title: Factors influencing modes of transport and travel time for obstetric care: a mixed methods study in Zambia and Uganda.
abstract: Transportation is an important barrier to accessing obstetric care for many pregnant and postpartum women in low-resource settings, particularly in rural areas. However, little is known about how pregnant women travel to health facilities in these settings. We conducted 1633 exit surveys with women who had a recent facility delivery and 48 focus group discussions with women who had either a home or a facility birth in the past year in eight districts in Uganda and Zambia. Quantitative data were analysed using univariate statistics, and qualitative data were analysed using thematic content analysis techniques. On average, women spent 62-68 min travelling to a clinic for delivery. Very different patterns in modes of transport were observed in the two countries: 91% of Ugandan women employed motorized forms of transportation, while only 57% of women in Zambia did. Motorcycle taxis were the most commonly used in Uganda, while cars, trucks and taxis were the most commonly used mode of transportation in Zambia. Lower-income women were less likely to use motorized modes of transportation: in Zambia, women in the poorest quintile took 94 min to travel to a health facility, compared with 34 for the wealthiest quintile; this difference between quintiles was ∼50 min in Uganda. Focus group discussions confirmed that transport is a major challenge due to a number of factors we categorized as the 'three A's:' affordability, accessibility and adequacy of transport options. Women reported that all of these factors had influenced their decision not to deliver in a health facility. The two countries had markedly different patterns of transportation for obstetric care, and modes of transport and travel times varied dramatically by wealth quintile, which policymakers need to take into account when designing obstetric transport interventions.
authors.affiliation: Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th Street, 722 West 168th Street, New York, NY 10032, USA USAID Maternal and Child Survival Program (MCSP)/ICF International, Washington DC Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th Street, 722 West 168th Street, New York, NY 10032, USA ers2113@columbia.edu.
authors.forename: Emma
authors.initials: E
authors.lastname: Sacks
authors.affiliation: Department of Health Policy and Management, Columbia University Mailman School of Public Health, New York, USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Vail
authors.affiliation: Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th Street, 722 West 168th Street, New York, NY 10032, USA.
authors.forename: Katherine
authors.initials: K
authors.lastname: Austin-Evelyn
authors.affiliation: Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th Street, 722 West 168th Street, New York, NY 10032, USA.
authors.forename: Dana
authors.initials: D
authors.lastname: Greeson
authors.affiliation: Department of Community Health and Behavioral Sciences, Makerere University School of Public Health, Kampala, Uganda.
authors.forename: Lynn M
authors.initials: LM
authors.lastname: Atuyambe
authors.affiliation: The Institute of Economic and Social Research, University of Zambia, Lusaka, Zambia and.
authors.forename: Mubiana
authors.initials: M
authors.lastname: Macwan'gi
authors.affiliation: Department of Health Policy and Management, Columbia University Mailman School of Public Health, New York, USA.
authors.forename: Margaret E
authors.initials: ME
authors.lastname: Kruk
authors.affiliation: Robert F. Wagner Graduate School of Public Service, New York University, New York, NY, USA.
authors.forename: Karen A
authors.initials: KA
authors.lastname: Grépin
mesh_terms: D000293:Adolescent; D000328:Adult; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D008427:Maternal Health Services; D011247:Pregnancy; D013997:Time Factors; D014186:Transportation / Q000379:methods*; D014195:Travel; D055815:Young Adult; D015024:Zambia
keywords: Maternal health; neonatal health; obstetric emergencies; sub-Saharan Africa; transport