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.