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BMC Public Health
Published in: BMC Public Health 1/2012

Open Access 01-12-2012 | Research article

Geographical access to care at birth in Ghana: a barrier to safe motherhood

Authors: Peter W Gething, Fiifi Amoako Johnson, Faustina Frempong-Ainguah, Philomena Nyarko, Angela Baschieri, Patrick Aboagye, Jane Falkingham, Zoe Matthews, Peter M Atkinson

Published in: BMC Public Health | Issue 1/2012

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Abstract

Background

Appropriate facility-based care at birth is a key determinant of safe motherhood but geographical access remains poor in many high burden regions. Despite its importance, geographical access is rarely audited systematically, preventing integration in national-level maternal health system assessment and planning. In this study, we develop a uniquely detailed set of spatially-linked data and a calibrated geospatial model to undertake a national-scale audit of geographical access to maternity care at birth in Ghana, a high-burden country typical of many in sub-Saharan Africa.

Methods

We assembled detailed spatial data on the population, health facilities, and landscape features influencing journeys. These were used in a geospatial model to estimate journey-time for all women of childbearing age (WoCBA) to their nearest health facility offering differing levels of care at birth, taking into account different transport types and availability. We calibrated the model using data on actual journeys made by women seeking care.

Results

We found that a third of women (34%) in Ghana live beyond the clinically significant two-hour threshold from facilities likely to offer emergency obstetric and neonatal care (EmONC) classed at the ‘partial’ standard or better. Nearly half (45%) live that distance or further from ‘comprehensive’ EmONC facilities, offering life-saving blood transfusion and surgery. In the most remote regions these figures rose to 63% and 81%, respectively. Poor levels of access were found in many regions that meet international targets based on facilities-per-capita ratios.

