National and subnational estimates of coverage and travel time to emergency obstetric care in Afghanistan: Modeling of spatial accessibility

Transport accessibility and hospital attributes: A nonlinear analysis of their impact on Women's prenatal care seeking behavior

Ensuring women receive vital prenatal care is crucial for maternal and newborn health. Limited research explores factors influencing prenatal care-seeking from a geospatial perspective. This study, based on a substantial Wuhan dataset (23,947 samples), investigates factors influencing prenatal care-seeking, focusing on transport accessibility and hospital attributes. Findings indicate a nuanced relationship: (1) A non-linear trend, resembling an inverted "U," reveals the complex interplay between transport accessibility, hospital attributes, and prenatal care visits. Hospital attributes have a more pronounced impact than transport accessibility. (2) Interaction analysis underscores that lower prenatal care visits relate to low-income and education levels, despite reasonable public transport accessibility. (3) Spatial disparities are significant, with suburban areas facing increased obstacles compared to urban areas, particularly for those in suburban rural areas. This study enhances understanding by emphasizing threshold effects and spatial heterogeneity, offering valuable perspectives for refining prenatal care policies and practices.

Validating indicators for monitoring availability and geographic distribution of emergency obstetric and newborn care (EmoNC) facilities: A study triangulating health system, facility, and geospatial data

Availability of emergency obstetric and newborn care (EmONC) is a strong supply side measure of essential health system capacity that is closely and causally linked to maternal mortality reduction and fundamentally to achieving universal health coverage. The World Health Organization's indicator "Availability of EmONC facilities" was prioritized as a core indicator to prevent maternal death. The indicator focuses on whether there are sufficient emergency care facilities to meet the population need, but not all facilities designated as providing EmONC function as such. This study seeks to validate "Availability of EmONC" by comparing the value of the indicator after accounting for key aspects of facility functionality and an alternative measure of geographic distribution. This study takes place in four subnational geographic areas in Argentina, Ghana, and India using a census of all birthing facilities. Performance of EmONC in the 90 days prior to data collection was assessed by examining facility records. Data were collected on facility operating hours, staffing, and availability of essential medications. Population estimates were generated using ArcGIS software using WorldPop to estimate the total population, and the number of women of reproductive age (WRA), pregnancies and births in the study areas. In addition, we estimated the population within two-hours travel time of an EmONC facility by incorporating data on terrain from Open Street Map. Using these data sources, we calculated and compared the value of the indicator after incorporating data on facility performance and functionality while varying the reference population used. Further, we compared its value to the proportion of the population within two-hours travel time of an EmONC facility. Included in our study were 34 birthing facilities in Argentina, 51 in Ghana, and 282 in India. Facility performance of basic EmONC (BEmONC) and comprehensive EmONC (CEmONC) signal functions varied considerably. One facility (4.8%) in Ghana and no facility in India designated as BEmONC had performed all seven BEmONC signal functions. In Argentina, three (8.8%) CEmONC-designated facilities performed all nine CEmONC signal functions, all located in Buenos Aires Region V. Four CEmONC-designated facilities in Ghana (57.1%) and the three CEmONC-designated facilities in India (23.1%) evidenced full CEmONC performance. No sub-national study area in Argentina or India reached the target of 5 BEmONC-level facilities per 20,000 births after incorporating facility functionality yet 100% did in Argentina and 50% did in India when considering only facility designation. Demographic differences also accounted for important variation in the indicator's value. In Ghana, the total population in Tolon within 2 hours travel time of a designated EmONC facility was estimated at 99.6%; however, only 91.1% of women of reproductive age were within 2 hours travel time. Comparing the value of the indicator when calculated using different definitions reveals important inconsistencies, resulting in conflicting information about whether the threshold for sufficient coverage is met. This raises important questions related to the indicator's validity. To provide a valid measure of effective coverage of EmONC, the construct for measurement should extend beyond the most narrow definition of availability and account for functionality and geographic accessibility.

