title: Geographical access to care at birth in Ghana:  a barrier to safe motherhood.
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.
authors.affiliation: Spatial Ecology and Epidemiology Group, Tinbergen Building, Department of Zoology, University of Oxford, South Parks Road, Oxford, United Kingdom. peter.gething@zoo.ox.ac.uk
authors.forename: Peter W
authors.initials: PW
authors.lastname: Gething
authors.forename: Fiifi Amoako
authors.initials: FA
authors.lastname: Johnson
authors.forename: Faustina
authors.initials: F
authors.lastname: Frempong-Ainguah
authors.forename: Philomena
authors.initials: P
authors.lastname: Nyarko
authors.forename: Angela
authors.initials: A
authors.lastname: Baschieri
authors.forename: Patrick
authors.initials: P
authors.lastname: Aboagye
authors.forename: Jane
authors.initials: J
authors.lastname: Falkingham
authors.forename: Zoe
authors.initials: Z
authors.lastname: Matthews
authors.forename: Peter M
authors.initials: PM
authors.lastname: Atkinson
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D040362:Geographic Information Systems; D005869:Ghana; D006268:Health Facilities / Q000706:statistics & numerical data*; D006297:Health Services Accessibility / Q000592:standards* / Q000706:statistics & numerical data; D054624:Health Status Disparities; D006801:Humans; D008427:Maternal Health Services / Q000592:standards* / Q000706:statistics & numerical data; D008875:Middle Aged; D009035:Mothers; D011247:Pregnancy; D037841:Pregnant People; D013997:Time Factors; D014195:Travel / Q000706:statistics & numerical data*; D016387:Women's Health; D055815:Young Adult