Conclusions

Detailed data assembly combined with geospatial modelling can provide nation-wide audits of geographical access to care at birth to support systemic maternal health planning, human resource deployment, and strategic targeting. Current international benchmarks of maternal health care provision are inadequate for these purposes because they fail to take account of the location and accessibility of services relative to the women they serve.
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Literature
1.
Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, Lopez AD, Lozano R, Murray CJL: Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet. 2010, 375 (9726): 1609-1623. 10.1016/S0140-6736(10)60518-1.CrossRefPubMed
2.
WHO, UNICEF, UNFPA, World Bank: Trends in maternal mortality: 1990 to 2010: estimates developed by WHO, UNICEF, UNFPA and the World Bank. 2012, Geneva: World Health Organization, 59-
3.
AbouZahr C: New estimates of maternal mortality and how to interpret them: choice or confusion?. Reprod Health Matters. 2011, 19 (37): 117-128. 10.1016/S0968-8080(11)37550-7.CrossRefPubMed
4.
van den Broek NR, Falconer AD: Maternal mortality and Millennium Development Goal 5. Br Med Bull. 2011, 99 (1): 25-38. 10.1093/bmb/ldr033.CrossRefPubMed
5.
WHO, ICM, FIGO: Making pregnancy safer: the critical role of the skilled attendant. A joint statement by WHO, ICM and FIGO. 2004, Geneva: World Health Organisation, 18-
6.
Ghana Statistical Service (GSS), Ghana Health Service (GHS), Macro International: Ghana Maternal Health Survey 2007. 2009, Calverton: GSS, GHS, and Macro International, 221-
7.
Lim SS, Stein DB, Charrow A, Murray CJL: Tracking progress towards universal childhood immunisation and the impact of global initiatives: a systematic analysis of three-dose diphtheria, tetanus, and pertussis immunisation coverage. Lancet. 2008, 372 (9655): 2031-2046. 10.1016/S0140-6736(08)61869-3.CrossRefPubMed
8.
Noor AM, Mutheu JJ, Tatem AJ, Hay SI, Snow RW: Insecticide-treated net coverage in Africa: mapping progress in 2000–07. Lancet. 2009, 373 (9657): 58-67. 10.1016/S0140-6736(08)61596-2.CrossRefPubMed
9.
Palella FJ, Delaney KM, Moorman AC, Loveless MO, Fuhrer J, Satten GA, Aschman DJ, Holmberg SD, Investigators HIVOS: Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. N Engl J Med. 1998, 338 (13): 853-860. 10.1056/NEJM199803263381301.CrossRefPubMed
10.
Lule E, Ramana GNV, Ooman N, Epp J, Huntington D, JE R: Achieving the millennium development goal of improving maternal health: determinants, interventions and challenges. HNP discussion paper. 2005, Washington, DC: The World Bank
11.
Campbell OMR, Graham WJ: Strategies for reducing maternal mortality: getting on with what works. Lancet. 2006, 368 (9543): 1284-1299. 10.1016/S0140-6736(06)69381-1.CrossRefPubMed
12.
Filippi V, Ronsmans C, Campbell OMR, Graham WJ, Mills A, Borghi J, Koblinsky M, Osrin D: Maternal survival 5 - Maternal health in poor countries: the broader context and a call for action. Lancet. 2006, 368 (9546): 1535-1541. 10.1016/S0140-6736(06)69384-7.CrossRefPubMed
13.
Buor D, Bream K: An analysis of the determinants of maternal mortality in sub-Saharan Africa. Journal of Womens Health. 2004, 13 (8): 926-938. 10.1089/jwh.2004.13.926.CrossRef
14.
Matthews Z, Channon A, Neal S, Osrin D, Madise N, Stones W: Examining the “urban advantage” in maternal health care in developing countries. PLoS Med. 2010, 7 (9): e1000327-10.1371/journal.pmed.1000327.CrossRefPubMedPubMedCentral
15.
Gabrysch S, Cousens S, Cox J, Campbell OMR: 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. PLoS Med. 2011, 8 (1): e1000394-10.1371/journal.pmed.1000394.CrossRefPubMedPubMedCentral
16.
De Allegri M, Ridde V, Louis VR, Sarker M, Tiendrebeogo J, Ye M, Mueller O, Jahn A: Determinants of utilisation of maternal care services after the reduction of user fees: A case study from rural Burkina Faso. Health Policy. 2011, 99 (3): 210-218. 10.1016/j.healthpol.2010.10.010.CrossRefPubMed
17.
Titaley CR, Dibley MJ, Roberts CL: Factors associated with underutilization of antenatal care services in Indonesia: results of Indonesia Demographic and Health Survey 2002/2003 and 2007. BMC Publ Health. 2010, 10: 485-10.1186/1471-2458-10-485.CrossRef
18.
Malqvist M, Sohel N, Do TT, Eriksson L, Persson L-A: Distance decay in delivery care utilisation associated with neonatal mortality. A case referent study in northern Vietnam. BMC Publ Health. 2010, 10: 762-10.1186/1471-2458-10-762.CrossRef
19.
