Skilled attendance at childbirth is crucial for decreasing maternal and neonatal mortality, yet many women in low- and middle-income countries deliver outside of health facilities, without skilled help. The main conceptual framework in this field implicitly looks at home births with complications. We expand this to include "preventive" facility delivery for uncomplicated childbirth, and review the kinds of determinants studied in the literature, their hypothesized mechanisms of action and the typical findings, as well as methodological difficulties encountered.

Maternal and perinatal mortality could be reduced if all women delivered in settings where skilled attendants could provide emergency obstetric care (EmOC) if complications arise. Research on determinants of skilled attendance at delivery has focussed on household and individual factors, neglecting the influence of the health service environment, in part due to a lack of suitable data. The aim of this study was to quantify the effects of distance to care and level of care on women's use of health facilities for delivery in rural Zambia, and to compare their population impact to that of other important determinants. Using a geographic information system (GIS), we linked national household data from the Zambian Demographic and Health Survey 2007 with national facility data from the Zambian Health Facility Census 2005 and calculated straight-line distances. Health facilities were classified by whether they provided comprehensive EmOC (CEmOC), basic EmOC (BEmOC), or limited or substandard services. Multivariable multilevel logistic regression analyses were performed to investigate the influence of distance to care and level of care on place of delivery (facility or home) for 3,682 rural births, controlling for a wide range of confounders. Only a third of rural Zambian births occurred at a health facility, and half of all births were to mothers living more than 25 km from a facility of BEmOC standard or better. As distance to the closest health facility doubled, the odds of facility delivery decreased by 29% (95% CI, 14%–40%). Independently, each step increase in level of care led to 26% higher odds of facility delivery (95% CI, 7%–48%). The population impact of poor geographic access to EmOC was at least of similar magnitude as that of low maternal education, household poverty, or lack of female autonomy. Lack of geographic access to emergency obstetric care is a key factor explaining why most rural deliveries in Zambia still occur at home without skilled care. Addressing geographic and quality barriers is crucial to increase service use and to lower maternal and perinatal mortality. Linking datasets using GIS has great potential for future research and can help overcome the neglect of health system factors in research and policy. Please see later in the article for the Editors' Summary

Background: Many epidemiological studies require a measure of socioeconomic position. The monetary measure preferred by economists is consumption expenditure; the wealth index has been proposed as a reliable, simple alternative to expenditure and is extensively used. Methods: A systematic review was conducted of the agreement between wealth indices and consumption expenditure, summarising the agreement and exploring factors affecting agreement. Results: Seventeen studies using 36 datasets met the inclusion criteria. Of these, 22 demonstrated weak agreement, 10 moderate agreement, and four strong agreement. There was some evidence that agreement is higher: in middle-income settings; in urban areas; for wealth indices with a greater number of indicators; and for wealth indices including a wider range of indicators. Conclusions: The wealth index is mostly a poor proxy for consumption expenditure.

This study aims to investigate the relation between distance to health facilities, measured as continuous travel time, and mortality among infants and children younger than 5 years of age in rural Burkina Faso, an area with low health facility density. The study included 24,555 children born between 1993 and 2005 in the Nouna Health and Demographic Surveillance System. The average walking time from each village to the closest health facility was obtained for both the dry and the rainy season, and its effect on infant (<1 year), child (1–4 years), and under-5 mortality overall was analyzed by Cox regression. The authors observed 3,426 childhood deaths, corresponding to a 5-year survival of 85%. Walking distance was significantly related to both infant and child mortality, although the shape of this effect varied distinctly between the 2 age groups. Overall, under-5 mortality, adjusted for confounding, was more than 50% higher at a distance of 4 hours compared with having a health facility in the village (P < 0.0001, 2 sided). The region of residence was an additional determinant for under-5 mortality. The findings of this study emphasize the importance of geographic accessibility of health care for child survival in sub-Saharan Africa and demonstrate the need to improve health-care access to achieve the Millennium Development Goals.

Antenatal care (ANC) is one of the recommended interventions to reduce maternal and neonatal mortality. Yet in most Sub-Saharan African countries, high rates of ANC coverage coexist with high maternal and neonatal mortality. This disconnect has fueled calls to focus on the quality of ANC services. However, little conceptual or empirical work exists on the measurement of ANC quality at health facilities in low-income countries. We developed a classification tool and assessed the level of ANC service provision at health facilities in Zambia on a national scale and compared this to the quality of ANC received by expectant mothers.