Geographic access to care is not a determinant of child mortality in a rural Kenyan setting with high health facility density

Abstract

BackgroundPolicy-makers evaluating country progress towards the Millennium Development Goals also examine trends in health inequities. Distance to health facilities is a known determinant of health care utilization and may drive inequalities in health outcomes; we aimed to investigate its effects on childhood mortality.MethodsThe Epidemiological and Demographic Surveillance System in Kilifi District, Kenya, collects data on vital events and migrations in a population of 220,000 people. We used Geographic Information Systems to estimate pedestrian and vehicular travel times to hospitals and vaccine clinics and developed proportional-hazards models to evaluate the effects of travel time on mortality hazard in children less than 5 years of age, accounting for sex, ethnic group, maternal education, migrant status, rainfall and calendar time.ResultsIn 2004-6, under-5 and under-1 mortality ratios were 65 and 46 per 1,000 live-births, respectively. Median pedestrian and vehicular travel times to hospital were 193 min (inter-quartile range: 125-267) and 49 min (32-72); analogous values for vaccine clinics were 47 (25-73) and 26 min (13-40). Infant and under-5 mortality varied two-fold across geographic locations, ranging from 34.5 to 61.9 per 1000 child-years and 8.8 to 18.1 per 1000, respectively. However, distance to health facilities was not associated with mortality. Hazard Ratios (HR) were 0.99 (95% CI 0.95-1.04) per hour and 1.01 (95% CI 0.95-1.08) per half-hour of pedestrian and vehicular travel to hospital, respectively, and 1.00 (95% CI 0.99-1.04) and 0.97 (95% CI 0.92-1.05) per quarter-hour of pedestrian and vehicular travel to vaccine clinics in children <5 years of age.ConclusionsSignificant spatial variations in mortality were observed across the area, but were not correlated with distance to health facilities. We conclude that given the present density of health facilities in Kenya, geographic access to curative services does not influence population-level mortality.

Geographic Accessibility to Health Services and Neonatal Mortality Among Very-Low Birthweight Infants in South Carolina

“…This study is consistent with Combier et al (2013), Dummer and Parker (2004), and Moisi et al (2010) that travel time is not associated with neonatal mortality, while studies by Gryzbowski et al (2011), Okwaraji et al (2012, Ravelli et al (2011), andShoeps et al (2011) found a significant association with under-5 mortality and perinatal mortality (stillbirths and neonatal deaths). However, direct comparisons are not warranted for several reasons.…”

“…In such studies, pedestrian travel was the most common form of transport (Combier et al, 2013;Moisi et al, 2010;Okwaraji et al, 2012). The majority of studies consisted of a much larger sample size (Combier et al, 2013;Dummer & Parker, 2004;Grzybowski et al, 2011;Moisi et al, 2010;Okwaraji et al, 2012;Ravelli et al, 2011). Consistent with Combier et al (2013), and Grzybowski et al (2011), we excluded births less than 20 weeks gestation.…”

“…Some other studies have evaluated the impact of road distance traveled to health facilities on either perinatal, neonatal, or infant mortality in both developed (Lisonkova et al, 2011;Pasquier et al, 2007;Pilkington, Blondel, Drewniak, & Zeitlin, 2014) and developing (Armstrong Schellenberg et al, 2008;Kashima et al, 2012;Lohela, Campbell, & Gabrysch, 2012;Malqvist, Sohel, Do, Eriksson, & Persson, 2010) countries but with varied results. Very few studies have used a more accurate measure, namely travel time to health care services, and studied its impact on mortality in infancy (Combier et al, 2013;Dummer & Parker, 2004;Grzybowski, Stoll, & Kornelsen, 2011;Moisi et al, 2010;Okwaraji, Cousens, Berhane, Mulholland, & Edmond, 2012;Ravelli et al, 2011;Schoeps, Gabrysch, Niamba, Sie, & Becher, 2011). Of those studies that utilized a distance-or time-based measure of access, there were vast differences in sample size, exclusion/inclusion criteria, and geographic region of study.…”

“…It is important to distinguish between industrialized and developing nations as many developing nations do not have the infrastructure in place to provide emergent ambulatory services to a hospital or healthcare facility. In such studies, pedestrian travel was the most common form of transport (Combier et al, 2013;Moisi et al, 2010;Okwaraji et al, 2012). The majority of studies consisted of a much larger sample size (Combier et al, 2013;Dummer & Parker, 2004;Grzybowski et al, 2011;Moisi et al, 2010;Okwaraji et al, 2012;Ravelli et al, 2011).…”

“…Not many of those studies have utilized a time-based measure of access, and none have examined its impact on neonatal mortality among a high-risk infant group. Of the seven studies analyzed in this literature review, three concluded a null association (Combier et al, 2013;Dummer & Parker, 2004;Okwaraji et al, 2012) between the travel time to nearest perinatal hospital or actual delivery facility and infant death, while four studies found positive associations (Grzybowski et al, 2011;Moisi et al, 2010;Ravelli et al, 2011;Schoeps et al, 2011) even after adjusting for confounders.…”