Gabrysch S, Campbell OMR: Still too far to walk: literature review of the determinants of delivery service use. BMC Pregnancy Childbirth. 2009, 9: 34-10.1186/1471-2393-9-34.CrossRefPubMedPubMedCentral
20.
Thaddeus S, Maine D: Too far to walk - maternal mortality in context. Soc Sci Med. 1994, 38 (8): 1091-1110. 10.1016/0277-9536(94)90226-7.CrossRefPubMed
21.
Hounton S, Chapman G, Menten J, De Brouwere V, Ensor T, Sombie I, Meda N, Ronsmans C: Accessibility and utilisation of delivery care within a skilled care initiative in rural Burkina Faso. Trop Med Int Health. 2008, 13: 44-52.CrossRefPubMed
22.
Buor D: Analysing the primacy of distance in the utilization of health services in the Ahafo-Ano South district, Ghana. Int J Health Plann Manage. 2003, 18 (4): 293-311. 10.1002/hpm.729.CrossRefPubMed
23.
Zhang LM, Ding H: Analysis of the causes of maternal death in China. Bull World Health Organ. 1988, 66 (3): 387-390.PubMed
24.
Kwast BE, Rochat RW, Kidane-Mariam W: Maternal Mortality in Addis Ababa, Ethiopia. Stud Fam Plann. 1986, 17 (6): 288-301. 10.2307/1966906.CrossRefPubMed
25.
Barnes-Josiah D, Myntti C, Augustin A: The "three delays" as a framework for examining maternal mortality in Haiti. Soc Sci Med. 1998, 46 (8): 981-993. 10.1016/S0277-9536(97)10018-1.CrossRefPubMed
26.
Cham M, Sundby J, Vangen S: Maternal mortality in the rural Gambia, a qualitative study on access to emergency obstetric care. Reprod Heal. 2005, 2 (1): 3-10.1186/1742-4755-2-3.CrossRef
27.
Essendi H, Mills S, Fotso J-C: Barriers to formal emergency obstetric care services' utilization. J Urban Health. 2011, 88: 356-369. 10.1007/s11524-010-9481-1.CrossRef
28.
Killewo J, Anwar I, Bashir I, Yunus M, Chakraborty J: Perceived delay in healthcare-seeking for episodes of serious illness and its implications for safe motherhood interventions in rural Bangladesh. J Health Popul Nutr. 2006, 24 (4): 403-412.PubMedPubMedCentral
29.
Ministry of Health (MOH), Ghana Health Service (GHS), Government of Ghana: National Assessment for Emergency Obstetric and Newborn Care. 2011, Accra: MOH, GHS, Government of Ghana, 248-
30.
WHO: Monitoring emergency obstetric care: a handbook. 2009, Geneva: World Health Organization, 152-
31.
Noor AM, Alegana VA, Gething PW, Snow RW: A spatial national health facility database for public health sector planning in Kenya in 2008. Int J Health Geogr. 2009, 8: 13-10.1186/1476-072X-8-13.CrossRefPubMedPubMedCentral
32.
Noor AM, Amin AA, Gething PW, Atkinson PM, Hay SI, Snow RW: Modelling distances travelled to government health services in Kenya. Trop Med Int Health. 2006, 11 (2): 188-196. 10.1111/j.1365-3156.2005.01555.x.CrossRefPubMedPubMedCentral
33.
Gething PW, Noor AM, Zurovac D, Atkinson PM, Hay SI, Nixon MS, Snow RW: Empirical modelling of government health service use by children with fevers in Kenya. Acta Trop. 2004, 91 (3): 227-237. 10.1016/j.actatropica.2004.05.002.CrossRefPubMedPubMedCentral
34.
Costa LS, Nassi CD, Pinheiro RS, Almeida RMVR: Accessibility of selected hospitals and medical procedures by means of aerial and transit network-based measures. Health Serv Manage Res. 2003, 16 (2): 136-140. 10.1258/095148403321591456.CrossRefPubMed
35.
Perry B, Gesler W: Physical access to primary health care in Andean Bolivia. Soc Sci Med. 2000, 50 (9): 1177-1188. 10.1016/S0277-9536(99)00364-0.CrossRefPubMed
36.
The Prevention of Maternal Mortality Network: Barriers to treatment of obstetric emergencies in rural communities of West Africa. The Prevention of Maternal Mortality Network. Stud Fam Plann. 1992, 23 (5): 279-291.CrossRef
37.
Young JC, Garro LY: Variation in the choice of treatment in two Mexican communities. Soc Sci Med. 1982, 16 (16): 1453-1465. 10.1016/0277-9536(82)90060-0.CrossRefPubMed
38.
Dulin MF, Ludden TM, Tapp H, Blackwell J, de Hernandez BU, Smith HA, Furuseth OJ: Using geographic information systems (GIS) to understand a community's primary care needs. J Am Board Fam Med. 2010, 23 (1): 13-21. 10.3122/jabfm.2010.01.090135.CrossRefPubMed
39.
Bailey PE, Keyes EB, Parker C, Abdullah M, Kebede H, Freedman L: Using a GIS to model interventions to strengthen the emergency referral system for maternal and newborn health in Ethiopia. Int J Gynecol Obstet. 2011, 115 (3): 300-309. 10.1016/j.ijgo.2011.09.004.CrossRef
40.
Ghana Statistical Service (GSS), Ghana Health Service (GHS), ICF Macro: Demographic and Health Survey 2008. 2009, Accra: GSS, GHS, and ICF Macro, 483-
41.
