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The fifth Millennium Development Goal (MDG-5) calls for reducing the maternal mortality ratio (MMR) by three quarters between 1990 and 2015 (United Nations Development Programme 2008). One of the key strategies to reduce maternal mortality has been to ensure that women give birth with a skilled attendant (Campbell & Graham 2006). The skilled attendant should be a health professional with midwifery skills and have a supporting environment, including access to higher levels of obstetric care in case of complications (Graham et al. 2001). It remains a challenge to provide such environments, especially in remote areas where access to health care is limited.
There are many obstacles to skilled attendant uptake, but physical distance to a health facility is thought to be a key factor (Gabrysch & Campbell 2009). Distance can capture aspects of remoteness such as poverty, low levels of education, strong traditional values, limited access to information and poor road infrastructure (Achadi et al. 2007; Hounton et al. 2008a). Long distances can be an actual barrier to reaching a health facility, but they can also be a deterrent to trying to seek care (Thaddeus & Maine 1994).
The evidence in support of an association between distance to health facilities and uptake of professional care at birth is strong. Studies in Burkina Faso, Mali, Malawi, Bangladesh, Zambia and Cambodia have found a linear relationship between increasing distance to a health centre and decreasing proportions of institutional births (Yanagisawa et al. 2006; Hounton et al. 2008b; Gabrysch et al. 2011) or births with a health professional (van den Broek et al. 2003; Chowdhury et al. 2006; Yanagisawa et al. 2006). Similarly, studies in Indonesia (Achadi et al. 2007), Haiti (Gage & Guirlene Calixte 2006), Cambodia (Yanagisawa et al. 2006) and Burkina Faso (Hounton et al. 2008a) showed that increasing distance to the nearest hospital reduced the level of uptake of a health professional at birth. These associations persisted after adjustment for various socio-economic factors in all sites, except in Cambodia where evidence for an effect was only observed in unadjusted analysis.
The relationship between distance to a health facility and the risk of a woman dying is less clear. Increasing remoteness (Le Bacq & Rietsema 1997; Bartlett et al. 2005), living in rural compared with urban areas (Ronsmans et al. 2009) and time taken to reach a health facility (Urassa et al. 1995; Ganatra et al. 1998; Taguchi et al. 2003; Brentlinger et al. 2005) all are associated with an increasing risk of maternal death. However, the relationship between actual physical distance to a health facility and maternal mortality remains uncertain. In Pakistan, the odds of dying increased 1.5 times only in women living more than 40 miles from a hospital compared with those living within 40 miles. This association was lost once adjusted for maternal age, parity, obstetric history and socio-economic factors (Fikree et al. 1997). In a case–control study in rural west Maharashtra, India, women who died lived significantly further away from an appropriate treatment facility than women who survived childbirth, but no adjustments were made (Ganatra et al. 1998). In Burkina Faso, distance from home to a health centre or nearest hospital was not associated with maternal death (Hounton et al. 2008b).
Understanding the barriers to uptake of obstetric care remains crucial in achieving the MDG-5 goal. The aim of this study is to explore the influence of distance and uptake of professional assistance during birth on maternal mortality. We analysed original studies from Indonesia and Bangladesh, which measured physical distance to health facilities, professional assistance during birth and maternal mortality.
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The population survey in Indonesia identified 1234 women who survived birth between April 2004 and March 2006. 32.8% births were attended by a health professional with the majority either in the woman's (48%) or the midwife's home (34%). Of the births with a health professional, 53% were with a health-centre midwife, 21% used a village-based midwife, 14% a hospital-based midwife, 4% a private midwife, 1% did not specify the type of midwife, and 7% used a doctor. In Bangladesh, 53 924 women delivered between 1987 and 2005. 23.6% delivered with a health professional, of which 27.1% were in the woman's home and 72.9% in a health facility. All the midwives in this area are ICDDR-B midwives.
Uptake of a health professional during delivery and birth decreased with increasing distance to a health centre (test for linear trend: Indonesia, P = 0.005; Bangladesh, P < 0.001) and increasing distance to a hospital (test for linear trend: Indonesia, P = 0.05; Bangladesh, P < 0.001) (Table 2).
