Who Is Left Behind and Where? Spatial Inequalities in Healthcare Access Among Women in Bangladesh

<title>Abstract</title> <p>Background Despite two decades of healthcare expansion in Bangladesh, barriers to healthcare access among women remain persistently high and geographically uneven. Prior studies relied exclusively on regression-based approaches, leaving the spatial concentration of barriers unidentified. This study examines the prevalence, determinants, and spatial distribution of barriers among currently married reproductive-aged women using the most recent nationally representative Bangladesh Demographic and Health Survey 2022. Methods We analyzed data from 20,029 currently married women aged 15–49 years. Barriers were defined as reporting at least one difficulty: obtaining money, distance to facilities, getting permission, or going alone. Multivariable logistic regression identified independent determinants. Spatial analysis integrated four complementary methods: Global Moran's I for autocorrelation, Getis-Ord Gi* for hotspot detection, Kriging for surface interpolation, and SaTScan for cluster detection. Results Overall, 66.2% of women reported at least one barrier. After adjustment, secondary and higher education were associated with 21% and 39% lower odds, respectively; the wealthiest women had 41% lower odds than the poorest, and women with high autonomy had 35% lower odds. Divisional inequalities persisted, with Chattogram and Mymensingh showing higher odds and Khulna and Rangpur lower odds. Spatial analysis confirmed significant non-random clustering, with hotspots in northern Mymensingh, southwestern Chattogram, and eastern Sylhet, and cold spots in northern Rangpur and western Khulna. SaTScan identified two statistically significant clusters: a primary cluster in southeastern Chattogram encompassing the Chittagong Hill Tracts periphery (relative risk 1.24, p &lt; 0.001) and a secondary cluster spanning Mymensingh, Sylhet, and northeastern Dhaka (relative risk 1.10, p &lt; 0.01). Kriging revealed a high-barrier corridor crossing the Mymensingh–Dhaka divisional boundary, invisible to divisional-level planning. Conclusions This study reveals that healthcare barriers in Bangladesh concentrate in identifiable geographic zones rather than being uniformly distributed. Southeastern Chattogram, northern Mymensingh, and eastern Sylhet are the highest-priority areas, each requiring context-specific responses: indigenous-community outreach in Chattogram, infrastructure investment in Mymensingh, and mobility-norm interventions in Sylhet. Coordinated cross-divisional planning for the Mymensingh–Dhaka corridor is additionally needed. Geographically differentiated health system responses are essential to reaching the most structurally excluded women in Bangladesh. Trial registration: Not applicable.</p>