The influence of distance and level of care on delivery place in rural Zambia: a study of linked national data in a geographic information system.
The influence of distance and level of care on delivery place in rural Zambia: a study of linked national data in a geographic information system.
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DOI：
10.1371/journal.pmed.1000394
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发表时间：
2011-01-25
期刊：
影响因子：
15.8
通讯作者：
Campbell OM
中科院分区：
文献类型：
--
作者：
Gabrysch S;Cousens S;Cox J;Campbell OM
Sabine Gabrysch及其同事利用地理信息系统中的相关国家数据，调查了到护理中心的距离和护理水平对赞比亚农村妇女使用卫生设施分娩的影响。如果所有妇女都能在出现并发症时由熟练助产士提供紧急产科护理的环境中分娩，孕产妇和围产期死亡率就能降低。关于熟练助产的决定因素的研究侧重于家庭和个人因素，忽视了保健服务环境的影响，部分原因是缺乏适当的数据。本研究的目的是量化护理距离和护理水平对赞比亚农村妇女使用保健设施分娩的影响，并将其对人口的影响与其他重要决定因素进行比较。利用地理信息系统（GIS），我们将2007年赞比亚人口与健康调查的全国家庭数据与2005年赞比亚卫生设施普查的全国设施数据联系起来，并计算直线距离。卫生设施按是否提供全面的EmOC （CEmOC）、基本的EmOC （BEmOC）、有限的或不合格的服务进行分类。采用多变量多水平logistic回归分析，对3,682名农村新生儿进行了多变量多水平logistic回归分析，以调查护理距离和护理水平对分娩地点（设施或家庭）的影响，控制了广泛的混杂因素。在赞比亚农村地区，只有三分之一的分娩是在卫生机构进行的，而在所有分娩中，有一半的母亲所居住的地方距离卫生保健中心标准或更高标准的设施超过25公里。由于到最近的卫生设施的距离增加了一倍，设施分娩的几率降低了29%（95%置信区间，14%-40%）。独立而言，护理水平每提高一步，送往医院的几率就会提高26% （95% CI, 7%-48%）。地理上缺乏获得EmOC的机会对人口的影响至少与母亲教育程度低、家庭贫困或缺乏女性自主权的影响相似。缺乏地理位置上的产科急诊是解释为什么赞比亚大多数农村分娩仍然在没有熟练护理的情况下在家中进行的一个关键因素。消除地理和质量障碍对于增加服务使用和降低孕产妇和围产期死亡率至关重要。利用地理信息系统连接数据集对未来的研究具有很大的潜力，并且可以帮助克服在研究和政策中忽视卫生系统因素的问题。每年约有36万名妇女死于怀孕和分娩，其中20多万在撒哈拉以南非洲，在那里，妇女在怀孕期间或怀孕后死亡的终生风险仍然高达1 / 31（而发达国家为1 / 4300）。千年发展目标5的具体目标是到2015年将产妇死亡率降低四分之三。如果所有妇女都在有熟练助产士（如助产士）的环境中分娩，并且在出现并发症时能为母亲和婴儿提供紧急产科护理，那么低收入国家的大多数孕产妇和新生儿死亡是可以避免的。然而，每年大约有5000万妇女在没有熟练护理的情况下在家分娩。妇女在卫生设施中由熟练助产士护理分娩的可能性取决于许多因素。这些因素包括母亲及其家庭的特征，如教育水平和家庭财富，以及保健服务环境的各个方面，例如，与最近的保健设施的距离以及该设施提供的护理质量。然而，迄今为止的研究通常侧重于家庭和个人因素，忽视了卫生服务环境对分娩地点选择的影响，主要是因为没有适当的数据。在赞比亚农村的这项研究中，研究人员旨在量化卫生服务环境的影响，即到卫生保健的距离和提供的护理水平，对孕妇使用卫生设施分娩的影响。为了综合考虑这些因素，研究人员比较了距离对医疗质量的影响，以及其他重要因素，如贫困和教育程度。研究人员利用地理信息系统（GIS）将国家家庭数据（来自2007年赞比亚人口与健康调查）与国家设施数据（来自2005年赞比亚卫生设施普查）联系起来，并计算了妇女村庄和卫生设施之间的直线距离。根据所报告的执行8项产科急诊信号功能中一定数量的能力，将保健设施分为提供全面产科急诊、基本产科急诊或有限或不合格服务三类：可注射抗生素、可注射催产素、可注射抗惊厥药、人工移除胎盘、人工移除残留产品、辅助阴道分娩、剖宫产和输血，以及人员配置、开放时间和转诊能力标准。研究人员使用了来自3,682名农村新生儿的数据，并进行了多变量多水平logistic回归分析，以调查距离最近的分娩设施的距离和护理水平是否会影响分娩地点（卫生设施或家庭），同时保持其他影响因素不变。这组科学家发现，在赞比亚农村，只有三分之一的分娩是在卫生机构进行的，在所有分娩的母亲中，有一半居住在距离提供基本紧急产科服务的卫生机构25公里以上的地方。由于到最近的卫生机构的距离增加了一倍，妇女在卫生机构分娩的几率降低了29%。独立地说，在最近的分娩设施提供的产科急诊水平每提高一步，就会增加妇女在该设施分娩的可能性（增加26%的几率）。研究人员估计，地理位置差的产科急诊服务的影响程度与产妇教育程度低、家庭贫困或缺乏女性自主权的影响程度相似。这项研究的结果表明，地理位置难以获得紧急产科护理是解释为什么大多数赞比亚农村妇女仍然在没有熟练护理的情况下在家分娩的关键因素。因此，为了增加在保健设施分娩的妇女人数，从而降低孕产妇和新生儿死亡率，必须解决使用分娩服务的地理和质量障碍。此外，本研究中使用的方法——使用GIS连接数据集——在未来的研究中具有很大的潜力，因为它可以帮助探索卫生系统因素对其他健康问题的影响。请通过本摘要的在线版本（http://dx.doi.org/10.1371/journal.pmed.1000394）访问这些网站。关于产科急诊的资料由联合国人口基金（人口基金）提供。关于产妇保健的各种专题由卫生组织、卫生组织非洲区域办事处、人口基金、世卫组织提供有关千年发展目标5的详细信息家庭护理国际提供有关孕产妇和新生儿健康的更多信息避免孕产妇死亡和残疾规划提供关于紧急产科和新生儿护理需求评估的信息2015年倒计时跟踪孕产妇、新生儿和儿童生存方面的进展世卫组织提供免费在线观看BBC“为生命而战”视频，介绍不同国家的分娩经验
Using linked national data in a geographic information system system, Sabine Gabrysch and colleagues investigate the effects of distance to care and level of care on women's use of health facilities for delivery in rural Zambia. Maternal and perinatal mortality could be reduced if all women delivered in settings where skilled attendants could provide emergency obstetric care (EmOC) if complications arise. Research on determinants of skilled attendance at delivery has focussed on household and individual factors, neglecting the influence of the health service environment, in part due to a lack of suitable data. The aim of this study was to quantify the effects of distance to care and level of