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6 Fertility and Reproductive Health Many aspects of urban life have the potential to affect fertility and reproductive health, but not all of these can be said to be distinctively urban. The broad fea- tures of the urban economy its dominance by industry and services, its work- places situated outside the home were noted so long ago in discussions of the demographic transition (Notestein, 1953) that they have almost ceased to be re- garded as urban. Indeed, as discussed earlier in this report, many rural areas have been assuming similar characteristics, especially in the regions surrounding large cities. Lower infant and child mortality is also broadly characteristic of cities, and lower mortality reduces some of the risks parents face in adopting strategies of low fertility. But the mechanisms are not obviously urban in character; surely lower mortality would exert much the same sort of influence in rural villages. Mi- grants are a distinctive presence in urban environments, and the fact that they have recently made transitions from other contexts raises issues of disruption, adjust- ment, and selectivity. Apart from migration, however, there remains the question of what is gained by situating fertility and reproductive health decisions within specifically urban contexts. What does this "embedding" achieve? Does it bring to light any implications for services and programs? To begin, we should offer a word of explanation on the meaning of the phrase "reproductive health." It refers to "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity, in all matters re- lating to the reproductive system and its processes" (United Nations, 1994: 202~. The concept provides a framework for thinking about sex and reproduction, high- lighting not only family planning, conception, and birth, but also the imbalances in decision-making autonomy between men and women, the possibilities of coer- cion and even violence in their relations, and the different health risks to which they may be knowingly or unknowingly exposed. A broad perspective is espe- cially helpful where adolescents are concerned, because young men and women are often woefully ignorant about matters of conception and health risk, are still 199

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200 CITIES TRANSFORMED testing the limits of their autonomy in decision making vis-a-vis their elders and the other sex, and yet must often make choices that can foreclose options for adult life and compromise their later decision-making powers. Programs in the area of reproductive health include those dealing with contraception, but also encom- pass initiatives aimed at sexual violence; reproductive tract infections; and sexu- ally transmitted diseases (STDs), including HIV/AIDS. They extend as well to services intended to ensure healthy pregnancies and deliveries and safe abortion. With this set of issues in mind, we turn in the first section of the chapter to the distinctive features of urban environments. Two features warrant special attention. First, the socioeconomic diversity and the forms of social interaction found in cities may encourage urban parents to make deeper investments in their children's schooling, a strategy that typically entails lower fertility. Social interaction may also focus attention on the means by which lower fertility can be achieved, that is, on modern contraception. It is possible that urban environments influence the ways in which adolescents make their transitions to adulthood and the terms upon which marriage search is conducted. Second, the urban services and program en- vironment differs in many ways from that of rural areas. It is much more diverse, especially in the roles taken by the private sector and in the multiplicity of gov- ernmental units that have a say in the management and delivery of health services. It is remarkable how little research attention has been paid to the specifically urban aspects of reproductive health programs. The problem is not that these programs are mainly rural; especially in the areas of STDs and HIV/AIDS, many programs are situated in cities and address health issues that are of special concern to urban populations. Rather, the problem is that the conceptual frameworks that inform program design and evaluation do not appear to have been thoroughly ap- praised from an urban perspective. The service providers who work in cities may well be attentive to urban possibilities and constraints, but the research literature has conspicuously failed to provide them with concepts and guidelines tailored to their environments. Having set forth the main concepts in the first section of the chapter, we give in the second section an empirical overview of urban fertility, contraceptive use, and selected measures of reproductive health, drawing from the survey data supplied by the Demographic and Health Surveys (DHS). We next explore the fertility transitions that are under way in cities, seeking to differentiate the transitions that accompany economic development from those produced by economic crises. The succeeding sections of the chapter consider three urban groups of particular im- portance: the urban poor, migrants, and adolescents. We then offer reflections on the distinctive features of urban service delivery. The final section presents conclusions and recommendations. THE URBAN DIMENSION Urban residents face a variety of constraints and opportunities that influence decisions about marriage search, the number of children to bear, and the manner

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FERTILITY AND REPRODUCTIVE HEALTH 201 in which children are raised. Like rural parents, those in urban areas strive to pro- tect their children's health and their own. Rural and urban parents no doubt hold similar fundamental values, but they face different economic and social environ- ments and may find that they must adopt productive and reproductive strategies specific to these environments. In what follows, we first discuss the features of urban settings that can influence family building and the pursuit of reproductive health. We then examine the programs and services that can determine whether urban families have access to the means to reach their goals. Social and Economic Contexts There can be little doubt that a great number of family reproductive strategies are on display in cities. Consider the case of Natal, a Brazilian city of some 680,000 residents within the urban agglomeration. By no current standard would Natal be considered a megacity, and yet across its neighborhoods one sees an astonishing range of fertility levels. Franca (2001) illustrates this diversity, showing that the total fertility rates (TFRs) of Natal's neighborhoods can be as different as those of Switzerland and Nigeria (see Figure 6-1~. This spatial expression of reproductive diversity suggests, although it does not prove, that urban neighborhoods must exert an important influence on fertility decisions. As argued in previous chapters, the fact that cities exhibit a diversity of reproductive strategies is not sufficient to make ,, .,,,,,,,,,, .t, ............... ,, . ~ . ..~.,~ -.~ ~ ~ .$::::::::::.:::.:.:.:.:.:2 : l ~ ~ if::::::::: ::::::::::: r .. E: ~~.~ ~ ': :~. .~Ix. ~ ~ ~ .,~ ~.,.~.,., . to 2 1: ~0- : r ~ ~~ ~~ ~~ idiot ::: 734:: :::::::::::: :: _ ::::::::::: ::>b~::: ,:.~: :::: : ~~ ~~:~ :::~:~:~ ~ ~:~'~,,~ ~:~ i: :: :~ : ~~ ~ : ,': FIGURE 6-1 Total fertility rates in the neighborhoods of Natal, Brazil, as com- pared with rates in Europe and sub-Saharan Africa. SOURCE: Franca (2001~.

