title: Equality in Maternal and Newborn Health: Modelling Geographic Disparities in Utilisation of Care in Five East African Countries.
abstract: BACKGROUND
  Geographic accessibility to health facilities represents a fundamental barrier to utilisation of maternal and newborn health (MNH) services, driving historically hidden spatial pockets of localized inequalities. Here, we examine utilisation of MNH care as an emergent property of accessibility, highlighting high-resolution spatial heterogeneity and sub-national inequalities in receiving care before, during, and after delivery throughout five East African countries.
  
  
  METHODS
  We calculated a geographic inaccessibility score to the nearest health facility at 300 x 300 m using a dataset of 9,314 facilities throughout Burundi, Kenya, Rwanda, Tanzania and Uganda. Using Demographic and Health Surveys data, we utilised hierarchical mixed effects logistic regression to examine the odds of: 1) skilled birth attendance, 2) receiving 4+ antenatal care visits at time of delivery, and 3) receiving a postnatal health check-up within 48 hours of delivery. We applied model results onto the accessibility surface to visualise the probabilities of obtaining MNH care at both high-resolution and sub-national levels after adjusting for live births in 2015.
  
  
  RESULTS
  Across all outcomes, decreasing wealth and education levels were associated with lower odds of obtaining MNH care. Increasing geographic inaccessibility scores were associated with the strongest effect in lowering odds of obtaining care observed across outcomes, with the widest disparities observed among skilled birth attendance. Specifically, for each increase in the inaccessibility score to the nearest health facility, the odds of having skilled birth attendance at delivery was reduced by over 75% (0.24; CI: 0.19-0.3), while the odds of receiving antenatal care decreased by nearly 25% (0.74; CI: 0.61-0.89) and 40% for obtaining postnatal care (0.58; CI: 0.45-0.75).
  
  
  CONCLUSIONS
  Overall, these results suggest decreasing accessibility to the nearest health facility significantly deterred utilisation of all maternal health care services. These results demonstrate how spatial approaches can inform policy efforts and promote evidence-based decision-making, and are particularly pertinent as the world shifts into the Sustainable Goals Development era, where sub-national applications will become increasingly useful in identifying and reducing persistent inequalities.
authors: WorldPop Project, Geography & Environment, University of Southampton, Southampton, United Kingdom.|Flowminder Foundation, Stockholm, Sweden.
authors: Corrine W
authors: http://orcid.org/0000-0002-7889-3473
authors: CW
authors: Ruktanonchai
authors: WorldPop Project, Geography & Environment, University of Southampton, Southampton, United Kingdom.|Flowminder Foundation, Stockholm, Sweden.
authors: Nick W
authors: NW
authors: Ruktanonchai
authors: ICS Integrare, Barcelona, Spain.
authors: Andrea
authors: A
authors: Nove
authors: ICS Integrare, Barcelona, Spain.
authors: Sofia
authors: S
authors: Lopes
authors: WorldPop Project, Geography & Environment, University of Southampton, Southampton, United Kingdom.|Flowminder Foundation, Stockholm, Sweden.
authors: Carla
authors: C
authors: Pezzulo
authors: WorldPop Project, Geography & Environment, University of Southampton, Southampton, United Kingdom.|Flowminder Foundation, Stockholm, Sweden.
authors: Claudio
authors: C
authors: Bosco
authors: WorldPop Project, Geography & Environment, University of Southampton, Southampton, United Kingdom.|Flowminder Foundation, Stockholm, Sweden.
authors: Victor A
authors: VA
authors: Alegana
authors: The DHS Program, ICF International, Rockville, Maryland, United States of America.
authors: Clara R
authors: CR
authors: Burgert
authors: Open Health Initiative, East African Community Secretariat, Arusha, Tanzania.
authors: Rogers
authors: R
authors: Ayiko
authors: Open Health Initiative, East African Community Secretariat, Arusha, Tanzania.
authors: Andrew Sek
authors: AS
authors: Charles
authors: Ministry of Public Health and Fight Against AIDS, Bujumbura, Burundi.
authors: Nkurunziza
authors: N
authors: Lambert
authors: Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania.
authors: Esther
authors: E
authors: Msechu
authors: Ministry of Health, Nairobi, Kenya.
authors: Esther
authors: E
authors: Kathini
authors: Division of Social Statistics and Demography & Centre for Global Health, Population, Poverty and Policy, Faculty of Social and Human Sciences, University of Southampton, Southampton, United Kingdom.
authors: Zoë
authors: Z
authors: Matthews
authors: WorldPop Project, Geography & Environment, University of Southampton, Southampton, United Kingdom.|Flowminder Foundation, Stockholm, Sweden.
authors: Andrew J
authors: AJ
authors: Tatem
mesh_terms: D000328:Adult; D002063:Burundi; D002662:Child Health Services / Q000592:standards / Q000706:statistics & numerical data*; D036861:Delivery, Obstetric / Q000706:statistics & numerical data; D005260:Female; D005843:Geography; D006268:Health Facilities / Q000706:statistics & numerical data; D006297:Health Services Accessibility / Q000592:standards / Q000706:statistics & numerical data*; D054625:Healthcare Disparities / Q000592:standards / Q000706:statistics & numerical data*; D006801:Humans; D007231:Infant, Newborn; D007630:Kenya; D016015:Logistic Models; D008427:Maternal Health Services / Q000592:standards / Q000706:statistics & numerical data*; D011247:Pregnancy; D011295:Prenatal Care / Q000706:statistics & numerical data; D012432:Rwanda; D013636:Tanzania; D014454:Uganda