Urban health survey shows ‘startling’ findings

It seems Bangladeshi families have taken with the idea of having two children as a new survey finds couples living even in slums have significantly reduced their family size.

The surprising findings of the ‘Bangladesh Urban Health Survey 2013’ also revealed a declining trend in intra-urban inequality between slums and non-slums in family size, use of family-planning methods, skilled birth attendants and nutritional status.

Yet, the survey showed under-five children mortality rate inexplicably much higher in slums than non-slums.

The preliminary findings of the survey conducted seven years after the first one in 2006 were disseminated on Tuesday in Dhaka.

Health and Family Welfare Minister Mohammed Nasim, US Ambassador in Dhaka Dan Mozena and British High Commissioner Robert Gibson were present among others during the dissemination.

The survey measured the changes in key health outcomes and sources of care for various health services and examined whether intra-urban differences in the health outcomes have narrowed between the years 2006 and 2013.

It has been carried out at a time when demographers predict all future population growth in Bangladesh will be in urban areas.

Slums now make up about a third of the city corporations, but are growing twice as fast as overall urban city corporation, which means in 20 years slums will be half of the city corporations.

But according to the government’s mid-term review of the health sector development programme HPNSDP, urban health remained “the least-attended” area of the government.

Compared to rural poor, the urban poor lack government infrastructure and health services located within their reach for their needs.

The survey released on Tuesday also found NGOs and private sectors were the choice of urban slums as they found them within their reach.

But unregulated private sector has pushed up their medical costs as the survey found the rate of unnecessary C-section deliveries has increased manifolds.

“The inequality concerns based on which NGOs started working on urban health have started improving,” Dr Kanta Jamil, a Senior Advisor of the USAID’s Office of Population, Health, Nutrition and Education, who was one of the key presenters, told bdnews24.com.

The American and British development agencies USAID and DfID funded the survey conducted by the government’s National Institute of Population Research and Training (NIPORT) with the support of ICDDR,B and US-based MEASURE Evaluation.

They interviewed nearly 54,000 households in city corporation slums, non-slum areas, and other urban slums that include district municipalities and large towns or Pourasabhas where more than 45,000 people live.

Reuters

Two-thirds of men and women living in slums were found migrants while the remaining third had always lived there.

Men are most likely to migrate for works while women mostly because of marriage.

At least 20 percent of the migrants in Dhaka slums came from Barisal though the division accounts for only 6 percent of national population that explains climatic factors pushed coastal people to the cities.

Environmental reasons have been found to have accounted seven percent of all migration to city slums.

However, household conditions showed slightly improvement compared to 2006, though three out of four slum households were in the lowest two wealth quintiles compared with one in five in non-slum areas.

Almost all have access to electricity as well as improved water source now compared to 2006, though they have to stand in long queue to fetch water from a common source.

Toilet sharing is very high in slums that limit their access to improved sanitation.

However, personal mobile phone use has jumped to 92 percent from 20 percent in 2006.

Interestingly, the proportion of slum households on government land has declined to 8 percent from 20 percent in 2006.

Family size

The government’s national target of reaching replacement-level fertility or women having two children has already been achieved in slums. The rate is even lower in the non-slum areas of city corporations.

The survey found the total fertility rate (TFR) 1.7 births per woman in city corporation non-slum, while two births per woman in slum and 1.9 in other urban areas.

Between 2006 and 2013 the fertility rate has declined by 0.5 births per woman in slums.

However, there have been no changes in tendency to marry off girls early, resulting in early pregnancy.

Family Planning

The contraceptive prevalence rate, which is traditionally common among Bangladeshi poor, has been found to be the highest in the urban slums and lowest in non-slums.

Between two surveys, the rate has increased by 12 percentage points in the slums and only two percentage points in non-slums.

Couples in slums have almost achieved the national goal of reaching 72 percent by 2016, though short-acting methods like pills are their preferred choice.

Private sector is the main source of availing those methods for the slums dwellers.

The use of long-acting and permanent methods is as low as five to seven percent in all three surveyed areas.

Mothers’ health

The disparity with non-slum dwellers has lessened slightly, though only half of the women living in slums receive medical care during pregnancies, ANC, from trained providers.

Facility delivery is also highest among women living in non-slums and lowest in slums.

Very few home deliveries are attended by medically trained providers in all there surveyed areas.

The NGO sector is the primary source of getting ANC for women in slums, while the private sector is the main source for women in city corporation’s non-slum areas.

In all three urban areas, newborns are less likely to receive the post-natal check-up from a medically trained provider than their mothers.

Reuters

Only 2-4 percent of newborns in all urban domains receive all the essential newborn care inputs.

The survey found an alarming rise of C-section in all three areas.

The private sector mostly performs the C-section, between 65 percent and 80 percent in the three survey urban areas, pushing up the costs of deliveries for poor urban women.

Child health and nutrition

During 2009 to 2013, one in 18 children in slums died before reaching their fifth birthday.

In slums, under-five deaths declined by 30 percent while the under-one deaths declined by 22 percent. Still, the rate is much higher than the non-slum areas, ICDDR, B, director of the child health division Dr Shams El Arifeen said while presenting the findings.

Under-five mortality in slums is twice that of non-slums.

This shows that with slums growing twice as fast the overall city corporations, the child mortality rate was also likely to go up.

Nutrition levels, which pose a national challenge for Bangladesh, remained dismal in slums with half of under-five children found to be stunted or too short for their age.

In the last seven years, however, there had been “a slight improvement” in the nutritional status in both slums and non-slums, narrowing down the disparity between the two groups.

The overall wasting rate surpassed the WHO specified emergency level of 15 percent in both slum and non-slum areas.

In the past seven years, wasting has increased from 11 percent to 16 percent in non-slum areas, while remaining static at 19 percent in slums.

Difficult to explain

Director of ICDDR,B’s Population Division Dr Peter Kim Streatfield, one of the key researchers of the survey, said it was difficult to explain why the child mortality rate was so high in the slums and also in the non-slum areas.

For example, he told bdnews24.com, population density in slums was around 200,000 per square kilometre and in non-slums 20,000 per square kilometre.

“So, with high crowding in slums more children were expected to be susceptible to ARI (acute respiratory tract infections) like pneumonia. But the rates of ARI are similar (with non-slums),” he found.

“With more people sharing toilets in slums, sometimes with five to 50 others, diarrhoea rate among children should be different than non-slum areas.

“But it’s same….there is no difference,” he said. The non-slums with better facilities show the same rate of incidence.

“It’s perhaps something about environment (that causes child deaths) but I cannot understand what exactly it is. We’ll have to analyse the data for that,” he said.

The environmental reason, he believed, could be accidents like drowning, fire or road traffic as mothers in slums remain mostly busy with works leaving their children at home with no adults to take care.

One in three women in slums works full time compared with one in six in non-slum areas.

Public-Private partnership

Dr Kanta Jamil said the two-children-family campaign had found acceptance as had been evident in the survey.

“Maybe, living spaces were their concerns, but it’s good to see that the two-child family concept has gains ground in the slums is a big surprise for us,” she said.

She said a private-public mix could be “a good approach” to ensure dealing with challenging urban healthcare.

“But some kind of regulation (for private sector) is needed,” she added.