Centre for Maternal Adolescent Reproductive and Child Health (MARCH), London School of Hygiene and Tropical Medicine, London, UK.
Centre Muraz, Bobo Dioulasso, Burkina Faso.
Trop Med Int Health. 2019 Jan;24(1):31-42. doi: 10.1111/tmi.13170. Epub 2018 Nov 18.
Although distance has been identified as an important barrier to care, evidence for an effect of distance to care on child mortality is inconsistent. We investigated the association of distance to care with self-reported care seeking behaviours, neonatal and post-neonatal under-five child mortality in rural areas of Burkina Faso.
We performed a cross-sectional survey in 14 rural areas from November 2014 to March 2015. About 100 000 women were interviewed on their pregnancy history and about 5000 mothers were interviewed on their care seeking behaviours. Euclidean distances to the closest facility were calculated. Mixed-effects logistic and Poisson regressions were used respectively to compute odds ratios for care seeking behaviours and rate ratios for child mortality during the 5 years prior to the survey.
Thirty per cent of the children lived more than 7 km from a facility. After controlling for confounding factors, there was a strong evidence of a decreasing trend in care seeking with increasing distance to care (P ≤ 0.005). There was evidence for an increasing trend in early neonatal mortality with increasing distance to care (P = 0.028), but not for late neonatal mortality (P = 0.479) and post-neonatal under-five child mortality (P = 0.488). In their first week of life, neonates living 7 km or more from a facility had an 18% higher mortality rate than neonates living within 2 km of a facility (RR = 1.18; 95%CI 1.00, 1.39; P = 0.056). In the late neonatal period, despite the lack of evidence for an association of mortality with distance, it is noteworthy that rate ratios were consistent with a trend and similar to or larger than estimates in early neonatal mortality. In this period, neonates living 7 km or more from a facility had an 18% higher mortality rate than neonates living within 2 km of a facility (RR = 1.18; 95%CI 0.92, 1.52; P = 0.202). Thus, the lack of evidence may reflect lower power due to fewer deaths rather than a weaker association.
While better geographic access to care is strongly associated with increased care seeking in rural Burkina Faso, the impact on child mortality appears to be marginal. This suggests that, in addition to improving access to services, attention needs to be paid to quality of those services.
尽管距离已被确定为护理的重要障碍，但距离护理对儿童死亡率的影响证据并不一致。我们调查了距离护理与自我报告的护理寻求行为、新生儿和新生儿后 5 岁以下儿童死亡率在布基纳法索农村地区之间的关系。
我们于 2014 年 11 月至 2015 年 3 月在 14 个农村地区进行了一项横断面调查。大约 10 万名妇女接受了妊娠史访谈，约 5000 名母亲接受了护理寻求行为访谈。计算了到最近设施的欧几里得距离。使用混合效应逻辑回归和泊松回归分别计算了护理寻求行为的比值比和调查前 5 年儿童死亡率的率比。
30%的儿童居住在距离设施 7 公里以上的地方。在控制了混杂因素后，有强有力的证据表明，随着距离护理的增加，寻求护理的意愿呈下降趋势（P≤0.005）。随着距离护理的增加，早期新生儿死亡率呈上升趋势（P=0.028），但晚期新生儿死亡率（P=0.479）和新生儿后 5 岁以下儿童死亡率（P=0.488）没有上升趋势。在出生后的第一周，距离设施 7 公里或以上的新生儿死亡率比距离设施 2 公里以内的新生儿高 18%（RR=1.18；95%CI 1.00，1.39；P=0.056）。在晚期新生儿期，尽管死亡率与距离之间的关系没有证据，但值得注意的是，比率比与趋势一致，且与早期新生儿死亡率的估计值相似或更大。在此期间，距离设施 7 公里或以上的新生儿死亡率比距离设施 2 公里以内的新生儿高 18%（RR=1.18；95%CI 0.92，1.52；P=0.202）。因此，缺乏证据可能反映了由于死亡人数较少而导致的较低效力，而不是较弱的关联。
尽管更好的地理上获得护理与农村布基纳法索护理寻求的增加密切相关，但对儿童死亡率的影响似乎微不足道。这表明，除了改善服务获取之外，还需要关注这些服务的质量。
