Impact of Geographic Access on Intuitional Delivery Care Utilization in Low and Middle-income Countries

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Published: 9th Dec 2019

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The impact of geographic access on intuitional delivery care utilization in low and middle-income countries: Systematic Review and Meta-Analysis

Background

Access to and quality of health services are a high priority for investments designed to increase health services utilization which eventually improve health outcomes ⁽¹⁾. Healthcare access is defined in terms of geographic, financial, temporal, digital/eHealth and cultural access, and availability of services ^{(2, 3)}. The digital dimension of healthcare access addresses the digital connectivity/communication with healthcare providers, peer groups, and computerized health applications ⁽²⁾. Temporal access addresses the time required to get services (waiting time in reception, time spent in receiving treatment and time to next appointment) and its trade-offs ⁽²⁾. Availability is the opportunity to get the right type of healthcare, appropriate healthcare providers, materials and equipment ⁽³⁾. Financial accessibility focuses on the costs of services, and users’ ability and willingness to pay for, as well as to be protected from financial consequences of health care costs ^{(2, 3)}. The cultural dimension of access focuses on the acceptability of health services to individual users and communities, such as language match, trust to provider and public stigma. On the other hand, the geographic dimensions of access is the measure of the physical distance or travel time to service delivery points ^{(2, 3)}.

People living in low and middle-income countries (LMICs) tend to have less access to health care services than those in high income countries ⁽³⁾. Furthermore, within these countries, the poor and those living in rural areas have less access to these services ^{(2, 3)}. In rural areas, and for congested urban centres, the geographical dimension of access could be more important than urban centres with good transportation infrastructure; in those settings, service users might be expected to walk long distances and/or spend more time on travelling ⁽²⁾. Availability of transport services, nature of roads (seasonal impassibility), mountains and rivers may also play a role in accessing health care services ⁽⁴⁾.

Moreover, for any reason, the nearest health facility might not be the facility of choice. Not all services are provided at all levels of health facilities ⁽⁴⁾. For instance, in many countries, comprehensive emergency obstetric care (CEmOC) is not available at the lowest health facilities. In most countries, it is only available at hospitals, and for this reason pregnant women and their families may be required to travel further away for childbirth ⁽⁵⁾.

Studies from Zambia and Malawi found that the odds of facility delivery was higher among those who had physical access to higher level of care facilities ^{(6, 7)}. Analysis of the 2012 Haiti DHS and 2013 SPA data found that health facilities service readiness within 10 kilometre of radius of a given cluster was associated with an increased use of delivery services ⁽⁸⁾. Similarly, in Malawi and Zambia, living close to facility providing delivery service was significantly associated with health facility delivery ⁽⁷⁾. It was also noted that the increase in geographic distance was associated with a decrease in the use of health facility delivery ^{(6, 9)}.

However, it was found that having access to obstetric care facilities within one-hour ^{(10, 11)} and three kilometres ^{(12, 13)} of distance were not significantly associated with institutional delivery. Therefore, this study synthesized the evidence on the influence of geographic access on institutional delivery care use in low and middle-income countries.

Method

Search strategy

Our search included the following databases: MEDLINE, EMBASE, CINAHL, PsycINFO, Scopus and Maternity & Infant Care. We used multiple combinations of search terms or keywords, such as delivery care, geographic access, observational studies, low and middle-income countries, and Boolean operators (Table 1). The searching terms/keywords first used in OVID MEDLINE were adapted to the other databases. We also conducted a hand search of reference lists.

Study selection

Search results were imported into EndNote software to aggregate relevant articles and to manage duplications. Two authors independently screened the titles and abstracts to determine if the returned electronic search articles were related to the study. The respective lists of articles of both authors were combined and full-text articles were reviewed against the inclusion and exclusion criteria. Disagreements were resolved through discussion with a third reviewer, and we calculated inter-reviewer reliability; that is, the percentage of agreement between reviewers (Cohen’s kappa) ⁽¹⁴⁾.

Inclusion and exclusion criteria

We included studies only conducted in low-income and middle-income countries as defined by the World Bank ⁽¹⁵⁾ and published in English. We took studies published since 2000 that was the introduction of the Millennium Development Goals (MDGs) up to December 31, 2016. We have included quantitative cross-sectional studies, cohort and case-control studies. We excluded experimental or intervention studies and organization reports in our analysis. The studies had to report on the influence of geographic accessibility on maternal delivery service use.

Outcome measures

We selected articles that reported geographic access on delivery care use. Our outcome measure was utilization of institutional delivery.

Study quality assessment

Two authors independently assessed the methodological quality of each study using the Joanna Briggs Institute’s (JBI) critical appraisal checklist for studies reporting prevalence data ⁽¹⁶⁾ and cohort studies ⁽¹⁷⁾. Disagreements were resolved by discussion with a third reviewer.

Data extraction

We extracted data on influence of geographic accessibility on maternal delivery care use. We used data extraction form that include general information (publication details and country), and specific information (study setting, study design, study population, sample size, main findings) (Table 2). We created a summary matrix with the data extracted from all individual studies. Two authors independently extracted the data from the included studies into the constructed matrices. Discrepancies were resolved by discussion and the original study was reviewed to resolve further discrepancies.

Analysis

The results of studies were extracted, reviewed and reported in a systematic format. A Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA ) checklist ⁽¹⁸⁾ was used to synthesize and report the findings. A meta-analytic procedure was used to compute and aggregate effect sizes. The pooled effect size (Odds Ratio – OR) was calculated using a random effects model. The Q statistics, I² and Tau squared (τ²) were used to examine heterogeneity of studies. The analysis was done using ProMeta software, version 3.0.

Results

Search Results

We retrieved 394 articles, of which 33 duplicates were removed. Three hundred ten articles were excluded based on title and abstract. The remaining 51 articles were reviewed using a full-text article. Twenty articles were excluded; for instance, four were focused only on skilled birth attendant ^(19-22), and were not for the general population ^{(23, 24)} (Fig 1). Thirty-one studies were identified based on the eligibility criteria; 16 included in qualitative synthesis (systematic review) and 15 in quantitative synthesis (meta-analysis) (Fig 1). Data extracted from the 31 studies are shown in Table 2. Four of the 31 studies were a linked analysis of population and health facility surveys ^{(6, 7, 25, 26)} (Table 2). With the exception of three studies ^(10-12), all the other studies showed a significant association between physical access and delivery care use.

