The decision to seek care

Perceived accessibility of health services plays a significant role in influencing people’s decision to seek care. In particular, long distance to the nearest health facility is a disincentive to seeking care (Alwar et al, 2000). In Matlab, Bangladesh, the use of a trained attendant at birth dropped by a half when the distance from the home to the health centre was more than one kilometre (ICDDR, B, 2005).

The effect of distance becomes stronger with a lack of transportation and poor roads (Thaddeus and Maine, 1994). A study in rural Western Kenya shows that 80 per cent of women delivered outside a health facility with 22 per cent of women receiving no assistance at all. A contributing factor in their decision to give birth at home is the length of time taken to walk to a health facility. Distance also prevented some women from attending an ante-natal clinic during their pregnancy (van Eijk et al, 2006).

Long distances entail higher cost of transport, another factor that delays both the decision to seek and ability to reach care (Downing and Setni, 2001). Costs include hiring a vehicle and driver, fuel expenses, and the opportunity costs or loss of productive time of the person accompanying the woman (Ransom and Yinger, 2002). Hamlin (2004) finds that in Ethiopia, even when access to roads is available, women can encounter delays of several days whilst families raise the money to pay for hiring a vehicle. Even short distances are subject to this difficulty. Transport costs of accessing health facilities have been calculated to represent 25 per cent of the total outlay on health in north-east Brazil (Terra de Souza et al, 2000) and 28 per cent in Cameroon (Sauerborn et al, 1995).

Women’s mobility in times of obstetric emergency may be further limited by social restrictions on their movement (Oxaal and Baden, 1996). For example, in some countries when obstetric complications arise, women must ask their husband’s permission to seek care. The Prevention of Maternal Mortality Network (1992) provides an example from Nigeria, where a woman with obstructed labour, who lived ten minutes walk from the hospital, could not leave the house because her husband was away on business. By the time he returned and gave permission for her to be taken to hospital, she had developed obstetric fistula and the baby was dead in utero (Oxaal and Baden, 1996).