title: Travel time to maternity care and its effect on utilization in rural Ghana: a multilevel analysis.
abstract: Rates of neonatal and maternal mortality are high in Ghana. In-facility delivery and other maternal services could reduce this burden, yet utilization rates of key maternal services are relatively low, especially in rural areas. We tested a theoretical implication that travel time negatively affects the use of in-facility delivery and other maternal services. Empirically, we used geospatial techniques to estimate travel times between populations and health facilities. To account for uncertainty in Ghana Demographic and Health Survey cluster locations, we adopted a novel approach of treating the location selection as an imputation problem. We estimated a multilevel random-intercept logistic regression model. For rural households, we found that travel time had a significant effect on the likelihood of in-facility delivery and antenatal care visits, holding constant education, wealth, maternal age, facility capacity, female autonomy, and the season of birth. In contrast, a facility's capacity to provide sophisticated maternity care had no detectable effect on utilization. As the Ghanaian health network expands, our results suggest that increasing the availability of basic obstetric services and improving transport infrastructure may be important interventions.
authors.affiliation: Institute for Health Metrics and Evaluation, Department of Global Health, University of Washington, 2301 5th Avenue #600, Seattle, WA 98121, USA.
authors.forename: Samuel H
authors.initials: SH
authors.lastname: Masters
authors.forename: Roy
authors.initials: R
authors.lastname: Burstein
authors.forename: George
authors.initials: G
authors.lastname: Amofah
authors.forename: Patrick
authors.initials: P
authors.lastname: Abaogye
authors.forename: Santosh
authors.initials: S
authors.lastname: Kumar
authors.forename: Michael
authors.initials: M
authors.lastname: Hanlon
mesh_terms: D000328:Adult; D005260:Female; D005869:Ghana; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D008427:Maternal Health Services / Q000706:statistics & numerical data*; D055361:Multilevel Analysis; D011247:Pregnancy; D019035:Rural Health Services / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors; D013997:Time Factors; D014195:Travel / Q000706:statistics & numerical data*
keywords: Access; Antenatal care; Geographic information systems (GIS); Ghana; Health service utilization; In-facility delivery; Maternity care; Travel-time