Study quality

We evaluated the quality of the included studies using the JBI’s critical appraisal checklist for cross-sectional and cohort studies ^{(16, 17)} and it turned out with an average score of 75.16%. Of the included studies, only three of them were graded as poor quality ^(27-29).

Heterogeneity test

Studies included in estimating the pooled effect of access to obstetric care facility beyond 60 minutes of travel showed that they were statistically heterogeneous. The Q-value was 23.23 with 8 degrees of freedom and P-value = 0.003. The I² statistic (a measure of the proportion of the variance in the observed effects that is due to the variance in the true effects), was 65.56, which demonstrates that about 66% of the variance in the observed effects was due to the variance in the true effects. Tau squared (τ²) is the variance of the true effect sizes, whereas Tau (τ) is the standard deviation of the true effects (both in log units). The estimated τ² and τwere 0.24 and 0.49, respectively. The prediction interval was from 0.06 to 0.77. Therefore, in most populations, we would expect that the odds ratio for delivery care use would fall from 0.06 (94% for those who had no access) to 0.77 (23% who relatively had access to obstetric care facilities).

In case of access to obstetric health facility within five kilometre of their usual place of residence, the included studies were not statistically heterogeneous. The estimated Q-value was 10.71 with 6 degrees of freedom and P-value = 0.098. The estimated I² was 43.99, which tells us that about 44% of the variance in the observed effects was due to the variance in the true effects. The estimated τ² and τwere 0.03 and 0.19, respectively. The prediction interval was from 1.34 to 3.85. Therefore, in most population, we would expect that the odds ratio for delivery care use would fall from 1.34 (34% for those who had no access) to 3.85 (285% who relatively had access to obstetric care facilities).

Additional records identified through other sources
(n = 39)

Records identified through database searching
(n = 355)

Identification

Records after duplicates removed
(n = 361)

Screening

Records excluded
(n = 310)

Records screened
(n = 51)

20 full-text articles were excluded:

Not in English (1),

Descriptive studies (4),

Didn’t report geographic access (6),

Not for general population (2)

Outcome variable not well-defined (3)

Only for skilled birth attendant (4)

Full-text articles assessed for eligibility
(n = 31)

Eligibility

Studies included in qualitative synthesis
(n = 16)

Included

Studies included in quantitative synthesis (meta-analysis)
(n = 15)

Fig 1: Systematic Review and Meta-Analysis flow diagram adapted from the 2009 PRISMA Statement ⁽¹⁸⁾

Impact of geographic access on delivery care use

Having no access to obstetric care facility within 60 minutes of walk

The pooled estimates (Odds Ratio) showed that impact of geographic access on institutional delivery care use was 0.21 (95% Confidence interval = 0.14, 0.31). This indicates that pregnant women who had no access to obstetric care facilities within 60 minutes of walk were 79% less likely to give birth at health institutions (Fig 2). The Trim and Fill analysis found that there is no need of additional studies to balance the symmetry of the funnel plot. However, the Funnel plot showed a slightly asymmetrical effect (Fig 3) but the Egger’s test found that there is no publication bias (P-value = 0.21).

Fig 2: Forest plot of effect sizes and 95% confidence intervals showing the effect of one hour and more travel time on delivery care use

Fig 3: Funnel plot on having no access to obstetric care facility within one hour travel time

Having access to obstetric care facility within 5 kilometre

The pooled estimate found that pregnant women who had access to obstetric care facilities within 5km were 2.27 times more likely to give birth at health institutions (95% Confidence interval = 2.27; 1.82, 2.82) (Fig 4). The Trim and Fill analysis found out that no more studies are required to balance the symmetry. Both the Funnel plot (Fig 5) and the Egger’s test showed that there is no publication bias in the included studies (P-value = 0.74).

Fig 4: Forest plot of effect sizes and 95% confidence intervals showing the effect of geographic access within 5km on delivery care use

Fig 5: Funnel plot on geographic access to obstetric care facility within 5km

Furthermore, the qualitative synthesis of most of the studies showed that geographic access had an effect on obstetric care use. Physical access to obstetric care facilities was assessed in two ways; that is, in terms of geographic distance and travel time to health care facilities. Looking at travel time to reach nearby obstetric care facilities, when the travelling time goes down to half an hour and less, pregnant women were more likely to have health facility delivery ⁽³⁰⁾. However, in another two studies, having access to delivery care facility within one-hour ⁽¹⁰⁾ and half an hour ⁽¹¹⁾ were not associated with institutional delivery. One the other hand, every one-hour increase in travel time to the nearby obstetric care facilities was associated with a 20% decrease in the odds of facility delivery ⁽²⁶⁾.

In addition to travel time, a one-kilometre increase in walking distance to obstetric care facilities was significantly associated with a significant decrease in health facility delivery ^{(9, 25, 31-33)}. In rural Zambia, every doubling of distance to the nearest obstetric care facility was significantly associated with a 29% decrease in health facility delivery ⁽⁶⁾. Moreover, the odds of health facility delivery was decreased by 65% in Malawi and 27% in Zambia for every 10 kilometre increase in distance to the closest obstetric care facility ⁽⁷⁾.

The odds of health facility delivery was higher among pregnant women who had physical access to obstetric care facilities within 10 ^{(25, 34)} and five ⁽²⁸⁾ kilometres. However, having access to obstetric care facilities within three ⁽¹²⁾ and two kilometres ⁽¹³⁾ were not significantly associated with institutional delivery care use. In Burkina Faso, pregnant women who were residing seven or more kilometres away from obstetric care facilities were more likely to have home births ⁽³⁵⁾.

