The influence of distance and level of care on health facility delivery in rural Zambia: A study linking national data in a Geographic Information System

Background: An estimated 225,000 maternal deaths, 904,000 neonatal deaths and 1.02 million stillbirths annually are intra-partum related. Most of these deaths occur in low- and middle-income countries and could be prevented if all women delivered in a setting where a skilled attendant can provide Emergency Obstetric Care (EmOC) in case of complications. Epidemiological research on determinants of skilled attendance at delivery has so far focussed on household and individual factors and neglected the influence of distance and level of care, partly due to a lack of data on health service availability. Methods: Using a Geographic Information System, we linked national household data from the Zambian Demographic and Health Survey 2007 with national facility data from the Zambian Health Facility Census 2005 and calculated straight-line distances. Health facilities were classified by whether they provided Comprehensive EmOC, Basic EmOC, limited or substandard services. Multivariable multilevel logistic regression analyses were performed to investigate the influence of distance and level of care on place of delivery for 3682 rural births. Results: Only a third of rural Zambian births occurred in a health facility, and half of all births were to mothers living more than 25km from a Basic EmOC facility. For each doubling of distance to the closest health facility, the odds of facility delivery decreased by 28% (95% CI: 14%-40%). Independently, each increase in level of care at the closest facility led to 36% higher odds of facility birth (95% CI: 9%-70%). If all mothers lived within 5km of a Basic EmOC facility, an estimated 16% of home deliveries could be avoided, a population attributable fraction of similar magnitude as for education or wealth. Discussion: Lack of geographic access to EmOC is a key factor explaining why most rural deliveries in Zambia still occur at home without skilled care; this needs to be addressed to lower maternal and perinatal mortality.