Abstract
BackgroundIn 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.MethodsWe 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.ResultsThe 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.ConclusionsBoth 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.
Highlights
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
Travel time estimated from the Malaria Atlas Project (MAP) friction surface and that obtained using OSM data showed good alignment (Pearson correlation coefficients over 0.75 in all countries, see Additional file 1), apart from a few clusters with long travel time of ≥5 h estimated using the MAP friction surface
The numbers of Demographic and Health Surveys (DHS) clusters, livebirths and hospitals used in our final analysis are shown in Table 2, together with summary statistics of travel time to the nearest hospital and the percentage of births in hospitals by country
Summary
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. In high-burden and resource-scarce settings, such as countries of sub-Saharan Africa, the use of skilled care at birth is still far from universal [1]. A number of studies have shown that wealthier women consistently report higher use of skilled care at childbirth than their poorer counterparts [5,6,7]. The direct (e.g. medical bills) and indirect (e.g. transportation, lost earnings) costs associated with seeking and using skilled childbirth care may be unaffordable [8, 9]
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