Discussion

The main findings of this meta-analysis and systematic review were that geographic access to obstetric care facilities, measured in either physical distance and/or travel time, had an impact on intuitional delivery use. Pregnant women who were living within a five-kilometre of an obstetric care facility had the higher odds of intuitional delivery as compared to those living beyond a physical distance of five-kilometre. In terms of walking time, the odds of using institutional delivery was low among pregnant women who had no access to obstetric care facilities within one-hour walking time. This implies that long distance has a dual influence on institutional delivery service utilization. It can be a barrier for both reaching obstetric care facilities and discouraging to seek care. The problem further worsens for rural pregnant women who often have no access to reliable transportation systems.

Furthermore, it was observed that both a single kilometre and a one-hour increase in accessing obstetric care facilities were associated with lower odds of intuitional delivery. This was consistent with the concept of distance decay ⁽³⁶⁾, where interactions varied inversely with distance. The greater the distance, the greater the barrier and the less the interaction would be. Therefore, the further away a pregnant woman lives from an obstetric care facility, the less likely she will use institutional delivery service.

Even though the study was the first of its kind, it had several limitations. It took only one of the three delays model – delay in reaching health care facilities ⁽³⁷⁾ and measures of healthcare access ^{(2, 3)}; even it did not address the different means of transportation, travel costs and terrains. There were also variations in the operationalization and measurement of geographic access to obstetric care facilities. It was due to the unavailability of a universally agreed clear cut-off point, in either a geographic distance and/or travel time, for a health facility to be accessible or not. The World Health Organization has put distance and travel time as a measure of physical accessibility ⁽³⁸⁾; however, there was no clear cut-off point for its measurement. Different countries are using different cut-off points; for instance, Ethiopia uses a 10 km ⁽³⁹⁾ distance whereas the United States of America and the United Kingdom use 30 minutes of travel time ⁽⁴⁰⁾ for measuring geographic access to health care services.

Even though the analysis was done using both distance and travel time, still it was subjected to measurement errors. The physical distance used in the studies was not uniformly measured; whilst some studies used a direct physical distance, the rest used walking tracks. Making comparisons and judgement based on measured physical distance is subjected to errors where the geography and transportation infrastructure largely vary within and among countries. Moreover, though the World Health Organization recommends using travel time, instead of physical distance, for assessing geographic accessibility ⁽³⁸⁾ unless stratifications are used, it could pose problems in making a comparison. The value of and actual travelling time varies depending on people; for instance, age and condition of the person, and the transportation mode used, and thus its strength as access barrier varies too.

In conclusion, it was found that the more closely the obstetric care facilities, the more likely that pregnant women to use institutional deliveries. Researchers should account the different measures of geographic accessibility, taking into consideration of means of transportation, travel cost and terrains, for measuring how obstetric care accessibility and utilization of intuitional deliveries interact with each other. Furthermore, future research is also needed to compare each of the measures of health care access how they could influence utilization of obstetric care services.

