Measuring spatial equity and access to maternal health services using enhanced two step floating catchment area method (E2SFCA) - a case study of the Indian Sundarbans

Int J Equity Health. 2016 Jun 7;15:87. doi: 10.1186/s12939-016-0376-y.


Introduction: Inaccessibility due to terrain and lack of transport leaves mothers travelling for long hours before reaching a facility to deliver a child. In the present article we analyzed the issue of spatial inaccessibility and inequity of maternal health services in the Indian Sundarbans where complex topography and repeated climatic adversities make access to health services very difficult.

Methods: We based the article on the health-GIS study conducted in the Patharpratima Block of the Sundarbans in the year 2012. The region has 87 villages that are inhabited, of which 54 villages are in the deltaic (river locked) region and 33 villages are located in the non-deltaic region of the block. We mapped all public and private maternal health facilities and road and water transport network. For measuring inaccessibility, we use the enhanced two-step floating catchment area method (E2SFCA). For assessing inequity in spatial access, we developed an area-based socioeconomic score and constructed a concentration curve to depict inequity. We used ARC GIS 10.3.1 and Stata 11 software for our analysis.

Results: The maternal health facilities are primarily located in the non-deltaic region of the block. On an average it takes 33.81 min to reach the closest maternal health facility. Fifty-two villages out of eighty seven villages have access scores less than the score calculated using Indian Primary Health Standards. Ten villages cannot access any maternal health facility; twenty-six villages have access scores of less than one doctor for 1000 pregnant women; fifty-six villages have access scores less than the block average of 3.54. The access scores are lower among villages in the deltaic region compared to the non-deltaic region. The concentration curve is below the line of equality showing that access scores were lower among villages that were socio-economically disadvantaged.

Conclusions: Maternal health facilities are not equitably accessible to the populations that are disadvantaged and living in the remote pockets of the study region. Provision of a referral transport system along with a resilient infrastructure of roads is critical to improve access in these islands.

Keywords: Concentration curve; Enhanced two step floating catchment area method; Equity; Geographic information system; Gravity models; Maternal health; Spatial accessibility; Sundarbans.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Catchment Area, Health / statistics & numerical data*
  • Female
  • Geography*
  • Health Services Accessibility / standards*
  • Health Services Accessibility / statistics & numerical data
  • Healthcare Disparities / standards
  • Healthcare Disparities / statistics & numerical data
  • Humans
  • Maternal Health Services / statistics & numerical data
  • Maternal Health Services / supply & distribution*
  • Pregnancy
  • Rural Population / statistics & numerical data