În rural Haiti, the physical accessibility of maternal health services is an important predictor of use, even when individual characteristics are taken into account.1 According to an analysis of data from the 2000 Haiti Demographic and Health Survey (DHS), births in neighborhoods linked to the nearest urban center by an unpaved road or a path were less likely to involve four or more prenatal visits than were those in neighborhoods with a paved road (odds ratios, 0.3–0.4). Compared with births to women living within five kilometers of a hospital, births to women living 30 kilometers or more from a hospital were less likely to be attended or to take place in a health facility (0.2 and 0.3, respectively).
In Haiti, the poorest country in the Western Hemisphere, political instability, economic decline and deterioration of the road system since the early 1990s have led to sharp reductions in maternal health services throughout the country. Even though programs run by nongovernmental organizations have filled some of the gaps, women in rural Haiti rarely deliver with the help of trained medical personnel. Studies on the use of maternal health services have tended to examine only factors related to the mother, with little consideration of the health infrastructure—a matter of particular importance in developing countries. Because increasing the numbers of women seen by health professionals and at facilities during pregnancy and childbirth is key to improving the health of mothers and their babies, researchers examined the association between physical access to health facilities and use of prenatal and delivery services.
Data on women's characteristics came from the women's questionnaire of the 2000 DHS, in which 10,519 women aged 15–49 provided information on the source, content and number of prenatal care visits; timing of the first prenatal care visit; and place of and assistance at delivery for every birth in the preceding five years. The analyses were restricted to the 4,533 births to rural women for which complete information was available. The researchers also used data from the DHS community questionnaire, which asked key informants questions on road conditions in their neighborhoods, topography, availability of public transportation, and distance to the nearest urban areas and health facilities. Informants were asked the travel time to each health facility identified, whether it was public or private, and what services it provided. Chi-square analysis and multilevel logistic regression were used to identify associations between individual- and community-level characteristics and four maternal care outcomes: initiation of prenatal care in the first trimester, receipt of at least four prenatal visits, attendance at delivery by a trained health worker and delivery in a health facility.
Half of the births were to women who lived in mountainous areas; for four in 10, the road to the nearest urban center was unpaved and in bad condition. The majority of births (84%) occurred in neighborhoods that did not have a prenatal care provider; however, 81% of the births occurred within five kilometers of a health center that provided such care. The distance to the nearest hospital was 30 kilometers or more for 44% of births, and the majority of the births (71%) were to mothers who had no means of transportation. The average birth occurred in neighborhoods where 35% of households were in the lowest quintile of household wealth. Thirty-nine percent of births were to women who were in the lowest wealth quintile, and half were to women who had had no education.
Overall, mothers received prenatal care in the first trimester for 24% of births; for 23% of births, the mothers had four or more prenatal visits. One in 10 births were attended by trained personnel; a similar proportion occurred in a medical facility. Although the levels of maternal care–seeking behavior were low in general, bivariate analyses revealed significant variations related to accessibility. Receipt of four or more prenatal visits, delivery assistance by a trained health worker and delivery at a facility were all more common in nonmountainous areas and in neighborhoods with a health facility within five kilometers than in mountainous and more remote areas. As the distance from a hospital increased, the likelihood of an attended delivery and of an institutional delivery decreased. For example, the proportion of births occurring in a medical facility ranged from 25% for women living within five kilometers of a hospital to 7% for women who lived 30 kilometers or more from a hospital. Road conditions also were associated with variations in use—in neighborhoods linked to an urban center by a paved road, births were more likely to involve early prenatal care, four or more prenatal visits, attended delivery and delivery at a medical facility than births in neighborhoods with unpaved roads or paths linking them to urban areas. Attendance at delivery by trained medical personnel was more common in neighborhoods with a prenatal care provider than in those without.
In the multivariate analyses, which included all individual-level controls, living in a mountainous region was associated with lower odds of assisted delivery and of institutional delivery, but not of early prenatal care or of making four or more prenatal visits; conversely, poor road conditions were associated with lower odds of early prenatal care and of making four or more prenatal visits, but not of assisted delivery or of delivery in a medical institution. The odds that a delivery was attended by a health professional and the odds that it occurred in a medical facility were reduced if the mother lived in a mountainous region (odds ratios, 0.6 and 0.5, respectively). Early receipt of prenatal care and receipt of four or more prenatal visits were each less likely in neighborhoods with poor road conditions than in those with paved roads (0.5–0.6 and 0.3–0.5, respectively). Neighborhood poverty was negatively associated with early prenatal care, four or more prenatal visits, medical attendance at delivery and institutional delivery (0.9 for all four outcomes).
The researchers conclude that although decreasing the distance women have to travel to obtain maternal health services will in turn increase the use of such services, "investments in community infrastructure, including road transportation networks, will also be required if barriers to the accessibility of service are to be effectively reduced." Any attempt to increase maternal care–seeking behavior in rural Haiti will "require resources to be targeted at the most impoverished areas and development of strategies for reaching those not yet reached."—L. Melhado
1. Gage AJ and Calixte MG, Effects of the physical accessibility of maternal health services on their use in rural Haiti, Population Studies, 2006, 60(3):271–288.