Table 2. Maternal mortality ratio and uptake of a health professional at birth by distance to a health facility in Serang and Pandeglang, Indonesia (2004–2006), and Matlab, Bangladesh (1987–2005)
|Births with a health professional, % (n)||Maternal deaths per 100 000 births (95% CI)||Births with a health professional, % (n)||Maternal deaths per 100 000 births (95% CI)|
|Overall||32.8 (443)||320 (290, 353)||23.6 (12 713)||318 (272, 369)|
|Distance to a health centre (km)|
|≤1||57.6 (139)||245 (190, 316)||38.4 (4186)||220 (141, 327)|
|>1–≤2.5||38.9 (55)||324 (241, 436)||21.8 (4324 )||317 (244, 406)|
|>2.5–≤5||36.3 (168)||302 (250, 363)||18.5 (4100)||356 (282, 444)|
|>5–≤7.5||16.4 (31)||323 (258, 406)||10.4 (103)||401 (109, 1026)|
|>7.5–≤10||16.3 (25)||450 (340, 594)||–||–|
|>10||15.4 (25)||389 (297, 508)||–||–|
|Distance to a hospital (km)|
|≤10||53.9 (212)||267 (218, 328)||30.4 (94)||0|
|>10–≤20||28.5 (74)||333 (257, 403)||23.4 (6605)||331 (268, 406)|
|>20 ≤ 30||23.4 (57)||317 (258, 390)||23.8 (6014)||300 (236, 376)|
|>30 ≤ 40||28.7 (36)||282 (201, 396)||–||–|
|>40–≤50||28.0 (28)||379 (254, 564)||–||–|
|>50||14.1 (36)||474 (356, 631)||–||–|
Levels of maternal mortality were similar in Indonesia (320 per 100 000 births (95% CI: 290, 353) and Bangladesh (318 per 100 000 (95% CI: 272, 369) (Table 2). In Indonesia and Bangladesh, there was evidence for an increase in the odds of dying with a linear increase in distance to a health centre in the crude analysis (Indonesia: OR 1.04, 95% CI: 1.00–1.07; Bangladesh: OR 1.15, 95% CI: 0.99–1.33), but this was no longer observed once adjusted for maternal age, education, wealth and parity (Indonesia: OR 1.02, 95% CI: 0.98–1.06, Bangladesh: OR 1.13, 95% CI: 0.97–1.31) (Table 3a,b).
Table 3. (a) Distance to a health centre (km) and odds of a maternal death in Serang and Pandeglang, Indonesia (2004–2006), (b) Distance to a health centre and odds of a maternal death in Matlab, Bangladesh (1987–2005)
|Distance to a health centre (km)||Overall||Health professional present at time of birth or at time of death||Health professional NOT present at time of birth or at time of death|
|Unadjusted odds ratio (95% CI)||Adjusted odds ratioa (95% CI)||Unadjusted odds ratio (95% CI)||Adjusted odds ratioa (95% CI)||Unadjusted odds ratio (95% CI)||Adjusted odds ratioa (95% CI)|
|>1–≤2.5||1.24 (0.57, 2.73)||1.23 (0.54, 2.81)||1.63 (0.65, 4.09)||2.33 (0.79, 6.87)||1.06 (0.39, 2.89)||0.98 (0.34, 2.79)|
|>2.5–≤5||0.82 (0.46, 1.46)||0.73 (0.39, 1.34)||0.86 (0.40, 1.83)||0.87 (0.37, 2.03)||0.81 (0.40, 1.65)||0.78 (0.37, 1.610|
|>5–≤7.5||1.58 (0.78, 3.20)||1.07 (0.49, 2.32)||4.73 (1.82, 12.31)||2.17 (0.73, 6.49)||0.97 (0.42, 2.21)||0.67 (0.28, 1.60)|
|>7.5–≤10||1.40 (0.67, 2.91)||1.1 (0.50, 2.46)||3.69 (1.36, 10.01)||3.05 (1.03, 9.06)||0.89 (0.37, 2.13)||0.76 (0.31, 1.87)|
|>10||1.62 (0.78, 3.41)||1.1 (0.50, 2.52)||3.18 (1.11, 9.11)||2.11 (0.60, 7.38)||1.43 (0.59, 3.46)||0.93 (0.36, 2.41)|
|Continuous||1.04 (1.00, 1.07)||1.02 (0.98, 1.06)||1.08 (1.05, 1.12)||1.07 (1.02, 1.11)||1.03 (0 .98, 1.08)||1.01 (0.96, 1.07)|
|>1–≤2.5||1.68 (0.99, 2.85)||1.50 (0.88, 2.56)||3.16 (1.50, 6.66)||2.72 (1.29, 5.75)||1.21 (0.57, 2.58)||1.15 (0.54, 2.45)|
|>2.5–≤5||1.84 (1.10, 3.09)||1.69 (1.00, 2.84)||4.27 (2.07, 8.81)||3.90 (1.88, 8.08)||1.20 (0.57, 2.53)||1.17 (0.55, 2.46)|
|>5–≤7.5||2.30 (0.78, 6.81)||1.92 (0.64, 5.74)||12.57 (3.35, 47.14)||9.17 (2.39, 35.14)||0.79 (0.10, 6.25)||0.71 (0.09, 5.65)|
|Continuous||1.15 (0.99, 1.33)||1.13 (0.97, 1.31)||1.05 (1.25, 1.82)||1.47 (1.22, 1.78)||1.00 (0.79, 1.27)||1.00 (0.78, 1.27)|
