Distance to care, care seeking and child mortality in rural Burkina Faso: findings from a population-based cross-sectional survey

Objective: Although distance has been identified as an important barrier to care, evidence for an effect of distance to care on child mortality is inconsistent. We investigated the association of distance to care with self-reported care seeking behaviours, neonatal and post-neonatal under-five child mortality in rural areas of Burkina Faso. Methods: We performed a cross-sectional survey in 14 rural areas from November 2014 to March 2015. About 100 000 women were interviewed on their pregnancy history and about 5000 mothers were interviewed on their care seeking behaviours. Euclidean distances to the closest facility were calculated. Mixed-effects logistic and Poisson regressions were used respectively to compute odds ratios for care seeking behaviours and rate ratios for child mortality during the 5 years prior to the survey. Results: Thirty per cent of the children lived more than 7 km from a facility. After controlling for confounding factors, there was a strong evidence of a decreasing trend in care seeking with increasing distance to care (P ≤ 0.005). There was evidence for an increasing trend in early neonatal mortality with increasing distance to care (P = 0.028), but not for late neonatal mortality (P = 0.479) and post-neonatal under-five child mortality (P = 0.488). In their first week of life, neonates living 7 km or more from a facility had an 18% higher mortality rate than neonates living within 2 km of a facility (RR = 1.18; 95%CI 1.00, 1.39; P = 0.056). In the late neonatal period, despite the lack of evidence for an association of mortality with distance, it is noteworthy that rate ratios were consistent with a trend and similar to or larger than estimates in early neonatal mortality. In this period, neonates living 7 km or more from a facility had an 18% higher mortality rate than neonates living within 2 km of a facility (RR = 1.18; 95%CI 0.92, 1.52; P = 0.202). Thus, the lack of evidence may reflect lower power due to fewer deaths rather than a weaker association. Conclusion: While better geographic access to care is strongly associated with increased care seeking in rural Burkina Faso, the impact on child mortality appears to be marginal. This suggests that, in addition to improving access to services, attention needs to be paid to quality of those services. Burkina Faso is a landlocked country in West Africa with a population in 2015 estimated at 18 106 000 inhabitants (https://esa.un.org/unpd/wpp). About three‐quarters of the population live in rural areas, largely depend on subsistence agriculture, and about half of the population live below the poverty line 13. Since 1990, the under‐five mortality rate has declined from an estimated 202 deaths per 1000 live births to 89 in 2015 1. The government is the main health service provider, managing 83% of the facilities within the country in 2014 14. The country is divided into 13 regions and 63 health districts each with one district or regional hospital. In 2014, the public health system included four Centres Hospitaliers Universitaires (CHU), nine Centres Hospitaliers Regionaux (CHR), 47 Centres Medicaux avec Antenne Chriurgicale (CMA) and 1859 primary health facilities, corresponding to about one hospital per 300 000 inhabitants and one primary facility per 10 000 inhabitants. In rural areas, primary health facilities, run by nurses, are the most common point of care and provide a basic package of outpatient services. At the time of the study, free antenatal care (ANC) and subsidised childbirth and emergency obstetric and neonatal care (EmONC) were provided in all public facilities (basic EmONC in first level facilities, comprehensive EmONC in second and third level facilities). Details of services provided and their availability, as reported by the 2014 Service Availability and Readiness Assessment (SARA), are given in Table 1 14. At the community level, case management of malaria with artemisinin‐based combination therapy (ACT) was scaled up in 2010 15, and late 2013, the Micronutrient Initiative, together with the Ministry of Health (MoH), launched the Zinc Alliance for Child Health (ZACH), with the aim of scaling up oral rehydration salt (ORS) and zinc for treating childhood diarrhoea. Services, trainings, and essential medicines available in health facilities (%) Source: 2014 Service Availability and Readiness Assessment (SARA). We performed a cross‐sectional household survey in 14 clusters across the country from November 2014 to March 2015. Clusters were selected for inclusion in a randomised trial evaluating the effect of a radio campaign on family behaviours and child mortality 16, 17. Each cluster was centred around a town with a community FM radio station and included approximately 40 000 inhabitants with limited access to television. The latter was achieved by excluding the communities living in and within 5 km of towns, villages with electricity or with more than 5000 inhabitants. With the exception of Kantchari cluster, the study population had access to a regional or district hospital in the town located at the centre of the cluster. In all villages, a census of households was performed with Geographical Positioning System (GPS) co‐ordinates recorded. All women of the reproductive age were