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Research article
John Paul Quattrochi
Simmons University
Corresponding Author
ORCiD: https://orcid.org/0000-0003-0591-5931
License:
This work is licensed under a CC BY 4.0 License. Read Full License
Background: Despite important progress, the burden of under-5 mortality remains unacceptably high, with an estimated 5.3 million deaths in 2018. Lack of access to health care is a major risk factor for under-5 mortality, and distance to health care facilities has been shown to be associated with less access to care in multiple contexts, but few such studies have used a counterfactual approach to produce causal estimates. Methods: We combined retrospective reports on 22,088 births between 1980 and 2000 from the 2000 Malawi Demographic and Health Survey with a 1998 health facility census that includes the date of construction for each facility, including 335 maternity or maternity/dispensary facilities built in rural areas between 1980 and 1998. Using a difference-in-differences approach with Cox proportional hazards models, we estimated the effect of a reduction in distance to nearest facility, conditional on initial distance, on under-5 mortality. Using a difference-in-difference approach with linear probability models, we estimated the effect of a reduction in distance to nearest facility on number of antenatal visits prior to delivery, place of delivery, receiving skilled assistance during delivery, and receiving a check-up following delivery. Findings: We found no effects of a decrease in distance to the nearest health facility on the hazard of death before age five years. We also found no effect of reduced distance to nearest facility on utilization of maternal health services. The effects estimated here likely depend on the quality of health care, the availability of transportation, the demand for health services, and the underlying causes of mortality, among other factors. Conclusion: Reducing under-5 mortality and increasing utilization of care in rural Malawi and similar settings may require more than the construction of new health infrastructure.
Keywords
health care utilization, Malawi, distance to nearest health facility
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CURRENT STATUS: Published
View the published article at BMC Health Services Research.
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On 17 Sep, 2020
Editorial decision: Accept
On 15 Sep, 2020
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Editorial decision: Minor revision
On 11 Sep, 2020
Editor assigned
On 08 Sep, 2020
Submission checks complete
On 07 Sep, 2020
Editor invited
On 07 Sep, 2020
No comments provided
Review #2 received
Received 28 Aug, 2020
Editorial decision: Minor revision
On 28 Aug, 2020
Reviewer #2 agreed
On 24 Aug, 2020
Review #1 received
Received 24 Aug, 2020
Reviewer #1 agreed
On 21 Aug, 2020
Editor assigned
On 20 Aug, 2020
Reviewers invited
Invitations sent on 20 Aug, 2020
Submission checks complete
On 19 Aug, 2020
Editor invited
On 19 Aug, 2020
No comments provided
Review #1 received
Received 20 Jul, 2020
Editorial decision: Major revision
On 20 Jul, 2020
Review #2 received
Received 17 Jul, 2020
Reviewer #2 agreed
On 15 Jul, 2020
Reviewer #1 agreed
On 08 Jul, 2020
Editor assigned
On 05 May, 2020
Reviewers invited
Invitations sent on 05 May, 2020
Editor invited
On 04 May, 2020
Submission checks complete
On 22 Apr, 2020
Version 1
Posted 28 Apr, 2020
No comments provided
Editorial decision: Revise before sending to peer reviewers
On 26 Apr, 2020
Editor assigned
On 15 Apr, 2020
Submission checks complete
On 14 Apr, 2020
Editor invited
On 14 Apr, 2020
First submitted
On 13 Apr, 2020
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See the published version of this preprint at BMC Health Services Research.
This is a preprint, a preliminary version of a manuscript that has not completed peer review at a journal. Research Square does not conduct peer review prior to posting preprints. The posting of a preprint on this server should not be interpreted as an endorsement of its validity or suitability for dissemination as established information or for guiding clinical practice.
Learn more about In Review
Research article
John Paul Quattrochi
Simmons University
Corresponding Author
ORCiD: https://orcid.org/0000-0003-0591-5931
Badges
Prescreen
This manuscript passed our Prescreen assessment
Complete author information
Appropriate declaration statements
Potential risks to human health
Prescreen
Peer Review Timeline
CURRENT STATUS: Published
View the published article at BMC Health Services Research.
No community comments so far
Submission checks complete
On 17 Sep, 2020
Editorial decision: Accept
On 15 Sep, 2020
No comments provided
Editorial decision: Minor revision
On 11 Sep, 2020
Editor assigned
On 08 Sep, 2020
Submission checks complete
On 07 Sep, 2020
Editor invited
On 07 Sep, 2020
No comments provided
Review #2 received
Received 28 Aug, 2020
Editorial decision: Minor revision
On 28 Aug, 2020
Reviewer #2 agreed
On 24 Aug, 2020
Review #1 received
Received 24 Aug, 2020
Reviewer #1 agreed
On 21 Aug, 2020
Editor assigned
On 20 Aug, 2020
Reviewers invited
Invitations sent on 20 Aug, 2020
Submission checks complete
On 19 Aug, 2020
Editor invited
On 19 Aug, 2020
No comments provided
Review #1 received
Received 20 Jul, 2020
Editorial decision: Major revision
On 20 Jul, 2020
Review #2 received
Received 17 Jul, 2020
Reviewer #2 agreed
On 15 Jul, 2020
Reviewer #1 agreed
On 08 Jul, 2020
Editor assigned
On 05 May, 2020
Reviewers invited
Invitations sent on 05 May, 2020
Editor invited
On 04 May, 2020
Submission checks complete
On 22 Apr, 2020
Version 1
Posted 28 Apr, 2020
No comments provided
Editorial decision: Revise before sending to peer reviewers
On 26 Apr, 2020
Editor assigned
On 15 Apr, 2020
Submission checks complete
On 14 Apr, 2020
Editor invited
On 14 Apr, 2020
First submitted
On 13 Apr, 2020
Metrics
Comments: 0
PDF Downloads: ...
HTML Views: ...
License:
This work is licensed under a CC BY 4.0 License. Read Full License
View the published article at BMC Health Services Research.
Background: Despite important progress, the burden of under-5 mortality remains unacceptably high, with an estimated 5.3 million deaths in 2018. Lack of access to health care is a major risk factor for under-5 mortality, and distance to health care facilities has been shown to be associated with less access to care in multiple contexts, but few such studies have used a counterfactual approach to produce causal estimates. Methods: We combined retrospective reports on 22,088 births between 1980 and 2000 from the 2000 Malawi Demographic and Health Survey with a 1998 health facility census that includes the date of construction for each facility, including 335 maternity or maternity/dispensary facilities built in rural areas between 1980 and 1998. Using a difference-in-differences approach with Cox proportional hazards models, we estimated the effect of a reduction in distance to nearest facility, conditional on initial distance, on under-5 mortality. Using a difference-in-difference approach with linear probability models, we estimated the effect of a reduction in distance to nearest facility on number of antenatal visits prior to delivery, place of delivery, receiving skilled assistance during delivery, and receiving a check-up following delivery. Findings: We found no effects of a decrease in distance to the nearest health facility on the hazard of death before age five years. We also found no effect of reduced distance to nearest facility on utilization of maternal health services. The effects estimated here likely depend on the quality of health care, the availability of transportation, the demand for health services, and the underlying causes of mortality, among other factors. Conclusion: Reducing under-5 mortality and increasing utilization of care in rural Malawi and similar settings may require more than the construction of new health infrastructure.
Figure 1
Figure 2
Figure 3
Figure 4
The full text of this article is available to read as a PDF.
This is a list of supplementary files associated with this preprint. Click to download.
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