care on women's use of health facilities for delivery in rural Zambia, and to compare their population impact to that of other important determinants. Using a geographic information system (GIS), we linked national household data from the Zambian Demographic and Health Survey 2007 with national facility data from the Zambian Health Facility Census 2005 and calculated straight-line distances. Health facilities were classified by whether they provided comprehensive EmOC (CEmOC), basic EmOC (BEmOC), or limited or substandard services. Multivariable multilevel logistic regression analyses were performed to investigate the influence of distance to care and level of care on place of delivery (facility or home) for 3,682 rural births, controlling for a wide range of confounders. Only a third of rural Zambian births occurred at a health facility, and half of all births were to mothers living more than 25 km from a facility of BEmOC standard or better. As distance to the closest health facility doubled, the odds of facility delivery decreased by 29% (95% CI, 14%–40%). Independently, each step increase in level of care led to 26% higher odds of facility delivery (95% CI, 7%–48%). The population impact of poor geographic access to EmOC was at least of similar magnitude as that of low maternal education, household poverty, or lack of female autonomy. Lack of geographic access to emergency obstetric care is a key factor explaining why most rural deliveries in Zambia still occur at home without skilled care. Addressing geographic and quality barriers is crucial to increase service use and to lower maternal and perinatal mortality. Linking datasets using GIS has great potential for future research and can help overcome the neglect of health system factors in research and policy. Please see later in the article for the Editors' Summary Approximately 360,000 women die each year in pregnancy and childbirth, of which more than 200,000 in sub-Saharan Africa, where a woman's lifetime risk of dying during or following pregnancy remains as high as 1 in 31 (compared to 1 in 4,300 in the developed world). The target of Millennium Development Goal 5 is to reduce the maternal mortality ratio by three quarters by 2015. Most maternal and neonatal deaths in low-income countries could be prevented if all women delivered their babies in settings where skilled birth attendants (such as midwives) were available and could provide emergency obstetric care to both mothers and babies in case of complications. Yet every year roughly 50 million women give birth at home without skilled care. The likelihood of a woman giving birth in a health facility under the care of a skilled birth attendant depends on many factors. These include characteristics of the mother and her family, such as education level and household wealth, and aspects of the health service environment—distance to the nearest health facility and the quality of care provided at that facility, for example. However, research to date has typically focused on household and individual factors, neglecting the influence of the health service environment on choice of delivery place, largely because suitable data was not available. In this study in rural Zambia, the researchers aimed to quantify the effects of the health service environment, namely distance to health care and the level of care provided, on pregnant women's use of health facilities for giving birth. To put these factors in context, the researchers compared the impact of distance to quality care on place of delivery