In Pakistan, Poor and Rural Women Must Travel Farther To Give Birth in a Facility

Abstract

Poor and rural women in Pakistan are disadvantaged in terms of their access to institutional services, according to a geographic analysis of data from nine districts. (1) On average, married women who reported giving birth within the past three years lived seven kilometers by road from the nearest health facility offering care; the average distance ranged from five kilometers among the wealthiest women to 10 kilometers among the poorest. Women's odds of delivering in a facility decreased by 3% per additional kilometer of distance from the nearest facility, although this association held only in rural areas. Living within 10 kilometers of a facility offering or emergency obstetric was positively associated with institutional (odds ratios, 1.8 and 1.7, respectively). To examine relationships between geographic and economic access to a health facility and institutional delivery, researchers linked survey data for individual women and health facilities in study districts with data on distance between the primary sampling unit of women's residence and health facilities in those districts. The individual data were drawn from a 2005 survey that asked married women in selected households in primary sampling units about their health before, during and after delivery, as well as about their social and demographic characteristics. Household wealth was measured in quartiles (lowest, lower middle, upper middle and highest) on the basis of such criteria as ownership of certain household amenities and types of construction materials used for the household's dwelling. The sample of women was restricted to the 4,435 women who reported giving birth in the past three years. Facility data were drawn from a 2008 survey of all health facilities, ranging from large public teaching and district hospitals to private registered clinics and community pharmacies. A structured questionnaire was used to ask individuals in charge of facilities about the type and level of available reproductive health care; it included questions about staff, equipment and client amenities. The sample included all 763 facilities that offered obstetric services before 2005. Of those, 547 were considered able to provide only normal delivery (i.e., assisted vaginal in a health facility that lacked an operating room), 91 could also provide basic emergency obstetric care (assisted deliveries, manual extraction of the placenta and removal of retained products) and 125 could further provide comprehensive emergency obstetric care (cesarean sections and blood transfusions). In addition, as part of the individual and health facility surveys, the exact locations of primary sampling units and facilities were determined using global positioning system (GPS) devices. The researchers used the GPS data to create georeferenced digital maps that included health facilities, district and subdistrict boundaries, rivers and roads, and then used global information system software to calculate exact road distances between prima ry sampling units and health facilities within each district. Two measures of geographic access to services were created: the distance from each primary sampling unit to the nearest health facility, and the highest level of within 10 kilometers of each primary sampling unit. Multilevel mixed-effects logistic regression analyses were conducted to examine associations between geographic access, wealth status and institutional delivery. Most women (84%) lived in a rural area; 20% lived in households in the lowest wealth quartile, 24% in the lower middle, 27% in the upper middle and 29% in the highest. …