There was evidence for an interaction between distance to a health centre and assistance by a health professional on maternal mortality in crude analyses (Indonesia, P = 0.038; Bangladesh, P = 0.008), and therefore, the analysis was separated into whether or not a woman was attended by a health professional. For women who were assisted by a health professional, the odds of dying increased with increasing distance from a health centre (adjusted ORs per 1 km increase: Indonesia 1.07, 95% CI: 1.02–1.11; Bangladesh 1.47, 95% CI: 1.22–1.78) (Table 3). In Indonesia, this was more strongly observed among women who lived further than 5 km from a health centre than those who lived within 5 km of a health centre (adjusted OR: 2.2, 95% CI: 1.09–4.5, P = 0.03, Figure 1a). In Bangladesh, the increase in mortality with distance was more linear (Figure 1b). For women who were not assisted by a health professional, there was no evidence for increased odds of dying with increasing distance to a health centre in both Indonesia and Bangladesh (P > 0.05, Table 3). No other interactions were observed between distance to a health centre and either maternal age, wealth, parity or education on maternal mortality.
Figure 1. Maternal mortality ratio by presence or absence of a health professional and deliveries with a health professional (%) by distance to a health centre, (a) Serang and Pandeglang, Indonesia (2004–2006), (b) Matlab, Bangladesh (1987–2005).
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The above analysis was repeated to explore the relationship between distance to the nearest hospital and uptake of a health professional and maternal mortality. There was no evidence for an association between distance to a hospital and maternal mortality (Indonesia: adjusted OR per 1 km increase 1.00, 95% CI: 1.00–1.01; Bangladesh: adjusted OR per 1 km increase 1.00, 95% CI: 0.96–1.04). There was no evidence for an interaction between distance to a hospital and uptake of professional assistance (data not shown). Excluding deaths before labour and delivery attenuated values of the ORs, but the conclusions remain unchanged (data not shown).
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We found that among women assisted by a health professional, there appears to be an increase in maternal mortality with increasing distance to a health centre. In women who did not use a health professional, there is no variation in maternal mortality with distance to a health centre. When uptake of professional birth attendance is generally very low, women will only seek professional care in an emergency and they may do so too late for a midwife or doctor to be able to save their lives. In such circumstances, women who use a health professional have higher levels of maternal mortality than those who do not (Midhet et al. 1998; Brentlinger et al. 2005; Chowdhury et al. 2007; Christian et al. 2008; Hounton et al. 2008b; Ronsmans et al. 2009). The association between maternal mortality and distance to a health centre among women giving birth with a health professional is therefore perhaps not surprising. Reviews by Thaddeus and Maine (1994) and Gabrysch and Campbell (2009) emphasise how distance increases not only the delay in reaching a healthcare facility, but also influences a woman and her family's decision to seek care. Distance can act as a barrier to seek care early and only when the illness becomes serious is the decision made to travel to a health facility. About half of all births with a health professional in Indonesia and a third in Bangladesh were in the woman's home, suggesting that health professionals may face similar barriers to families when trying to overcome long distances. Very little is known about the barriers faced by health professionals in attending home births. Evidence from Bangladesh suggests that midwives found it difficult to travel far away from the health centre, even though transport by boat was provided (Blum et al. 2006). For those women who do not seek care, distance to a health facility has no bearing on their pregnancy-related health outcome. They do not depend on timely access to a health facility to seek care or how long a midwife takes to come to their home.
