title: Facility distance and child mortality: a multi-country study of health facility access, service utilization, and child health outcomes.
abstract: Access to health facilities remains limited in many resource-poor settings, and women and their children often have to travel far to seek care. However, data on distance are scarce, and it is unclear whether distance is associated with worse child health outcomes. We estimate the relationships between distance to facility, service utilization and child mortality in low- and middle-income countries.
  
  
  
  Population-representative data are pooled from 29 demographic and health surveys across 21 low- and middle-income countries. Multivariable logistic models and meta-analysis regressions are used to estimate associations between facility distance, child mortality, and health care utilization in the pooled sample as well as for each survey.
  
  
  
  Compared with children who live within 1 km of a facility, children living within 2 km, 3 km, and 5 km of a facility have a 7.7% [95% confidence interval (CI): 0.927 - 1.251], 16.3% (95% CI: 1.020 - 1.327) and 25% (95% CI: 1.087 - 1.439) higher odds of neonatal mortality, respectively; children living farther than 10 km have a 26.6% (95% CI: 1.108 - 1.445) higher odds of neonatal mortality. Women living farther than 10 km from a facility have a 55.3% lower odds of in-facility delivery compared with women who live within 1 km [odds ratio (OR): 0.447; 95% CI: 0.394 - 0.508].
  
  
  
  Even relatively small distances from health facilities are associated with substantial mortality penalties for children. Policies that reduce travel distances and travel times are likely to increase utilization of health services and reduce neonatal mortality.
authors.affiliation: Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA.
authors.forename: Mahesh
authors.initials: M
authors.lastname: Karra
authors.affiliation: Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA.
authors.forename: Günther
authors.initials: G
authors.lastname: Fink
authors.affiliation: Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA.
authors.forename: David
authors.initials: D
authors.lastname: Canning
mesh_terms: D000328:Adult; D000067576:Child Health; D046688:Child Mortality / Q000639:trends*; D002675:Child, Preschool; D003906:Developing Countries / Q000706:statistics & numerical data; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D007226:Infant Mortality / Q000639:trends*; D007231:Infant, Newborn; D016015:Logistic Models; D008297:Male; D008427:Maternal Health Services / Q000706:statistics & numerical data; D015201:Meta-Analysis as Topic; D015999:Multivariate Analysis; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D011247:Pregnancy; D014195:Travel
keywords: Distance; antenatal care; child mortality; facility delivery; service availability