Not all cities are the same: different tales of maternal health indicators in 62 sub-Saharan African conurbations

Background: Sub-Saharan Africa (SSA) accounts for the majority of global maternal and perinatal deaths. Maternal healthcare service provision in SSA cities is not commensurate with the region's fastest rate of urbanisation, and widespread inter-urban inequalities are diminishing the urban health advantage. We estimate and compare the coverage of six key indicators covering utilisation, content and continuity of care for maternal and newborn care of 62 SSA conurbations (core cities with adjacent peri-urban areas) in 33 countries. Methods: We linked the most recent Demographic and Health Surveys (DHS) conducted after 2010 in SSA countries with conurbation boundaries of settlements with ≥0.3 million inhabitants. We defined six indicators related to the most recent livebirth in the 3-year survey recall period and estimated their levels: 1) coverage: use of antenatal care (ANC1+ and ANC4+ visits) and facility-based childbirth (FBC) care; 2) content: caesarean section (CS), postnatal care for the woman within 48 hours of birth (PNC48), and newborns weighed at birth. We estimate indicator levels at i) national-urban and ii) conurbation-level. We then appraised continuity of care by comparing the coverage between indicators (ANC1+ versus ANC4+; FBC versus PNC48; FBC vs newborn weighed) in percentage points (pp). We extend an existing typology of performance across conurbations. Results: We included 20,104 livebirths (120 to 876 per conurbation). ANC1+ had the highest coverage (median 98%) and smallest variability; 74% of conurbations had coverage of ≥95%. ANC4+ was lower than ANC1+ at median 72% (range 37%-97% across conurbations). Continuity from ANC1+ to ANC4+ varied; a third of conurbations had a >30pp relative loss, with the most extreme case of 62pp. FBC median was 94% across conurbations, only three had levels <50%. CS median was 11% (range 1.4%-32%), while PNC48 median was 72%, (range 22%-93%). Newborns weighed at birth had the widest variability - from 18% to ≥95%. PNC48 was lower than FBC in the majority (56/62) of conurbations. We identified nine best performed conurbations (above average on all five indicators excluding CS), including Kumasi and Nairobi; and a further eleven high-performing (mix of high and average across indicators). Five conurbations performed consistently poorly (Sokoto, Uyo, Abuja, N’Djamena, Maiduguri). The remaining 37 conurbations had inconsistent performance across the five indicators. Conclusions: These unique and heterogeneous patterns are useful for the identification of policy priorities to improve the performance of urban maternal and newborn health systems in SSA. The innovative approach included the largest number of conurbations and accounted for peri-urban areas while developing a conurbation’s typology based on performance.