Abstract
INTRODUCTION: timely access to safe cesarean section (c-section) delivery can save the lives of mothers and neonates. This paper explores how distance affects c-section access in rural sub-Saharan Africa, where women in labor present to health centers before being referred to district hospitals for surgical care. METHODS: this study included all adult women delivering via c-section between April 2017 and March 2018 in Kirehe District, Rwanda. We assessed the association between travel times and village-level c-section rates. RESULTS: the estimated travel time from home-to-health center was 26 minutes (IQR: 13, 41) and from health center-to-hospital was 43 minutes (IQR: 2, 59). There was no significant association between travel time from home-to-health center and c-section rates (RR=1.01, p=0.42), but the association was significant for health center-to-hospital travel times (RR=0.96, p=0.01); for every 15-minute increase in travel time, there was a 4% decrease in c-sections for a health center catchment area. CONCLUSION: in the context of decentralized health services, minimizing health center to hospital referral barriers is of utmost importance for improving c-section access in rural sub-Saharan Africa.