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      Barriers for pregnant women living in rural, agricultural villages to accessing antenatal care in Cambodia: A community-based cross-sectional study combined with a geographic information system

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          Abstract

          Background

          Maternal morbidity and mortality is still a major public health issue in low- and middle-income countries such as Cambodia. Improving access to antenatal care (ANC) services for pregnant women has been widely recognized as one of the most effective means of reducing maternal mortality and morbidity. As such, this study examined the barriers for pregnant women living in rural, agricultural villages to accessing ANC based on data collected in the Ratanakiri province, one of the least developed provinces in Cambodia, using a combination of a community-based cross-sectional survey and a geographic information system (GIS).

          Methods

          A community-based cross-sectional survey was conducted among 377 mothers with children under the age of two living in 62 villages in the Ratanakiri province, Cambodia, in December 2015. Face-to-face interviews were conducted to ask mothers about their ANC service use, knowledge of ANC, barriers to accessing health facilities, and complications they experienced during the most recent pregnancy. At the same time, GIS data were also collected using a Global Positioning System (GPS) to accurately measure actual travel distance of pregnant women to access health facilities and to examine geographical and environmental barriers in greater detail.

          Results

          Only a third of the mothers met the recommendations made by the World Health Organization (WHO) of receiving ANC four times or more (achieved ANC4+), and a quarter of the mothers had never received ANC during their most recent pregnancy. Factors positively associated with achieving ANC4+ were mother’s secondary or higher education (adjusted odds ratio [AOR] = 5.50, 95% confidence interval [CI]: 1.74, 17.37), being aware that receiving ANC is recommended (AOR = 2.74, 95% CI: 1.25, 6.00), and knowledge about the recommended frequency for ANC (AOR = 2.26, 95% CI: 7.22). Actual travel distance was negatively associated with achieving ANC4+. Mothers who had to travel 10.0–14.9 km were 68% less likely (AOR = 0.32, 95% CI: 0.10, 0.99), and those who had to travel 15.0 km or longer were 79% less likely (AOR = 0.21, 95% CI: 0.07, 0.62) to have achieved ANC 4+, both compared to those who travelled 5.0 km or less. While most previous studies have used a straight-line to measure distance traveled, this study much more accurately measured the actual distance traveled by using a GIS. As a result, there was a statistically significant discrepancy between actual travel distance and straight-line distance.

          Conclusions

          This study revealed promoting factors and barriers for ANC use among pregnant women living in remote, agricultural villages in Cambodia. Furthermore, this study highlights the importance of measuring travel distances accurately to ensure that targeted interventions for ANC are not misguided by straight-line distances. The methodology used in this study can be applied widely to other developing countries, especially in remote areas with limited road networks where there may be a large discrepancy between actual and straight-line distances.

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          Most cited references 40

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          Constructing socio-economic status indices: how to use principal components analysis.

          Theoretically, measures of household wealth can be reflected by income, consumption or expenditure information. However, the collection of accurate income and consumption data requires extensive resources for household surveys. Given the increasingly routine application of principal components analysis (PCA) using asset data in creating socio-economic status (SES) indices, we review how PCA-based indices are constructed, how they can be used, and their validity and limitations. Specifically, issues related to choice of variables, data preparation and problems such as data clustering are addressed. Interpretation of results and methods of classifying households into SES groups are also discussed. PCA has been validated as a method to describe SES differentiation within a population. Issues related to the underlying data will affect PCA and this should be considered when generating and interpreting results.
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            Strategies for reducing maternal mortality: getting on with what works.

