BackgroundAppropriate facility-based care at birth is a key determinant of safe motherhood but geographical access remains poor in many high burden regions. Despite its importance, geographical access is rarely audited systematically, preventing integration in national-level maternal health system assessment and planning. In this study, we develop a uniquely detailed set of spatially-linked data and a calibrated geospatial model to undertake a national-scale audit of geographical access to maternity care at birth in Ghana, a high-burden country typical of many in sub-Saharan Africa.MethodsWe assembled detailed spatial data on the population, health facilities, and landscape features influencing journeys. These were used in a geospatial model to estimate journey-time for all women of childbearing age (WoCBA) to their nearest health facility offering differing levels of care at birth, taking into account different transport types and availability. We calibrated the model using data on actual journeys made by women seeking care.ResultsWe found that a third of women (34%) in Ghana live beyond the clinically significant two-hour threshold from facilities likely to offer emergency obstetric and neonatal care (EmONC) classed at the ‘partial’ standard or better. Nearly half (45%) live that distance or further from ‘comprehensive’ EmONC facilities, offering life-saving blood transfusion and surgery. In the most remote regions these figures rose to 63% and 81%, respectively. Poor levels of access were found in many regions that meet international targets based on facilities-per-capita ratios.ConclusionsDetailed data assembly combined with geospatial modelling can provide nation-wide audits of geographical access to care at birth to support systemic maternal health planning, human resource deployment, and strategic targeting. Current international benchmarks of maternal health care provision are inadequate for these purposes because they fail to take account of the location and accessibility of services relative to the women they serve.

ObjectivesFirst, our objective was to estimate socio-economic inequalities in the use of postnatal care (PNC) compared with those in the use of care at birth and antenatal care. Second, we wanted to compare inequalities in the use of PNC between facility births and home births and to determine inequalities in the use of PNC among mothers with high-risk births.Methods and FindingsRich–poor ratios and concentration indices for maternity care were estimated using the third round of the District Level Household Survey conducted in India in 2007–08. Binary logistic regression models were used to examine the socio-economic inequalities associated with use of PNC after adjusting for relevant socio-economic and demographic characteristics. PNC for both mothers and newborns was substantially lower than the care received during pregnancy and child birth. Only 44% of mothers in India at the time of survey received any care within 48 hours after birth. Likewise, only 45% of newborns received check-up within 24 hours of birth. Mothers who had home births were significantly less likely to have received PNC than those who had facility births, with significant differences across the socio-economic strata. Moreover, the rich-poor gap in PNC use was significantly wider for mothers with birth complications.ConclusionsPNC use has been unacceptably low in India given the risks of mortality for mothers and babies shortly after birth. However, there is evidence to suggest that effective use of pregnancy and childbirth care in health facilities led to better PNC. There are also significant socio-economic inequalities in access to PNC even for those accessing facility-based care. The coverage of essential PNC is inadequate, especially for mothers from economically disadvantaged households. The findings suggest the need for strengthening PNC services to keep pace with advances in coverage for care at birth and prenatal services in India through targeted policy interventions.

As the deadline for the millennium development goals approaches, it has become clear that the goals linked to maternal and newborn health are the least likely to be achieved by 2015. It is therefore critical to ensure that all possible data, tools and methods are fully exploited to help address this gap. Among the methods that are under-used, mapping has always represented a powerful way to ‘tell the story’ of a health problem in an easily understood way. In addition to this, the advanced analytical methods and models now being embedded into Geographic Information Systems allow a more in-depth analysis of the causes behind adverse maternal and newborn health (MNH) outcomes. This paper examines the current state of the art in mapping the geography of MNH as a starting point to unleashing the potential of these under-used approaches. Using a rapid literature review and the description of the work currently in progress, this paper allows the identification of methods in use and describes a framework for methodological approaches to inform improved decision-making. The paper is aimed at health metrics and geography of health specialists, the MNH community, as well as policy-makers in developing countries and international donor agencies.

BackgroundThe Community-based Health Planning and Services (CHPS) initiative is a major government policy to improve maternal and child health and accelerate progress in the reduction of maternal mortality in Ghana. However, strategic intelligence on the impact of the initiative is lacking, given the persistant problems of patchy geographical access to care for rural women. This study investigates the impact of proximity to CHPS on facilitating uptake of skilled birth care in rural areas.Methods and FindingsData from the 2003 and 2008 Demographic and Health Survey, on 4,349 births from 463 rural communities were linked to georeferenced data on health facilities, CHPS and topographic data on national road-networks. Distance to nearest health facility and CHPS was computed using the closest facility functionality in ArcGIS 10.1. Multilevel logistic regression was used to examine the effect of proximity to health facilities and CHPS on use of skilled care at birth, adjusting for relevant predictors and clustering within communities. The results show that a substantial proportion of births continue to occur in communities more than 8 km from both health facilities and CHPS. Increases in uptake of skilled birth care are more pronounced where both health facilities and CHPS compounds are within 8 km, but not in communities within 8 km of CHPS but lack access to health facilities. Where both health facilities and CHPS are within 8 km, the odds of skilled birth care is 16% higher than where there is only a health facility within 8km.ConclusionWhere CHPS compounds are set up near health facilities, there is improved access to care, demonstrating the facilitatory role of CHPS in stimulating access to better care at birth, in areas where health facilities are accessible.

