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

Introduction

Giving birth in a healthcare facility with the guidance of skilled healthcare providers allows access to necessary medical interventions, ensures timely postnatal care, facilitates early detection of potential health issues, and ultimately leads to better health outcomes for both the mother and the child (Lee et al., 2022).

In contrast, a low level of institutional delivery has contributed to the underutilization of organized healthcare resources, resulting in a high maternal mortality rate, with 810 daily maternal deaths recorded globally in 2017 (World Health Organization, 2019a). An overwhelming proportion (94%) of these deaths occurred in low- and middle-income countries (LMIC), with a significant contribution from Sub-Saharan Africa (SSA) (World Health Organization, 2014, 2019a, 2019b). Furthermore, the absence of medical attention during pregnancy and childbirth can result in severe and long-lasting health issues (World Health Organization, 2014).

Various challenges and barriers impede institutional delivery, particularly in SSA, where less than 60% of births are attended by skilled personnel, in contrast to 96% in high-income countries (World Health Organization Regional Office for Africa, 2014). Among the East African countries, Ethiopia had the lowest institutional delivery rate, with a value of 26.2%, in stark contrast to the highest rate of 97% in Mozambique and a pooled rate of 87.47% for the entire region (Doctor, Nkhana-Salimu & Abdulsalam-Anibilowo, 2018; Central Statistical Agency (CSA) [Ethiopia] and ICF, 2016; Tesema & Tessema, 2021; Uganda Bureau of Statistics, 2017; Were et al., 2017).

The multifaceted dynamics that influence institutional delivery can be classified into demand- and supply side factors. Among supply side factors, distance to healthcare facilities significantly affects physical accessibility (Kumar, Dansereau & Murray, 2014; McGuire, Kreif & Smith, 2021; Nesbitt et al., 2016; Dotse-Gborgbortsi et al., 2020). Furthermore, travel time to healthcare facilities, influenced by factors such as transportation infrastructure quality, geographic landscape, and the economic conditions of mothers, also plays a pivotal role (Dahab & Sakellariou, 2020; Weiss et al., 2020). These interrelated factors intricately shape access to healthcare services, particularly childbirth (Dotse-Gborgbortsi et al., 2022; Karra, Fink & Canning, 2017; McGuire, Kreif & Smith, 2021). Moreover, this nexus between healthcare accessibility and the likelihood of institutional delivery is closely tied to urban-rural residence, contributing to disparities in healthcare access (Dotse-Gborgbortsi et al., 2022; Gao & Kelley, 2019; Dotse-Gborgbortsi et al., 2020).

Ethiopia has undertaken initiatives to improve institutional delivery and maternal health, including the expansion of the healthcare infrastructure (DeMaria, Smith & Berhane, 2022; Ethiopia Ministry of Health, 2010, 2015). This may have reduced the proximity to health facilities over time, coupled with interventions and policies to enhance institutional delivery (Berelie et al., 2020; Zewdu Amdie, Landers & Woo, 2022). The Ethiopian Demographic and Health Survey (EDHS) reported an increase in institutional delivery rates from 10% in 2011 to 26% in 2016 (Central Statistical Agency (CSA) [Ethiopia] and ICF, 2012, 2016). However, limited evidence exists on households’ distance from nearby health facilities and their impact on institutional delivery rates at the national scale. Thus, this study investigates the role of distance on institutional delivery trends over time by integrating data from two rounds of the EDHS survey with geographic positioning system (GPS) information for households and health facilities, as well as Ethiopian road network data.

Methods

Result

Trends of change in distance to health facilities

The mean distance (in kilometers) of households to their closest public health facilities varies across Ethiopia (Fig. 1). The national average transportation distance was 22.4 km (95% CI [17.3–27.4]) in 2011 and 20.2 km (95% CI [15.9–24.6]) in 2016. Except for three regions (Southern Nations, Nationalities, and Peoples Region (SNNPR), Benshangul-Gumuz, and Harari), the mean distance between villages and facilities decreased between 2011 and 2016 (see Fig. 1).

