title: "Not too far to walk": the influence of distance on place of delivery in a western Kenya health demographic surveillance system.
abstract: BACKGROUND
  Maternal health service coverage in Kenya remains low, especially in rural areas where 63% of women deliver at home, mainly because health facilities are too far away and/or they lack transport. The objectives of the present study were to (1) determine the association between the place of delivery and the distance of a household from the nearest health facility and (2) study the demographic characteristics of households with a delivery within a demographic surveillance system (DSS).
  
  
  METHODS
  Census sampling was conducted for 13,333 households in the Webuye health and demographic surveillance system area in 2008-2009. Information was collected on deliveries that had occurred during the previous 12 months. Digital coordinates of households and sentinel locations such as health facilities were collected. Data were analyzed using STATA version 11. The Euclidean distance from households to health facilities was calculated using WinGRASS version 6.4. Hotspot analysis was conducted in ArcGIS to detect clustering of delivery facilities. Unadjusted and adjusted odds ratios were estimated using logistic regression models. P-values less than 0.05 were considered significant.
  
  
  RESULTS
  Of the 13,333 households in the study area, 3255 (24%) reported a birth, with 77% of deliveries being at home. The percentage of home deliveries increased from 30% to 80% of women living within 2 km from a health facility. Beyond 2 km, distance had no effect on place of delivery (OR 1.29, CI 1.06-1.57, p = 0.011). Heads of households where women delivered at home were less likely to be employed (OR 0.598, CI 0.43-0.82, p = 0.002), and were less likely to have secondary education (OR 0.50, CI 0.41-0.61, p < 0.0001). Hotspot analysis showed households having facility deliveries were clustered around facilities offering comprehensive emergency obstetric care services.
  
  
  CONCLUSIONS
  Households where the nearest facility was offering emergency obstetric care were more likely to have a facility delivery, but only if the facility was within 2 km of the home. Beyond the 2-km threshold, households were equally as likely to have home and facility deliveries. There is need for further research on other factors that affect the choice of place of delivery, and their relationships with maternal mortality.
authors.affiliation: College of Health Sciences, School of Medicine, Department of Reproductive Health, Moi University, P, O, Box 4606, Eldoret, Kenya. waleghwaem@hotmail.com.
authors.forename: Emily
authors.initials: E
authors.lastname: Mwaliko
authors.forename: Raymond
authors.initials: R
authors.lastname: Downing
authors.forename: Wendy
authors.initials: W
authors.lastname: O'Meara
authors.forename: Dinah
authors.initials: D
authors.lastname: Chelagat
authors.forename: Andrew
authors.initials: A
authors.lastname: Obala
authors.forename: Timothy
authors.initials: T
authors.lastname: Downing
authors.forename: Chrispinus
authors.initials: C
authors.lastname: Simiyu
authors.forename: David
authors.initials: D
authors.lastname: Odhiambo
authors.forename: Paul
authors.initials: P
authors.lastname: Ayuo
authors.forename: Diana
authors.initials: D
authors.lastname: Menya
authors.forename: Barasa
authors.initials: B
authors.lastname: Khwa-Otsyula
mesh_terms: D016001:Confidence Intervals; D036861:Delivery, Obstetric; D003710:Demography; D004632:Emergency Medical Services; D005260:Female; D040362:Geographic Information Systems; D006297:Health Services Accessibility; D006801:Humans; D007630:Kenya; D008427:Maternal Health Services; D016017:Odds Ratio; D012424:Rural Population; D016138:Walking