Background
Methods
Study setting
Data collection
Estimation of Euclidian distance
Modelling of travel time in a GIS
Village/area of residence | District | Province | Features of the roads between the village and Herat Hospital | Reference time (minutes) | Initial model results (minutes) | Final model results (minutes) |
---|---|---|---|---|---|---|
Guzara district centre | Guzara | Herat | Paved roads | 15 | 21.5 | 21.5 |
Qala-i-Naw district centre | Qala-i-Naw | Badghis | All types of roads passing through mountains | 240-300 | 188.9 | 244.7 |
Karukh district centre | Karukh | Herat | Paved roads | 30-40 | 38.8 | 38.8 |
Turghundi | Kushk | Herat | Paved roads but not very smooth | 120 | 93.7 | 93.7 |
Islam Qala | Kohsan | Herat | Paved roads only | 90-100 | 97.1 | 97.1 |
Shahrak district centre | Shahrak | Ghor | In the mountains | 540-600 | 304.7 | 415.1 |
Dara-Takht | Chishiti Sherif | Herat | Tracks | 360 | 244.9 | 250.9 |
Shindand district centre | Shindand | Herat | Paved roads | 100-120 | 128.3 | 130.3 |
Chishiti Sherif district centre | Chishiti Sherif | Herat | Tracks | 270 | 208.4 | 208.4 |
Obe district centre | Obe | Herat | Tracks but relatively flat | 150-180 | 162.4 | 162.5 |
Pashtun Zarghun district centre | Pashtun Zarghun | Herat | Tracks but relatively flat | 90 | 117.2 | 117.2 |
Chartaz | Jawand | Badghis | All types of roads passing through mountains | 720 | 383.4 | 728.6 |
The definition of a delay and the variables in the conceptual framework
1. Referral | 2. Social class hierarchy | 3. Relational factors | 4. Environmental factors | 5. Obstetric factors | 6. Transportation factors |
---|---|---|---|---|---|
No. health facilities before admission to CEmOC | Asset-based socio-economic status | Husband’s participation in community activities in last 12 months | Season | Complication type | Transferred in an ambulance |
Husband’s occupation | No. people the husband can rely on to borrow a small amount of money from | Urban/rural | Antenatal care utilization | Community usually has a vehicle | |
Husband’s education | No. people the husband can rely on in long-term emergency | Parity | Reported difficulty obtaining a vehicle | ||
Family type (nuclear vs. extended family) | |||||
Woman’s birth family lives nearby |
Data analysis
Ethics clearance
Results
Euclidian distance
Risk factors
| N | Straight-line distance (km) [IQ range] | p-value* | N | Modelled travel time (hours) [IQ range] | p-value* | N | Reported travel time (hours) [IQ range] | p-value* | N | Delay (hours) [IQ range] | p-value* |
---|---|---|---|---|---|---|---|---|---|---|---|---|
The number of health facilities visited before CEmOC
| ||||||||||||
2 or more | 69 | 79.2 [21.4, 116.5] | 69 | 2.1 [1.0, 4.1] | 67 | 29.5 [8.2, 88.0] | 67 | 24.9 [7.0, 84.3] | ||||