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202 CITIES TRANSFORMED the case for neighborhood effects. The spatial diversity must persist when controls are introduced for individual socioeconomic characteristics, and it must be shown that forms of interaction take place within neighborhoods that shape individual knowledge and behavior. Of course, interactions limited to defined spaces, such as neighborhoods, do not exhaust the possibilities. As Chapter 2 makes clear, city residents can participate in multiple networks and associations, only some of which may intersect in their neighborhoods of residence. For example, the separation of workplace from place of residence that is characteristic of cities allows for the development of spatially separated reference groups. In our view, the theories set forth in Chapter 2 make a persuasive case for the proposition that neighborhoods, networks, and reference groups influence fer- tility and reproductive health decisions in the cities of poor countries. But this case rests mainly on analogies with the experience of rich countries. For the poor countries with which we are concerned, the empirical evidence on urban social interaction and fertility is meager indeed. In a few aspects of urban reproductive health sexual networks and STDs in particular the social interactions are bet- ter documented. In the broader realm of health, the empirical record is quite rich, offering many examples that illustrate the operation of neighborhood effects and the influence of spatially concentrated disadvantage (see Chapter 7~. But with respect to fertility and much of reproductive health, research is still in a documen- tation and data-gathering phase. A first step in assembling the documentation is to show that spatial units such as neighborhoods are something more than the aggregation of their residents' characteristics. To merit consideration, they must have some separable, durable traits with an urban character.) In very recent research, Weeks, Getis, Yang, Rashed, and Gadalla (2002) assemble evidence that is suggestive of neighbor- hood effects in Cairo. Examining geocoded census data for Greater Cairo, they discover a wide range of fertility rates across the city's shiakhas (see Box 6.1) and, more to the point, are able to show that substantial spatial differences remain after controls are introduced for the usual socioeconomic predictors of fertility. It ap- pears that in Cairo, at least, the spatial component is durable enough to withstand this first round of testing. But evidence of social interaction, whether in the confines of neighborhoods or in social networks arrayed across the urban space, is required to isolate the dis- tinctively urban features of decision making in fertility and reproductive health. As we have argued, the early Taichung study (Freedman and Takeshita, 1969) pro- vided strong evidence that the social networks of urban women supply conduits for the exchange of information about contraception (see Chapter 2~. Recent mul- tilevel, longitudinal research on social networks in the periurban and rural areas of tin multilevel models with individuals clustered within areas, statisticians often introduce unmea- sured areal traits termed "random" or "fixed" effects, depending on their relation to the measured traits and commonly find these effects to be statistically important even with controls in place for individual characteristics.

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FERTILITY AND REPRODUCTIVE HEALTH 203 BOX 6.1 Spatial Differences in Fertility Rates: Greater Cairo In ongoing research using geographic information systems (GIS) in Greater Cairo, Weeks, Getis, Yang, Rashed, and Gadalla (2002) have uncovered substantial differences in fertility rates across this city's neighborhoods. Census data were used to map fertility rates by shiakhas small districts within the Cairo metropolitan area that are akin to U.S. census tracts. As can be seen in the map below, the lowest fertility rates were found near the center of Cairo (near Talaat Harb Square) and the highest at the suburban edges, where men and women tend to be less educated, higher percentages of women are married, and fewer women work outside the home. Many of the high-fertility shiakhas have fertility levels similar to those of rural Egyptian villages. Multivariate analyses revealed that neighborhood context has a substantial impact on fertility even net of controls for conventional predictors of fertility. Weeks and colleagues also discovered substantial variation by shiakha in the coefficients of these predictors. . ~ ; ~ , ., ~ : .~ . / . ~ } ~ i.-. -- ! ~ ~ ~! - : ....................... ...................................... .:.:.:.:. .. ....... ............. ,.~ By mte 1 less l:h~an 2 2- 2.49 2.5 - 2~99 3- 3.49 3 5~ - 3 99 . . . ~ or higher

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204 CITIES TRANSFORMED Ghana, Kenya, and Malawi has reconfirmed the importance of these networks to contraceptive use (Behrman, Kohler, and Watkins, 2001; Casterline, Montgomery, Agyeman, Aglobitse, and Kiros, 2001~. We are not aware of any other studies of this sort that are set in the cities of developing countries. For the moment, there- fore, the urban case must rest almost entirely on a persuasive theory. The key theoretical concepts are those of diversity and spatial proximity. Be- cause they are highly diverse in social and economic terms but relatively compact in spatial terms, urban populations present a greater range of accessible models of behavior than is seen in rural areas and offer greater possibilities for social comparison. In cities, for instance, an uneducated young mother may find a few better-educated friends and peers in her social networks. Whether through conver- sation or by example, these women can give her a keener sense of the time that is involved in properly preparing a child for success in school. When the urban poor live near others with somewhat higher incomes, they may be able to recognize in their neighbors' behavior new strategies for upward economic mobility. Urban settings also present a parade of new consumption possibilities (as seen in con- sumer durables, for example), and the prospects for securing them may motivate desires for smaller families. As Granovetter (1973) argues, individuals are often connected to novel infor- mation and social examples by the "weak ties" of their social networks. For the urban poor, social exclusion and spatial segregation can inhibit the formation of such weak ties, or disconnect them. The poor then lose out on opportunities to evaluate novel behavioral strategies and lack the full range of local models who could illustrate their implications. As urban parents and would-be parents survey their environments, they are likely to come upon some examples illustrating how important education is to up- ward mobility and others illustrating either its relative unimportance or the risks of squandering educational investments. The examples provided in networks and neighborhoods may also demonstrate that substantial infusions of parental time and resources are needed to protect and support human capital investments in chil- dren. Recognizing that they have limited time and money, parents may conclude that only a few children can be afforded if such an innovative reproductive strategy is to be pursued. By this route, they may be prompted to consider modern con- traception, another relatively new dimension of choice, with each contraceptive method presenting uncertain benefits, costs, and (perceived) risks to health. These considerations are packaged in the literature under the heading of the "quantity-quality trade-off" (see, among others, Willis, 1973; Knodel, Chamra- trithirong, and Debavalya, 1987; Parish and Willis, 1993~. The theory describes how in certain situations, families will find it in their best interest to bear fewer children but to invest more in developing the human capital of each child. In Chapters 4 and 5, we present empirical evidence showing that children's school enrollment rates are decidedly higher in the cities of developing countries than in rural villages, and that fertility rates are decidedly lower. These are not isolated

