Are We There Yet? Assessing the Burden of Travel on Maternal Health Care Utilization and Child Mortality in Developing Countries

Mahesh Karra, Günther Fink, David Canning

David Canning Guenther FinkMahesh Karra


The problem
Over the past two decades, low- and middle-income countries (LMICs) have made considerable progress towards reducing child mortality. In spite of these achievements, almost six million children under the age of five are estimated to have died in 2015. Many of these deaths could likely be avoided if high quality antenatal care and delivery at health facilities were available to mothers and their children. Yet access to high quality health services remains low in many settings.

Distance to health care facilities has been identified as one of the main potential barriers to health service access. However, while there is strong evidence that long distances to facilities lead to lower utilization of health services, the evidence is less clear about whether long distances to facilities are linked to poor health outcomes.

What did we do?
We pooled nationally representative health and facility distance data from 21 low- and middle-income countries to investigate the relationships between distance to facility, service utilization and child mortality. The large data set, which had actual distance measures, allowed us to overcome two key methodological problems faced by previous studies:

a) Measurement error in estimated distance to facility, due to incomplete facility data and household location data that is scrambled to preserve anonymity;

b) Insufficient sample size in national samples to be able to detect significant effects on child mortality and other rare health outcomes.

What did we find?
1. Children in low- and middle-income countries live closer to facilities than commonly perceived.

Figure 1: Distribution of Distances to the Nearest Facility by Country

Our results suggest that a majority of children live within 3 km of a facility. Much of the existing literature focuses on children living more than 5 or 10 km from a facility. We have shown that this subgroup represents only around 30 percent of children in LMICs today. However, relatively small distances are associated with remarkably large differences in health seeking behaviour. Compared to mothers who live within 1 km, mothers living 3 km from a facility have, on average, a 22 percent lower odds of receiving four or more antenatal care visits and have a 30 percent lower odds of delivering at facilities.

2. Facility distance is strongly associated with neonatal survival. Compared to children who live within 1 km of a facility, children living farther than 10 km have a 27 percent higher odds of neonatal mortality.

Figure 2: The effect of distance to health facility on antenatal care received, facility delivery, and neonatal death: pooled analysis*

(*Notes: The results are based on the logistic regression results that are reported in Table 1 of our published article. The odds ratios are for each distance category, compared to the reference group of living within 1 km of a facility. The error bars indicate the 95 percent confidence interval. The purple horizontal line at 1 represents the odds ratio value under the null hypothesis.)

What do our findings mean?
Taken together, our findings suggest that while average distances to health facilities in low- and middle-income countries are likely to be smaller than is commonly perceived, improving access to facilities may still play a considerable role in improving health access and child health outcomes. Increasing the number of facilities may be one strategy for reaching this objective. However a large number of facilities, each with a low patient load, could increase costs and lower the quality of service provision. Improving access to transport may be an alternative strategy that could have similar benefits at a substantially lower cost. Overall, policies and programmes that improve access in more remote areas are likely to not only yield substantial increases in the coverage rates of critical public health interventions but may also contribute substantially to further reductions in under-5 mortality.

Read more:

M Karra, G Fink, and D Canning. Facility Distance and Child Mortality: A Multi-Country Study of Health Facility Access, Service Utilization, and Child Health Outcomes. Int. J. Epidemiol. 2016. DOI: 10.1093/ije/dyw062 [Free to access until 20 August 2016].

Wang H, Liddell CA, Coates MM, et al. Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990–2013: A systematic analysis for the Global Burden of Disease Study 2013. The Lancet 2014;384:957–79. doi:10.1016/S0140-6736(14)60497-9.

UNICEF/WHO, World Bank, UNDP. Levels and Trends in Child Mortality: 2013. Geneva, Switzerland: : World Health Organization 2013.

Gabrysch S, Campbell OMR. Still too far to walk: literature review of the determinants of delivery service use. BMC Pregnancy Childbirth 2009;9:34.

Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med 1994;38:1091–110

Mahesh Karra is a fourth year doctoral student in Global Health Economics at the Harvard T.H. Chan School of Public Health. His academic and research interests are broadly in development economics, health economics, quantitative methods, and applied demography. His most recent research focuses on examining the short- and long-term impacts of family planning on fertility, maternal and child health, and downstream economic outcomes including female labour force participation, income growth, and wealth.

Günther Fink is an Associate Professor of International Health Economics at the Harvard T.H. Chan School of Public Health. His work focuses on developing and evaluating new and innovative approaches to improving child health and child development. He has also worked on evaluations of national and community-based health insurance initiatives in Ghana and Burkina Faso, community-based health workers programs in Nigeria, and large-scale private and public sector initiatives to reduce the burden of malaria in Angola, Namibia, Uganda and Zambia.

David Canning is the Richard Saltonstall Professor of Population Sciences and Professor of Economics and International Health. His research on demographic change focuses on the effect of changes in age structure on aggregate economic activity, and the effect of changes in longevity on economic behaviour. In terms of health, his research focuses on health as a form of human capital and its effect on worker productivity. He is also the Deputy Director of the Program on the Global Demography of Aging and is the Associate Director of the Harvard Center for Population and Development Studies.

Follow the Harvard T.H. Chan School of Public Health on Twitter @HarvardChanSPH


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