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Too poor or too far? Partitioning the variability of hospital-based childbirth by poverty and travel time in Kenya, Malawi, Nigeria and Tanzania

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  • Wong, Kerry L.M.
  • Brady, Oliver J.
  • Campbell, Oona M.R.
  • Banke-Thomas, Aduragbemi
  • Benova, Lenka

Abstract

Background: In sub-Saharan Africa, women are most likely to receive skilled and adequate childbirth care in hospital settings, yet the use of hospital for childbirth is low and inequitable. The poorest and those living furthest away from a hospital are most affected. But the relative contribution of poverty and travel time is convoluted, since hospitals are often located in wealthier urban places and are scarcer in poorer remote area. This study aims to partition the variability in hospital-based childbirth by poverty and travel time in four sub-Saharan African countries. Methods: We used data from the most recent Demographic and Health Survey in Kenya, Malawi, Nigeria and Tanzania. For each country, geographic coordinates of survey clusters, the master list of hospital locations and a high-resolution map of land surface friction were used to estimate travel time from each DHS cluster to the nearest hospital with a shortest-path algorithm. We quantified and compared the predicted probabilities of hospital-based childbirth resulting from one standard deviation (SD) change around the mean for different model predictors. Results: The mean travel time to the nearest hospital, in minutes, was 27 (Kenya), 31 (Malawi), 25 (Nigeria) and 62 (Tanzania). In Kenya, a change of 1SD in wealth led to a 33.2 percentage points change in the probability of hospital birth, whereas a 1SD change in travel time led to a change of 16.6 percentage points. The marginal effect of 1SD change in wealth was weaker than that of travel time in Malawi (13.1 vs. 34.0 percentage points) and Tanzania (20.4 vs. 33.7 percentage points). In Nigeria, the two were similar (22.3 vs. 24.8 percentage points) but their additive effect was twice stronger (44.6 percentage points) than the separate effects. Random effects from survey clusters also explained substantial variability in hospital-based childbirth in all countries, indicating other unobserved local factors at play. Conclusions: Both poverty and long travel time are important determinants of hospital birth, although they vary in the extent to which they influence whether women give birth in a hospital within and across countries. This suggests that different strategies are needed to effectively enable poor women and women living in remote areas to gain access to skilled and adequate care for childbirth.

Suggested Citation

  • Wong, Kerry L.M. & Brady, Oliver J. & Campbell, Oona M.R. & Banke-Thomas, Aduragbemi & Benova, Lenka, 2020. "Too poor or too far? Partitioning the variability of hospital-based childbirth by poverty and travel time in Kenya, Malawi, Nigeria and Tanzania," LSE Research Online Documents on Economics 103300, London School of Economics and Political Science, LSE Library.
    • Handle: RePEc:ehl:lserod:103300
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    References listed on IDEAS

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    1. Thaddeus, Sereen & Maine, Deborah, 1994. "Too far to walk: Maternal mortality in context," Social Science & Medicine, Elsevier, vol. 38(8), pages 1091-1110, April.
    2. Kerry L M Wong & María Clara Restrepo-Méndez & Aluísio J D Barros & Cesar G Victora, 2017. "Socioeconomic inequalities in skilled birth attendance and child stunting in selected low and middle income countries: Wealth quintiles or deciles?," PLOS ONE, Public Library of Science, vol. 12(5), pages 1-17, May.
    3. Teketo Kassaw Tegegne & Catherine Chojenta & Deborah Loxton & Roger Smith & Kelemu Tilahun Kibret, 2018. "The impact of geographic access on institutional delivery care use in low and middle-income countries: Systematic review and meta-analysis," PLOS ONE, Public Library of Science, vol. 13(8), pages 1-16, August.
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    1. Banke-Thomas, Aduragbemi & Avoka, Cephas & Olaniran, Abimbola & Balogun, Mobolanle & Wright, Ololade & Ekerin, Olabode & Benova, Lenka, 2021. "Patterns, travel to care and factors influencing obstetric referral: Evidence from Nigeria's most urbanised state," Social Science & Medicine, Elsevier, vol. 291(C).
    2. Alem Desta Wuneh & Afework Mulugeta Bezabih & Lars Åke Persson & Yemisrach Behailu Okwaraji & Araya Abrha Medhanyie, 2022. "“If I Was Educated, I Would Call the Ambulance and Give Birth at the Health Facility”—A Qualitative Exploratory Study of Inequities in the Utilization of Maternal, Newborn, and Child Health Services i," IJERPH, MDPI, vol. 19(18), pages 1-14, September.
    3. Suchi Kapoor Malhotra & Howard White & Nina Ashley O. Dela Cruz & Ashrita Saran & John Eyers & Denny John & Ella Beveridge & Nina Blöndal, 2021. "Studies of the effectiveness of transport sector interventions in low‐ and middle‐income countries: An evidence and gap map," Campbell Systematic Reviews, John Wiley & Sons, vol. 17(4), December.

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