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FERTILITY AND REPRODUCTIVE HEALTH 205 empirical regularities, but alternative positions along the two axes of a quantity- quality transition. The costs and benefits perceived by rural households tend to produce family strategies involving higher fertility and lower human capital in- vestments in children.2 Urban configurations of benefits and costs, however, lead to lower-fertility, higher-investment strategies (Caldwell, 1 976; Stecklov, 1 997; Lee, 2000~. Two motivating factors are involved in the quantity-quality transition: the perceptions that net economic returns to schooling are high and that the full costs of child-rearing strategies supportive of schooling are also high (Montgomery, Arends-Kuenning, and Mete, 2000~. Some parents can see at first hand how schooling is required for advancement in the workplace. Others must acquire a sense of schooling's economic returns from social observations and comparisons and from the media. Parents may also need to acquire information about appropri- ate child-rearing strategies. As some research has shown (notably LeVine, Dexter, Velasco, LeVine, Joshi, Stuebing, and Tapia-Uribe, 1994; Stuebing, 1997), moth- ers who have had some schooling themselves tend to employ more verbal, time- intensive styles of interaction with their children. Such attentiveness has the effect of raising the costs of child rearing for parents while increasing the present and future benefits for their children. Other opportunity costs of schooling also need to be weighed: time in school is time subtracted from family or wage work, and this may be an important consideration for the poor. Even if poor parents agree that schooling promises their children substantial returns, they may not be able to invest in it to the extent that richer parents can. The negative and threatening aspects of urban diversity can also affect parental views of the time and supervisory effort required in child rearing. As Randall and LeGrand (2001: 31) note for Senegal: The city (especially Dakar) is viewed as an environment in which bringing up children well is particularly difficult, where parents must face the effects of the economic crisis (poverty, unemployment, crowding), the presence of bad elements, and the ease for children to escape from parental authority and bring themselves up in the streets. 2In traditional rural societies, children provide status, resources, and old-age support to their par- ents, and these are incentives for higher fertility. But rural populations are not excluded from the quantity-quality transition. The rural fertility transitions of Kenya (Brass and Jolly, 1993) and Thai- land (Knodel, Chamratrithirong, and Debavalya, 1987) can be viewed as examples in which rural parents invested in their children so as to better prepare them for urban livelihoods. In a sense, urban populations provide distant reference groups for rural populations, and in some cases, connections through migration and relatives can provide rural villagers with specific urban examples. In Vietnam, as noted by White, Djamba, and Dang (2001: 3), "Parents must now cope with rising costs of education and other expenses, if they want to guarantee the social mobility of their children. This strategy of grooming children for good jobs started among the rich and urban residents, but it expanded to other groups across the society."

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206 CITIES TRANSFORMED Compared to life in villages, in cities more parental time and invest- ment is required to produce a well-brought up child, and this, along with the costs of supporting a family, motivates family size limitation. As these authors describe the situation, in Dakar the temptations and proximity of social risks for children have the effect of raising the full costs of child rearing. Parental anxieties are no doubt heightened by the ubiquitous presence of street children, who serve as vivid reminders of what can happen if parents do not remain vigilant. For urban adolescents and young unmarried adults, the surrounding social and economic environment also presents a great diversity of novel and untested be- havioral options. Indeed, in some countries the very notion of adolescence a period interposed between childhood and full adulthood is a recent develop- ment, and adolescents may lack guidance on how to negotiate this new terrain. Amin, Diamond, Haved, and Newby (1998) describe the case of young female garment workers in Dhaka, Bangladesh, who must reconcile the strictures of pur- dah (the strict isolation of women inside the home) with their own factory wage work, which takes them outside the home and into direct contact with men in the roles of coworkers, bosses, and potential social partners. As most of these young women are recent migrants from rural villages, their own parents can provide little by way of guidance about city environments and risks. In conversation, the gar- ment workers exhibit a mix of pride and anxiety about their new situations. They take up distinctive habits of dress to signal their special status while allowing their parents to conduct marriage search in the traditional manner. These women will enter marriage with cash dowries that they have amassed through their own work, and will also be equipped with some knowledge of how to negotiate with men as partners resources unknown to the Bangladeshi brides of generations past. The terrain such young women are traversing is new for them; in Hong Kong and Sin- gapore, by contrast, women began to face similar choices a quarter-century ago (Salaff, 1981~. The Program and Services Environment The services and reproductive health programs found in cities offer some re- sources that can be of use in spacing and limiting births, other resources meant to ensure safe conditions at delivery and swift assistance should complications arise, and still others that provide protection against sexually transmitted and related diseases. Rural areas also have services and programs of this general kind. What, then, are the important urban/rural differences in the program environment? Many of the studies that touch on these issues are found in what might be called a "gray literature," that is, in project reports and memoranda. These mate- rials must reflect a great deal of specific expertise and experience in reproductive health that could be drawn upon in a comprehensive review. To date, however,

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FERTILITY AND REPRODUCTIVE HEALTH 207 researchers have not collated and organized this knowledge in a way that distills its lessons for program design, service delivery, and evaluation. The panel's own efforts to survey the literature identified seven distinctive features of urban service environments that deserve further consideration. First, the diverse composition of cities and the absence of certain social con- trols on behavior that are exercised in rural villages may raise the profile of some reproductive health problems. Urban sexual networks, the role of prostitution, subpopulations of drug users, and communities of migrants separated from their families all can increase the risks of STDs and HIV/AIDS. In city life, adoles- cents can elude the watchful eyes and discipline of family elders and neighbors and find themselves at risk of violence, pregnancy, and disease. Urban socioe- conomic composition is also expressed in the levels of demand for preventive services, such as contraception, and at least on average, city residents have greater abilities to pay for preventive and curative care. Second, many countries are undertaking ambitious programs of governmental decentralization, and these political reforms are introducing new municipal, state, and regional units of government (see Chapter 9 for a full account). In the era be- fore these reforms were initiated, responsibility for the delivery of family planning and reproductive health services generally rested with national ministries, which held the requisite funds and technical expertise. Decentralization has introduced many uncertainties. As vertically organized delivery systems give way to more complex forms involving multiple units of government, what becomes of the ex- pertise and funds previously concentrated in the national ministries? Are national staff relocated and reassigned, or are municipal and regional units of government asked to acquire their own staff to oversee service delivery (Aitken, 1999~? What sorts of transfers from upper to lower tiers of government will sustain the repro- ductive health care system? How is information about health to be returned from the local to the national level to guide resource allocation? These appear to be highly complex matters, and it is surprising that they have attracted relatively little research attention to date. Scattered case studies are available Chapter 2 describes interesting recent results for the Philippines (Schwartz, Racelis, and Guilkey, 2000; Schwartz, Guilkey, and Racelis, 2002)- but nothing akin to a comprehensive review has been published. Of course, decen- tralization is still new, and it is often difficult to distinguish between the reforms being proposed and those actually being implemented. In principle, at least, the developments at the municipal and local levels might generate opportunities for local governments to engage indirectly in service delivery through monitoring and contractual relationships with the local private sector and nongovernmental organizations. Third, the private sector is a distinctive and prominent presence in urban repro- ductive health, and indeed, in urban health care more generally (see Chapter 7~. The urban private sector is highly heterogeneous, offering an array of expertise that ranges from traditional healers to chemist shops to highly trained surgeons.

