title: The influence of distance and quality of care on place of delivery in rural Ghana.
abstract: Facility delivery is an important aspect of the strategy to reduce maternal and newborn mortality. Geographic access to care is a strong determinant of facility delivery, but few studies have simultaneously considered the influence of facility quality, with inconsistent findings. In rural Brong Ahafo region in Ghana, we combined surveillance data on 11,274 deliveries with quality of care data from all 64 delivery facilities in the study area. We used multivariable multilevel logistic regression to assess the influence of distance and several quality dimensions on place of delivery. Women lived a median of 3.3 km from the closest delivery facility, and 58% delivered in a facility. The probability of facility delivery ranged from 68% among women living 1 km from their closest facility to 22% among those living 25 km away, adjusted for confounders. Measured quality of care at the closest facility was not associated with use, except that facility delivery was lower when the closest facility provided substandard care on the EmOC dimension. These results do not imply, however, that we should increase geographic accessibility of care without improving facility quality. While this may be successful in increasing facility deliveries, such care cannot be expected to reduce maternal and neonatal mortality.
authors: Epidemiology and Biostatistics Unit, Institute of Public Health, Heidelberg University, Heidelberg, Germany.
authors: Robin C
authors: RC
authors: Nesbitt
authors: Epidemiology and Biostatistics Unit, Institute of Public Health, Heidelberg University, Heidelberg, Germany.|Department of Public Health, University of Helsinki, Helsinki, Finland.
authors: Terhi J
authors: TJ
authors: Lohela
authors: Maternal &Child Health Intervention Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.
authors: Seyi
authors: S
authors: Soremekun
authors: Innovations for Maternal, Newborn and Child Health Initiative, Concern Worldwide US, New York, USA.
authors: Linda
authors: L
authors: Vesel
authors: Maternal &Child Health Intervention Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.|Kintampo Health Research Center, Ghana Health Service, Kintampo, Ghana.
authors: Alexander
authors: A
authors: Manu
authors: Department of Public Health, Flinders University, Adelaide, South Australia.
authors: Eunice
authors: E
authors: Okyere
authors: Maternal &Child Health Intervention Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.
authors: Chris
authors: C
authors: Grundy
authors: Kintampo Health Research Center, Ghana Health Service, Kintampo, Ghana.
authors: Seeba
authors: S
authors: Amenga-Etego
authors: Kintampo Health Research Center, Ghana Health Service, Kintampo, Ghana.|Department for Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
authors: Seth
authors: S
authors: Owusu-Agyei
authors: Maternal &Child Health Intervention Research Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.
authors: Betty R
authors: BR
authors: Kirkwood
authors: Epidemiology and Biostatistics Unit, Institute of Public Health, Heidelberg University, Heidelberg, Germany.
authors: Sabine
authors: S
authors: Gabrysch
mesh_terms: D000293:Adolescent; D000328:Adult; D036861:Delivery, Obstetric / Q000706:statistics & numerical data*; D005260:Female; D005869:Ghana; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D007226:Infant Mortality / Q000639:trends; D007231:Infant, Newborn; D016015:Logistic Models; D036801:Parturition / Q000502:physiology*; D011247:Pregnancy; D011787:Quality of Health Care / Q000706:statistics & numerical data*; D012424:Rural Population