@article{fdi:010095352,
  title = {{P}ersistence of geographic barriers to maternal care services following a health system strengthening initiative in rural {M}adagascar},
  author = {{I}hantamalala, {F}. {A}. and {R}andriamihaja, {M}. and {M}iller, {A}. {C}. and {R}akotonanahary, {R}. {J}. {L}. and {R}aza-{F}anomezanjanahary, {M}. and {K}otchofa, {J}. {A}. and {R}andriamanambintsoa, {M}. and {R}amarson, {H}. and {R}azafinjato, {B}. and {R}asoanandrasana, {V}. and {B}onds, {M}. and {F}innegan, {K}. {E}. and {G}architorena, {A}ndres},
  editor = {},
  language = {{ENG}},
  abstract = {{B}ackground{G}eographic access to healthcare continues to pose a significant challenge for pregnant women in rural areas of sub-{S}aharan {A}frica, resulting in consistently high rates of maternal mortality. {G}eographic barriers can persist even in settings where financial barriers have been reduced and health system strengthening ({HSS}) efforts are in place. {T}he aim of this study is to gain a precise understanding of spatiotemporal changes in access to and utilization of maternal care services in a rural district of {M}adagascar benefiting from {HSS} support.{M}ethods{W}e collected geolocated monthly information at the village level on antenatal care visits, deliveries and postnatal visits from the registries of 18 public primary health centers in {I}fanadiana {D}istrict, from 2016 to 2018. {S}imilar data were collected from a district-representative cohort via surveys on over 1500 households done in 2016 and 2018. {W}e estimated precise travel time from each village to the nearest health center to understand spatio-temporal variations in maternal care access, and to assess the impact of geographic barriers via statistical analyses while controlling for health system factors.{R}esults{W}omen who lived within a one-hour walk from a health facility in the {HSS} catchment area had rates of per capita utilization of most maternal health services were roughly twice that those who lived 1-2 h away and three times higher than those who lived over 2 h away (e.g. relative change for delivery at a health center was 0.60 [0.53-0.67] and 0.40 [0.36-0.45] for women living 1-2 h and over 2 h from a facility, respectively). {T}he exception was the first antenatal care visit ({ANC}1), for which travel time had more modest effect (e.g. relative change of 0.72 [0.67-0.77] over 2 h). {I}mprovements to primary care services due to {HSS} in this setting were only observed among women living within two hours from health centers. {S}tatistical models revealed that women's travel time from a health facility was the strongest determinant of maternal care service utilization.{C}onclusion{T}his study shows how a combination of geo-located health system information and population-representative data can help assess the impact of geographical barriers to maternal care in rural areas of sub-{S}aharan {A}frica. {I}t highlights that women who live more than 2 h from a health facility had virtually no access to maternal health services despite efforts in place to reduce financial barriers to care and strengthen the health system.},
  keywords = {{M}adagascar ; {U}niversal health coverage ; {H}ealth systems strengthening ; {M}aternal care ; {G}eographic barriers ; {MADAGASCAR}},
  booktitle = {},
  journal = {{BMC} {P}regnancy and {C}hildbirth},
  volume = {25},
  numero = {1},
  pages = {997 [11 p.]},
  year = {2025},
  DOI = {10.1186/s12884-025-08134-6},
  URL = {https://www.documentation.ird.fr/hor/fdi:010095352},
}