Evaluations of Spatial Accessibility and Equity of Multi-Tiered Medical System: A Case Study of Shenzhen, China

The Chinese government has implemented a medical system reform to improve the equity of healthcare resources since 2009. We selected Shenzhen as our study area and evaluated the accessibility and equity of the multi-tiered medical system in China using a novel multi-tiered two-step floating catchment area (MT2SFCA) method. We proposed the benchmark and applied the independent variables of travel time and facility attractiveness, along with a combination of the two factors, as tolerances to determine the new logistic cumulative distribution decay functions. Community health centers (CHCs) and hospitals were included while integrating their features. Results revealed that the MT2SFCA method was able to determine the particular advantages of CHCs and hospitals in the multi-tiered medical system. The CHCs offset the lower accessibility of hospitals in suburban areas and hospitals balanced the regional inequity caused by the CHC. Travel time is the main consideration of patients who have access to CHCs, whereas facility features are the main considerations of patients who have access to hospitals. Notably, both CHCs and hospitals are crucial for the whole multi-tiered medical system. Finally, we suggested modifications in different travel modes, weights of contributing factors, and the validation of decay functions to improve the MT2SFCA method.

Use of Physical Accessibility Modelling in Diagnostic Network Optimization: A Review

Diagnostic networks are complex systems that include both laboratory-tested and community-based diagnostics, as well as a specimen referral system that links health tiers. Since diagnostics are the first step before accessing appropriate care, diagnostic network optimization (DNO) is crucial to improving the overall healthcare system. The aim of our review was to understand whether the field of DNO, and especially route optimization, has benefited from the recent advances in geospatial modeling, and notably physical accessibility modeling, that have been used in numerous health systems assessment and strengthening studies. All publications published in English between the journal’s inception and 12 August 2021 that dealt with DNO, geographical accessibility and optimization, were systematically searched for in Web of Science and PubMed, this search was complemented by a snowball search. Studies from any country were considered. Seven relevant publications were selected and charted, with a variety of geospatial approaches used for optimization. This paucity of publications calls for exploring the linkage of DNO procedures with realistic accessibility modeling framework. The potential benefits could be notably better-informed travel times of either the specimens or population, better estimates of the demand for diagnostics through realistic population catchments, and innovative ways of considering disease epidemiology to inform DNO.

Combination of Interventions Needed to Improve Maternal Healthcare Utilization: A Multinomial Analysis of the Inequity in Place of Childbirth in Afghanistan

Giving birth with a skilled birth attendant at a facility that provides emergency obstetric care services has better outcomes, but many women do not have access to these services in low- and middle-income countries. Individual, household, and societal factors influence women's decisions about place of birth. Factors influencing birthplace preference by type of provider and level of public facility are not well understood. Applying the Andersen Behavioral Model of healthcare services use, we explored the association between characteristics of women and their choice of childbirth location using a multinomial logistic regression, and conducted a scenario analysis to predict changes in the childbirth location by imposing various interventions. Most women gave birth at home (68.1%), while 15.1% gave birth at a public clinic, 12.1% at a public hospital, and 4.7% at a private facility. Women with higher levels of education, from households in the upper two wealth quintiles, and who had any antenatal care were more likely to give birth in public or private facilities than at home. A combination of multisector interventions had the strongest signals from the model for increasing the predicted probability of in-facility childbirths. This study enhances our understanding of factors associated with the use of public facilities and the private sector for childbirth in Afghanistan. Policymakers and healthcare providers should seek to improve equity in the delivery of health services. This study highlights the need for decisionmakers to consider a combination of multisector efforts (e.g., health, education, and social protection), to increase equitable use of maternal healthcare services.

