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

Abstract

Background: In sub-Saharan Africa, women are most likely to receive skilled and adequate childbirth care in hospital settings, yet the use of hospital for childbirth is low and inequitable. The poorest and those living furthest away from a hospital are most affected. But the relative contribution of poverty and travel time is convoluted, since hospitals are often located in wealthier urban places and are scarcer in poorer remote area. This study aims to partition the variability in hospital-based childbirth by poverty and travel time in four sub-Saharan African countries. Methods: We used data from the most recent Demographic and Health Survey in Kenya, Malawi, Nigeria and Tanzania. For each country, geographic coordinates of survey clusters, the master list of hospital locations and a high-resolution map of land surface friction were used to estimate travel time from each DHS cluster to the nearest hospital with a shortest-path algorithm. We quantified and compared the predicted probabilities of hospital-based childbirth resulting from one standard deviation (SD) change around the mean for different model predictors. Results: The mean travel time to the nearest hospital, in minutes, was 27 (Kenya), 31 (Malawi), 25 (Nigeria) and 62 (Tanzania). In Kenya, a change of 1SD in wealth led to a 33.2 percentage points change in the probability of hospital birth, whereas a 1SD change in travel time led to a change of 16.6 percentage points. The marginal effect of 1SD change in wealth was weaker than that of travel time in Malawi (13.1 vs. 34.0 percentage points) and Tanzania (20.4 vs. 33.7 percentage points). In Nigeria, the two were similar (22.3 vs. 24.8 percentage points) but their additive effect was twice stronger (44.6 percentage points) than the separate effects. Random effects from survey clusters also explained substantial variability in hospital-based childbirth in all countries, indicating other unobserved local factors at play. Conclusions: Both poverty and long travel time are important determinants of hospital birth, although they vary in the extent to which they influence whether women give birth in a hospital within and across countries. This suggests that different strategies are needed to effectively enable poor women and women living in remote areas to gain access to skilled and adequate care for childbirth.

“In cities, it’s not far, but it takes long”: comparing estimated and replicated travel times to reach life-saving obstetric care in Lagos, Nigeria

“…When both cost-friction surface approach and OSRM were compared previously, larger discrepancies were reported for long travel time estimates. 36 …”

Factors associated with healthcare seeking behaviour for children in Malawi: 2016

“…Some similar studies in resource limited settings have cited distance to the facilities [35] or unavailability of health services to be associated with lower HSB amongst the rural populations [36]. A multi‐country study conducted in SSA shows that people in Malawi took the least time to their nearest health facility compared to other countries [37]. However, amongst the rural populations, access to local health centres or hospitals is often constrained by a lack of transport and inability to meet the direct and indirect costs of a clinic visit [29].…”

Perceptions of Inequity in the Provision and Utilization of Maternal, Newborn, and Child Health Services in Tigray, Ethiopia. A Qualitative Explorative Study

“…Striving to reach the health-related SDG 3 targets for maternal and child health outcomes depends on progress in eliminating poverty de ned in SDG 1 (3). Studies in other parts of Ethiopia (26,27) and elsewhere (3,28) have documented similar ndings. The respondents suggested a way forward: initiating communitybased self-funding schemes, such as a green bank, i.e., contributing cereals every harvesting season to support the poor.…”

“…In our study, poor women, far away from health facilities, were found to utilize less services. Physical accessibility is associated with the utilization of services (28,31). Thus, emphasis should be given to strengthening the community-and home-based activities and expanding local maternal and child health services as suggested by the respondents.…”