Journal Article

Distance travelled and cost of transport for use of facility-based maternity services in rural Bangladesh: A cross-sectional survey

Background
Although maternal mortality in Bangladesh has decreased significantly, underutilisation of facilities for maternal health care continues to be a persistent challenge. Women often have to travel long distances and face transportation costs to deliver at a health facility. To reduce financial barriers, the Ministry of Health and Family Welfare introduced a demand-side financing programme that gives incentives to expectant mothers. We assessed the role of distance and transportation cost in the use of antenatal care, delivery, complication management, and postnatal care from a health facility.

Methods
We did this cross-sectional survey in 22 subdistricts in Bangladesh. From each subdistrict, three of nine unions and three villages from each union were selected through probability proportional to size in 2010. Mothers who had given birth in the preceding year were interviewed about distance from residence to a health facility, transportation cost, and mode of transport.

Findings
3300 women were interviewed. 1742 (53%) women received antenatal care, 647 (20%) received delivery care, and 343 (10%) received postnatal care at a health-care facility. On average, women travelled 6 km for antenatal check-ups (range 0–70 km) and postnatal check-ups (range 0–45 km) and 8 km for management of complications (range 0–50 km) or delivery (0–70 km). Most women used a non-motorised rickshaw or van to reach a health facility. On average, women spent Taka 100 (US$1·4, range 0-32·14) on transportation for antenatal care, Taka 432 ($6·17, range 0-100) for delivery, and Taka 132 ($1·89, range 0-35·71) for a postnatal check-up. For each additional kilometre, the cost increased by Taka 9 ($0·13) for antenatal care, Taka 31 ($0·44) for delivery, and Taka 8 ($0·11) for postnatal care.

Interpretation
Use of maternal health-care services at a health-care facility was low in rural Bangladesh. At present, the demand-side financing programme gives a flat payment of Taka 100 ($1·4) for transportation cost for each visit. This payment is insufficient. Programme managers should review the transportation allowance.