The relationship between distance to a health facility and birth with a health professional is strong and consistent with several other studies (Hodgkin 1996; Magadi et al. 2000; Tanser 2006). For both countries, previous published work has shown a linear relationship between distance to the nearest hospital (Achadi et al. 2007) or health facility (Chowdhury et al. 2006) and birth with a health professional, regardless of place of delivery. In the Indonesia study, the majority of births occurred at home and only 1.6% of all live births were delivered in a health facility. However, health-centre midwives were the main providers during delivery, and this perhaps also highlights the barriers faced by health professionals in attending home births. In Bangladesh, the safe motherhood programme was introduced in 1987 with the aim of increasing skilled attendance at delivery primarily in the women's home. In 1996, the programme was redesigned to become facility based, and midwives were asked to stop attending home births. The proportion of all births delivered with a midwife in a health facility rose from zero in 1987 to 26.8% in 2001 (Chowdhury et al. 2006). By 2005, 52.5% of all births were delivered in a health facility, and no births at home were attended by a health professional. It is therefore perhaps not unexpected that the associations between distance to a health centre and uptake of professional care during delivery are stronger in Bangladesh than in Indonesia.
The relationship between distance to a health centre and maternal mortality is much less strong than the relationship between distance to a health centre and uptake of professional assistance during delivery. High mortality in only those seeking care is probably due to late seeking care, but low uptake of professional assistance during delivery may be more related to the low quality of care once a woman reaches a health provider. There is increasing evidence that health professionals in poor countries may not have adequate skills or that the health facilities or home environment in which they work do not provide the necessary support (Blum et al. 2006). In 1989, the Government of Indonesia launched a safe motherhood programme, which aimed at assigning a midwife to every village. Within 7 years, midwives were posted in the majority of villages and the proportion of births attended by a health professional rose from 35% in 1989 to 69% in 2000 (Hatt et al. 2006). However, these programmes have focused on the individual providers, neglecting the essential supporting environment. In Bangladesh, basic conditions in rural areas may also prevent midwives from delivering skilled care (Blum et al. 2006). It is thus critical that one of the major roles that rural midwives play in reducing maternal deaths is ensuring timely and appropriate access to adequate obstetric care (Campbell & Graham 2006). However, without the supporting environment, including good transportation, the midwife's capabilities in many emergency situations remains limited. The Indonesian Government has recognised the potential of health centres for increasing deliveries with health professionals. In 2011, Jampersal was introduced, a health programme that provides women with universal free delivery care (Ministry of Health I 2011). However, this programme is only available to women who deliver in a health facility, and thus, barriers to access to a health centre remain the same.
We did not observe any associations between distance to a hospital and maternal mortality. In Bangladesh, the study area is more than 10 km from a hospital, and almost all births occurred between 10 and 30 km of the nearest hospital. Thus, there may not have been enough variation in distance to hospital to explore this association. In Indonesia, only 4% of women delivered in a hospital, such low uptake also limits the ability to explore associations between maternal mortality and distance to a hospital in this region.
There are some strengths to these studies; not only are these prospective studies, but special efforts were made to identify all maternal deaths in the study populations. It is possible though that we still missed some maternal deaths in early pregnancy or due to sensitive causes owing to under-reporting by relatives in both studies, and this may lead to differential misclassification if death reporting is related to distance to a health facility. The two studies have some limitations; we did not examine the relationship between distance to a health facility and specific causes of death. In Bangladesh, haemorrhage was the major cause of direct maternal mortality (Chowdhury et al. 2009) and timely access to emergency care for these women is crucial. However, just over a quarter of maternal deaths were due to indirect causes where the role of the midwife is limited. We do not have data on causes of death for the Indonesian study. In Bangladesh, distance was measured by a straight line between the woman's house and health facility rather than by road distance. In the Indonesian study, distance by road was used, but the data were collected at village level, and we may have underestimated some distances for women who live outside the village centre. This would dilute the effect of distance on risk of dying especially if these women are the most vulnerable and at greatest risk of pregnancy-related complications. The study was not designed to collect information on mode of transport, which may also influence the risk of dying and uptake of professional care. Our analysis also relies on women's usual place of residence, and often women stay with relatives around the time of delivery, which may have distorted our data on distance to a health facility. For the main analysis, we included deaths during pregnancy; these women may be less likely to have seen a health professional than women who died during labour and delivery. However, excluding deaths during pregnancy did not alter our conclusions for either study.
Our findings provide further insight into understanding the determinants of maternal mortality. Distance to a health facility may capture other aspects of remoteness that are difficult to measure quantitatively (Achadi et al. 2007; Hounton et al. 2008a), but may also influence a women's decision to use a health professional during delivery. Clearly, investment in midwives and their professional environment is important. However, improving access to adequate care, in particular for women who live far from health facilities, and encouraging women to seek appropriate and timely care are essential if the MDG-5 goal is to be achieved.