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208 CITIES TRANSFORMED Fee-for-service arrangements take on greater importance in the private sector, and service pricing raises questions of equity and ability to pay.3 In some countries, private providers interact with their clients through health insurance mechanisms, especially when patients are in the employ of the public-sector or "formal-sector" private firms. Rural areas generally lack the scale, diversified economies, and con- centrations of resources needed to support much private-sector activity in health. Some drugs and supplies can be purchased in rural markets, and traditional forms of health care are much in evidence, but on the whole it is the public sector that must provide rural villages with modern forms of care. Fourth, the question of access to services takes on a different cast in urban ar- eas. In urban settings, it is inadequate and potentially misleading to conceive of access as being measured by the physical distance to services. The greater density and variety of urban transport can greatly reduce the time it takes to reach services by comparison with access time in rural areas. Much less time is likely required to locate emergency care, such as that needed in cases of hemorrhage and other complications of childbirth, than is the case in most villages. However, time costs can still loom large in discouraging preventive and nonemergency forms of care. These costs should not be underestimated, particularly when services are located far from main transport routes and the clusters of residence and employ- ment for the urban poor. Moreover, delays in obtaining care are not just a matter of time and transport. In poor city neighborhoods, there can be as little knowl- edge of reproductive health as in remote rural villages. In both settings, delays in seeking health care can arise from the need to consult with men and family elders and obtain from them the funds needed to purchase care. Fifth, the quality aspect of service delivery merits comment. It is a common assumption that urban reproductive health services are of higher quality than rural services. As will be seen, careful comparisons have not always supported this view. Some aspects of quality have been found to differ for instance, urban clinics are more likely than their rural counterparts to have electricity but in terms of the interactions between staff and clients, the information exchanged, and the availability of essential supplies, the situations of urban and rural clinics can be much the same. Sixth, the roles that may be played in service delivery by communities and community organizations no doubt differ a great deal between cities and rural villages. Urban neighborhoods can be defined according to social criteria, in- volving notions of belonging, inclusion, and exclusion that may be difficult for outsiders to discern. The social capital of urban communities the matrix of for- mal and informal associations that can provide support, information, and a means of linking individuals to services also appear to have a distinctive character. Some service delivery systems that were developed for rural populations, such as 3Public-sector services, even if ostensibly free, often require patients to pay for drugs and supplies or to make side payments.

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FERTILITY AND REPRODUCTIVE HEALTH 209 community-based distribution networks, may need to be substantially adapted to serve urban populations (Tsui, Wasserheit, and Haaga, 1997~. Strategies for communicating about reproductive health that work well in rural villages may also need to be adjusted to the circumstances of urban life. Cities are characterized by a diversity and multiplicity of information. In large cities, information emanates from so many sources that a potential user of contraception may well find herself overwhelmed and unable to discern the quality of any single source. Individuals may have to rely on their social networks and local associ- ations for guidance to services. The localized networks of the urban poor may not offer them many leads, and the poor may not learn of new reproductive health services and initiatives unless special efforts are made to reach them. Seventh, urban/rural differences in the costs of service provision need to be considered (Tsui, Wasserheit, and Haaga, 1997~. It is difficult to persuade highly skilled health personnel to locate in remote rural villages absent a substantial wage premium. Professionals with school-age children are generally reluctant to sac- rifice their urban educational opportunities and often can do no more than take a tour of duty in the countryside. Rural health services requiring this sort of labor must pay higher real wages and cope with higher rates of turnover. Health ser- vices that depend on electricity and piped water may well be costlier to organize in rural areas. On the other hand, there may be offsetting savings stemming from the lower costs of rural housing, and some health professionals may prefer the slower pace of rural life. AN EMPIRICAL OVERVIEW This section provides a sketch of fertility, marriage, contraceptive use, conditions at childbirth, and HIV/AIDS that draws comparisons between urban and rural ar- eas and, where possible, highlights differences among cities by population size.4 It is the common view that, with regard to reproductive health, cities are far better served than rural areas. Expert assessments often suggest that urban services are more plentiful and generally of higher quality. Table 6-1 can be taken as represen- tative of this consensus. The figures shown are summaries of the responses of in- country evaluators of maternal care to a questionnaire that was standardized across countries (Bulatao and Ross, 2000~. In each of the dimensions shown in the table, the experts are more likely to classify urban than rural services as being adequate. One does expect cities to exhibit advantages in many aspects of reproduc- tive health. But as will be seen, the advantages that are suggested by averages taken over urban populations as a whole often conceal a great deal of intraurban heterogeneity. In fertility and contraceptive use, the urban averages appear to in- dicate an urban socioeconomic advantage. On closer inspection, however, cities are found to be more varied than might have been thought. As we consider more 4See Table C-3 in Appendix C for a list of cities in the 1-5 million range and those over 5 million.

