Distance matters: barriers to antenatal care and safe childbirth in a migrant population on the Thailand Myanmar border from 2007 to 2015, a pregnancy cohort study

I. BackgroundAntenatal care and delivery with skilled attendants substantially improve maternal health outcomes across the pregnancy spectrum, from conception to delivery. The Sustainable Development Goals recognize the need to expand these services to all pregnant women but there is limited data on access for migrants and in post-conflict regions. II. MethodsUsing geographic information systems established for malaria elimination efforts in Kayin state, Myanmar and Tak Province, Thailand, retrospective estimates of travel distances from home villages to maternal health facilities between 2007-2015 were made. Multivariable regressions were used to assess the relationships between distance to healthcare and 1) presentation for early pregnancy care, 2) complications during pregnancy like malaria infections, and 3) eventual outcome of the pregnancy. III. FindingsWomen who delayed antenatal care until the third trimester travelled 46% farther (DR: 1.46; CI: 1.39 - 1.53) compared to women who attended in the first trimester, and those with pregnancies complicated by Plasmodium falciparum malaria travelled 62% farther (DR: 1.62; CI: 1.44 - 1.82) than those without P. falciparum. Women did not deliver with skilled birth services and were lost to follow-up travelled 45% farther (distance ratio (DR): 1.45; CI: 1.40 - 1.51) than those who followed-up to deliver with skilled birth services. IV. InterpretationThis analysis supports substantial global evidence that travel distance disrupts access to care in limited resource regions. This is the first demonstration of empirical distance impacting maternal healthcare from early pregnancy to delivery of migrants living in post-conflict Thailand-Myanmar border regions, and future interventions should provide decentralized maternal healthcare to address these barriers. V. FundingThe Bill & Melinda Gates Foundation and the Wellcome Trust