The effects of changes in distance to nearest health facility on under-5 mortality and health care utilization in rural Malawi, 1980–1998
Abstract Background Despite important progress, the burden of under-5 mortality remains unacceptably high, with an estimated 5.3 million deaths in 2018. Lack of access to health care is a major risk factor for under-5 mortality, and distance to health care facilities has been shown to be associated...
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| Format: | Article |
| Language: | English |
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BMC
2020-09-01
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| Series: | BMC Health Services Research |
| Subjects: | |
| Online Access: | http://link.springer.com/article/10.1186/s12913-020-05738-w |
| _version_ | 1828399888219504640 |
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| author | John P. Quattrochi Kenneth Hill Joshua A. Salomon Marcia C. Castro |
| author_facet | John P. Quattrochi Kenneth Hill Joshua A. Salomon Marcia C. Castro |
| author_sort | John P. Quattrochi |
| collection | DOAJ |
| description | Abstract Background Despite important progress, the burden of under-5 mortality remains unacceptably high, with an estimated 5.3 million deaths in 2018. Lack of access to health care is a major risk factor for under-5 mortality, and distance to health care facilities has been shown to be associated with less access to care in multiple contexts, but few such studies have used a counterfactual approach to produce causal estimates. Methods We combined retrospective reports on 18,714 births between 1980 and 1998 from the 2000 Malawi Demographic and Health Survey with a 1998 health facility census that includes the date of construction for each facility, including 335 maternity or maternity/dispensary facilities built in rural areas between 1980 and 1998. We estimated associations between distance to nearest health facility and (i) under-5 mortality, using Cox proportional hazards models, and (ii) maternal health care utilization (antenatal visits prior to delivery, place of delivery, receiving skilled assistance during delivery, and receiving a check-up following delivery), using linear probability models. We also estimated the causal effect of reducing the distance to nearest facility on those outcomes, using a two-way fixed effects approach. Findings We found that greater distance was associated with higher mortality (hazard ratio 1.007 for one additional kilometer [95%CI 1.001 to 1.014]) and lower health care utilization (for one additional kilometer: 1.2 percentage point (pp) increase in homebirth [95%CI 0.8 to 1.5]; 0.8 pp. decrease in at least three antenatal visits [95% CI − 1.4 to − 0.2]; 1.2 pp. decrease in skilled assistance during delivery [95%CI − 1.6 to − 0.8]). However, we found no effects of a decrease in distance to the nearest health facility on the hazard of death before age 5 years, nor on antenatal visits prior to delivery, place of delivery, or receiving skilled assistance during delivery. We also found that reductions in distance decrease the probability that a woman receives a check-up following delivery (2.4 pp. decrease for a 1 km decrease [95%CI 0.004 to 0.044]). Conclusion Reducing under-5 mortality and increasing utilization of care in rural Malawi and similar settings may require more than the construction of new health infrastructure. Importantly, the effects estimated here likely depend on the quality of health care, the availability of transportation, the demand for health services, and the underlying causes of mortality, among other factors. |
| first_indexed | 2024-12-10T09:23:48Z |
| format | Article |
| id | doaj.art-6788e87b48ef4a21b37824a26a4edab8 |
| institution | Directory Open Access Journal |
| issn | 1472-6963 |
| language | English |
| last_indexed | 2024-12-10T09:23:48Z |
| publishDate | 2020-09-01 |
| publisher | BMC |
| record_format | Article |
| series | BMC Health Services Research |
| spelling | doaj.art-6788e87b48ef4a21b37824a26a4edab82022-12-22T01:54:36ZengBMCBMC Health Services Research1472-69632020-09-0120111210.1186/s12913-020-05738-wThe effects of changes in distance to nearest health facility on under-5 mortality and health care utilization in rural Malawi, 1980–1998John P. Quattrochi0Kenneth Hill1Joshua A. Salomon2Marcia C. Castro3Department of Public Health, Simmons UniversityCenter for Health Policy and Center for Primary Care and Outcomes Research, Stanford UniversityDepartment of Global Health and Population, Harvard T.H. Chan School of Public HealthDepartment of Global Health and Population, Harvard T.H. Chan School of Public HealthAbstract Background Despite important progress, the burden of under-5 mortality remains unacceptably high, with an estimated 5.3 million deaths in 2018. Lack of access to health care is a major risk factor for under-5 mortality, and distance to health care facilities has been shown to be associated with less access to care in multiple contexts, but few such studies have used a counterfactual approach to produce causal estimates. Methods We combined retrospective reports on 18,714 births between 1980 and 1998 from the 2000 Malawi Demographic and Health Survey with a 1998 health facility census that includes the date of construction for each facility, including 335 maternity or maternity/dispensary facilities built in rural areas between 1980 and 1998. We estimated associations between distance to nearest health facility and (i) under-5 mortality, using Cox proportional hazards models, and (ii) maternal health care utilization (antenatal visits prior to delivery, place of delivery, receiving skilled assistance during delivery, and receiving a check-up following delivery), using linear probability models. We also estimated the causal effect of reducing the distance to nearest facility on those outcomes, using a two-way fixed effects approach. Findings We found that greater distance was associated with higher mortality (hazard ratio 1.007 for one additional kilometer [95%CI 1.001 to 1.014]) and lower health care utilization (for one additional kilometer: 1.2 percentage point (pp) increase in homebirth [95%CI 0.8 to 1.5]; 0.8 pp. decrease in at least three antenatal visits [95% CI − 1.4 to − 0.2]; 1.2 pp. decrease in skilled assistance during delivery [95%CI − 1.6 to − 0.8]). However, we found no effects of a decrease in distance to the nearest health facility on the hazard of death before age 5 years, nor on antenatal visits prior to delivery, place of delivery, or receiving skilled assistance during delivery. We also found that reductions in distance decrease the probability that a woman receives a check-up following delivery (2.4 pp. decrease for a 1 km decrease [95%CI 0.004 to 0.044]). Conclusion Reducing under-5 mortality and increasing utilization of care in rural Malawi and similar settings may require more than the construction of new health infrastructure. Importantly, the effects estimated here likely depend on the quality of health care, the availability of transportation, the demand for health services, and the underlying causes of mortality, among other factors.http://link.springer.com/article/10.1186/s12913-020-05738-wUnder-5 mortalityUtilizationMaternal healthDistanceService availabilityMalawi |
| spellingShingle | John P. Quattrochi Kenneth Hill Joshua A. Salomon Marcia C. Castro The effects of changes in distance to nearest health facility on under-5 mortality and health care utilization in rural Malawi, 1980–1998 BMC Health Services Research Under-5 mortality Utilization Maternal health Distance Service availability Malawi |
| title | The effects of changes in distance to nearest health facility on under-5 mortality and health care utilization in rural Malawi, 1980–1998 |
| title_full | The effects of changes in distance to nearest health facility on under-5 mortality and health care utilization in rural Malawi, 1980–1998 |
| title_fullStr | The effects of changes in distance to nearest health facility on under-5 mortality and health care utilization in rural Malawi, 1980–1998 |
| title_full_unstemmed | The effects of changes in distance to nearest health facility on under-5 mortality and health care utilization in rural Malawi, 1980–1998 |
| title_short | The effects of changes in distance to nearest health facility on under-5 mortality and health care utilization in rural Malawi, 1980–1998 |
| title_sort | effects of changes in distance to nearest health facility on under 5 mortality and health care utilization in rural malawi 1980 1998 |
| topic | Under-5 mortality Utilization Maternal health Distance Service availability Malawi |
| url | http://link.springer.com/article/10.1186/s12913-020-05738-w |
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