title: Utilisation of health services and geography: deconstructing regional differences in barriers to facility-based delivery in Nepal.
abstract: While established that geographical inaccessibility is a key barrier to the utilisation of health services, it remains unknown whether disparities are driven only by limited access to these services, or are also attributable to health behaviour. Significant disparities exist in health outcomes and the coverage of many critical health services between the mountains region of Nepal and the rest of the country, yet the principal factors driving these regional disparities are not well understood. Using national representative data from the 2011 Nepal Demographic and Health Survey, we examine the extent to which observable factors explain the overall differences in the utilisation of maternal health services. We apply nonlinear Blinder-Oaxaca-type decomposition methods to quantify the effect that differences in measurable characteristics have on the regional coverage gap in facility-based delivery. The mean coverage of facility-based deliveries was 18.6 and 36.3 % in the mountains region and the rest of Nepal, respectively. Between 54.8 and 74.1 % of the regional coverage gap was explained by differences in observed characteristics. Factors influencing health behaviours (proxied by mothers' education, TV viewership and tobacco use, and household wealth) and subjective distance to the health facility were the major factors, contributing between 52.9 and 62.5 % of the disparity. Mothers' birth history was also noteworthy. Policies simultaneously addressing access and health behaviours appear necessary to achieve greater coverage and better health outcomes for women and children in isolated areas.
authors.affiliation: School of Population Health, The University of Queensland, Public Health Building, Herston Road, Herston, QLD, 4006, Australia, a.hodge@uq.edu.au.
authors.forename: Andrew
authors.initials: A
authors.lastname: Hodge
authors.forename: Abbey
authors.initials: A
authors.lastname: Byrne
authors.forename: Alison
authors.initials: A
authors.lastname: Morgan
authors.forename: Eliana
authors.initials: E
authors.lastname: Jimenez-Soto
mesh_terms: D002648:Child; D002662:Child Health Services / Q000706:statistics & numerical data*; D003430:Cross-Sectional Studies; D036861:Delivery, Obstetric; D005260:Female; D005843:Geography; D006297:Health Services Accessibility; D006301:Health Services Needs and Demand; D006302:Health Services Research / Q000379:methods; D054625:Healthcare Disparities; D006801:Humans; D008427:Maternal Health Services / Q000706:statistics & numerical data*; D008875:Middle Aged; D009035:Mothers / Q000523:psychology / Q000706:statistics & numerical data*; D009390:Nepal; D010342:Patient Acceptance of Health Care; D011247:Pregnancy; D012111:Residence Characteristics; D012959:Socioeconomic Factors; D055815:Young Adult