The geographical distribution of health facilities and their shortest transportation routes from the villages of mothers who delivered in the two rounds of EDHS are shown in Fig. 2.

On the left side of the figure, the map shows the locations of the health facilities available in the 2011 EDHS along with the shortest transportation routes from the villages of the mothers who delivered during that period. Similarly, the map on the right-hand side displays the distribution of health facilities in the 2016 round and the corresponding shortest transportation route.

Trends of institutional delivery

Figure 3 shows the changes in institutional delivery rates across survey rounds. In 2011, 90% of births occurred at home compared to 73.8% in 2016. Figure 4 shows the rate of institutional delivery over time for the most recent births, between 2006 and 2016. As shown in the figure, the proportion of births in health facilities increased over the study period from 13.8% in 2006 to 22.7% in 2012, and 39.5% in 2016.

Discussion

This study examined the role of health facility distance on institutional delivery in Ethiopia. Despite the notable increase in the rate of institutional deliveries, rising from 10% to 26.2% between 2011 and 2016, and a slight reduction in the average distance to healthcare facilities by 2.2 km during this period, the likelihood of women giving birth at healthcare facilities remained low. Notably, while the impact of distance to healthcare facilities was modest, it tended to play a significant role throughout the timeframe.

This study underscores the considerable hurdles women face in accessing timely and safe maternal healthcare. Specifically, it reveals that women in labor may need to travel more than 20 km on average to reach a healthcare facility via the road network, highlighting the formidable barriers to accessing essential maternal health services. These challenges are further compounded by factors such as poor road infrastructure (Abdulkadr et al., 2022), limited transportation accessibility (Mushir & Hailemariam, 2015), financial constraints that inhibit transportation payments, and limited capacity of healthcare systems, which are common in many low-resource settings, including Ethiopia.

Furthermore, the role of distance in institutional delivery seems far from a straightforward one-dimensional relationship (Chen et al., 2022). For instance, the distance to healthcare facilities can impact the cost of accessing care due to transportation expenses and affect a woman’s ability to easily reach the facility. This is particularly critical in settings such as Ethiopia, where road network coverage is less than 41% of that required in the country (WFP, 2022) and limited-capacity healthcare systems pose significant challenges (Shiferaw et al., 2015; Yitbarek et al., 2023). It is evident in the current study where regions with a greater average distance to healthcare facilities, such as Somalia and Afar had lowest institutional delivery, which is consistent with previous studies (Awol, Edosa & Jemal, 2023; Karra, Fink & Canning, 2017; McGuire, Kreif & Smith, 2021). This underscores the pivotal role of the distance from healthcare facilities as gatekeepers in terms of accessibility (Chen et al., 2022). However, women living closer to healthcare facilities are more likely to complete ANC visits, which could motivate them to opt for institutional delivery, resulting in a virtuous cycle of delivery at health facilities (Dotse-Gborgbortsi et al., 2022).

Regression analysis also indicated that mothers who were more educated, had a lower birth order, completed more ANC visits, lived in wealthier urban households, and cohabited with more educated husbands were more likely to deliver at health facilities. These determinants remained consistent across both rounds of the survey despite the overall increase in institutional delivery. This is in line with previous research from 74 LMICs countries (Hasan et al., 2021) and Ethiopia (Fikre & Demissie, 2012; Gabrysch & Campbell, 2009; Gedilu, Debalkie & Setegn, 2018), which found that more educated women were more likely to deliver in healthcare facilities (Tesema & Tessema, 2021). This can be explained by multiple prospective pathways. For instance, more educated women are likely to have greater access to financial resources, greater health knowledge, and increased awareness of the potential benefits of institutional delivery (Mitikie, Wassie & Beyene, 2020). Additionally, they are more likely to cohabit with more educated partners, which can positively influence social norms and household decision-making. In line with previous studies (Gedilu, Debalkie & Setegn, 2018; Mitikie, Wassie & Beyene, 2020; Yoseph et al., 2020), our analysis also showed that women who completed more ANC visits were more likely to deliver at facilities, possibly because ANC visits build relationships with healthcare providers and foster trust (Hailemariam et al., 2023).