BackgroundThe efforts and commitments to accelerate progress towards the Millennium Development Goals for maternal and newborn health (MDGs 4 and 5) in low and middle income countries have focused primarily on providing key medical interventions at maternity facilities to save the lives of women at the time of childbirth, as well as their babies. However, in most rural communities in sub-Saharan, access to maternal and newborn care services is still limited and even where services are available they often lack the infrastructural prerequisites to function at the very basic level in providing essential routine health care services, let alone emergency care. Lists of essential interventions for normal and complicated childbirth, do not take into account these prerequisites, thus the needs of most health facilities in rural communities are ignored, although there is enough evidence that maternal and newborn deaths continue to remain unacceptably high in these areas.MethodsThis study uses data gathered through qualitative interviews in Kitonyoni and Mwania sub-locations of Makueni County in Eastern Kenya to understand community and provider perceptions of the obstacles faced in providing and accessing maternal and newborn care at health facilities in their localities.ResultsThe study finds that the community perceives various challenges, most of which are infrastructural, including lack of electricity, water and poor roads that adversely impact the provision and access to essential life-saving maternal and newborn care services in the two sub-locations.ConclusionsThe findings and recommendations from this study are important for the attention of policy makers and programme managers in order to improve the state of lower-tier health facilities serving rural communities and to strengthen infrastructure with the aim of making basic routine and emergency obstetric and newborn care services more accessible.

The Ganges-Brahmaputra-Meghna delta of Bangladesh is one of the most populous deltas in the world, supporting as many as 140 million people. The delta is threatened by diverse environmental stressors including salinity intrusion, with adverse consequences for livelihood and health. Shrimp farming is recognised as one of the few economic adaptations to the impacts of the rapidly salinizing delta. Although salinity intrusion and shrimp farming are geographically co-located in the delta, there has been no systematic study to examine their geospatial associations with poverty. In this study, we use multiple data sources including Census, Landsat Satellite Imagery and soil salinity survey data to examine the extent of geospatial clustering of poverty within the delta and their associative relationships with salinity intensity and shrimp farming.The analysis was conducted at the union level, which is the lowest local government administrative unit in Bangladesh. The findings show a strong clustering of poverty in the delta, and whilst different intensities of salinization are significantly associated with increasing poverty, neither saline nor freshwater shrimp farming has a significant association with poverty. These findings suggest that whilst shrimp farming may produce economic growth, in its present form it has not been an effective adaptation for the poor and marginalised areas of the delta. The study demonstrates that there are a series of drivers of poverty in the delta, including salinization, water logging, wetland/mudflats, employment, education and access to roads, amongst others that are discernible spatially, indicating that poverty alleviation programmes in the delta require strengthening with area-specific targeted interventions.

Climate‐dependent subsistence agriculture remains the main livelihood for most populations in Ghana. The spatiotemporal variations in rainfall and temperature have influence particularly in poorly‐developed agrarian regions with limited or no irrigation infrastructure. Therefore, a systematic understanding of climate patterns across space and time is important for mitigating against food insecurity and household poverty. Using over a century of high‐spatial resolution data, this study examines the spatiotemporal variations in rainfall and temperature across Ghana to identify climate‐stressed locations with potential effect on the production of major staple crops. The data for the analysis were drawn from the University of Delaware's Gridded Precipitation and Temperature Monthly Climatology version 4.01. The analysis was restricted to the main crop‐growing periods (March to December). The Mann‐Kendall nonparametric regression test was used to examine significant changes in rainfall variability and temperature at the district level. The results show that Ghana's climate has become progressively drier over the last century and prone to drought conditions. The most climate‐stressed districts are clustered within the three northern regions (Upper West, Upper East, and Northern) and the Western region. The most recent census in Ghana shows that the three northern regions also have the highest prevalence of subsistence agriculture. The findings from this study have implications for targeted interventions such as the Ghanaian government's recent policy initiative aimed at alleviating rural poverty by encouraging youth participation in agriculture along with efforts to intensifying crop production using modern farming techniques.

The maternal care fee exemption policies specifically targeted towards the poorest women had limited impact on the uptake of skilled birth care.