The influences of distance on health facility delivery in rural Zambia

Skilled attendance at delivery is crucial for decreasing maternal and neonatal mortality. My literature review showed that epidemiological research on factors influencing whether women receive skilled attendance has so far been hampered by a lack of data on health service availability, and is often restricted to investigating household and individual factors. Distance to health services, however, is likely to play an important role. The availability of geographic coordinates in both national household survey, population census and health facility census in Zambia provides the opportunity to combine user and provider information on a large scale. These datasets were linked to investigate the influence that distance has on place of delivery, while adjusting for other influential factors such as education, wealth and autonomy in a multilevel model. Classifying Zambian health facilities according to their level of delivery care showed that 88% of facilities are not staffed or equipped to provide even Basic Emergency Obstetric Care (EmOC) and therefore cannot save a mother's life in case of complications. Around half of the Zambian population lives further than 15km from a Basic EmOC facility; less than 10% in urban areas and over 70% in rural areas. Using data from over 3000 rural births, I demonstrate that the odds of delivering in a facility are 4 times higher within 1km of a facility as compared to 20km, and additionally 2.5 times higher if that facility offers Comprehensive EmOC rather than substandard care. If all mothers lived within 5km of Basic EmOC, 16% of home deliveries could be avoided, a population attributable fraction of similar magnitude as for education or wealth. Lack of geographical access to EmOC is a key factor explaining why most rural deliveries in Zambia still occur at home without skilled care; this needs to be addressed to lower maternal and neonatal mortality.