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Background Geographic access to obstetric care facilities has a significant influence on women’s uptake of institutional delivery care. However, this effect was not consistent across studies. Some studies reported that geographic access to obstetric care facilities had no influence on the use of facility delivery. Therefore, this systematic review and meta-analysis synthesized and pooled the influence of geographic access on institutional delivery service uptake in low and middle-income countries. Methods Multiple combinations of search terms were used to search articles from six databases and a hand search of reference lists performed. We included observational studies conducted in low and middle-income countries which reported the influence of geographic access on delivery care use. The pooled effects of geographic access on institutional delivery care use were calculated using a random-effects model with a 95% confidence interval. Findings In this study a total of 31 studies were included. Among these studies, 15 met criteria for inclusion in the meta-analyses, while the remaining 16 were summarized using qualitative synthesis. Studies included in the analysis where women had to walk 60 minutes or less to access a health facility delivery were significantly heterogeneous. Having access to obstetric care facilities within five kilometres was significantly associated with institutional deliveries (pooled OR = 2.27; 95% CI = 1.82, 2.82). Similarly, a travelling time of 60 minutes or less was significantly associated with higher odds of health facility delivery (pooled OR = 3.30; 95% CI = 1.97, 5.53). Every one-hour and one-kilometre increase in travel time and distance, respectively, was negatively associated with institutional delivery care use. Interpretation Geographic access measured in either physical distance and/or travel time was significantly associated with women’s use of facility delivery. The greater the distance and/or travel time to obstetric care facilities, the greater the barrier and the lesser the service uptake.
The search strategy included the following databases: MEDLINE, EMBASE, CINAHL, PsycINFO, Scopus and Maternity & Infant Care. Multiple combinations of search terms or keywords, such as delivery or obstetric care, childbirth, geographic/physical access or proximity, observational studies, low and middle-income countries, and Boolean operators were used (see S1 Table). The search terms/keywords first used in OVID MEDLINE were adapted to the other databases mentioned above. In addition to this, a hand search of reference lists was carried out. Search results were imported into EndNote software to aggregate relevant articles and to manage duplications. Two authors independently screened the titles and abstracts to determine if the returned electronic search articles were related to the study. The respective lists of articles of both authors were combined and full-text articles were reviewed against the inclusion and exclusion criteria. Disagreements were resolved through discussion with a third reviewer. Studies published in English and conducted in LMICs as defined by the World Bank [21] were included. Quantitative cross-sectional studies, cohort and case-control studies published since January 1, 2000 (the year the Millennium Development Goals (MDGs) were introduced) up to December 31, 2016 were included. The article search, for all the above-mentioned databases, was started on May 23, 2017 and ended on September 18, 2017. The most recent articles included in this paper were published in 2016. There was no experimental/ interventional study identified in the search process. Organization reports were excluded in this analysis. To be included, the studies had to report on the influence of geographic accessibility on maternal delivery service use. Articles that reported geographic access on institutional delivery care use were selected. The measurement of the study outcome was utilization of institutional delivery care. The methodological quality of the included studies was assessed using the Joanna Briggs Institute critical appraisal (assessment of risk of bias) checklists. The Joanna Briggs Institute, which is internationally known as JBI, along with its collaborators developed a systematic review reviewer’s manual. The aims of the JBI critical appraisal tools are to assess the methodological quality of a study and to determine to what extent a study addressed the possibility of bias in its design, conduct and data analysis [22]. For instance, JBI has critical appraisal checklists for prevalence studies, cohort and case-control studies [22]. The critical appraisal checklist for prevalence studies has nine criteria with options of Yes, No, Unclear or Not Applicable for each individual prevalence study. Based on this individual study assessment, an overall appraisal, either to be included or excluded, is given to that particular study [23]. Similarly, the JBI appraisal checklist has 11 criteria for cohort [24] and 10 criteria for case-control [25] studies. Therefore, two authors independently assessed the methodological quality of each study using the JBI critical appraisal checklist for studies reporting prevalence data [23], cohort [24] and case-control [25] studies. Disagreements were resolved by discussion with a third reviewer. Data on the influence of geographic accessibility on maternal delivery care use were extracted. A data extraction form that included general information (publication details and country), and specific information (study setting, study design, study population, sample size, main findings) was used (Table 1). A summary matrix with the data extracted from all individual studies was created. Two authors independently extracted the data from the included studies into the constructed matrices. Discrepancies were resolved by discussion and the original study was reviewed to resolve further discrepancies. The results of studies were extracted, reviewed and reported in a systematic format. A Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist [50] was used to synthesize and report the findings. This analysis was aimed to give a qualitative and quantitative synthesis. The qualitative synthesis was done for the 16 articles which were not included in the meta-analysis procedure. The results of this synthesis, along with studies included in the meta-analysis procedure, are presented in an evidence table (Table 1) and narrated in detail. A meta-analytic procedure was used to compute and aggregate effect sizes. The pooled effect size (Odds Ratio—OR) was calculated using a random effects model. The adjusted odds ratio estimates of each individual study were used in this meta-analysis. The Q statistics, I2 and Tau squared (τ2) were used to examine the heterogeneity of studies. The analysis was done using ProMeta software, version 3.0.
