Association between proximity to a health center and early childhood mortality in Madagascar.
OBJECTIVE
To evaluate the association between proximity to a health center and early childhood mortality in Madagascar, and to assess the influence of household wealth, maternal educational attainment, and maternal health on the effects of distance.


METHODS
From birth records of subjects in the Demographic and Health Survey, we identified 12565 singleton births from January 2004 to August 2009. After excluding 220 births that lacked global positioning system information for exposure assessment, odds ratios (ORs) and their 95% confidence intervals (CIs) for neonatal mortality and infant mortality were estimated using multilevel logistic regression models, with 12345 subjects (level 1), nested within 584 village locations (level 2), and in turn nested within 22 regions (level 3). We additionally stratified the subjects by the birth order. We estimated predicted probabilities of each outcome by a three-level model including cross-level interactions between proximity to a health center and household wealth, maternal educational attainment, and maternal anemia.


RESULTS
Compared with those who lived >1.5-3.0 km from a health center, the risks for neonatal mortality and infant mortality tended to increase among those who lived further than 5.0 km from a health center; the adjusted ORs for neonatal mortality and infant mortality for those who lived >5.0-10.0 km away from a health center were 1.36 (95% CI: 0.92-2.01) and 1.42 (95% CI: 1.06-1.90), respectively. The positive associations were more pronounced among the second or later child. The distance effects were not modified by household wealth status, maternal educational attainment, or maternal health status.


CONCLUSIONS
Our study suggests that distance from a health center is a risk factor for early childhood mortality (primarily, infant mortality) in Madagascar by using a large-scale nationally representative dataset. The accessibility to health care in remote areas would be a key factor to achieve better infant health.
Department of Public Health and Health Policy, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan. saori_ksm@ybb.ne.jp
Saori
S
Kashima
Etsuji
E
Suzuki
Toshiharu
T
Okayasu
Razafimahatratra
R
Jean Louis
Akira
A
Eboshida
S V
SV
Subramanian
D000293:Adolescent; D000328:Adult; D001719:Birth Certificates; D016001:Confidence Intervals; D003695:Delivery of Health Care / Q000706:statistics & numerical data; D003710:Demography; D005260:Female; D005843:Geography; D006268:Health Facilities / Q000706:statistics & numerical data*; D006297:Health Services Accessibility; D006306:Health Surveys / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D008270:Madagascar / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D017063:Outcome Assessment, Health Care; D012017:Referral and Consultation; D055815:Young Adult