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248 CITIES TRANSFORMED In South Africa, however, there is little evidence of any long-term upward trend in the percentage of women giving birth in their teens, which has consis- tently ranged between 30 and 40 percent (Kaufman, de Wet, and Stadler, 2000~. The determinants of teen sexual activity were examined in a large survey of ado- lescents in urban and rural areas of South Africa's province of KwaZulu-Natal (Kaufman, Clark, Manzini, and May, 2002~. This study examined the likelihood of sexual intercourse in the 12 months preceding the survey, and among those ado- lescents with recent sexual partners, the likelihood of consistent use of condoms. The study is especially noteworthy in the context of this report it gives careful attention to the neighborhood and other multilevel effects that figure prominently in the discussion of Chapter 2. In KwaZulu-Natal province, some 49 percent of the boys and 46 percent of the girls reported having had intercourse in the preceding year; among those who had had intercourse, condoms were reported to have been used at the time of last intercourse by 49 percent of the boys and 46 percent of girls. Recent intercourse was much more likely among the black South African adolescents than among the whites or Indians in the sample, but for blacks no urban/rural difference could be detected, other things held constant.34 For adolescent girls but not for boys several measures of neighborhood context appeared to reduce the likelihood of recent sex. These context measures included the proportion of other neighborhood adolescents enrolled in primary or secondary school, and, among those aged 20 and above, the proportion who had graduated from secondary school. These indicators were strongly associated with lower likelihood of recent intercourse, other things being held constant. Such contextual effects are consistent with theories of social learning and peer or role model effects, as described in Chapter 2, in which local reference groups draw attention to the returns to schooling and underscore the dangers of activities, such as early sex, that might threaten school completion.35 In the South African neigh- borhoods in which wage rates for adolescents were relatively high, the likelihood of recent intercourse was found to be relatively low for girls, although no effect on the likelihood of intercourse could be detected for boys. Among those adolescents who were sexually active, measures of household poverty were associated with a lesser likelihood of condom usage (for girls), and having an adult in the household with secondary schooling sharply increased the 34The factors held constant included the adolescent's age, quality of housing, and whether the house- hold contained an adult with 12 or more years of schooling, the last of these having a pronounced negative effect on the likelihood of girls having had recent sex, although no apparent effect for boys. 35Note, however, that teen mothers in South Africa have schooling options open to them that would not have been available in other developing countries (Kaufman, de Wet, and Stadler, 2000). They are permitted to return to school after giving birth, and many teen mothers evidently take advantage of this opportunity (a practice that gives rise to unusually long intervals between first and second births). The keen desire to continue schooling is due partly to its connection with brideprice: schooling is regarded as much enhancing the woman's economic potential in marriage.

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FERTILITY AND REPRODUCTIVE HEALTH 249 likelihood of condom use for both girls and boys.36 The educational context measures, however, displayed inconsistent effects, and other contextual measures (neighborhood levels of involvement in community groups, sports associations, and religious groups) exhibited little interpretable influence on either intercourse or condom use. The effects of local labor market conditions were similar for boys and girls, with higher wages being associated with a greater likelihood of condom use. As Kaufman et al. (2002: 25) conclude, "if young people perceive that it is possible to work for reasonable wages, they are more likely to engage in safer sex practices." A complementary study of teen childbearing in urban South Africa provides a glimpse of the complexities of adolescence in this environment. Kaufman, de Wet, and Stadler (2000) examined the consequences of teen pregnancy and childbearing through interviews with teen mothers and young men in their early twenties, many of whom were already fathers. (The urban interviews were conducted in Soweto, the collection of townships to the southwest of Johannesburg.) Although accounts of rape and coercion often appear in studies of adolescent pregnancy elsewhere, the participants in this South African study infrequently mentioned coercion and forced sex in discussions of why girls get pregnant; these were acknowledged as possibilities, but not represented to the interviewers as common occurrences. (It may be that in South Africa, a certain amount of coercion in sexual relationships is taken to be "normal.") In both Soweto and the study's rural sites, young women readily admitted that they had considered abortion upon discovering their preg- nancies, and they tried to give the interviewers a realistic sense of the pros and cons involved in the decision to take their own pregnancies to term. As in the KwaZulu-Natal study described above, Kaufman and colleagues found no sharp urban/rural differences here. The recent Nairobi Cross-Sectional Slums Survey, mentioned above, found that adolescents in the slums initiate sex earlier than those in the rest of Kenya (almost 1 year earlier for girls and 6 months earlier for boys). Moreover, in con- trast to what was found in the South African study, one-quarter of Nairobi girls reported that coercive pressures were applied in these first encounters (Magadi and Zulu, 2002~. In some cities, many young women are believed to be involved with much older men "sugar daddies," as they are known who supply them with money and gifts in exchange for sex. Poor adolescents are believed to be es- pecially vulnerable to such relationships. In cities such as Nairobi and Yaounde, sugar daddies appear to be much in evidence (Luke, 2002; Meekers and Calves, 1997~. They are especially risky sex partners because sugar daddies have more nonmarital sex in general than other urban men, and more relationships with pros- titutes in particular. 36The effects of poverty on teen pregnancy have been highlighted in other studies of South Africa, one example being that of Pick and Cooper (1997) for a periurban area of Cape Town, in which teenage pregnancy was found to be very common among less-educated women.

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250 CITIES TRANSFORMED Adolescent girls present special difficulties for reproductive health programs because their need for protection comes into conflict with traditional values em- phasizing that for girls, sex is to occur only within marriage. Even clinic staff and outreach workers can be uncomfortable in dealing with adolescents (Magnani, Gaffikin, Leao de Aquino, Seiber, de Conceic~ao Chagas Almeida, and Lipovsek, 2001~. For their part, adolescents may fear being recognized in clinics or scolded by clinic staff (for South Africa, see the discussion in Kaufman, de Wet, and Stadler, 2000~. Several studies have shown that urban youth are unlikely to ap- proach their parents for advice about reproductive health but willingly seek such information from their peers, which is unlikely to be reliable (Senderowitz, 1995; Center for Population Options, 1992; Dietz, 1990; Meekers, Ahmed, and Mo- latlhegi, 2001; Magnani, Seiber, Zielinkski Gutierrez, and Vereau, 2001; Speizer, Mullen, and Amegee,2001~. Not surprisingly, studies of the services that succeed in attracting teens find that services need to be perceived as being conveniently located and of high qual- ity (Magnani, Gaffikin, Leao de Aquino, Seiber, de Conceic~ao Chagas Almeida, and Lipovsek, 2001~. It is interesting that adolescents appear to be much con- cerned about whether their communities accept and endorse the provision of ser- vices for youth. Studies of Salvador, Brazil, and Lusaka, Zambia, revealed that community acceptance was more important to adolescents than the "youth-friend- liness" of the services that were provided (Magnani, Gaffikin, Leao de Aquino, Seiber, de Conceic~ao Chagas Almeida, and Lipovsek, 2001; Nelson, Magnani, and Bond, 2000~. Effective programs also take account of the diversity of sexual experiences among youth; they strive to build on existing skills and knowledge; and they make use of a greater variety of providers, including those in the private sector (Hughes and McCauley, 1998~. The private sector may be especially important in supplying teens with pro- tection against HIV/AIDS and other STDs. Condoms and birth control pills are readily available at many urban pharmacies, and adolescents often feel that such settings offer them greater anonymity and convenience than is the case for public- sector clinics (Meekers, Ahmed, and Molatlhegi, 2001~. As will be discussed later, the quality of care available at pharmacies can be poor; they can fail to pro- vide teens (and others) with correct and adequate information about contracep- tives and STDs (Magnani, Gaffikin, Leao de Aquino, Seiber, de Conceic~ao Cha- gas Almeida, and Lipovsek, 2001; Meekers, 2001~. Social marketing programs (including Social Marketing for Adolescent Sexual Health [SMASH], which has run projects in Botswana, Cameroon, Guinea, and South Africa) are beginning to focus on how to make best use of the private sector in marketing contraceptives to youth. In many countries, both adolescents and adults regard condom use as unnecessary and even insulting within steady sexual relationships (Van Rossem and Meekers, 2000; Population Services International and Population Reference Bureau, 2000~. It has proven difficult for reproductive health programs to counter