1 | 173 | 48.6 [10.8, 98.9] | 174 | 1.6 [0.6, 2.7] | 172 | 5.3 [3.1, 13.7] | 172 | 3.8 [1.4, 11.5] | ||||
None (came straight to CEmOC) | 159 | 7.8 [0.4, 18.0] | <0.0001 | 159 | 0.6 [0.6, 1.0] | <0.0001 | 158 | 0.8 [0.5, 1.5] | <0.0001 | 158 | 0 [-0.2, 0.4] | <0.0001 |
Complication type
| ||||||||||||
Haemorrhage in early pregnancy | 60 | 10.4 [0.4, 37.9] | 60 | 0.7 [0.6, 2.0] | 58 | 4.5 [1.0, 29.5] | 58 | 2.5 [0.2, 28.9] | ||||
Severe pre-eclampsia | 51 | 7.8 [0,4, 33.9] | 51 | 0.6 [0.6, 1.3] | 50 | 3.0 [0.7, 26.5] | 50 | 1.9 [0.1, 23.1] | ||||
APH | 55 | 16.3 [2.9, 89.0] | 55 | 0.9 [0.6, 2.3] | 54 | 3.4 [0.8, 8.0] | 54 | 1.5 [0.3, 5.6] | ||||
Eclampsia | 93 | 27.1 [3.1, 84.1] | 93 | 1.1 [0.6, 2.5] | 93 | 3.5 [1.0, 9.0] | 93 | 2.2 [0.1, 4.9] | ||||
Impending rupture of the uterus | 38 | 52.3 [14.1, 98.9] | 38 | 1.6 [0.9, 2.7] | 38 | 6.4 [1.5, 14.3] | 38 | 4.6 [0.3, 11.1] | ||||
Rupture of the uterus | 30 | 65.7 [7.8, 106.3] | 30 | 1.6 [0.6, 2.5] | 29 | 5.0 [1.0, 10.0] | 29 | 2.8 [0.6, 7.5] | ||||
PPH | 48 | 21.3 [10.1, 63.9] | 48 | 1.0 [0.6, 1.9] | 47 | 1.3 [0.5, 4.0] | 47 | 0.2 [-0.1, 1.2] | ||||
Sepsis | 23 | 85.0 [9.7, 155.3] | 24 | 2.6 [0.7, 7.8] | 24 | 21.3 [2.8, 68.5] | 24 | 12.4 [1.9, 54.9] | ||||
Other | 4 | 74.4 [23.8, 109.9] | <0.0001 | 4 | 3.1 [1.7, 8.4] | 0.0041 | 3 | 16.3 [2.0, 27.0] | 0.0003 | 4 | 9.1 [0.8, 19.1] | <0.0001 |
Parity
| ||||||||||||
6 or more | 90 | 19.9 [5.9, 75.0] | 90 | 1.0 [0.6, 2.3] | 87 | 4.0 [1.0, 13.0] | 87 | 2.2 [0.3, 10.7] | ||||
3-5 | 96 | 14.2 [0.4, 71.4] | 96 | 0.8 [0.6, 1.9] | 94 | 2.7 [0.7, 9.5] | 94 | 1.4 [0.1, 6.9] | ||||
1-2 | 78 | 48.6 [9.9, 106.3] | 78 | 1.6 [0.6, 2.7] | 78 | 5.0 [1.2, 14.5] | 78 | 2.9 [0.2, 9.4] | ||||
Nullipara | 109 | 11.7 [0.4, 71.7] | 0.0078 | 109 | 0.8 [0.6, 2.0] | 0.0608 | 108 | 3.0 [0.5, 10.5] | 0.1786 | 108 | 1.6 [-0.1, 8.1] | 0.3409 |
Antenatal Care
| ||||||||||||
No ANC | 123 | 43.5 [7.1, 101.6] | 123 | 1.6 [0.6, 3.3] | 123 | 5.0 [1.5, 17.0] | 123 | 3.0 [0.2, 13.8] | ||||
1-3 visits | 161 | 21.5 [4.1, 79.2] | 161 | 1.0 [0.6, 1.9] | 159 | 3.5 [1.0, 9.8] | 159 | 2.2 [0.1, 6.8] | ||||
4 or more visits | 91 | 9.0 [0.4, 50.9] | 0.0005 | 91 | 0.6 [0.6, 1.6] | 0.0002 | 88 | 1.9 [0.5, 6.8] | 0.0032 | 88 | 0.6 [-0.1, 5.4] | 0.0390 |
Reported difficulty in obtaining transportation
| ||||||||||||
Very difficult | 59 | 80.7 [37.2, 133.4] | 59 | 3.1 [1.4, 6.6] | 57 | 12.0 [4.0, 27.0] | 57 | 6.4 [1.6, 20.8] | ||||
Moderately difficult | 124 | 34.9 [12.0, 93.3] | 124 | 1.4 [0.6, 2.6] | 122 | 4.4 [1.0, 10.0] | 122 | 2.1 [0.4, 7.0] | ||||
Not difficult | 211 | 7.8 [0.4, 48.6] | <0.0001 | 211 | 0.6 [0.6, 1.6] | <0.0001 | 210 | 2.5 [0.5, 8.0] | <0.0001 | 210 | 1.2 [-0.1, 5.9] | <0.0001 |
Community access to a vehicle
| ||||||||||||
No | 44 | 82.7 [30.4, 143.1] | 44 | 3.3 [1.1, 7.1] | 42 | 12.3 [4.5, 34.2] | 42 | 6.6 [0.6, 33.2] | ||||
