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“Too Far to Walk”: 20 Years Later, Distance Remains a Barrier to Maternal Health

Posted on October 14, 2016October 27, 2017

By: Sarah Hodin, MPH, CD(DONA), LCCE, National Senior Manager of Maternal Newborn Health Programs, Steward Health Care

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:

  1. Decision to seek maternity care at a health facility (the first delay)
  2. Arrival at a health facility once the decision has been made (the second delay)
  3. 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.

Do you think “Too Far to Walk” is still relevant in the global maternal health field today? Join the conversation on Twitter and Facebook or email us with your insight.

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CATEGORIESCATEGORIES: Maternal Health
TOPICSTOPICS: Antenatal Care Barriers to Health Care Access Cesarean Section Emergency Obstetric and Newborn Care Facility-based Births Health Systems Inequities & Inequalities Maternal Mortality Quality of Care Social Determinants

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The posts on this blog do not necessarily reflect the views of the Maternal Health Task Force. Our objective is to provide a platform for our Editorial Committee and other experts to post a myriad of data and evidence, as well as opinions/views that exist in the field which will contribute to expanding the maternal health dialogue.
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This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant T76MC00001 and entitled Training Grant in Maternal and Child Health. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.
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