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FERTILITY AND REPRODUCTIVE HEALTH 251 this view. For instance, a program among city youth in Cameroon drew upon peer education, promotions in night clubs, mass media campaigns, and other strategies and evidently succeeded in increasing the use of condoms for birth control. How- ever, its efforts did not increase condom use for prevention of STDs (Van Rossem and Meekers, 2000; Population Services International and Population Reference Bureau, 2000~. In addition to clinics, schools and workplaces are potentially important in- tervention sites for adolescents. In contrast with the situation in high-income countries, where most adolescents attend secondary schools, in poor countries many adolescents remain in middle or even primary school, and many never proceed to secondary schooling. The age heterogeneity of primary and middle school students probably discourages frank talk by health educators about the specifics of reproductive health. Successful programs have been implemented outside schools, such as through employers of young people (e.g., garment fac- tories, hotels), through advertising targeted to youth, and through private health providers. These programs are just as important as school-based efforts, espe- cially in regions where school enrollment among adolescents is low (Senderowitz and Stevens, 2001~. A focus on school and work may miss urban girls, however. Girls are much less likely than boys to take part in school-based or community youth activities; they may be expected to work at home and, as in Egypt, may be required to refrain from public interactions. Reaching girls in such environments requires creative effort. In one example, a program in Maqattam, a community on the outskirts of Cairo, offers cash to girls who delay marriage until age 18. The monetary reward gives girls some leverage with their parents, as well as a sense of empowerment (Mensch, Bruce, and Greene, 1998~. URBAN SERVICE DELIVERY As we noted at the beginning of this chapter, to date there has been no compre- hensive appraisal of reproductive health services in urban areas. In discussing the urban poor, migrants, and adolescents, we referred to literature specific to these subgroups. Below we discuss aspects of service delivery that can affect urban populations as a whole. The panel's review of the reproductive health literature indicated several areas in which research is much needed. Decentralization of Reproductive Health Services In many countries, the political economy of reproductive health care is undergo- ing a fundamental transformation. With decentralization and health-sector reform, local authorities are becoming responsible for implementing what were once cen- tralized, vertically organized programs of service delivery. The full implications of these developments are not yet known, but there are likely to be both positive

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252 CITIES TRANSFORMED and negative aspects. The allocation of responsibilities to local government units should increase the flexibility of service delivery and heighten sensitivities to lo- cal needs and resources. Yet the division of responsibilities also raises questions about how effort will be coordinated across governmental lines, which tiers of government will monitor equity in access to services, and how health externalities that spill over local governmental boundaries will be managed. Free-rider prob- lems can arise in decisions about the siting of hospitals and clinics, as when one local government is reluctant to finance services for fear that they will be used by residents of a neighboring locality. Governmental responsibilities can be dis- puted, as in the case of periurban areas where lines of governmental authority are unclear, and small cities may be placed within large regional frameworks in which their needs are given insufficient attention. In theory, decentralization puts management in the hands of those "closer to the ground," who are thought to better understand local conditions and needs. It allows flexible allocation and use of resources, promotes capacity building through local investment in personnel and systems, and gives communities the op- portunity to participate in decision making about health. But decentralization also requires greater management capabilities and knowledge of reproductive health at all levels of government, and such systems can work effectively only if there are strong linkages and two-way communication across levels of government. The in- crease in the number of contending groups and interests in a decentralized system can hinder service delivery, as noted by Aitken (1999: 117~: In the Philippines, a newly appointed provincial governor stopped the implementation of a ... health project in his province because he opposed the family planning component. In Colombia, a Na- tional Women's Health Policy was passed in 1992 under a sympa- thetic minister, but three years later there was still no action because no funds had been budgeted at the state level. More recently, as part of the Colombian health-sector reform, new agencies called Empre- sas Promotoras de Salud (EPSs) have been made responsible for the purchase of health services for individuals. Because the law did not specify which family planning services were to be covered by the new health plan, the EPSs decided that contraceptives were not preventive health measures and have been unwilling to cover them. In addition, local participation need not imply any openness to the local poor, who can be effectively excluded unless mechanisms for monitoring their participation are put in place (Policy Project, 2000; Langer, Nigenda, and Catino, 2000; Hardee, Agarwal, Luke, Wilson, Pendzich, Farrell, and Cross, 1998~. In view of the difficulties involved, it would not be surprising to find gross inefficiencies arising in the early stages of decentralization reforms. In India and Nepal, for example, lack of experience with reproductive health at the local level

