The constraints of distance and poverty on institutional deliveries in Pakistan: evidence from georeference-linked data.

While institutional deliveries in Pakistan have risen substantially over the last few years, the change has mainly occurred among the wealthy and those with access to services in urban areas. We assess the influence of economic and geographic access to health facilities on institutional deliveries by linking household survey data and georeferenced distance to facilities equipped to provide services for obstetric care in nine districts in Pakistan. Multilevel mixed-effect logistic regression analyses show that the net effect of an increase in distance to a facility by 1 kilometer is to decrease the odds of an institutional delivery by 3 percent. In contrast, household wealth and availability of at least basic emergency care within 10 kilometers substantially increase the odds of an institutional delivery. These effects are more pronounced in rural areas than in urban areas. Disadvantages faced by poor rural women can be minimized by upgrading existing facilities at district and subdistrict levels to provide comprehensive emergency care and by facilitating transportation of poor rural women directly to these facilities when they experience life-threatening complications of childbirth.