Yes | 354 | 16.5 [0.4, 75.0] | <0.0001 | 354 | 0.9 [0.6, 2.0] | <0.0001 | 350 | 3.0 [1.0, 10.0] | <0.0001 | 350 | 1.6 [0.1, 7.0] | 0.0005 |
Ambulance use
| ||||||||||||
Yes | 61 | 76.9 [41.2, 106.3] | 61 | 2.1 [1.4, 3.1] | 60 | 6.8 [4.0, 13.4] | 60 | 4.6 [2.3, 10.9] | ||||
No | 337 | 15.1 [0.4, 71.7] | <0.0001 | 337 | 0.9 [0.6, 1.9] | <0.0001 | 333 | 2.8 [0.7, 11.0] | <0.0001 | 333 | 1.4 [0.0, 8.4] | 0.0002 |
Seasons
| ||||||||||||
Summer | 88 | 25.9 [0.4, 93.3] | 88 | 1.0 [0.6, 2.6] | 86 | 5.7 [1.0, 15.0] | 86 | 4.0 [0.3, 13.4] | ||||
Fall | 102 | 17.2 [2.3, 75.8] | 102 | 1.0 [0.6, 2.2] | 102 | 3.0 [0.5, 7.0] | 102 | 1.3 [0.1, 5.4] | ||||
Winter | 104 | 22.3 [0.4, 83.0] | 105 | 1.0 [0.6, 1.9] | 104 | 3.8 [1.0, 11.6] | 104 | 1.9 [0, 8.4] | ||||
Spring | 108 | 21.5 [5.9, 78.9] | 0.8922 | 108 | 1.1 [0.6, 2.3] | 0.9072 | 105 | 3.5 [1.0, 9.5] | 0.1564 | 105 | 1.8 [0.2, 6.5] | 0.1403 |
Household socio-economic status
| ||||||||||||
Poorest | 105 | 80.7 [48.3, 117.8] | 105 | 2.5 [1.6, 4.4] | 103 | 8.0 [4.0, 17.5] | 103 | 4.9 [1.6, 14.6] | ||||
2nd poorest | 85 | 43.0 [16.3, 84.1] | 85 | 1.7 [0.8, 2.6] | 84 | 4.0 [1.3, 11.3] | 84 | 1.8 [0.3, 8.8] | ||||
3rd poorest | 105 | 13.4 [3.4, 39.3] | 105 | 0.7 [0.6, 1.5] | 103 | 2.0 [0.5, 9.0] | 103 | 1.2 [-0.1, 7.0] | ||||
Least poor | 107 | 0.4 [0.4, 7.8] | <0.0001 | 107 | 0.6 [0.6, 0.7] | <0.0001 | 106 | 1.0 [0.5, 5.0] | <0.0001 | 106 | 0.4 [-0.1, 3.9] | <0.0001 |
Occupation group
| ||||||||||||
Farming (including Kuchi/cattle herding) | 136 | 65.0 [24.3, 113.3] | 136 | 1.9 [1.0, 3.3] | 135 | 6.0 [2.5, 18.5] | 135 | 3.7 [0.6, 16.8] | ||||
Business/shopowners/drivers | 67 | 1.4 [0.4, 11.3] | 67 | 0.6 [0.6, 0.9] | 66 | 2.3 [0.5, 6.0] | 66 | 0.8 [0.1, 5.4] | ||||
Teachers, engineers, government officials | 26 | 3.1 [0.4, 16.5] | 26 | 0.6 [0.6, 1.0] | 25 | 1.0 [0.5, 6.5] | 25 | 0.4 [-0.1, 5.9] | ||||
Labourers | 152 | 16.4 [0.4, 63.7] | 152 | 0.8 [0.6, 1.8] | 149 | 2.0 [0.5, 8.0] | 149 | 1.2 [-0.1, 5.4] | ||||
Other | 21 | 59.7 [4.1, 98.9] | <0.0001 | 21 | 1.8 [0.6, 2.1] | <0.0001 | 21 | 3.3 [1.2, 15.0] | <0.0001 | 21 | 1.4 [0.3, 6.4] | 0.0007 |
Husband’s education
| ||||||||||||
No | 246 | 33.8 [6.9, 87.0] | 246 | 1.3 [0.6, 2.7] | 243 | 4.5 [1.0, 13.0] | 242 | 2.6 [0.2, 9.6] | ||||
Yes | 154 | 11.0 [0.4, 68.5] | 0.0019 | 154 | 0.8 [0.6, 1.8] | 0.0041 | 151 | 2.5 [0.7, 10.0] | 0.0547 | 151 | 0.9 [0, 7.2] | 0.1019 |
Participation in community activities in the last 12 months
| ||||||||||||
No | 263 | 24.2 [3.4, 87.0] | 263 | 1.1[ 0.6, 2.3] | 260 | 4.5 [1.0, 14.8] | 260 | 2.9 [0.2, 12.5] | ||||
Yes | 130 | 15.0 [3.1, 69.1] | 0.2084 | 130 | 0.9 [0.6, 2.1] | 0.1918 | 127 | 2.5 [0.8, 6.5] | 0.0155 | 127 | 0.8 [0.1, 5.4] | 0.0132 |
Number of people the husband can borrow a small amount of money from
| ||||||||||||
0 | 23 | 24.2 [9.7, 71.2] | 22 | 1.1 [0.6, 2.9] | 21 | 5.0 [1.0, 20.0] | 12 | 4.3 [0.6, 16.2] | ||||