Table 1: Search strategy for impact of geographic access on delivery care use

Databases	Search Terms
Medline	Midwifery/ or Maternal Health Services/ or Perinatal Care/ or Delivery, Obstetric/ or Obstetric Labor Complications/ or Labor, Obstetric/ or Caesarean Section/ or Obstetrics/ or Parturition/ or childbirth.mp. or Obstetric care.mp. or delivery care.mp. or delivery assistant.mp. or birth assistant.mp. or ((location or place) adj3 (birth or delivery)).mp. AND ((geographic or physical) adj5 (location* or access* or proximit* or distance)).mp. or ((time or distance) adj5 (walk* or driv* or travel)).mp. or Health Services Accessibility/ or Spatial access.mp. or “Catchment Area (Health)”/ or access to care.mp. AND Observational Study/ or exp Cohort Studies/ or Case-Control Studies/ or Cross-Sectional Studies/ or ecological stud.mp. AND ((low or middle) adj3 (countr or nation* or econom*)).mp. OR (Afghanistan or Benin or Burkina Faso or Burundi or Central African Republic or Chad or Comoros or Congo Democratic Republic or Eritrea or Ethiopia or Gambia or Guinea or Guinea-Bissau or Haiti or Korea Democratic People’s Republic or Liberia or Madagascar or Malawi or Mali or Mozambique or Nepal or Niger or Rwanda or Senegal or Sierra Leone or Somalia or South Sudan or Tanzania or Togo or Uganda or Zimbabwe or Armenia or Bangladesh or Bhutan or Bolivia or Cabo Verde or Cambodia or Cameroon or Congo Republic or Ivory Coast or Djibouti or Egypt or El Salvador or Ghana or Guatemala or Honduras or India or Indonesia or Kenya or Kiribati or Kosovo or Kyrgyz Republic or Lao PDR or Lesotho or Mauritania or Micronesia Federation or Moldova or Mongolia or Morocco or Myanmar or Nicaragua or Nigeria or Pakistan or Papua New Guinea or Philippines or Samoa or Sao Tome) and Principe) or Solomon Islands or Sri Lanka or Sudan or Swaziland or Syrian Arab Republic or Tajikistan or Timor-Leste or Tonga or Tunisia or Ukraine or Uzbekistan or Vanuatu or Vietnam or West Bank) and Gaza) or Yemen Republic or Zambia or Albania or Algeria or American Samoa or Angola or Argentina or Azerbaijan or Belarus or Belize or Bosnia) and Herzegovina) or Botswana or Brazil or Bulgaria or China or Colombia or Costa Rica or Cuba or Dominica or Dominican Republic or Equatorial Guinea or Ecuador or Fiji or Gabon or Georgia or Grenada or Guyana or Iran or Iraq or Jamaica or Jordan or Kazakhstan or Lebanon or Libya or Macedonia or Malaysia or Malaysia or Maldives or Marshall Islands or Mauritius or Mexico or Montenegro or Namibia or Palau or Panama or Paraguay or Peru or Romania or Russian Federation or Serbia or South Africa or Saint Lucia or Saint Vincent) and the Grenadines) or Suriname or Thailand or Turkey or Turkmenistan or Tuvalu or Venezuela).mp
Embase	Midwifery.mp. OR midwife/ OR Maternal Health Services.mp.OR health service/ OR perinatal care/ OR obstetric delivery/ OR labor complication/ OR labor/ OR cesarean section/ OR obstetrics/ OR Parturition.mp. OR birth/ or childbirth/ OR obstetric procedure/ OR maternal care/ OR delivery/ OR Delivery care.mp. OR Delivery assistant.mp. OR Birth assistant.mp. OR ((location or place) adj3 (birth or delivery)).mp. OR Delivery care.mp. AND ((geographic or physical) adj5 (location* or access* or proximit* or distance)).mp. OR ((time or distance) adj5 (walk* or driv* or travel)).mp. ORHealth Services Accessibility.mp. OR health care access/ OR Spatial access.mp. OR Access to care.mp. AND case control study/ or observational study/ or cohort analysis/ OR cross-sectional study/ OR Ecological stud.mp. AND ((low or middle) adj3 (countr* or nation* or econom*)).mp. OR (Afghanistan or Benin or Burkina Faso or Burundi or Central African Republic or Chad or Comoros or Congo Democratic Republic or Eritrea or Ethiopia or Gambia or Guinea or Guinea-Bissau or Haiti or Korea Democratic People’s Republic or Liberia or Madagascar or Malawi or Mali or Mozambique or Nepal or Niger or Rwanda or Senegal or Sierra Leone or Somalia or South Sudan or Tanzania or Togo or Uganda or Zimbabwe or Armenia or Bangladesh or Bhutan or Bolivia or Cabo Verde or Cambodia or Cameroon or Congo Republic or Ivory Coast or Djibouti or Egypt or El Salvador or Ghana or Guatemala or Honduras or India or Indonesia or Kenya or Kiribati or Kosovo or Kyrgyz Republic or Laos or Lesotho or Mauritania or Micronesia Federation or Moldova or Mongolia or Morocco or Myanmar or Nicaragua or Nigeria or Pakistan or Papua New Guinea or Philippines or Samoa or Sao Tome) and Principe) or Solomon Islands or Sri Lanka or Sudan or Swaziland or Syrian Arab Republic or Tajikistan or Timor-Leste or Tonga or Tunisia or Ukraine or Uzbekistan or Vanuatu or Vietnam or West Bank) and Gaza) or Yemen Republic or Zambia or Albania or Algeria or American Samoa or Angola or Argentina or Azerbaijan or Belarus or Belize or Bosnia) and Herzegovina) or Botswana or Brazil or Bulgaria or China or Colombia or Costa Rica or Cuba or Dominica or Dominican Republic or Equatorial Guinea or Ecuador or Fiji or Gabon or Georgia or Grenada or Guyana or Iran or Iraq or Jamaica or Jordan or Kazakhstan or Lebanon or Libya or Macedonia or Malaysia or Malaysia or Maldives or Marshall Islands or Mauritius or Mexico or Montenegro or Namibia or Palau or Panama or Paraguay or Peru or Romania or Russian Federation or Serbia or South Africa or Saint Lucia or Saint Vincent) and the Grenadines) or Suriname or Thailand or Turkey or Turkmenistan or Tuvalu or Venezuela).mp
