A look back on how far to walk: Systematic review and meta-analysis of physical access to skilled care for childbirth in Sub-Saharan Africa

Abstract

ObjectivesTo (i) summarize the methods undertaken to measure physical accessibility as the spatial separation between women and health services, and (ii) establish the extent to which distance to skilled care for childbirth affects utilization in Sub-Saharan Africa.MethodWe defined spatial separation as the distance/travel time between women and skilled care services. The use of skilled care at birth referred to either the location or attendant of childbirth. The main criterion for inclusion was any quantification of the relationship between spatial separation and use of skilled care at birth. The approaches undertaken to measure distance/travel time were summarized in a narrative format. We obtained pooled adjusted odds ratios (aOR) from studies that controlled for financial means, education and (perceived) need of care in a meta-analysis.Results57 articles were included (40 studied distance and 25 travel time), in which distance/travel time were found predominately self-reported or estimated in a geographic information system based on geographic coordinates. Approaches of distance/travel time measurement were generally poorly detailed, especially for self-reported data. Crucial features such as start point of origin and the mode of transportation for travel time were most often unspecified. Meta-analysis showed that increased distance to maternity care had an inverse association with utilization (n = 10, pooled aOR = 0.90/1km, 95%CI = 0.85–0.94). Distance from a hospital for rural women showed an even more pronounced effect on utilization (n = 2, pooled aOR = 0.58/1km increase, 95%CI = 0.31,1.09). The effect of spatial separation appears to level off beyond critical point when utilization was generally low.ConclusionAlthough the reporting and measurements of spatial separation in low-resource settings needs further development, we found evidence that a lack of geographic access impedes use. Utilization is conditioned on access, researchers and policy makers should therefore prioritize quality data for the evidence-base to ensure that women everywhere have the potential to access obstetric care.

Geographic access and maternal health services utilization in Sélingué Health District, Mali.

“…Our data points to the larger socio-structural disadvantages that women face, and must be addressed country-wide, not only in Sélingué, to see long-term progress in women's maternal health. Efforts and interventions should be centered around gender equality by virtue Our results align with previous studies that show higher educational attainment as signi cant in in uencing birth in a health facility [27,30]. Additionally, distance beyond ve km of a health facility was signi cantly associated with a decrease in health facility utilization.…”

Distance to care, care seeking and child mortality in rural Burkina Faso: findings from a population‐based cross‐sectional survey

“…Hospitals being located in towns, our study population therefore excluded communities living <5 km away from a hospital. A review has highlighted the fact that some studies suggest that use of hospitals for delivery care only increases substantially when women live very close to a hospital . Thus we cannot exclude the possibility that short distances to hospital (<5 km) are associated with increased child survival in Burkina Faso.…”

Too poor or too far? Partitioning the variability of hospital-based childbirth by poverty and travel time in Kenya, Malawi, Nigeria and Tanzania

“…It shapes people's options for care-seeking and their decision making [10], and can cause delays in reaching an adequate provider when needs arise [3]. The negative effect of poor physical accessibility on the use of skilled care at birth was first reviewed by Thaddeus and Maine in 1994 [4], and reaffirmed in systematic reviews, including Gabrysch and Campbell 2009 [3], Moyer and Mustafa 2013 [2], Wong et al 2017 [11] and Tegegne et al 2018 [12].…”