Modeling Geographical Accessibility and Inequalities to Childbirth Services in the Grand Nokoué Metropolitan Area, Benin

Abstract

Timely access to comprehensive , high-quality emergency obstetric and neonatal care can prevent maternal and neonatal mortality but remains challenging in Benin. We examine geographic accessibility to childbirth care (CBC) in Grand Nokoué, the largest conurbation in Benin. We gathered data on boundaries, health facilities, road network, elevation, land cover, relative wealth, urbanicity, and geo-traced travel speeds over 45 days during the rainy season. We modelled travel times (TT) to health facility offering CBC (stratified by level and sector) using the least-cost path algorithm, based on slowest, average, and fastest travel speeds. We estimated the percentage of women of childbearing age (WoCBA) within 30, 60, and 120 min of the nearest facility by subnational areas. We explored inequalities in TT by wealth quintile and urbanicity gradient. TT to nearest facility at average speed was 8 min and 24 min at slowest speed. For hospitals, this was 31 and 106 min, respectively. TT ranged from 2 to 38 min across arrondissements at average speeds. At average speeds, all WoCBA lived within 30 min of a health facility and 71.6% of a hospital. At slowest speed, this decreased to 84.7% and 22.9%, respectively, with substantial variations across arrondissements. TT to hospitals at average speed was five-fold longer among women from the poorest (50 min) compared to the richest quintile, while TT was shorter in the core urban (27 min) relative to peri-urban (46 min). TT to CBC varied by wealth and urbanicity gradient and was longer at the slowest speeds. Targeting peri-urban areas and poorest WoCBA with longer TT will reduce inequities.

Keywords: Benin; Grand Nokoué; Inequities; Maternal health; Relative wealth; Spatial accessibility; Travel time; Urban areas.

Fig. 1

The Grand Nokoué metropolitan area, Benin comprising of five communes, and 43 arrondissements. Maps of seven health zones and three départements are shown in supplementary Figures S1 and S2

Fig. 2

Locations of all 292 health facilities (29% in the public sector (24% managed by the government and 5% by confessional) and 71% in the private sector) offering childbirth care in the Grand Nokoué metropolitan area in Benin in 2023, by level. The inset (yellow circle) represents Cotonou Commune

Fig. 3

High resolution (30 m × 30 m) travel time to facilities offering childbirth care, by travel speed scenario (minimum, average and maximum) in Grand Nokoué metropolitan area, Benin. The dark boundary lines represent the seven health zones. Arrondissement-level maps are shown in Supplementary Figure S10)

Fig. 4

High resolution (30 m × 30 m) travel time to childbirth care in hospitals by travel speed scenario (minimum, average and maximum) in Grand Nokoué metropolitan area, Benin. Arrondissement-level maps are shown in Supplementary Figure S11

Fig. 5

Equiplot of variation of travel time using average speed scenario to childbirth care relative to wealth index disaggregated by level of facility and Département within Grand Nokoué metropolitan area, Benin