Douglas DH: Least-cost Path in GIS Using an Accumulated Cost Surface and Slopelines. Cartographica: The International Journal for Geographic Information and Geovisualization. 1994, 31 (3): 37-51. 10.3138/D327-0323-2JUT-016M.CrossRef
42.
Collischonn W, Pilar JV: A direction dependent least-cost-path algorithm for roads and canals. Int J Geogr Inf Sci. 2000, 14 (4): 397-406. 10.1080/13658810050024304.CrossRef
43.
Teng M, Wu C, Zhou Z, Lord E, Zheng Z: Multipurpose greenway planning for changing cities: A framework integrating priorities and a least-cost path model. Landscape and Urban Planning. 2011, 103 (1): 1-14. 10.1016/j.landurbplan.2011.05.007.CrossRef
44.
Huck M, Jedrzejewski W, Borowik T, Jedrzejewska B, Nowak S, Myslajek RW: Analyses of least cost paths for determining effects of habitat types on landscape permeability: wolves in Poland. Acta Theriol. 2011, 56 (1): 91-101. 10.1007/s13364-010-0006-9.CrossRefPubMed
45.
Howey MCL: Multiple pathways across past landscapes: circuit theory as a complementary geospatial method to least cost path for modeling past movement. J Archaeol Sci. 2011, 38 (10): 2523-2535. 10.1016/j.jas.2011.03.024.CrossRef
46.
Choi Y, Nieto A: Optimal haulage routing of off-road dump trucks in construction and mining sites using Google Earth and a modified least-cost path algorithm. Autom Constr. 2011, 20 (7): 982-997. 10.1016/j.autcon.2011.03.015.CrossRef
47.
Bagli S, Geneletti D, Orsi F: Routeing of power lines through least-cost path analysis and multicriteria evaluation to minimise environmental impacts. Environmental Impact Assessment Review. 2011, 31 (3): 234-239. 10.1016/j.eiar.2010.10.003.CrossRef
48.
Tanser F, Gijsbertsen B, Herbst K: Modelling and understanding primary health care accessibility and utilization in rural South Africa: An exploration using a geographical information system. Soc Sci Med. 2006, 63 (3): 691-705. 10.1016/j.socscimed.2006.01.015.CrossRefPubMed
49.
Langmuir E: Mountain-craft and Leadership. 1984, Leicester: The Scottish Sport Council/MLTB, Cordee
50.
51.
Witter S, Adjei S, Armar-Klemesu M, Graham W: Providing free maternal health care: ten lessons from an evaluation of the national delivery exemption policy in Ghana. Health Action. 2009, 2:
52.
Asante F, Chikwama C, Daniels A, Armar-Klemesu M: Evaluating the economic outcomes of the policy of fee exemption for maternal delivery care in Ghana. Ghana Med J. 2007, 41 (3): 110-117.PubMedPubMedCentral
53.
Ghana Statistical Service: Ghana 2003 Core Welfare Indicators Questionnaire (CWIQ II) Survey Report: Statistical Abstract In. 2005, Accra: Ghana Statistical Service
54.
Battese GE, Harter RM, Fuller WA: An error-components model for prediction of county crop areas using survey and satellite data. J Am Stat Assoc. 1988, 83 (401): 28-36. 10.1080/01621459.1988.10478561.CrossRef
55.
Service GS: Population and Housing Census: Summary Report of Final Results. 2000, Accra: Ghana Statistical Service, 2002-
56.
Linard C, Gilbert M, Snow RW, Noor AM, Tatem AJ: Population distribution, settlement patterns and accessibility across Africa in 2010. PLoS One. 2012, 7 (2): e31743-10.1371/journal.pone.0031743.CrossRefPubMedPubMedCentral
57.
LeBacq F, Rietsema A: High maternal mortality levels and additional risk from poor accessibility in two districts of Northern Province, Zambia. Int J Epidemiol. 1997, 26 (2): 357-363. 10.1093/ije/26.2.357.CrossRef
58.
Kwast BE: Postpartum haemorrhage: Its contribution to maternal mortality. Midwifery. 1991, 7 (2): 64-70. 10.1016/S0266-6138(05)80229-3.CrossRefPubMed
59.
Pirkle CM, Fournier P, Tourigny C, Sangare K, Haddad S: Emergency Obstetrical Complications in a Rural African Setting (Kayes, Mali): The Link Between Travel Time and In-Hospital Maternal Mortality. Matern Child Health J. 2011, 15 (7): 1081-1087. 10.1007/s10995-010-0655-y.CrossRefPubMed
60.
61.
UNICEF, WHO, UNFPA: Guidelines for Monitoring Availability and Use of Obstetric Services. 1997, New York: United Nations Children’s Fund
62.
Armar-Klemesu M: Personal communication: Dr Margaret Armar-Klemesu, Noguchi Institute. 2011
Metadata
Title
Geographical access to care at birth in Ghana: a barrier to safe motherhood
Authors
Peter W Gething
Fiifi Amoako Johnson
Faustina Frempong-Ainguah
Philomena Nyarko
Angela Baschieri
Patrick Aboagye
Jane Falkingham
Zoe Matthews
Peter M Atkinson
Publication date
01-12-2012
Publisher
BioMed Central
Published in
BMC Public Health / Issue 1/2012
Electronic ISSN: 1471-2458
DOI
https://doi.org/10.1186/1471-2458-12-991

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