PsycINFO	exp MIDWIFERY/ OR exp Birth/ or Maternal Health Service.mp. OR Perinatal Care.mp. OR exp Obstetrical Complications/ or exp Obstetrics/ or exp “Labor (Childbirth)”/ or exp Caesarean Birth/ or Delivery, Obstetric.mp. OR exp Obstetrical Complications/ OR Parturition.mp. OR Obstetric care.mp. OR Delivery care.mp. OR Delivery assistant.mp. OR Birth assistant.mp. OR ((location or place) adj3 (birth or delivery)).mp. AND ((geographic or physical) adj5 (location or access* or proximit* or distance)).mp. OR ((time or distance) adj5 (walk* or driv* or travel)).mp. OR Health Services Accessibility.mp. OR Spatial access.mp. OR Access to care.mp. AND Observational Study.mp. OR Cohort Study.mp. OR Case-Control Studies.mp. OR Cross-Sectional Studies.mp. OR Ecological studies.mp. AND ((low or middle) adj3 (countr* or nation* or econom*)).mp. OR (Afghanistan or Benin or Burkina Faso or Burundi or Central African Republic or Chad or Comoros or Congo Democratic Republic or Eritrea or Ethiopia or Gambia or Guinea or Guinea-Bissau or Haiti or Korea Democratic People’s Republic or Liberia or Madagascar or Malawi or Mali or Mozambique or Nepal or Niger or Rwanda or Senegal or Sierra Leone or Somalia or South Sudan or Tanzania or Togo or Uganda or Zimbabwe or Armenia or Bangladesh or Bhutan or Bolivia or Cabo Verde or Cambodia or Cameroon or Congo Republic or Ivory Coast or Djibouti or Egypt or El Salvador or Ghana or Guatemala or Honduras or India or Indonesia or Kenya or Kiribati or Kosovo or Kyrgyz Republic or Laos or Lesotho or Mauritania or Micronesia Federation or Moldova or Mongolia or Morocco or Myanmar or Nicaragua or Nigeria or Pakistan or Papua New Guinea or Philippines or Samoa or Sao Tome) and Principe) or Solomon Islands or Sri Lanka or Sudan or Swaziland or Syrian Arab Republic or Tajikistan or Timor-Leste or Tonga or Tunisia or Ukraine or Uzbekistan or Vanuatu or Vietnam or West Bank) and Gaza) or Yemen Republic or Zambia or Albania or Algeria or American Samoa or Angola or Argentina or Azerbaijan or Belarus or Belize or Bosnia) and Herzegovina) or Botswana or Brazil or Bulgaria or China or Colombia or Costa Rica or Cuba or Dominica or Dominican Republic or Equatorial Guinea or Ecuador or Fiji or Gabon or Georgia or Grenada or Guyana or Iran or Iraq or Jamaica or Jordan or Kazakhstan or Lebanon or Libya or Macedonia or Malaysia or Malaysia or Maldives or Marshall Islands or Mauritius or Mexico or Montenegro or Namibia or Palau or Panama or Paraguay or Peru or Romania or Russian Federation or Serbia or South Africa or Saint Lucia or Saint Vincent) and the Grenadines) or Suriname or Thailand or Turkey or Turkmenistan or Tuvalu or Venezuela).mp
Maternity & Infant Care	Midwifery.mp. OR Maternal Health Services.mp. OR Perinatal Care.mp. OR Delivery, Obstetric.mp. OR Labor, Obstetric.mp. OR Caesarean Section.mp. OR Obstetrics.mp. OR (Parturition or childbirth).mp. OR (Obstetric care or delivery care).mp. OR (Delivery assistant* or birth assistant).mp. OR ((location or place) adj3 (birth or delivery)).mp. AND ((geographic or physical) adj5 (location or access* or proximit* or distance)).mp. OR ((time or distance) adj5 (walk* or driv* or travel)).mp. OR (Health Services Accessibility or Spatial access).mp. OR Access to care.mp. AND Observational Study.mp. OR Cohort Studies.mp. OR Case-Control Studies.mp. OR Cross-Sectional Studies.mp. OR Ecological stud.mp. AND ((low or middle) adj3 (countr or nation* or econom*)).mp. OR (Afghanistan or Benin or Burkina Faso or Burundi or Central African Republic or Chad or Comoros or Congo Democratic Republic or Eritrea or Ethiopia or Gambia or Guinea or Guinea-Bissau or Haiti or Korea Democratic People’s Republic or Liberia or Madagascar or Malawi or Mali or Mozambique or Nepal or Niger or Rwanda or Senegal or Sierra Leone or Somalia or South Sudan or Tanzania or Togo or Uganda or Zimbabwe or Armenia or Bangladesh or Bhutan or Bolivia or Cabo Verde or Cambodia or Cameroon or Congo Republic or Ivory Coast or Djibouti or Egypt or El Salvador or Ghana or Guatemala or Honduras or India or Indonesia or Kenya or Kiribati or Kosovo or Kyrgyz Republic or Laos or Lesotho or Mauritania or Micronesia Federation or Moldova or Mongolia or Morocco or Myanmar or Nicaragua or Nigeria or Pakistan or Papua New Guinea or Philippines or Samoa or Sao Tome) and Principe) or Solomon Islands or Sri Lanka or Sudan or Swaziland or Syrian Arab Republic or Tajikistan or Timor-Leste or Tonga or Tunisia or Ukraine or Uzbekistan or Vanuatu or Vietnam or West Bank) and Gaza) or Yemen Republic or Zambia or Albania or Algeria or American Samoa or Angola or Argentina or Azerbaijan or Belarus or Belize or Bosnia) and Herzegovina) or Botswana or Brazil or Bulgaria or China or Colombia or Costa Rica or Cuba or Dominica or Dominican Republic or Equatorial Guinea or Ecuador or Fiji or Gabon or Georgia or Grenada or Guyana or Iran or Iraq or Jamaica or Jordan or Kazakhstan or Lebanon or Libya or Macedonia or Malaysia or Malaysia or Maldives or Marshall Islands or Mauritius or Mexico or Montenegro or Namibia or Palau or Panama or Paraguay or Peru or Romania or Russian Federation or Serbia or South Africa or Saint Lucia or Saint Vincent) and the Grenadines) or Suriname or Thailand or Turkey or Turkmenistan or Tuvalu or Venezuela).mp
