title: Determinants of delays in travelling to an emergency obstetric care facility in Herat, Afghanistan: an analysis of cross-sectional survey data and spatial modelling.
abstract: BACKGROUND
  Women's delays in reaching emergency obstetric care (EmOC) facilities contribute to high maternal and perinatal mortality and morbidity in low-income countries, yet few studies have quantified travel times to EmOC and examined delays systematically. We defined a delay as the difference between a woman's travel time to EmOC and the optimal travel time under the best case scenario. The objectives were to model travel times to EmOC and identify factors explaining delays. i.e., the difference between empirical and modelled travel times.
  
  
  METHODS
  A cost-distance approach in a raster-based geographic information system (GIS) was used for modelling travel times. Empirical data were obtained during a cross-sectional survey among women admitted in a life-threatening condition to the maternity ward of Herat Regional Hospital in Afghanistan from 2007 to 2008. Multivariable linear regression was used to identify the determinants of the log of delay.
  
  
  RESULTS
  Amongst 402 women, 82 (20%) had no delay. The median modelled travel time, reported travel time, and delay were 1.0 hour [Q1-Q3: 0.6, 2.2], 3.6 hours [Q1-Q3: 1.0, 12.0], and 2.0 hours [Q1-Q3: 0.1, 9.2], respectively. The adjusted ratio (AR) of a delay of the "one-referral" group to the "self-referral" group was 4.9 [95% confidence interval (CI): 3.8-6.3]. Difficulties obtaining transportation explained some delay [AR 2.1 compared to "no difficulty"; 95% CI: 1.5-3.1]. A husband's very large social network (> = 5 people) doubled a delay [95% CI: 1.1-3.7] compared to a moderate (3-4 people) network. Women with severe infections had a delay 2.6 times longer than those with postpartum haemorrhage (PPH) [95% CI: 1.4-4.9].
  
  
  CONCLUSIONS
  Delays were mostly explained by the number of health facilities visited. A husband's large social network contributed to a delay. A complication with dramatic symptoms (e.g. PPH) shortened a delay while complications with less-alarming symptoms (e.g. severe infection) prolonged it. In-depth investigations are needed to clarify whether time is spent appropriately at lower-level facilities. Community members need to be sensitised to the signs and symptoms of obstetric complications and the urgency associated with them. Health-enhancing behaviours such as birth plans should be promoted in communities.
authors: PhD programme, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK. atsumi.hirose@gmail.com.
authors: Atsumi
authors: A
authors: Hirose
authors: Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK. matthias.borchert@charite.de.|Institute of Tropical Medicine and International Health, Charité - Universitätsmedizin, Berlin, Germany. matthias.borchert@charite.de.
authors: Matthias
authors: M
authors: Borchert
authors: Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK. jonathan.cox@lshtm.ac.uk.
authors: Jonathan
authors: J
authors: Cox
authors: World Vision International, Herat, Afghanistan. ahmdshah@yahoo.com.
authors: Ahmad Shah
authors: AS
authors: Alkozai
authors: Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK. veronique.filippi@lshtm.ac.uk.
authors: Veronique
authors: V
authors: Filippi
mesh_terms: D000328:Adult; D000346:Afghanistan; D003430:Cross-Sectional Studies; D004461:Eclampsia; D004630:Emergencies; D005260:Female; D040362:Geographic Information Systems; D006761:Hospitals; D006801:Humans; D008962:Models, Theoretical; D018986:Motor Vehicles / Q000706:statistics & numerical data; D007744:Obstetric Labor Complications; D009774:Obstetrics; D006473:Postpartum Hemorrhage; D011225:Pre-Eclampsia; D011247:Pregnancy; D011248:Pregnancy Complications; D011295:Prenatal Care / Q000706:statistics & numerical data; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012424:Rural Population; D012621:Seasons; D012944:Social Support; D062206:Spatial Analysis; D013997:Time Factors; D014186:Transportation; D014195:Travel / Q000706:statistics & numerical data*; D014505:Urban Population; D014592:Uterine Hemorrhage; D014597:Uterine Rupture
references: Stud Fam Plann. 2000 Dec;31(4):309-24
references: 11198068
references: BMC Pregnancy Childbirth. 2012;12:20
references: 22455614
references: J Obstet Gynaecol. 2002 Jul;22(4):385-8
references: 12521460
references: Br Med Bull. 2003;67:27-37
references: 14711752
references: Soc Sci Med. 1994 Apr;38(8):1091-110
references: 8042057
references: Health Policy Plan. 1997 Mar;12(1):50-7
references: 10166102
references: Bull World Health Organ. 1998;76(6):591-8
references: 10191555
references: Am J Public Health. 1999 Aug;89(8):1187-93
references: 10432904
references: Acta Obstet Gynecol Scand. 2005 Jan;84(1):11-6
references: 15603561
references: Lancet. 2005 Mar 5-11;365(9462):864-70
references: 15752530
references: Trop Med Int Health. 2006 Feb;11(2):188-96
references: 16451343
references: Int Fam Plan Perspect. 2006 Mar;32(1):17-27
references: 16723298
references: Soc Sci Med. 2006 Aug;63(3):691-705
references: 16574290
references: Acta Obstet Gynecol Scand. 2006;85(7):797-804
references: 16817076
references: Glob Public Health. 2007;2(4):359-72
references: 19283633
references: BJOG. 2009 Aug;116(9):1210-7
references: 19459864
references: PLoS Med. 2011;8(1):e1000394
references: 21283606
references: J Urban Health. 2011 Jun;88 Suppl 2:S356-69
references: 20700769
references: Matern Child Health J. 2011 Oct;15(7):1081-7
references: 20697934
references: Soc Sci Med. 2011 Oct;73(7):1003-13
references: 21862194
references: BMC Public Health. 2012;12:991
references: 23158554
references: PLoS One. 2012;7(12):e52090
references: 23284882
references: BJOG. 2012 May;119(6):653-61
references: 22489760
references: Bull World Health Organ. 2002;80(3):228-34
references: 11984609