The question seems simple enough: how can a rapidly growing African city improve the health and care of its pregnant women and their babies? But ask this question while navigating the humid, traffic-congested streets of coastal Dar es Salaam with a population of 8.6 million, then ask it again in the copper-mining hub of Lubumbashi with 3.1 million inhabitants, some 1400 km inland, and you will discover there is no universal answer. Effective strategies in Tanzania’s commercial capital—with its port economy and informal settlements sprawling between planned neighbourhoods—will not simply translate to the Democratic Republic of Congo’s mining metropolis. Each city has its own health system shaped by unique demographic, geographical, sociopolitical, governance, infrastructural and cultural characteristics, demanding its own set of solutions.
The nexus between urbanisation and health is not new. Recently, it has gained renewed attention in global health circles due to evidence suggesting that the urban advantage—where urban residents tend to have better health outcomes—might be diminishing or reversing in some cases. With more than half the world’s population now living in cities, and African urban centres growing faster than anywhere else, the recent Lancet Countdown to 2030 report for women’s, children’s and adolescents’ health rightly prioritised urban living as a key trend shaping maternal and child health. While the growing focus on urbanisation is welcome, the 2025 Countdown report also exemplifies a longstanding knowledge practice in global health: the tendency to prioritise standardisation and international comparability in measurement approaches. Global health estimates are useful for broad international comparisons and monitoring progress towards global health goals, but they fundamentally fail when the purpose is to understand the complexities within specific urban environments. Like trying to navigate a complex cityscape with a featureless map, they smooth away the very topography that defines urban health. We illustrate this through maternal health, where providing quality services along the continuum of pregnancy, childbirth and postpartum care is inherently complex. This makes maternal health outcomes particularly sensitive to the contextual urban factors that standardised measurements overlook.
Consider how most internationally comparable health metrics approach urbanicity—through crude urban-rural binaries which, while easy to analyse with secondary data, fail to capture what is actually ‘urban’ in ways that are meaningful to improve maternal health and care. These dichotomies frequently misclassify areas due to the somewhat arbitrary nature of urban and rural distinctions, with countries using varied administrative, population or hybrid criteria. Scholars have long recognised that this binary approach also obscures the spectrum of urbanicity—megacities, secondary cities and peri-urban areas—and deprioritises granular, city-specific understandings. Women’s diverse lived experiences navigating different types of urban spaces and services, as well as unique historical and governance specificities, get flattened into generic ‘urban’ variables. This means we often miss intra-urban health disparities, which might actually be greater than rural-urban differences.