Association of Travel Time and Residential Location With the Use of Antenatal Care and Institutional Delivery Services in Afghanistan

Background: Equitable access to maternal healthcare hinges on overcoming logistical and socio-economic challenges in many low- and middle-income countries (LMICs). Objectives: This study examines the association of travel time to health facilities and residential areas with the use of antenatal care (ANC) and institutional delivery services in Afghanistan. Methods: We used data from the Afghanistan Health Survey 2018, focusing on 1051 ever-married women aged 15-49 who had recently given birth and had ≥ 1 ANC session. The study measured the association of travel time and residential location, along with sociodemographic characteristics, on two primary outcomes: institutional deliveries and ANC service frequency. A generalized linear model facilitated the multivariable regression analyses. Results: The study found that travel time to health facilities and residential locations significantly influenced ANC utilization and institutional deliveries. Women with travel time of 0.5-2 and < 0.5 h to health facilities received 78% and 65% more ANC visits, respectively, than women with travel time of > 2 h to health facilities. Women who lived in rural areas received 50% fewer ANC visits compared to women who lived in urban areas. Women with travel time of 0.5-2 h were more likely to have institutional deliveries (odds ratio [OR] = 2.56, 95% confidence interval [CI]; 1.43-4.59) than those with travel time of > 2 h to health facilities. The likelihood of institutional deliveries was lower among rural resident women (OR = 0.62, 95% CI; 0.40-0.97) than their urban counterparts. Other predictors of ANC visits were women's education level and women's knowledge of complicated pregnancy, and other predictors of institutional deliveries were women's education level, decisions made for women about birthplace choice, and women's access to media. Conclusion: We have shown for the first time that access to health facilities and geographic disparities significantly influence maternal health service utilization in Afghanistan.