1-2 | 137 | 33.7 [6.9, 84.1] | 135 | 1.1 [0.6, 2.5] | 134 | 4.5 [1.0, 13.0] | 134 | 2.8 [0.2, 10.3] | ||||
3-4 | 136 | 23.2 [5.5, 89.0] | 137 | 1.2 [0.6, 2.1] | 136 | 3.5 [1.0, 13.5] | 136 | 2.0 [0.1, 10.1] | ||||
5 or more | 98 | 10.2 [0.4, 68.5] | 0.0296 | 99 | 0.8 [0.6, 2.1] | 0.0616 | 97 | 2.8 [0.8, 10.0] | 0.3663 | 87 | 1.2 [0.1, 7.0] | 0.5336 |
Number of people the husband can rely on in long-term emergency
| ||||||||||||
0 | 205 | 28.1 [5.7, 83.2] | 205 | 1.1 [0.6, 2.7] | 203 | 4.0 [1.0,14.0] | 203 | 1.9 [0.2, 12.4] | ||||
1-2 | 133 | 17.2 [0.4, 75.0] | 133 | 0.9 [0.6, 1.9] | 130 | 3.9 [1.0, 8.0] | 130 | 2.0 [0, 5.7] | ||||
3-4 | 22 | 15.6 [5.9, 94.5] | 22 | 1.0 [0.6, 2.0] | 22 | 2.0 [0.7, 5.5] | 22 | 0.7 [0.1, 3.9] | ||||
5 or more | 36 | 9.8 [0.4, 98.7] | 0.4958 | 36 | 0.9 [0.6, 2.0] | 0.2261 | 35 | 8.0 [2.0, 34.5] | 0.081 | 35 | 5.6 [0.6, 33.2] | 0.0595 |
Woman’s birth family lives nearby
| ||||||||||||
No | 83 | 27.1 [5.9, 82.0] | 85 | 1.1 [0.6, 2.0] | 84 | 4.6 [1.0, 14.8] | 84 | 2.6 [0.1, 13.1] | ||||
Yes | 289 | 18.3 [0.4, 79.2] | 0.3787 | 289 | 1.0 [0.6, 2.2] | 0.5561 | 284 | 3.5 [1.0, 10.0] | 0.2718 | 284 | 1.8 [0.2, 7.2] | 0.5272 |
Household type
| ||||||||||||
Nuclear | 220 | 16.5 [4.1, 76.3] | 220 | 1.0 [0.6, 2.0] | 214 | 3.1 [1.0, 11.0] | 214 | 1.5 [0.1, 7.5] | ||||
Extended | 181 | 24.4 [2.3, 89.0] | 0.3575 | 181 | 1.2 [0.6, 2.5] | 0.2263 | 181 | 4.5 [1.0, 14.3] | 0.165 | 181 | 2.8 [0.2, 10.7] | 0.2774 |
Residence
| ||||||||||||
Rural | 301 | 50.9 [16.0, 98.9] | 302 | 1.6 [0.8, 2.7] | 298 | 4.8 [1.5, 14.5] | 298 | 2.9 [0.4, 12.4] | ||||
Urban | 101 | 0.4 [0.4, 0.4] | <0.0001 | 101 | 0.6 [0.6, 0.6] | <0.0001 | 99 | 0.5 [0.5, 4.5] | <0.0001 | 99 | 0.2 [-0.1, 3.9] | <0.0001 |
Modelled travel time
Self-reported travel time
Bivariable and multivariable analyses of delay
Adjusted ratio to the reference group [95% CI] | p-value | ||
---|---|---|---|
Number of facilities visited before CEmOC
| |||
2 or more | 19.5 [13.7, 27.8] | <0.0001 | |
1 | 4.9 [3.8, 6.4] | <0.0001 | |
None (CEmOC only) | Reference | ||
Complication type
| |||
Haemorrhage in early pregnancy | 1.9 [1.2, 3.1] | 0.006 | |
Severe pre-eclampsia | 2.1 [1.3, 3.5] | 0.002 | |
APH | 1.6 [1.0, 2.6] | 0.042 | |
Eclampsia | 1.4 [0.9, 2.1] | 0.111 | |
Impending rupture of the uterus | 1.7 [1.0, 2.9] | 0.032 | |
Rupture of the uterus | 1.8 [1.1, 3.2] | 0.032 | |
PPH | Reference | ||
Severe infection | 2.6 [1.4, 4.9] | 0.002 | |
Other | 0.7 [0.2, 2.2] | 0.499 | |
Reported difficulties obtaining transportation
| |||
Very difficult | 2.1 [1.5, 3.0] | <0.0001 | |
Moderately difficult | 1.0 [0.8, 1.3] | 0.929 | |
Not difficult | Reference | ||
Number of people the husband can rely on in long-term emergency
| |||
0 | 1.4 [0.8, 2.3] | 0.257 | |
1-2 | 1.2 [0.7, 2.1] | 0.474 | |
3-4 | Reference | ||
5 or more | 2.0 [1.1, 3.7] | 0.033 |