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The influence of distance and quality on utilisation of birthing services at health facilities in Eastern Region, Ghana
  1. Winfred Dotse-Gborgbortsi1,2,
  2. Duah Dwomoh3,
  3. Victor Alegana1,2,4,5,
  4. Allan Hill6,
  5. Andrew J Tatem1,2,
  6. Jim Wright1
  1. 1School of Geography and Environmental Science, University of Southampton, Southampton, UK
  2. 2WorldPop Research Group, School of Geography and Environmental Science, University of Southampton, Southampton, UK
  3. 3Department of Biostatistics, School of Public Health, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
  4. 4Population Health Unit, Kenya Medical Research Institute - Wellcome Trust Research Programme P.O. Box 43640-00100, Nairobi, Kenya
  5. 5Faculty of Science and Technology, Lancaster University, Lancaster, UK
  6. 6Social Statistics and Demography, University of Southampton, Southampton, UK
  1. Correspondence to Winfred Dotse-Gborgbortsi; wwdg1n15{at}


Objectives Skilled birth attendance is the single most important intervention to reduce maternal mortality. However, studies have not used routinely collected health service birth data at named health facilities to understand the influence of distance and quality of care on childbirth service utilisation. Thus, this paper aims to quantify the influence of distance and quality of healthcare on utilisation of birthing services using routine health data in Eastern Region, Ghana.

Methods We used a spatial interaction model (a model that predicts movement from one place to another) drawing on routine birth data, emergency obstetric care surveys, gridded estimates of number of pregnancies and health facility location. We compared travel distances by sociodemographic characteristics and mapped movement patterns.

Results A kilometre increase in distance significantly reduced the prevalence rate of the number of women giving birth in health facilities by 6.7%. Although quality care increased the number of women giving birth in health facilities, its association was insignificant. Women travelled further than expected to give birth at facilities, on average journeying 4.7 km beyond the nearest facility with a recorded birth. Women in rural areas travelled 4 km more than urban women to reach a hospital. We also observed that 56% of women bypassed the nearest hospital to their community.

Conclusion This analysis provides substantial opportunities for health planners and managers to understand further patterns of skilled birth service utilisation, and demonstrates the value of routine health data. Also, it provides evidence-based information for improving maternal health service provision by targeting specific communities and health facilities.

  • maternal health
  • geographic information systems
  • obstetrics
  • public health
  • epidemiology

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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  • Handling editor Sanni Yaya

  • Contributors WDG and JW conceived the study and it was further developed by AH. AJT and VA contributed to the methods and provided review comments for the initial draft. WDG and DD analysed the data. WDG and JW wrote the initial draft and all authors contributed to subsequent drafts.

  • Funding Wellcome Trust (grant number: 204613/Z/16/Z) and UK Department for International Development (DFID). VA is funded through a Wellcome Trust Fellowship (number 211208). Part of this work was done during WDG’s time as a Commonwealth Scholar and currently supported by the Economic and Social Research Council through the South Coast Doctoral Training Partnership (grant number ES/P000673/1).

  • Map disclaimer The depiction of boundaries on the map(s) in this article do not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. The map(s) are provided without any warranty of any kind, either express or implied.

  • Competing interests WDG was employed by the Ghana Health Service from February 2008 to August 2015. He conducted this study during a study leave. All other authors have no competing interests.

  • Patient consent for publication Not required.

  • Ethics approval Ethical approval for this study was received from the University of Southampton (ERGO ID: 26328).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available in a public, open access repository. Data may be obtained from a third party and are not publicly available. Data on the number of estimated pregnancies are available from the WorldPop at Data on women delivering at health facilities in Ghana can be obtained from the Ghana Health Service.

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