CINHAL	Midwifery” OR “Maternal Health Services” OR “Perinatal Care” OR “Delivery, Obstetric” OR “Obstetric Emergencies” OR “Labor Complications” OR “Labor” OR “Labor Support” OR “Cesarean Section, Elective” OR “Cesarean Section” OR “Parturition” OR “Childbirth” OR “Obstetric Care” OR “Delivery Care (Saba CCC)” OR “Delivery assistant” OR “Birth Place” OR “Birth assistant” OR ““(location or place) adj3 (birth or delivery)”” OR ““(location or place) adj3 (birth or delivery)”” AND “geographic distance” OR “physical distance” OR “Geographic Locations”) OR “geographic proximit” OR “physical proximit” OR “physical location” OR “geographic acess” OR “geographic acess” OR “physical access” OR ““(time or distance) adj5 (walk* or driv* or travel)”” OR ““(time or distance) adj5 (walk* or driv* or travel)”” OR “walk time” OR “driv* time” OR “travel* time” OR “walk* distance” OR “driv* distance” OR “travel* distance” OR Health Services Accessibility”) OR (MH “Health Services Needs and Demand” ““Access to care”” OR ““Spatial access”” OR “Catchment Area (Health)” AND “Nonexperimental Studies” OR ““Observational Study”” OR “Cross Sectional Studies”) OR ““Cohort Studies”” OR “Case Control Studies” OR ““Ecological stud”” AND “Low and Middle Income Countries”) OR “Afghanistan or Benin or “Burkina Faso” or Burundi or “Central African Republic” or Chad or Comoros or “Congo Democratic Republic” or Eritrea or Ethiopia or Gambia or Guinea or Guinea-Bissau or Haiti or “Korea Democratic People’s Republic” or Liberia or Madagascar or Malawi or Mali or Mozambique or Nepal or Niger or Rwanda or Senegal or “Sierra Leone” or Somalia or “South Sudan” or Tanzania or Togo or Uganda or Zimbabwe or Armenia or Bangladesh or Bhutan or Bolivia or “Cabo Verde” or Cambodia or Cameroon or “Congo Republic” or “Ivory Coast” or Djibouti or Egypt or El-Salvador or Ghana or Guatemala or Honduras or India or Indonesia or Kenya or Kiribati or Kosovo or “Kyrgyz Republic” or Laos or Lesotho or Mauritania or “Micronesia Federation” or Moldova or Mongolia or Morocco or Myanmar or Nicaragua or Nigeria or Pakistan or “Papua New Guinea” or Philippines or Samoa or “Sao Tome and Principe” or “Solomon Islands” or Sri-Lanka or Sudan or Swaziland or “Syrian Arab Republic” or Tajikistan or Timor-Leste or Tonga or Tunisia or Ukraine or Uzbekistan or Vanuatu or Vietnam or “West Bank and Gaza” or “Yemen Republic” or Zambia or Albania or Algeria or “American Samoa” or Angola or Argentina or Azerbaijan or Belarus or Belize or Bosnia and Herzegovina or Botswana or Brazil or Bulgaria or China or Colombia or “Costa Rica” or Cuba or Dominica or “Dominican Republic” or “Equatorial Guinea” or Ecuador or Fiji or Gabon or Georgia or Grenada or Guyana or Iran or Iraq or Jamaica or Jordan or Kazakhstan or Lebanon or Libya or Macedonia or Malaysia or Malaysia or Maldives or “Marshall Islands” or Mauritius or Mexico or Montenegro or Namibia or Palau or Panama or Paraguay or Peru or Romania or “Russian Federation” or Serbia or “South Africa” or “Saint Lucia” or “Saint Vincent and the Grenadines” or Suriname or Thailand or Turkey or Turkmenistan or Tuvalu or Venezuela”
Scopus	midwifery OR “Maternal Health Services” OR “Perinatal Care” OR delivery, AND obstetric OR “Obstetric Labor Complications” OR labor OR “Caesarean Section” ) OR obstetrics OR parturition OR childbirth OR “Obstetric care” OR “Delivery care” OR “Delivery assistant” OR “Birth assistant” OR “(location or place) adj3 (birth or delivery)” ) AND “(geographic or physical) adj5 (location* or access* or proximit* or distance)” OR “(time or distance) adj5 (walk* or driv* or travel)” ) OR “Health Services Accessibility” OR “Spatial access” OR “Catchment Area (Health)” OR “Access to care” ) AND “Observational Study” OR “Cohort Studies” OR “Case-Control Studies” OR “Cross-Sectional Studies” OR “Ecological stud” ) AND “(low or middle) adj3 (countr or nation* or econom)” OR Afghanistan OR Benin or “Burkina Faso” OR Burundi OR “Central African Republic” OR Chad OR Comoros OR “Congo Democratic Republic” OR Eritrea or Ethiopia OR Gambia OR Guinea OR Guinea-Bissau OR Haiti OR “Korea Democratic People’s Republic” OR Liberia OR Madagascar OR Malawi OR Mali OR Mozambique OR Nepal OR Niger OR Rwanda OR Senegal* OR “Sierra Leone” OR Somalia OR “South Sudan” OR Tanzania OR Togo OR Uganda OR Zimbabwe OR Armenia OR Bangladesh OR Bhutan OR Bolivia OR “Cabo Verde” OR Cambodia ORCameroon OR “Congo Republic” OR “Ivory Coast” OR Djibouti OR Egypt OR El-Salvador OR Ghana OR Guatemala OR Honduras OR India OR Indonesia OR Kenya OR Kiribati OR Kosovo OR “Kyrgyz Republic” OR Laos OR Lesotho OR Mauritania OR “Micronesia Federation” OR Moldova OR Mongolia ORMorocco OR Myanmar OR Nicaragua OR Nigeria OR PakistanOR “Papua New Guinea” OR Philippines OR Samoa OR “Sao Tome and Principe” OR “Solomon Islands” OR Sri-Lanka OR Sudan OR Swaziland OR “Syrian Arab Republic” OR Tajikistan OR Timor-Leste OR Tonga OR Tunisia ORUkraine OR Uzbekistan OR Vanuatu OR Vietnam OR “West Bank and Gaza” OR “Yemen Republic” OR Zambia OR Albania OR Algeria OR “American Samoa” OR Angola OR Argentina ORAzerbaijan OR Belarus OR Belize OR Bosnia and Herzegovina OR Botswana OR Brazil OR Bulgaria OR China OR Colombia OR “Costa Rica” OR Cuba OR Dominica OR “Dominican Republic” OR “Equatorial Guinea” OREcuador OR Fiji OR Gabon OR Georgia ORGrenada OR Guyana ORIran OR Iraq OR Jamaica OR Jordan OR Kazakhstan OR Lebanon OR Libya OR Macedonia OR Malaysia OR Malaysia OR Maldives OR “Marshall Islands” OR Mauritius OR Mexico OR Montenegro OR Namibia OR Palau OR Panama OR Paraguay OR Peru OR Romania OR “Russian Federation” ORSerbia OR “South Africa” OR “Saint Lucia” OR “Saint Vincent and the Grenadines” OR Suriname OR Thailand OR Turkey OR Turkmenistan OR Tuvalu OR Venezuela
Hand search: Google Scholar	Varieties of key terms from the above-mentioned were used; and 39 papers turned out.

