We analyzed the effects of geographical access to health facilities on the use of maternal healthcare services in Benin utilizing a national-representative sample from two rounds of DHS datasets along with GIS data on health center locations. We confirmed that distance from residential area to the closest health center, after controlling for potential confounders, had negative effects on the use of appropriate healthcare for pregnancy and childbirth except for at least four ANCs. This adverse effect of distance on maternal healthcare utilization is consistent with the results of numerous previous studies in Sub-Saharan African countries (10, 11, 21–23).
There are three points to be discussed here. First, although we confirmed the adverse effect of distance on maternal healthcare utilization in Benin, this effect was mainly observed in the northern part. It is recognized that the north of Benin is more rural and less equipped with health infrastructure than the South. For instance, three departments in the southern part—Atlantique, Ouémé, and Littoral— encompass 48 percent of all 1,155 private health facilities in the country (24). Thus, expecting women in South generally have easier access to maternal healthcare compared to their counterparts in the North. Conversely, the average distance to the closest health center was longer, and the percentage of women using appropriate maternal health care was actually lower in the North (Table 1). Thus, geographical access to health facilities becomes critically important to access the necessary maternal healthcare in the North. A previous study conducted in Benin found consistent difficulties in accessing maternal healthcare among women in rural areas compared to urban areas (6).
In general, the negative impact of distance on healthcare utilization increases when it is combined with a lack of transportation in developing countries (25, 26). Regarding means of transport, Table 1 shows that the community’s ownership rates of bicycles and motorbikes were higher in the North than in the South, implying that these vehicles are more common transport means for people in the northern part. The results of the logistic regressions showed that the ownership rate of motorbikes had positive effects on women’s uptake of facility delivery and SBA in the North (Table 2). Since a higher ownership rate of motorbikes per cluster also indicates better road conditions of the community, transport infrastructure is critical for women’s use of appropriate maternal healthcare. Previous studies in Mali and Nepal showed similar results in that poor road conditions reduced the likelihood of receiving timely ANC (27, 28).
Second, our finding that distance to health facilities had a negative effect on the use of at least one ANC but no effect for four or more ANCs is consistent with previous studies in Tanzania (29), Zambia (30), and Ethiopia (31). However, other empirical studies conducted in many African countries found adverse effects of distance on women’s uptake of four ANC visits (23). Regarding this, empirical studies in Nigeria (32) and other low- and middle-income countries (33), reported that regardless of distance, absence of good medication and health workers, disparity between the nature of antenatal provision and the expectations of the women prevent women’s uptake of ANC. In Benin, the persistent shortage of healthcare workers leads to low performance of health facilities and quality of healthcare (12, 34), leading to lowered motivation to go to healthcare facilities. Thus, policy interventions should target the demand and supply sides of maternal healthcare. Particularly, efforts should be made to provide a healthcare system with qualified and sufficient workers.
Third, regarding the threshold of distance, our PSM analysis confirmed that women living within 5 km from the closest health center were more likely to use maternal healthcare compared to their counterparts. This result is consistent with the systematic review of 31 empirical studies that showed that living within 5 km of obstetrical facilities was significantly associated with a higher likelihood of delivering a baby at a health facility (26). A study in Haiti also showed that the availability of health centers within 5 km of a residence increased the odds of receiving ANC services (35). Our study confirmed the appropriateness of the definition of “geographical accessibility to healthcare” by Benin’s NHDP 2009–2018 as the percentage of the population living within 5 km from the closest health center (20).