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

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...

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Bibliographic Details
Published in:International journal for equity in health 2020-01, Vol.19 (1), p.15-15, Article 15
Main Authors: Wong, Kerry L M, Brady, Oliver J, Campbell, Oona M R, Banke-Thomas, Aduragbemi, Benova, Lenka
Format: Article
Language:English
Subjects:
Algorithms
Birth
Births
Childbirth & labor
Clusters
Delivery (Childbirth)
Delivery, Obstetric - statistics & numerical data
Demographic aspects
Demography
Distribution
Distribution of wealth
Economic aspects
Emergency medical care
Equality
Female
Friction
Health
Health aspects
Health equity
Health facilities
Health Services Accessibility - economics
Health Services Accessibility - statistics & numerical data
Health surveys
Hospital-based childbirth
Households
Humans
Kenya
Low- and middle-income countries
Malawi
Maternal health
Maternal health services
Medical care quality
Nigeria
Physical accessibility
Polls & surveys
Poor women
Poverty
Poverty - statistics & numerical data
Pregnancy
Pregnant women
Principal components analysis
Questionnaires
Setting (Literature)
Shortest-path problems
Social aspects
Sub-Saharan Africa
Tanzania
Time
Time Factors
Transportation
Travel
Travel - statistics & numerical data
Travel time
Variability
Wealth inequality
Womens health
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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. 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. 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. 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. 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.
ISSN:1475-9276
1475-9276
DOI:10.1186/s12939-020-1123-y