Table 2: Characteristics of studies included in systematic review and meta-analysis

Study and country	Study design and setting	Study population and sample size	Results	Geographic access on delivery care use	Remark (quality)
Karkee et al (2013), Nepal ⁽²⁷⁾ ≥60 minutes	Community based prospective cohort study	644 pregnant women up to 45 days of postpartum period	547 (85%) of them gave birth at health facility	≤30 minute travel time was significantly associated with health facility delivery; AOR = 11.61: 5.77 – 24.04 Ref: >60minutes Inverse of ≤30 ( take Ref: ≤30 minute) >60minutes: AOR = 0.09: 0.04, 0.17	Included in meta-analysis Poor quality (4/10)
Joshi et al (2016), Nepal ⁽²⁹⁾ ≥60 minutes	Community based cross-sectional study	275 women who gave birth in the past 5 years	35% had delivered at health facility	Increased institutional delivery for ≤60 minutes of travel time to nearest delivery health facility; AOR = 7.7: 4.1, 14.4 Ref: >60 minute Inverse of ≤60 (take Ref: ≤60 minutes) >60 minutes: AOR = 0.13: 0.07, 0.24	Included in meta-analysis Poor quality (4/9)
Kawakatsu et al (2014), Kenya ⁽⁴¹⁾ ≥60 minutes	Community based cross-sectional study	2026 women who had children aged from 12-24 months	48% were institutional delivery	≤20 minute travel time was associated with increased institutional delivery; AOR = 2.48: 1.74 – 3.55 Ref: >60minutes Inverse of ≤20 (take Ref: ≤20 minute) >60minutes: AOR = 0.40: 0.28, 0.57	Included in meta-analysis Good quality (9/9)
Hailu & Berhe (2014), Ethiopia ⁽⁴²⁾ ≥60 minutes	Community based cross-sectional study	485 women of reproductive age who gave birth in the past two years	31.5% gave birth at health facilities	An increased institutional delivery for <60 minute of travel to nearest health facility; AOR = 3.3: 1.15 – 9.52 Ref: ≥60minutes Inverse of <60 (take Ref: <60 minute) ≥60minutes: AOR = 0.30: 0.11, 0.87	Included in meta-analysis Good quality (8/9)
Habte & Demissie (2015), Ethiopia ⁽⁴³⁾ ≥60 minutes	Community based cross-sectional study	816 women who gave birth in the past two years	31% of births were in health facility	Decreased institutional delivery for >60 minute travel time; >60 minute; AOR = 0.22: 0.09, 0.55 Ref: <30 minute	Included in meta-analysis Good quality (7/9)
Wagle et al (2004), Nepal ⁽⁴⁴⁾ ≥60 minutes	Community based cross-sectional study	308 women who gave birth within 45 days of the survey	50.6% of deliveries were in health facility	A traveling time of >60 minutes to a maternity hospital led to an increased odds of home delivery; AOR = 7.9; 3.7, 16.6 Ref: <60 minutes For institutional delivery – take the inverse of home delivery; AOR = 0.13: 0.06, 0.27	Included in meta-analysis Good quality (7/9)
Feyissa & Genemo (2014), Ethiopia ⁽⁴⁵⁾ ≥60 minutes and ≤5km	Unmatched case control	320 women aged 15-49 years	80 cases (institutional) and 240 home deliveries	≥10 km; OR = 0.665: 0.173, 0.954 Ref: <5km Travel time: Ref; >2hour <60 minute; AOR = 3.554; 0.884, 14.283 (Not sig) Take Ref <60; then AOR for >2 hour = 0.28; 0.07, 1.13	Included in meta-analysis Good quality (7/9)
Worku & Alemay (2016), Ethiopia ⁽⁴⁶⁾ ≥60 minutes	Community based cross-sectional study	573 women who gave birth 12 months preceding the survey	16.9% were health facility births	Travel time to closest health facility: Ref; >2 hour <60 minutes: AOR = 5.2; 2.8, 12.3 1 to 2 hour not significant Take ref <60: AOR for >2hr = 0.19; 0.08, 0.36	Included in meta-analysis Good quality (7/9)
Van et al (2006), Kenya ⁽⁴⁷⁾ ≥60 minutes	Community based cross-sectional study	635 women who gave birth 12 months preceding the survey	83% were outside health facility; of these 80%, 18% & 3% were in their house, TBA house & on the way to health facility	Travel time: Birth outside health facility Ref: <60 minutes of walk >60 minutes of walk: AOR = 2.75; 1.33, 5.68 Take inverse of birth outside health facility to health facility delivery Ref: <60 minutes of walk >60 minutes of walk: AOR = 0.36; 0.18, 0.75	Included in meta-analysis Good quality (7/9)
Lwelamira et al (2012), Tanzania ⁽⁴⁸⁾ ≤5km	Community based cross-sectional study	984 women gave birth 2 years prior	54% were in institutional deliveries	>10 km; OR = 0.62: 0.47, 0.81 Ref: <5km	Included in meta-analysis Good quality (7/9)
Yanagisawa et al (2006), Cambodia ⁽⁴⁹⁾ ≤5km	Community based cross-sectional study	980 women aged 15-49 who gave birth within 3 months	55.2% were health facility	Distance to Health Centre is for facility delivery; Ref: >5km <2km; OR = 3.35; 2.10, 5.34 Distance to Hospital is for facility delivery; Ref: ≥20km <10km: OR= 3.32: 2.02, 5.45	Included in meta-analysis Good quality (7/9)
Gage & Guirle (2006), Haiti ⁽⁵⁰⁾ ≤5km	Community based cross-sectional study	4533 rural women aged 15-49 years	9.6% were intuitional deliveries	Distance to hospital; Ref <5km 5-14 km: OR = 0.339; 0.197, 0.584	Included in meta-analysis Good quality (7/9)
Kesterton et al (2012), India ⁽⁵¹⁾ ≤5km	Community based cross-sectional study	98777 and 90303 women aged 15-49 who had births within 3 years preceding the survey	Trend (1989 to 1998) is 15-25%	Distance to hospital: Ref: >30km ≤5km: OR = 2.43; 1.93, 3.06	Included in meta-analysis Good quality (7/9)
Mageda & Mmbaga (2015), Tanzania ⁽⁵²⁾ ≤5km	Community based cross-sectional study	598 women who gave birth 12 months preceding the survey	56% were health facility births	Distance to health facility: Ref; ≥10km <5km; OR = 2.3: 1.3, 3.9	Included in meta-analysis Good quality (7/9)
Faye et al (2011), Senegal ⁽⁵³⁾ ≤5km	Community based cross-sectional study	373 women who gave birth in the last 12months	22% were home delivery	Distance to health centre; Home births >5km; OR = 2.24; 1.21, 4.15 Ref: ≤5km	Included in meta-analysis Good quality (7/9)
Anyait et al (2012), Uganda ⁽¹²⁾ ≤5km	Community based cross-section study	500 women who gave birth in the past two years	45.4% delivered in health facility	Having access to obstetric care facility within 3km is not associated with facility delivery Crude OR = 1.9: 1.2, 3.1; No Confidence interval for AOR	Included in systematic review Good quality (7/9)