            The concept of knowing what works in terms of reducing maternal mortality is complicated by a huge diversity of country contexts and of determinants of maternal health. Here we aim to show that, despite this complexity, only a few strategic choices need to be made to reduce maternal mortality. We begin by presenting the logic that informs our strategic choices. This logic suggests that implementation of an effective intrapartum-care strategy is an overwhelming priority. We also discuss the alternative configurations of such a strategy and, using the best available evidence, prioritise one strategy based on delivery in primary-level institutions (health centres), backed up by access to referral-level facilities. We then go on to discuss strategies that complement intrapartum care. We conclude by discussing the inexplicable hesitation in decision-making after nearly 20 years of safe motherhood programming: if the fifth Millennium Development Goal is to be achieved, then what needs to be prioritised is obvious. Further delays in getting on with what works begs questions about the commitment of decision-makers to this goal.
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              Maternal mortality: who, when, where, and why.

              The risk of a woman dying as a result of pregnancy or childbirth during her lifetime is about one in six in the poorest parts of the world compared with about one in 30 000 in Northern Europe. Such a discrepancy poses a huge challenge to meeting the fifth Millennium Development Goal to reduce maternal mortality by 75% between 1990 and 2015. Some developed and transitional countries have managed to reduce their maternal mortality during the past 25 years. Few of these, however, began with the very high rates that are now estimated for the poorest countries-in which further progress is jeopardised by weak health systems, continuing high fertility, and poor availability of data. Maternal deaths are clustered around labour, delivery, and the immediate postpartum period, with obstetric haemorrhage being the main medical cause of death. Local variation can be important, with unsafe abortion carrying huge risk in some populations, and HIV/AIDS becoming a leading cause of death where HIV-related mortaliy rates are high. Inequalities in the risk of maternal death exist everywhere. Targeting of interventions to the most vulnerable--rural populations and poor people--is essential if substantial progress is to be achieved by 2015.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – original draft
                Role: ConceptualizationRole: Data curationRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Writing – review & editing
                Role: Formal analysisRole: Writing – review & editing
                Role: Data curationRole: Writing – review & editing
                Role: Data curationRole: Writing – review & editing
                Role: Data curationRole: Writing – review & editing
                Role: SupervisionRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                19 March 2018
                2018
                : 13
                : 3
                Affiliations
                [1 ] Research and Education Center for Prevention of Global Infectious Diseases of Animals, Tokyo University of Agriculture and Technology, Tokyo, Japan
                [2 ] Office of International Academic Affairs, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
                [3 ] Graduate Education and Research Training Program in Decision Science for Sustainable Society, Kyushu University, Fukuoka, Japan
                [4 ] University of North Texas Health Science Center, University of North Texas, Denton, Texas, United States of America
                [5 ] National Center for Parasitology, Entomology & Malaria Control (CNM), Ministry of Health, Phnom Penh, Cambodia
                Boston University School of Public Health, UNITED STATES
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Article
                PONE-D-17-30008
                10.1371/journal.pone.0194103
                5858830
                29554118
                © 2018 Yasuoka et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Counts
                Figures: 2, Tables: 4, Pages: 20
                Product
                Funding
                This work was supported by JSPS KAKENHI Grant Number JP15H05284. (Japan Society for the Promotion of Science: http://www.jsps.go.jp/english/index.html) The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Medicine and Health Sciences
                Women's Health
                Maternal Health
                Antenatal Care
                Medicine and Health Sciences
                Women's Health
                Maternal Health
                Pregnancy
                Medicine and Health Sciences
                Women's Health
                Obstetrics and Gynecology
                Pregnancy
                Engineering and Technology
                Measurement
                Distance Measurement
                Engineering and Technology
                Civil Engineering
                Transportation Infrastructure
                Roads
                Engineering and Technology
                Transportation
                Transportation Infrastructure
                Roads
                People and Places
                Geographical Locations
                Asia
                Cambodia
                Medicine and Health Sciences
                Pediatrics
                Child Health
                Medicine and Health Sciences
                Public and Occupational Health
                Child Health
                People and Places
                Population Groupings
                Families
                Mothers
                Computer and Information Sciences
                Geoinformatics
                Geographic Information Systems
                Earth Sciences
                Geography
                Geoinformatics
                Geographic Information Systems
                Custom metadata
                All relevant data are within the paper and its Supporting Information files.

                Uncategorized

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