title: Remoteness and maternal and child health service utilization in rural Liberia: A population-based survey.
abstract: BACKGROUND
  This study seeks to understand distance from health facilities as a barrier to maternal and child health service uptake within a rural Liberian population. Better understanding the relationship between distance from health facilities and rural health care utilization is important for post-Ebola health systems reconstruction and for general rural health system planning in sub-Saharan Africa.
  
  
  METHODS
  Cluster-sample survey data collected in 2012 in a very rural southeastern Liberian population were analyzed to determine associations between quartiles of GPS-measured distance from the nearest health facility and the odds of maternal (ANC, facility-based delivery, and PNC) and child (deworming and care seeking for ARI, diarrhea, and fever) service use. We estimated associations by fitting simple and multiple logistic regression models, with standard errors adjusted for clustered data.
  
  
  RESULTS
  Living in the farthest quartile was associated with lower odds of attending 1-or-more ANC checkup (AOR = 0.04, P < 0.001), 4-or-more ANC checkups (AOR = 0.13, P < 0.001), delivering in a facility (AOR = 0.41, P = 0.006), and postnatal care from a health care worker (AOR = 0.44, P = 0.009). Children living in all other quartiles had lower odds of seeking facility-based fever care (AOR for fourth quartile = 0.06, P < 0.001) than those in the nearest quartile. Children in the fourth quartile were less likely to receive deworming treatment (AOR = 0.16, P < 0.001) and less likely (but with only marginal statistical significance) to seek ARI care from a formal HCW (AOR = 0.05, P = 0.05). Parents in distant quartiles more often sought ARI and diarrhea care from informal providers.
  
  
  CONCLUSIONS
  Within a rural Liberian population, distance is associated with reduced health care uptake. As Liberia rebuilds its health system after Ebola, overcoming geographic disparities, including through further dissemination of providers and greater use of community health workers should be prioritized.
authors.affiliation: Last Mile Health, Zwedru, Liberia.
authors.forename: Avi
authors.initials: A
authors.lastname: Kenny
authors.affiliation: Last Mile Health, Boston, MA, USA ; Harvard Medical School, Boston, MA, USA ; Cambridge Health Alliance, Cambridge, MA, USA.
authors.forename: Gaurab
authors.initials: G
authors.lastname: Basu
authors.affiliation: Last Mile Health, Boston, MA, USA.
authors.forename: Madeleine
authors.initials: M
authors.lastname: Ballard
authors.affiliation: Last Mile Health, Zwedru, Liberia.
authors.forename: Thomas
authors.initials: T
authors.lastname: Griffiths
authors.affiliation: Harvard Medical School, Boston, MA, USA.
authors.forename: Katherine
authors.initials: K
authors.lastname: Kentoffio
authors.affiliation: Last Mile Health, Zwedru, Liberia.
authors.forename: Jean Bosco
authors.initials: JB
authors.lastname: Niyonzima
authors.affiliation: Last Mile Health, Boston, MA, USA ; Harvard Medical School, Boston, MA, USA ; Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: G Andrew
authors.initials: GA
authors.lastname: Sechler
authors.affiliation: Last Mile Health, Zwedru, Liberia.
authors.forename: Stephen
authors.initials: S
authors.lastname: Selinsky
authors.affiliation: Last Mile Health, Boston, MA, USA ; Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: Rajesh R
authors.initials: RR
authors.lastname: Panjabi
authors.affiliation: Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Siedner
authors.affiliation: Georgetown University Medical Center, Washington, DC, USA.
authors.forename: John D
authors.initials: JD
authors.lastname: Kraemer