|The Influence of Distance and Level of Care on Delivery Place in Rural Zambia: A Study of Linked National Data in a Geographic Information System|
||Gabrysch S, Cousens S, Cox J, Campbell OM.
||PLoS Medicine, 8(1):e1000394. doi: 10.1371/journal.pmed.1000394.
Background: Maternal and perinatal mortality could be reduced if all women delivered in settings where skilled attendants
could provide emergency obstetric care (EmOC) if complications arise. Research on determinants of skilled attendance at
delivery has focussed on household and individual factors, neglecting the influence of the health service environment, in
part due to a lack of suitable data. The aim of this study was to quantify the effects of distance to care and level of care on
women’s use of health facilities for delivery in rural Zambia, and to compare their population impact to that of other
Methods and Findings: Using a geographic information system (GIS), we linked national household data from the Zambian
Demographic and Health Survey 2007 with national facility data from the Zambian Health Facility Census 2005 and
calculated straight-line distances. Health facilities were classified by whether they provided comprehensive EmOC (CEmOC),
basic EmOC (BEmOC), or limited or substandard services. Multivariable multilevel logistic regression analyses were
performed to investigate the influence of distance to care and level of care on place of delivery (facility or home) for 3,682
rural births, controlling for a wide range of confounders. Only a third of rural Zambian births occurred at a health facility,
and half of all births were to mothers living more than 25 km from a facility of BEmOC standard or better. As distance to the
closest health facility doubled, the odds of facility delivery decreased by 29% (95% CI, 14%–40%). Independently, each step
increase in level of care led to 26% higher odds of facility delivery (95% CI, 7%–48%). The population impact of poor
geographic access to EmOC was at least of similar magnitude as that of low maternal education, household poverty, or lack
of female autonomy.
Conclusions: Lack of geographic access to emergency obstetric care is a key factor explaining why most rural deliveries in
Zambia still occur at home without skilled care. Addressing geographic and quality barriers is crucial to increase service use
and to lower maternal and perinatal mortality. Linking datasets using GIS has great potential for future research and can
help overcome the neglect of health system factors in research and policy.