Too poor or too far? Partitioning the variability in hospital birth by poverty and travel time in four sub-Saharan countries

Poverty and long travel time are barriers to using skilled care at birth, especially care provided at hospitals which can be located far and result in high direct and indirect costs. In parts of sub- Saharan Africa, about one third of births occur in hospitals. This thesis aimed to assess the relative contributions of poverty and long travel time to the probability of giving birth in a hospital in Kenya, Malawi, Nigeria and Tanzania. I first reviewed the literature related to measuring the distance/travel time between women and health facilities in sub-Saharan Africa. Although the measurements and standards adopted by included studies were diverse, the impeding effect of living far from health facilities on use of childbirth care was prominent. In the second study, we compared two approaches to create high-resolution poverty maps in Kenya, Malawi, Nigeria and Tanzania. We found that the spatial variation in poverty and its determinants differed across countries, which should be considered when choosing the most suitable mapping approach. For each country, we used the better-performing approach to construct a national poverty map. These maps showed the highest concentration of poverty in remote locations, where population density was low and the allocation of resources potentially expensive. Next, we assessed the wealth inequality in travel time to the nearest hospital and its trade-off against minimizing overall travel time in the four countries. Travel time was calculated by overlaying locations of the population, wealth subgroups and hospitals. We simulated alternative hospital locations to identify the shortest overall travel time and the narrowest equity gap possible. Results suggest that hospitals in the four countries are currently well placed to minimize overall travel time, but they create wide inequality gaps by wealth. Lastly, we assessed the relative contributions of poverty, travel time, and other factors on the probability of hospital birth in the four countries. Poverty and travel time were important, and they played different roles within and across countries, meaning different strategies are needed to increase hospital-based childbirth. Nonetheless, these strategies alone do not address all barriers, and further research of where they do not lead to the desire result is required to help devise tailor-made actions