The nexus between geographical distance and institutional delivery trends in Ethiopia: evidence from nationwide surveys

Abstract

Background: Giving birth in a healthcare facility with the guidance of skilled healthcare providers allows access to necessary medical interventions. Ethiopia has implemented several strategies to enhance institutional delivery and decrease maternal mortality; however, the rate of institutional delivery remains low. This study examines the role of distance to healthcare institutions on institutional delivery in Ethiopia, and how this has changed over time.

Method: This study used data from two rounds of the Ethiopian Demographic and Health Survey (2011 and 2016), a spatial database detailing the locations of healthcare facilities, and Ethiopian road network data. The sample included 22,881 women who delivered within the 5 years preceding each survey and lived in 1,295 villages. Bivariate and multivariable logistic regression analyses were used to investigate how the distance to health facilities and other potential determinants influenced institutional delivery trends.

Results: The rate of institutional deliveries in Ethiopia has increased from 10% in 2011 to 26% in 2016. Likewise, the average transportation distance to health facilities has decreased from 22.4 km in 2011 to 20.2 km in 2016 at the national level. Furthermore, a one-kilometer increase in the distance to the nearest health facility was associated with a 1% decrease in the likelihood of delivering at a health facility in 2016 (odds ratio (OR) = 0.99, 95% CI [0.98-0.99], p < 0.05). Additionally, mothers who are more educated, have completed more antenatal care visits, live in wealthier households in more urban areas, and cohabit with more educated husbands are more likely to deliver at healthcare facilities. These variables showed consistent relevance in both survey rounds, suggesting that key determinants remained largely unchanged throughout the study period.

Conclusion: The impact of distance from health facilities on institutional delivery in Ethiopia remains evident, although its influence is relatively modest. The other factors, including education, antenatal care, socioeconomic status, urban residence, and partner education, remained consistent between the two surveys. These determinants have consistently influenced institutional delivery, highlighting the importance of a comprehensive approach that addresses both access to and socioeconomic factors to improve maternal and infant health across the country.

Keywords: Accessibility of health services; Distance to health facilities; Facility delivery; Facility distance; Institutional delivery; Maternal health.

Figure 1. Mean distance of health facilities across different regions of the country for most recent births in the 5 years preceding the 2011 and 2016 EDHS.

Figure 2. Geographical distribution of health facilities and shortest transportation routes from households of mothers delivered in 2011 (Top) and 2016 (Bottom) EDHS rounds.

Map produced using data from Demographic and Health Surveys (DHS) (https://www.dhsprogram.com/data/available-datasets.cfm), Ethiopian road network (https://data.humdata.org/dataset/roads-network?) and the geocoded Master Health Facility List for Africa (https://data.humdata.org/dataset/health-facilities-in-sub-saharan-africa). Map source: ArcGIS.

Figure 3. Place of delivery for most recent births in the 5 years preceding the 2011 and 2016 EDHS.

Figure 4. Trends of place of delivery for most recent births in the cumulative 10 years preceding the 2011 and 2016 EDHS.