interviewed on their pregnancy history and about 5000 mothers with at least one under‐five child was selected, using systematic random sampling, to be interviewed on their care seeking behaviours (contraception uptake, ANC attendance and place of delivery for the last pregnancy of more than 6 months duration, care seeking for child’s fever, cough, fast/difficult breathing, diarrhoea in the 2 weeks prior to interview). Sample size calculations for evaluation purposes have been reported elsewhere 16, 17. A list of 1564 public health facilities located in or near the 14 clusters included in the study was obtained from the Burkina Faso MoH along with their GPS co‐ordinates. Prior to the survey, fieldworkers received 2 weeks training. The data collection involved 84 fieldworkers who were deployed across the 14 clusters. Questionnaires were programmed into Personal Digital Assistants (PDA) and interviews were performed in local languages. Re‐interviews were requested for 7% of women due to incompleteness and/or inconsistencies, and all re‐interviews were completed. The study was approved by the ethics committees of the Burkina Faso MoH and the London School of Hygiene and Tropical Medicine. Women recorded their consent to participate in the survey on the PDA. This study was embedded in a randomised trial evaluating the effect of a radio campaign on family behaviours and child mortality 16, 17. The trial was registered at ClinicalTrial.gov (Identifier: {“type”:”clinical-trial”,”attrs”:{“text”:”NCT01517230″,”term_id”:”NCT01517230″}}NCT01517230). Mortality analyses were performed using the survival‐time family of commands in Stata 13.1. The primary outcomes of interest were neonatal (0 to 27 days of life) and post‐neonatal under‐five child (1 to 59 months of life) mortality. Neonatal mortality was further broken down into early (0 to 6 days of life) and late neonatal mortality (7 to 27 days of life). The period under study was restricted to the 5 years prior to the first month of the survey; i.e. from November 2009 to October 2014. The proportion of missing months of birth was low, at 2.6%, and these were randomly imputed according to the DHS method 18. Rate ratios for child mortality were computed using a mixed‐effects Poisson regression, with cluster fitted as a fixed effect and village fitted as random effect. Controlling for cluster accounted for any effect of the radio campaign on child mortality, though the evaluation did not detect an effect 17. Euclidean distances from each household to the closest public health facility (all types) and to the closest public hospital (CHU, CHR or CMA) were calculated in kilometres. Missing GPS co‐ordinates (5%) were replaced by the village mean distance. Distance to the closest facility was grouped into four categories (<2 km, 2–4 km, 4–7 km and >7 km), corresponding approximately to quartiles of the population. In Kantchari cluster, nearly all the children (99.6%) lived 30 km or more away from a hospital. Analyses of distance to the closest hospital therefore excluded Kantchari cluster, and distance to the closest hospital was grouped into three categories (<10 km, 10–20 km and >20 km), corresponding approximately to tertiles. The model included the household wealth quintile, mother’s age at the child’s birth, child’s gender and age (split into the following bands: <1, 1–5, 6–11, 12–17, 18–23, 24–35 and 36–59 months old) as forced variables. Other covariates associated with both the child mortality and distance to the closest facility or hospital were included as potential confounding factors: at the mother's level, ethnicity, religion, education level, marital status and duration of residence in the village; at the child level, birth order, preceding and succeeding birth interval lengths. The household wealth quintile was generated from a household wealth index computed from the first component of a polychoric principal component analysis of 22 household assets and goods 19. Care seeking behaviours included use of a modern contraceptive method, attendance at four or more ANC visits, facility delivery and care seeking for childhood illness. Modern contraception was defined as oral contraception, intra‐uterine device (IUD), implant, injectable, sterilisation, diaphragm or spermicidal agents. The analysis of the association between distance to the closest facility and care seeking behaviours used mixed‐effects logistic regression with cluster as a fixed effect and village as a random effect. The evaluation of the radio campaign found some evidence for an effect on care seeking behaviours 16, 17 and controlling for cluster will have accounted for this. The model included the household wealth quintile, mother's age at interview, child's gender and age at interview as forced variables. Mother's ethnicity, religion, education level, marital status, duration of residence in the village, and parity (number of stillbirths and live births) were included as potential confounders. Effect modification by household wealth tertile and mother's school attendance was assessed by fitting a linear interaction term between the factor of interest and the distance to facility in the final model in order to investigate whether the association of distance to care with either self‐reported care seeking behaviours or child mortality differed by socio‐economic status and maternal education.