De Allegri et al (2011), Burkina Faso ⁽²⁸⁾ ≤5km	Community based cross-sectional study	435 women reported pregnant 12 months prior to the survey	72% were health facility delivery	Having access to obstetric care facility within 5km increased institutional delivery; AOR = 28.42, Robust Standard Error = 11.90; No Confidence interval for AOR	Included in systematic review Poor quality (4/9)
Kitui et al (2013), Kenya ⁽¹³⁾ ≤5km	Community based cross-sectional study	3967 women aged 15-49 who had births within 5 years preceding the survey	46.8% were health facility births	Distance to health facility: AOR not significant 2-5km: COR: 0.5: 0.46, 0.68 Ref: <2km Confidence interval not given for AOR	Included in systematic review Good quality (7/9)
De Allegri et al (2015), Burkina Faso ⁽³⁵⁾ Ref ≤6km	Community based cross-sectional study	420 women of recent history of childbirth	11% of home delivery	A distance of ≥7 km was significantly associated with an increased in home delivery; AOR = 19.33; 3.37, 110.88 Ref ≤6km	Included in systematic review Good quality (5/8)
Jain et al (2015), Pakistan ⁽²⁵⁾ ≤10km and 1km increase	Cross-sectional study, Linked health facility & household survey	763 obstetric care facilities and 4435 women who gave birth three years before the survey	21.0% of women had no access to delivery care facility within 10 kilometre	Odds of institutional delivery decreased by 3% with one kilometre increase in distance; AOR = 0.97 Having access to basic (AOR = 1.79) or comprehensive (AOR = 1.72) emergency obstetric care within 10 kilometre increased odds of institutional deliveries	Included in systematic review Good quality (9/9)
Ogolla (2015), Kenya ⁽³⁴⁾ ≤10km	Community based cross-sectional study	600 women aged 15-49 who had births within 6 months prior	33.3% were health facility births	Distance to nearest health facility; Ref: ≤10km >10 km; OR = 0.5: 0.3, 0.7	Included in systematic review Good quality (7/9)
Zegeye et al (2014), Ethiopia ⁽⁹⁾ 1km increase	Community based cross-sectional study	528 women who gave birth preceding the survey	8% of mothers gave birth in health facility	A 22% decrease in institutional delivery per one kilometre increase in walking distance to the nearest health centre; AOR = 0.78 (0.64, 0.96)	Included in systematic review Good quality (7/9)
Joharifard et al (2012), Rwanda ⁽³¹⁾ 1km increase	Community based cross-sectional study – Trend analysis	3106 lifetime deliveries from 895 women (18-50 years of age and gave birth within three years)	89.8% of them delivered in health facility	Facility delivery decreased per a single kilometre increase in distance to the closest health facility; AOR = 0.909 (0.846, 0.976)	Included in systematic review Good quality (5/9)
Kumar et al (2014), India ⁽³²⁾ 1km increase	Community based cross-sectional study	158897 women aged 15-49 years	36% were institutional births	A one kilometre increase in distance is associated with a 4.4% decrease in health facility delivery No CI for AOR or COR	Included in systematic review Good quality (7/9)
Hounton et al (2008), Burkina Faso ⁽³³⁾ 1km increase	Community & health facility based cross-sectional study	43 Health Facilities & census of women aged 12-49	81536 births; 3145 (38.4%) were institutional births	Institutional birth decrease with… Odds ratio/km; distance to health centre 0.77/km (<7.5km) & 0.97/km (≥7.5km) Distance to hospital; Odds ratio/10km = 0.83	Included in systematic review Good quality (7/9)
Lohela et al (2012), Malawi and Zambia ⁽⁷⁾ 10km increase	Cross-sectional study, linked analysis (Household survey (HHS) and health facility assessment (SPA))	8537 births (firstborn were included in case of multiple births ) 8842 total births 446 health facilities	Half of the births were in health facility	Health facility delivery decreased by 65% for every 10 km increase in distance; AOR = 0.35 (Malawi)	Included in systematic review Good quality (8/9)
Lohela et al (2012), Malawi and Zambia ⁽⁷⁾ 10km increase		3682 births (firstborn were included in case of multiple births ) 3771 total births 1131 health facilities	32.5% of births were in health facility	Health facility delivery decreased by 27% for every 10 km increase in distance; AOR = 0.73 (Zambia)	Included in systematic review Good quality (8/9)
Gabrysch et al (2011), Zambia ⁽⁶⁾ Doubling distance	Cross-sectional study, linked analysis (HHS & SPA)	3682 births (firstborn were included in case of multiple births) 1131 health facilities	32.5% births were health facility	A 29% decrease in odds of facility delivery for every doubling of distance	Included in systematic review Good quality (8/9)
Masters et al (2013), Ghana ⁽²⁶⁾ 1hr increase	Cross-sectional study; Linked population and health facility data	1172 mothers, and 1646 births, and 1268 facilities	39.0% were in facility deliveries	An increase in travel time of one hour decreased the odds of facility delivery by 20%; AOR = 0.80: 0.69, 0.93	Included in systematic review Good quality (8/8)
Teferra et al (2012), Ethiopia ⁽¹⁰⁾ <60 minutes	Community based cross-sectional study	371 women who gave birth 12 months preceding the survey	12.1% were health facility births	Travel time to closest health facility: AOR not significant <60 minutes: COR = 6.2; 1.87, 20.5 Ref: ≥60 minute Take <60 minute as Ref COR for ≥60 minute = 0.16; 0.05, 0.53; AOR not given	Included in meta-analysis Good quality (7/9)
Amano et al (2012), Ethiopia ⁽¹¹⁾ ≤30 minutes	Community based cross-sectional study	855 women who gave birth 12 months preceding the survey	12.3% were health facility births	Travel time to closest health facility: AOR not significant ≤30 minutes: COR = 2.04; 1.26, 3.30 Ref: >30 minute AOR not given	Included in systematic review Good quality (7/9)
Shimazaki et al (2013), Philippines ⁽³⁰⁾ ≤30 minutes	Community based cross-sectional study	354 women who gave birth in the 3 years	44.4% were HF delivery	Time taken to nearest HF; Ref: ≥31minutes 11-30 minutes; OR = 3.3; 1.7, 6.6 ≤10minutes: OR = 6.9; 3.4, 14.2	Included in systematic review Good quality (7/9)

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