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FERTILITY AND REPRODUCTIVE HEALTH 253 appears to have led to poor planning and implementation of reproductive health programs (Hardee, Agarwal, Luke, Wilson, Pendzich, Farrell, and Cross, 1998~. In the Philippines, where a Revolution of responsibilities for primary health care took place in the early 1990s, cities and municipalities began to spend more per capita on health, sometimes by reducing expenditures on other local services. Although the share of local expenditures going to family planning remained low, the increase in total expenditures appears to have had a positive influence on the use of family planning (Schwartz, Guilkey, and Racelis, 2002~. In Uganda, de- centralization led local governments to invest heavily in the construction of new clinics, perhaps with an eye to their local political constituencies, but they gave less emphasis to programs in family planning and maternal and child health, which could be used by nonresidents. Cross-district effects were also seen in this case. Where their neighbors were investing in public health care, some health districts responded by shifting their own spending to private health care (Akin, Hitchinson, and Strumpf, 2001~. It is not obvious that decentralization will improve social welfare unless higher-level tiers of government can establish systems of transfers and incentives that constrain and, when necessary, redirect the actions of local governments. Improving the Quality and Accessibility of Care Is the quality of reproductive health services higher in urban than in rural areas? That is the common belief (recall Table 6-1), and it receives support from some studies, but not from all. To assess the evidence on family planning services, the Family Planning Service Expansion and Technical Support (SEATS) project con- ducted a comprehensive examination of family planning service delivery in the ur- ban and rural areas of several countries in Africa (Ross), 2000~. This study found surprisingly little evidence of an urban advantage in the quality of service deliv- ery (Pearlman, Jones, Gorosh, Vogel, and Ojermark, 1998~. However, evidence in support of an urban advantage in service quality has appeared in a comparison of clinics in Lima with those in the rural areas of Peru (Mensch, Arends-Kuenning, Jain, and Garate, 1997~. Direct urban/rural comparisons of the kind made in these studies are unusual, and the lack of research makes it impossible to draw strong conclusions. Clearly, however, it should not be assumed that urban services are superior in the quality of care provided. Somewhat more research is available on the time costs borne by urban resi- dents to reach and receive reproductive health services, which have not been fully appreciated. Time costs are increased when clinics are open for only a few hours each day, when services are located far from the workplaces and homes of clients, and when crowding produces long waits at the clinic. Because many city residents work full-time, some of them juggling two or more jobs, they can find it difficult to attend health clinics during working hours and would benefit from longer hours of operation.

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254 CITIES TRANSFORMED According to a study of a family planning program in Jakarta, short hours at the government-sponsored clinic were a contributing factor in discouraging adop- tion of contraception (Lubis, 1986~. In Kingston, Jamaica, facilities were found to be highly concentrated near hospitals, major roads, and suburban commercial zones, sites that are inconvenient for many residents and particularly so for the urban poor (Bailey, Wynter, Lee, Jackson, Oliver, Munroe, Lyew-Ayee, Smith, and Clyde, 1996~. Similarly, in Cape Town, South Africa, access to many fa- cilities was found to require private transportation (Hoffman, Pick, Cooper, and Myers, 1997~. Rip, Keen, Woods, and Van Coeverden De Groot (1988) exam- ined prenatal care in a periurban area of Cape Town, trying to discover why many women did not use antenatal health services until the second trimester of their pregnancies. It became clear that use of the clinic was being discouraged by its inconvenient location, and that a clinic sited in the neighborhood would be likely to encourage prenatal care. (Women were also discouraged by long wait- ing times.) Similar research in the barrios of Caracas, Venezuela, and other sites (Rakowski and Kastner, 1985; Wawer, Lassner, and Hanff, 1986) revealed the im- portance of service location to access. Even if the time costs of access are lower than those in rural areas, these costs can play an important role in the reproductive health of poor urban residents. The Private Sector in Family Planning Services funded and delivered by the public sector have been a mainstay of re- productive health in rural and urban areas alike. As we have seen, the urban poor can be as dependent on the public sector as rural residents. Even though they are generally more expensive, private services are often preferred by urban women even by poor women because they are more accessible and appear to be of higher quality (Bailey, Wynter, Lee, Jackson, Oliver, Munroe, Lyew-Ayee, Smith, and Clyde, 1996; Lubis, 1986~. The favelas of Rio de Janeiro, for exam- ple, have many public health clinics and more than a few public hospitals, but most women obtain their contraceptives through private physicians and pharma- cies. Women may prefer these sources for their convenience, greater privacy, and shorter waiting times and longer hours of operation, as well as the greater range of contraceptive choices available by comparison with public clinics (Wawer, Lass- ner, and Hanff,1986~. However, the poorest women have little choice but to rely on free or low-cost public clinics. In some countries, the private sector consists mainly of pharmacies because nonprofit and other for-profit services are not well developed. In countries such as Bangladesh, the public sector appears to have all but abandoned cities to the pri- vate sector (Tantchou and Wilson, 2000; Ross, Stover, and Willard, 1999; Hardee, Agarwal, Luke, Wilson, Pendzich, Farrell, and Cross, 1998~. Recent research in Dhaka found that 80 percent of contraceptive users pay for their family plan- ning services (Routh, Thwin, Kane, and Baqui,2000~. A study of Faisalabad and

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FERTILITY AND REPRODUCTIVE HEALTH 255 Larkana, Pakistan, also found that both current family planning users and those who intend to use family planning in the future are willing and able to pay for hormonal methods of contraception. This was found to be true even for the very poor, probably because the monetary cost of family planning is so low (Kress and Winfrey, 1997; Afolabi Bambgoye and Ladipo,1992~. Many residents rely on pharmacies and commercial vendors to provide them with quick, convenient, and relatively inexpensive access to a variety of family planning methods, including condoms and even treatment for some reproductive health problems, such as STDs. In urban Nepal, it was found that social marketing of contraceptives through shops was successful because the shops were located close to workplaces and homes; they were also well stocked with supplies and appeared to offer some measure of privacy (Shrestha, Kane, and Hamal,1990~. The quality of private care at such outlets is not necessarily better, and some- times appears to be worse, than the care supplied by government health services (Kaye and Novell, 1994~. Private services may specialize in meeting narrowly medical or surgical needs and fail to offer basic services where these are unprof- itable. Among the private-sector health facilities in several African cities, only 35 percent offer family planning services (Ross), 2000~. In urban Nepal, for ex- ample, contraceptive retailers proved to be relatively well informed about some aspects of the oral pill, but in need of training about its side effects and the con- traindications for use, as well what to do should a pill be missed (Shrestha, Kane, and Hamal,1990~. A study of private pharmacists in Hanoi, Vietnam, also found that many of them were treating patients for STDs without referral to a physician. The pharmacists were often providing incorrect treatment and giving either wrong or grossly inadequate advice for follow-up care, partner notification, and condom use (Chalker, Chuc, Falkenberg, Do, and Tomson,2000~. Nongovernmental organizations (NGOs) can be quite successful in establish- ing private, nonprofit reproductive health programs, particularly when government programs are limited and the poor need greater access to services. In Santiago, Chile, an integrated maternal and child health program was set up by an NGO in a very poor neighborhood. This NGO clinic offered a greater number of family planning choices all free of charge than did the public clinic. The program appeared to have positive results with regard to contraceptive use, breastfeeding, and child health. Patients judged the quality of the program to be high, and the providers themselves believed they had learned new skills and gained accep- tance in the community (Alvarado, Zepeda, Rivero, Rico, Lopez, and topaz, l 999~. Sometimes NGO programs can fill a need that is not already being addressed by either government or private for-profit clinics. CONCLUSIONS AND RECOMMENDATIONS It has long been known that urban levels of fertility are lower than rural levels (this was the case even in historical Europe, as noted in Chapter 1) and, in the