In terms of household characteristics, our study, as well as previous studies (Gabrysch & Campbell, 2009; Hasan et al., 2021; Yoseph et al., 2020), found that women living in wealthier households were more likely to deliver in facilities. A possible explanation could be that wealth is correlated with education or that women from wealthier backgrounds find it easier to cover the costs of healthcare and travel. Husbands’ education was another important factor that was significantly and positively associated with institutional delivery in the 2016 EDHS, as found in other studies (Mitikie, Wassie & Beyene, 2020; Yoseph et al., 2020). One possible reason for this is that educated husbands are more likely to have occupations that cover health costs and related fees. Simultaneously, they may be more receptive toward modern medicine, informed of the advantages of institutional delivery, and better able to communicate with health care professionals.

This study had three main limitations. First, by calculating the distance to the nearest facility, we implicitly assumed that the women wanted to visit their closest health facility. This could introduce bias if women perceive quality to be poor in these facilities or if levels of absenteeism are high and facilities are de facto closed. Second, we did not examine cultural factors, although they have been identified as being important in previous studies. Finally, we did not investigate the quality of care in health facilities, which was not possible due to the lack of data.

Nonetheless, the findings of this study are relevant to policymakers for several reasons, as it is the first nationally representative evidence of the role of distance from Ethiopia, and the first study to use data on the individual location of each village, facility, and road network in the country. Although we have identified other determinants of institutional delivery, this finding highlights the need to increase the number of healthcare facilities, particularly in rural regions. In addition, given that travelling long distances can be cumbersome for women when infrastructure is poor, infrastructure quality needs to be improved, particularly in rural areas (Dotse-Gborgbortsi et al., 2022). Although building more healthcare facilities is achievable in the short term, staffing is likely to be a key limitation. Ethiopia suffers from a severe shortage of healthcare staff, as there are only 0.96 healthcare workers per 1,000 people, which is far below the WHO target of 4.45 per 1,000 population (Haileamlak, 2018; World Health Organization, 2016). Hence, an increase in the number of health facilities is likely to increase the recruitment and training of health care providers. Second, we highlight the importance of the factors that are likely to take longer to change. Whether women deliver at health facilities or not is associated with their broader socioeconomic status (education and wealth) and husbands. This underlines the fact that low levels of institutional delivery in Ethiopia are likely to have deep-rooted causes. Hence, the goal of improving institutional delivery is likely to go hand-in-hand with other improvements in people’s lives, which are likely to be achievable only in the long term.

In terms of future research, given the modest impact of distance from healthcare facilities on institutional delivery rates in Ethiopia, and considering the average national transportation distance of over 20 km and the road network coverage of less than 41%, further research is recommended to explore the effects of infrastructure improvement, specifically road network and reduction in distance, which might influence institutional delivery. Regional studies could provide insights into local variations and needs, whereas longitudinal research may reveal the long-term effects of infrastructure improvement on institutional delivery.

Conclusion

The impact of distance from healthcare facilities on institutional delivery in Ethiopia, although modest, remains notable. Over time, the rate of institutional delivery increased from 10% to 26.2%, in parallel with a reduction in the average national health facility distance from 22.4 to 20.2 km between 2011 and 2016. Despite this progress, institutional delivery rates remain lower than those in many other sub-Saharan African countries. Key factors influencing institutional delivery, such as education, antenatal care, socioeconomic status, urban residence, and partner education, have remained consistent across both surveys, underscoring the importance of addressing both physical accessibility and socioeconomic conditions. To improve maternal and infant health, policymakers and researchers should adopt a comprehensive approach that incorporates these determinants into policy development.

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