Table 2.

Options for improving geographic access to hospitals

Category	Option	Details/examples
Infrastructure	Develop additional advanced neonatal and obstetric capacity	In areas with no access to hospitals or other facilities providing advanced care (surgery, newborn intensive care) within 2 hours, such facilities could be established, or existing facilities could be upgraded. This must be done equitably, preferably using geographic mapping and population density analyses. In Tanzania, health centres are being upgraded for surgical capacity to increase access to surgical care across the country.75 89
	Construct roads, bridges and other physical connections	Extending road networks to rural communities, constructing bridges and providing ferries and other physical infrastructure to connect communities are means to reduce the time and distance to reach care. Bangladesh added over 50 000 km of roads and 300 km of bridges to the transportation network between 2001 and 2010, decreasing travel time and increasing access to facilities, which likely contributed to the reductions in maternal mortality observed in that period.90 A similar attribution is made for Cambodia.91
Transportation and referral	Expand use of public transportation and private vehicles	In many communities, public transportation options are available and predictable. Once women plan to reach delivery care early, these public buses, trains and share taxis can offer an affordable and reliable means of transportation. On-demand private taxis or community-owned vehicles are also a viable means of transportation for both rural and urban populations.
	Use ride-share technologies	As mobile penetration increases in low-income settings, ride-share is becoming increasingly popular, and this technology can be used in facilitating maternal transportation. An uber-like application piloted in Homa Bay County in Kenya was found to provide 1 hour access to skilled birth care to nearly 90% of users.92
	Mobilise community transportation funds	Community funds to cover emergency transportation have been used in a variety of locations. For example, Health and Insurance Management Services Organisation trains communities to manage their own low-cost emergency transportation fund in rural Tanzania.
	Provide dedicated medical transportation	When primary care centres have dedicated vehicles for medical transportation, reaching advanced care is easier and/or safer for patients. In rural Ghana, the provision of modified three-wheeled motorcycles to health centres was found to have resulted in a shifting of deliveries from primary care to advanced facilities.93
	Improved communication	New digital technologies and expanded mobile telephone and internet coverage mean that communication between facilities can improve. For example, WhatsApp is being used in rural Tanzania to ‘give report’ between referring and receiving facilities.
Waiting options	Establish dignified maternity waiting homes	Maternity waiting homes enable women who are very remotely located to stay in or close to a health facility when they are near term in order to be close to care when they go into labour. A recent study in Ethiopia found that hospitals with maternity waiting homes had 40%–50% lower rates of maternal and perinatal complications compared with hospitals without waiting options.94
	Encourage staying with relatives in towns with advanced obstetric and neonatal care during last few weeks of pregnancy	With increasing urbanisation throughout the world, including in low-income and lower middle-income countries, an increasing proportion of rural residents will have relatives living in urban and peri-urban areas where health facilities with advanced obstetric and neonatal care are likely to be found. Thus, encouraging pregnant women living in rural areas to temporarily stay with relatives in towns may be preferable than maternity waiting homes for some.
	Explore Airbnb-like options	Where there are no maternity waiting homes, lodging with a host can bring women closer to advanced care when they are near term. An Airbnb-like online platform would allow clients to select options that meet their specific needs (eg, hosting siblings or birth companions) and rate their lodging experience. This platform can be used to plan the stay during antenatal care and the rating function provides an important accountability mechanism. This initiative could be combined with a voucher scheme that defrays the cost of stay for the woman.
Financing mechanisms	Institute conditional cash transfer schemes for delivery in advanced facilities	Making monetary payments to women who deliver in advanced facilities can provide an incentive for women to continue to do so. Evidence from India’s Janani Suraksha Yojana programme and from studies in sub-Saharan Africa suggests that conditional cash transfers are a viable demand-side strategy to increase access to services and bridge equity gaps, but only if facilities are of adequate quality.95 96
	Provide vouchers for facility deliveries and/or transport	Voucher programmes can reduce or remove the cost of reaching and obtaining quality delivery care. Voucher programmes have enabled women in rural Uganda to access private transportation options during labour without any upfront costs and helped subsidise maternal care services for poor women in Kenya.97 98 These schemes can be further targeted for delivery in advanced facilities.