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256 CITIES TRANSFORMED modern era, that urban women are more likely to use contraception. Lower fertil- ity is an element of family reproductive strategies that emphasize investments in the human capital of children and modes of child rearing that are time-intensive. The combination of lower fertility and greater educational investments in chil- dren distinguishes urban populations from rural. On theoretical grounds, as we have noted, there is reason to think that patterns of social interaction in cities may serve to focus attention on the benefits of children's schooling. But rural families are beginning to adopt similar strategies, perhaps to prepare their chil- dren for urban or urbanized livelihoods, and fertility rates are also falling in rural areas. In studies of historical populations, delayed marriage is accorded a large role in lower urban fertility, and it still plays a major part. Demographers and demo- graphic surveys have tended to focus exclusively on age at marriage as the indi- cator of interest, but another and possibly more interesting aspect has to do with the nature of marriage search and the terms upon which marriage is entered. Ur- ban economies in some settings can now offer young unmarried women a modest measure of economic resources and enable them to enter marriage with a greater degree of autonomy and social confidence than might previously have been pos- sible. Studies of adolescence are beginning to focus on how attitudes toward gender equality in marriage take shape; it appears that schooling has an influ- ence, but it is possible that girls may be more influenced than boys. The urban element in gender beliefs has not been much studied, but we suspect that the diver- sity of urban life and the variety of urban reference groups and role models may well affect how adolescent girls come to understand the limits and possibilities of adult life. Our major conclusions relate to differences and similarities in reproductive behavior and outcomes across space and class, and are based on reviews of the literature and analyses of the DHS-United Nations urban database. These con- clusions provide the foundation for a set of recommendations for programs and research. Conclusions Fertility behavior and trends The urban/rural gap in fertility levels has remained roughly constant since the late 1970s in each of the developing regions of Africa, Asia, and Latin America. The panel's analysis of urban and rural fertility trends since the late 1970s uncovered no clear tendency for rural fertility rates to fall more rapidly than urban rates. As far as could be determined, the urban/rural gap in fertility levels has not changed much in these regions. Eventually, however, some measure of convergence is to be expected, as rural fertility rates continue to decline and urban fertility rates level off.

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FERTILITY AND REPRODUCTIVE HEALTH Reproductive health and access to services 257 The urban advantage in terms of reproductive health and access to family plan- ning and health care services is smaller than anticipated. The question of whether an urban advantage exists in reproductive health might not have been thought es- pecially interesting. Cities are obviously better endowed with health services of all kinds than rural areas and have both a larger and a more diverse private sector. This would appear to imply easier access to reproductive health services, greater effective control over the number and spacing of births, and a lower incidence of unintended pregnancy. Yet as the panel explored the issues with the data avail- able, we found evidence of a smaller urban advantage than would have been antic- ipated. Urban women do have lower levels of unmet need for contraception than rural women, and in general, the levels of unmet need tend to be lower in large cities than in small. But the incidence of mistimed and unwanted births does not appear to be any lower in cities, and it appears to vary little by city size. The urban advantages for maternal health are more clearly evident. Urban women are much more likely than rural women to have a physician or nurse/midwife present at childbirth, and we found this to be the case even among the urban poor. The urban poor are little better Nathan rural residents in several dimensions of reproductive health and access to services, and in some cases, they appear to be worse of: When attention is focused on poor urban residents, especially those who live in settlements of concentrated poverty, the urban advantage in terms of unmet need for contraception and mistimed and unwanted births almost dis- appears, and can even be reversed to become a disadvantage. In other areas of reproductive health, too, the situation of the urban poor resembles closely that of rural populations. In a comparison of a Karachi slum with rural areas of Pakistan, the maternal mortality rates suffered by the urban poor were found to be similar to those of some rural areas. Likewise, in one of the few studies in which the quality of urban reproductive services could be compared with that of rural services, little quality difference could be detected (Ross), 2000~. In summary, as we pass from broad generalizations about urban populations as a whole to a narrower focus on the urban poor, the contrasts with rural populations become much less marked. The urban poor operate with very little of the information they need to make good decisions about reproductive health. Time costs and transport pose difficul- ties for the poor that should not be underestimated. Pregnancy risks are not well understood by poor women or men, nor are other reproductive morbidities. There is some evidence to suggest that social interaction within low-income communi- ties may be beneficial, helping to circulate information about new services, and the mechanisms by which the poor come to be aware of health services deserve further study. Smaller cities are significantly underserved in terms of reproductive health services compared with larger cities. The disadvantages of smaller cities are ev- ident in several (if not all) of the health dimensions considered in this chapter.

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258 CITIES TRANSFORMED Levels of unmet need are higher in these cities, and levels of contraceptive use are lower. Women in small cities are also less likely to know how to protect them- selves against HIV/AIDS. As this infection spreads from the large cities to rural areas and smaller cities, both the urban poor and the residents of small cities need to be carefully considered in health policies and programs. Recommendations Decentralization of reproductive health The decentralization initiatives being undertaken by many national governments are introducing a new cast of policy makers and program implementors at the regional and local levels of government. The implications of decentralization for reproductive health are not well understood, and an analytic comparative review of country experience is now badly needed. Service delivery The panel's analysis revealed four priority areas for service de- livery: . Reach the urban poor. Improve services in smaller cities. Create appropriate services for adolescents. Augment HIV/AIDS prevention programs. Data collection Although national-level demographic measures are available in the DHS and other national-level surveys, the samples are not generally of a size that permits cities to be characterized reliably, to say nothing of neigh- borhoods within cities. As countries urbanize, however, data at finer spatial resolutions will increasingly be needed. High priority should be given to collecting demographic data that will allow comparisons among the situa- tions of rural areas, smaller cities, poor neighborhoods in large cities, and nonpoor neighborhoods in these cities. National-level surveys will continue to play an important role in comparative analyses of urban and rural popu- lations. We make specific recommendations for the DHS in Chapter 10 and Appendix F. Research We have advocated multilevel perspectives on fertility and reproductive health research, with a focus on the implications of intraurban diversity, neighborhood effects, social networks, and social capital. In view of the deficiencies in reproductive health information that characterize poor urban populations, research is much needed on how the poor acquire information about reproductive health and how they are linked to health services.