Addressing the global snakebite crisis with geo-spatial analyses - Recent advances and future direction

Venomous snakebite is a neglected tropical disease that annually leads to hundreds of thousands of deaths or long-term physical and mental ailments across the developing world. Insufficient data on spatial variation in snakebite risk, incidence, human vulnerability, and accessibility of medical treatment contribute substantially to ineffective on-ground management. There is an urgent need to collect data, fill knowledge gaps and address on-ground management problems. The use of novel, and transdisciplinary approaches that take advantage of recent advances in spatio-temporal models, 'big data', high performance computing, and fine-scale spatial information can add value to snakebite management by strategically improving our understanding and mitigation capacity of snakebite. We review the background and recent advances on the topic of snakebite related geospatial analyses and suggest avenues for priority research that will have practical on-ground applications for snakebite management and mitigation. These include streamlined, targeted data collection on snake distributions, snakebites, envenomings, venom composition, health infrastructure, and antivenom accessibility along with fine-scale models of spatio-temporal variation in snakebite risk and incidence, intraspecific venom variation, and environmental change modifying human exposure. These measures could improve and 'future-proof' antivenom production methods, antivenom distribution and stockpiling systems, and human-wildlife conflict management practices, while simultaneously feeding into research on venom evolution, snake taxonomy, ecology, biogeography, and conservation.

Facility-level determinants of quality routine intrapartum care in Afghanistan

BACKGROUND

Although there have been notable improvements in availability and utilization of maternal health care in Afghanistan over the last few decades, risk of maternal mortality remains very high. Previous studies have highlighted gaps in quality of emergency obstetric and newborn care practices, however, little is known about the quality of routine intrapartum care at health facilities in Afghanistan.

METHODS

We analyzed a subset of data from the 2016 Afghanistan Maternal and Newborn Health Quality of Care Assessment that comprised of observations of labor, delivery and immediate post-partum care, as well as health facility assessments and provider interviews across all accessible public health facilities with an average of five or more births per day in the preceding year (N = 77). Using the Quality of the Process of Intrapartum and Immediate Postpartum Care index, we calculated a quality of care score for each observation. We conducted descriptive and bivariate analyses and built a multivariate linear regression model to identify facility-level factors associated with quality of care scores.

RESULTS

Across 665 childbirth observations, low quality of care was observed such that no health facility type received an average quality score over 56%. The multivariate regression model indicated that availability of routine labor and delivery supplies, training in respectful maternity care, perceived gender equality for training opportunities, recent supervision, and observation during supervision have positive, statistically significant associations with quality of care.

CONCLUSIONS

Quality of routine intrapartum care at health facilities in Afghanistan is concerningly low. Our analysis suggests that multi-faceted interventions are needed to address direct and indirect contributors to quality of care including clinical care practices, attention to client experiences during labor and childbirth, and attention to staff welfare and opportunities, including gender equality within the health workforce.

Travel time, availability of emergency obstetric care, and perceived quality of care associated with maternal healthcare utilisation in Afghanistan: A multilevel analysis

Limited understanding of factors such as travel time, availability of emergency obstetric care (EmOC), and satisfaction/perceived quality of care on the utilisation of maternal health services exists in fragile and conflict-affect settings. We examined these key factors on three utilisation outcomes: at least one skilled antenatal care (ANC) visit, in-facility delivery, and bypassing the nearest public facility for childbirth in Afghanistan from 2010 to 2015. We used three-level multilevel mixed effects logistic regression models to assess the relationships between women's and their nearest public facilities' characteristics and outcomes. The nearest facility score for satisfaction/perceived quality was associated with having at least one skilled ANC visit (AOR: 2.02, 95% CI: 1.21, 3.36). Women whose nearest facility provided EmOC had a higher odds of in-facility childbirth compared to women whose nearest facility did not (AOR: 1.24, 95% CI: 1.04, 1.48). Nearest hospital travel time (AOR: 0.95, 95% CI: 0.93, 0.98) and nearest facility satisfaction/perceived quality (AOR: 0.34, 95% CI: 0.14, 0.82) were associated with lower odds of women bypassing their nearest facility. Afghanistan has made progress in expanding access to maternal healthcare services during the ongoing conflict. Addressing key barriers is essential to ensure that women have access to life-saving services.