In 1994, Thaddeus and Maine published their groundbreaking article, “Too Far to Walk: Maternal Mortality in Context.” The authors introduced a “three delays” framework, suggesting that issues of distance, cost and quality often impact a woman’s:
- Decision to seek maternity care at a health facility (the first delay)
- Arrival at a health facility once the decision has been made (the second delay)
- Opportunity to receive adequate maternity care once she arrives at the facility (the third delay)
Thaddeus and Maine noted that these barriers tend to affect women in low-resource settings and particularly women living in rural areas. The authors also proposed a number of potential solutions to overcome the distance barrier to maternal health care utilization:
- Building maternity waiting homes near hospitals where pregnant women can live temporarily prior to delivery
- Supporting communities to set aside communal funds specifically for transportation costs in cases of obstetric emergencies
- Moving health care services closer to where women live
- Ensuring that all health facilities have the capacity to perform cesarean sections and other emergency procedures
- Training traditional birth attendants to provide high quality maternity care in their local communities
More than 20 years later, distance remains a major barrier to maternity care for many women around the world. A study in rural Liberia found that women who lived the farthest distance from the local health facility were least likely to attend antenatal care, deliver in a health facility and receive postnatal care, even after taking into account women’s educational attainment, refugee status, marital status and age. Other studies identified distance as a barrier to facility-based delivery in Nepal, Kenya, Tanzania, Zambia and many other countries. In Ghana, about a third of women live at least two hours away from the nearest health facility and at least four hours away from a facility that provides emergency obstetric and newborn care services. Access to maternal health care can be an issue for women in rural areas of the United States as well, where birthing facilities are farther apart.
Where a woman lives should not dictate whether she can access high quality maternity care. The recommendations from Thaddeus and Maine deserve to be reexamined in our current context. Efforts to increase facility-based delivery must seriously consider the daily lives of women, including the many obstacles they encounter on the way to the health facility.
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Read more about geographic disparities in utilization of maternal and newborn health care in the newest MHTF-PLOS Collection.
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