Abstract
ObjectiveTo evaluate the association between proximity to a health center and early childhood mortality in Madagascar, and to assess the influence of household wealth, maternal educational attainment, and maternal health on the effects of distance.MethodsFrom birth records of subjects in the Demographic and Health Survey, we identified 12565 singleton births from January 2004 to August 2009. After excluding 220 births that lacked global positioning system information for exposure assessment, odds ratios (ORs) and their 95% confidence intervals (CIs) for neonatal mortality and infant mortality were estimated using multilevel logistic regression models, with 12345 subjects (level 1), nested within 584 village locations (level 2), and in turn nested within 22 regions (level 3). We additionally stratified the subjects by the birth order. We estimated predicted probabilities of each outcome by a three-level model including cross-level interactions between proximity to a health center and household wealth, maternal educational attainment, and maternal anemia.ResultsCompared with those who lived >1.5–3.0 km from a health center, the risks for neonatal mortality and infant mortality tended to increase among those who lived further than 5.0 km from a health center; the adjusted ORs for neonatal mortality and infant mortality for those who lived >5.0–10.0 km away from a health center were 1.36 (95% CI: 0.92–2.01) and 1.42 (95% CI: 1.06–1.90), respectively. The positive associations were more pronounced among the second or later child. The distance effects were not modified by household wealth status, maternal educational attainment, or maternal health status.ConclusionsOur study suggests that distance from a health center is a risk factor for early childhood mortality (primarily, infant mortality) in Madagascar by using a large-scale nationally representative dataset. The accessibility to health care in remote areas would be a key factor to achieve better infant health.
Highlights
A decrease in infant mortality by two-thirds between 1990 and 2015 is one of the 4th Millennium Development Goals [1]
Previous studies have shown that distance to a health center is a primary factor in measuring the accessibility to health services [3,4,5,6], a recent review concluded that there is no robust evidence of an association between distance to a health-care facility and early childhood mortality [7]
It is notable that the positive associations were slightly attenuated for those who lived $10 km away from a health center
Summary
A decrease in infant mortality by two-thirds between 1990 and 2015 is one of the 4th Millennium Development Goals [1]. Previous studies have shown that distance to a health center is a primary factor in measuring the accessibility to health services [3,4,5,6], a recent review concluded that there is no robust evidence of an association between distance to a health-care facility and early childhood mortality [7]. This may be due to the fact that previous studies failed to consider other primary determinants of child health, e.g., financial barriers to health care [7]. Two recent studies from Ethiopia and Kenya focused on the social factors (i.e., maternal educational attainment or household wealth) in their evaluations of the association between access to a health center and childhood health [3,8]
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