Emergency obstetric care access dynamics in Africa’s cities: Analysis of women’s self-reported care-seeking pathways in Kampala city, Uganda

Abstract

The rapid urbanization, particularly in Africa has posed several challenges that affect provision and accessibility of healthcare. The complex mix of providers, socio-economic inequalities, and inadequate infrastructure have been found to limit clients′ ability to reach and utilize routine and emergency health services. A growing body of literature shows poor health outcomes in African cities, including high institutional maternal mortality, which reflect poorly performing health systems. Understanding care-seeking pathways is necessary for improving health service delivery and ultimately improving health outcomes. We describe typologies and attributes of care-seeking pathways, using self-reported data from a cross-sectional survey of 433 women (15-49 years) who had obstetric complications, from nine health facilities in Kampala city. Participants′ average age was 26 (SD=6) years, and 55% (237/433) lived in the city suburbs. We identified four broad pathway sequences based on number and location of steps: pathways with one step, directly to a facility that could provide required care (42%, 183/433); two steps, mostly including direct referrals from basic and comprehensive obstetric facilities (40%, 171/433); three steps, including potentially delayed referral trajectories as women first return home (14%, 62/433); and ≥4 steps (4%, 17/433). Comprehensive obstetric facilities referred out 43% (79/184) of women who initially sought care in these facilities. Peripheral facilities referred 65% of women directly to the National Referral Hospital. Majority (60%, 34/57) of referred women first returned home before going to the final care facility. Our findings suggest that care pathways of women with obstetric complications in Kampala mostly comprise of at least two formal providers. This implies that efforts to strengthen urban health systems for maternal health should adopt broad or integrated approaches; and calls for improved inter-facility communication, streamlined referral processes and emergency transport availability. Future studies should investigate quality and experiences of care along the pathways.