A Rapid Assessment Scorecard to Identify Informal Settlements at Higher Maternal and Child Health Risk in Mumbai

The communities who live in urban informal settlements are diverse, as are
their environmental conditions. Characteristics include inadequate access to safe water
and sanitation, poor quality of housing, overcrowding, and insecure residential status.
Interventions to improve health should be equity-driven and target those at higher risk,
but it is not clear how to prioritise informal settlements for health action. In
implementing a maternal and child health programme in Mumbai, India, we had
conducted a detailed vulnerability assessment which, though important, was timeconsuming
and may have included collection of redundant information. Subsequent
data collection allowed us to examine three issues: whether community environmental
characteristics were associated with maternal and newborn healthcare and outcomes;
whether it was possible to develop a triage scorecard to rank the health vulnerability of
informal settlements based on a few rapidly observable characteristics; and whether the
scorecard might be useful for future prioritisation. The City Initiative for Newborn
Health documented births in 48 urban slum areas over 2 years. Information was
collected on maternal and newborn care and mortality, and also on household and
community environment. We selected three outcomes—less than three antenatal care
visits, home delivery, and neonatal mortality—and used logistic regression and
classification and regression tree analysis to test their association with rapidly
observable environmental characteristics. We developed a simple triage scorecard and
tested its utility as a means of assessing maternal and newborn health risk. In analyses
on a sample of 10,754 births, we found associations of health vulnerability with
inadequate access to water, toilets, and electricity; non-durable housing; hazardous
location; and rental tenancy. A simple scorecard based on these had limited sensitivity
and positive predictive value, but relatively high specificity and negative predictive
value. The scorecard needs further testing in a range of urban contexts, but we intend to
use it to identify informal settlements in particular need of family health interventions in
a subsequent program.