improving RMNCH coverage compared to rural areas
Limitations
The analysis is based on cross-country comparison using DHS and MICS surveys and cannot explain the mechanisms driving differential progress between areas. The document does not provide detailed analysis of within-urban inequalities or the specific contextual factors contributing to the erosion of capital city advantage.
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.