title: The influence of travel time on emergency obstetric care seeking behavior in the urban poor of Bangladesh: a GIS study.
abstract: Availability of Emergency Obstetric Care (EmOC) is crucial to avert maternal death due to life-threatening complications potentially arising during delivery. Research on the determinants of utilization of EmOC has neglected urban settings, where traffic congestion can pose a significant barrier to the access of EmOC facilities, particularly for the urban poor due to costly and limited transportation options. This study investigates the impact of travel time to EmOC facilities on the utilization of facility-based delivery services among mothers living in urban poor settlements in Sylhet, Bangladesh.
  
  
  
  A cross-sectional EmOC health-seeking behavior survey from 39 poor urban clusters was geo-spatially linked to a comprehensive geo-referenced dataset of EmOC facility locations. Geo-spatial techniques and logistic regression were then applied to quantify the impact of travel time on place of delivery (EmOC facility or home), while controlling for confounding socio-cultural and economic factors.
  
  
  
  Increasing travel time to the nearest EmOC facility is found to act as a strong deterrent to seeking care for the urban poor in Sylhet. Logistic regression results indicate that a 5-min increase in travel time to the nearest EmOC facility is associated with a 30 % decrease (0.655 odds ratio, 95 % CI: 0.529-0.811) in the likelihood of delivery at an EmOC facility rather than at home. Moreover, the impact of travel time varies substantially between public, NGO and private facilities. A 5-min increase in travel time from a private EmOC facility is associated with a 32.9 % decrease in the likelihood of delivering at a private facility, while for public and Non-Government Organizations (NGO) EmOC facilities, the impact is lower (28.2 and 28.6 % decrease respectively). Other strong determinants of delivery at an EmOC facility are the use of antenatal care and mother's formal education, while Muslim mothers are found to be more likely to deliver at home.
  
  
  
  Geospatial evidence points to the need to strengthen referral and emergency transport systems in order to reduce urban travel time, and establish or relocate EmOC facilities closer to where the poor reside. However, female education and antenatal care coverage remain the most important determinants of facility delivery.
authors.affiliation: International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh. pancerarocco@gmail.com.
authors.forename: Rocco
authors.initials: R
authors.lastname: Panciera
authors.affiliation: James P. Grant School of Public Health, BRAC University, 5th Floor, (Level-6), icddr,b Building, 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh.
authors.forename: Akib
authors.initials: A
authors.lastname: Khan
authors.affiliation: International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh.
authors.forename: Syed Jafar Raza
authors.initials: SJR
authors.lastname: Rizvi
authors.affiliation: International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh.
authors.forename: Shakil
authors.initials: S
authors.lastname: Ahmed
authors.affiliation: International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh.|Institute of Development Studies (IDS), University of Sussex, Library Road, University of Sussex, Brighton, East Sussex, BN1 9RE, UK.
authors.forename: Tanvir
authors.initials: T
authors.lastname: Ahmed
authors.affiliation: International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh.
authors.forename: Rubana
authors.initials: R
authors.lastname: Islam
authors.affiliation: International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh.
authors.forename: Alayne M
authors.initials: AM
authors.lastname: Adams
mesh_terms: D000293:Adolescent; D000328:Adult; D001459:Bangladesh; D003430:Cross-Sectional Studies; D036861:Delivery, Obstetric / Q000379:methods / Q000706:statistics & numerical data; D004522:Educational Status; D004632:Emergency Medical Services / Q000379:methods / Q000706:statistics & numerical data*; D005260:Female; D040362:Geographic Information Systems; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006801:Humans; D008427:Maternal Health Services / Q000706:statistics & numerical data; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D011203:Poverty / Q000706:statistics & numerical data*; D011247:Pregnancy; D013997:Time Factors; D014195:Travel; D014505:Urban Population / Q000706:statistics & numerical data*; D055815:Young Adult
keywords: Emergency obstetric care; GIS; Health seeking; Travel time; Urban