title: Rural-Urban Inequity in Unmet Obstetric Needs and Functionality of Emergency Obstetric Care Services in a Zambian District.
abstract: BACKGROUND
  Zambia has a high maternal mortality ratio, 398/100,000 live births. Few pregnant women access emergency obstetric care services to handle complications at childbirth. We aimed to assess the deficit in life-saving obstetric services in the rural and urban areas of Kapiri Mposhi district.
  
  
  METHODS
  A cross-sectional survey was conducted in 2011 as part of the 'Response to Accountable priority setting for Trust in health systems' (REACT) project. Data on all childbirths that occurred in emergency obstetric care facilities in 2010 were obtained retrospectively. Sources of information included registers from maternity ward admission, delivery and operation theatre, and case records. Data included age, parity, mode of delivery, obstetric complications, and outcome of mother and the newborn. An approach using estimated major obstetric interventions expected but not done in health facilities was used to assess deficit of life-saving interventions in urban and rural areas.
  
  
  RESULTS
  A total of 2114 urban and 1226 rural childbirths occurring in emergency obstetric care facilities (excluding abortions) were analysed. Facility childbirth constituted 81% of expected births in urban and 16% in rural areas. Based on the reference estimate that 1.4% of childbearing women were expected to need major obstetric intervention, unmet obstetric need was 77 of 106 women, thus 73% (95% CI 71-75%) in rural areas whereas urban areas had no deficit. Major obstetric interventions for absolute maternal indications were higher in urban 2.1% (95% CI 1.60-2.71%) than in rural areas 0.4% (95% CI 0.27-0.55%), with an urban to rural rate ratio of 5.5 (95% CI 3.55-8.76).
  
  
  CONCLUSIONS
  Women in rural areas had deficient obstetric care. The likelihood of under-going a life-saving intervention was 5.5 times higher for women in urban than rural areas. Targeting rural women with life-saving services could substantially reduce this inequity and preventable deaths.
authors.affiliation: Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.|Department of Public Health, School of Medicine, University of Zambia, Lusaka, Zambia.
authors.forename: Selia
authors.initials: S
authors.lastname: Ng'anjo Phiri
authors.affiliation: Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.|Department of Public Health, School of Medicine, University of Zambia, Lusaka, Zambia.
authors.forename: Knut
authors.initials: K
authors.lastname: Fylkesnes
authors.affiliation: Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.
authors.forename: Karen Marie
authors.initials: KM
authors.lastname: Moland
authors.affiliation: Research Unit for Human Parasitology and the Environment, Faculty of Health and Medical Sciences, University of Copenhagen, Dyrlaegevej 100, DK-1870 Frederiksberg C, Copenhagen, Denmark.
authors.forename: Jens
authors.initials: J
authors.lastname: Byskov
authors.affiliation: Department of Obstetrics and Gynaecology, Haukeland University Hospital, Bergen, Norway.|Department of Clinical Science, University of Bergen, Bergen, Norway.
authors.forename: Torvid
authors.initials: T
authors.lastname: Kiserud
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D036861:Delivery, Obstetric; D004632:Emergency Medical Services; D005260:Female; D006297:Health Services Accessibility; D006301:Health Services Needs and Demand; D006801:Humans; D008427:Maternal Health Services; D008428:Maternal Mortality; D011247:Pregnancy; D012189:Retrospective Studies; D012424:Rural Population; D012959:Socioeconomic Factors; D014505:Urban Population; D055815:Young Adult; D015024:Zambia
references.citation: Bull World Health Organ. 2014 Aug 1;92(8):605-12
references.pmid: 25177075
references.citation: Bull World Health Organ. 2012 Jan 1;90(1):30-9, 39A
references.pmid: 22271962
references.citation: Lancet. 2006 Oct 7;368(9543):1284-99
references.pmid: 17027735
references.citation: Health Policy Plan. 2004 Oct;19 Suppl 1:i87-i95
references.pmid: 15452019
references.citation: Trop Med Int Health. 1998 Jul;3(7):584-91
references.pmid: 9705194
references.citation: Lancet. 2006 Oct 28;368(9546):1516-23
references.pmid: 17071285
references.citation: Reprod Health. 2014;11(1):14
references.pmid: 24563907
references.citation: Bull World Health Organ. 2001;79(6):561-8
references.pmid: 11436479
references.citation: Int J Gynaecol Obstet. 2001 Nov;75(2):111-21
references.pmid: 11684107
references.citation: BMC Pregnancy Childbirth. 2014;14:354
references.pmid: 25300789
references.citation: BMC Health Serv Res. 2013;13:113
references.pmid: 23522087
references.citation: BMC Health Serv Res. 2014;14:75
references.pmid: 24548767
references.citation: BMC Pregnancy Childbirth. 2014;14:219
references.pmid: 24996456
references.citation: Int J Equity Health. 2014;13:112
references.pmid: 25495052
references.citation: PLoS Med. 2011;8(1):e1000394
references.pmid: 21283606
references.citation: Bull World Health Organ. 2002;80(4):317-24
references.pmid: 12075369
references.citation: BMC Pregnancy Childbirth. 2014;14:323
references.pmid: 25223631
references.citation: BMJ. 2004 May 15;328(7449):1152
references.pmid: 15142897
references.citation: Lancet Glob Health. 2014 Jun;2(6):e323-33
references.pmid: 25103301
references.citation: BMJ. 2002 Apr 20;324(7343):942-5
references.pmid: 11964338
references.citation: BMC Pregnancy Childbirth. 2007;7:16
references.pmid: 17683590
references.citation: Trop Med Int Health. 2007 Oct;12(10):1239-47
references.pmid: 17956507
references.citation: Int J Gynaecol Obstet. 2006 Mar;92(3):308-19
references.pmid: 16442536
references.citation: Bull World Health Organ. 2014 Apr 1;92(4):246-53
references.pmid: 24700992
references.citation: Int J Gynaecol Obstet. 2005 Feb;88(2):181-93
references.pmid: 15694106
references.citation: Lancet. 2006 Sep 30;368(9542):1189-200
references.pmid: 17011946
references.citation: Health Res Policy Syst. 2009 Oct 24;7:23
references.pmid: 19852834
references.citation: Bull World Health Organ. 2009 Jan;87(1):30-8
references.pmid: 19197402