to that of other important factors, such as poverty and education. Using a geographic information system (GIS), the researchers linked national household data (from the 2007 Zambia Demographic and Health Survey) with national facility data (from the 2005 Zambian Health Facility Census) and calculated straight-line distances between women's villages and health facilities. Health facilities were classified as providing comprehensive emergency obstetric care, basic emergency obstetric care, or limited or substandard services by using reported capability to perform a certain number of the eight emergency obstetric care signal functions: injectable antibiotics, injectable oxytocics, injectable anticonvulsants, manual removal of placenta, manual removal of retained products, assisted vaginal delivery, cesarean section, and blood transfusion, as well as criteria on staffing, opening hours and referral capacity. The researchers used data from 3,682 rural births and multivariable multilevel logistic regression analyses to investigate whether distance to, and level of care at the closest delivery facility influence place of delivery (health facility or home), keeping other influential factors constant. The researchers found that only a third of births in rural Zambia occurred at a health facility, and half of all mothers who gave birth lived more than 25 km from a health facility that provided basic emergency obstetric services. As distance to the closest health facility doubled, the odds of a women giving birth in a health facility decreased by 29%. Independently, each step increase in the level of emergency obstetric care provided at the closest delivery facility led to an increased likelihood (26% higher odds) of a woman delivering her baby at a facility. The researchers estimated that the impact of poor geographic access to emergency obstetric services was of similar magnitude as that of low maternal education, household poverty, or lack of female autonomy. The results of this study suggest that poor geographic access to emergency obstetric care is a key factor in explaining why most women in rural Zambia still deliver their babies at home without skilled care. Therefore, in order to increase the number of women delivering in health facilities and thus reduce maternal and neonatal mortality, it is crucial to address the geographic and quality barriers to delivery service use. Furthermore, the methodology used in this study—linking datasets using GIS— has great potential for future research as it can help explore the influence of health system factors also for other health problems. Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000394. Information about emergency obstetric care is provided by the United Nations Population Fund (UNFPA) Various topics on maternal health are presented by WHO, WHO Regional Office Africa, by UNPFA, and UNICEF WHO offers detailed information about MDG5 Family Care International offers more information about maternal and neonatal health The Averting Maternal Death and Disability program (AMDD) provides information on needs assessments of emergency obstetric and newborn care Countdown to 2015 tracks progress in maternal, newborn, and child survival WHO provides free online viewing of BBC Fight for Life videos describing delivery experiences in different countries
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影响因子：
2.3
作者：
Howe, Laura D;Hargreaves, James R;Huttly, Sharon R A
通讯作者：
Huttly, Sharon R A
DOI：
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