Travel of pregnant women in emergency situations to hospital and maternal mortality in Lagos, Nigeria: a retrospective cohort study

Abstract

IntroductionPrompt access to emergency obstetrical care (EmOC) reduces the risk of maternal mortality. We assessed institutional maternal mortality by distance and travel time for pregnant women with obstetrical emergencies in Lagos State, Nigeria.MethodsWe conducted a facility-based retrospective cohort study across 24 public hospitals in Lagos. Reviewing case notes of the pregnant women presenting between 1 November 2018 and 30 October 2019, we extracted socio-demographic, travel and obstetrical data. The extracted travel data were exported to Google Maps, where driving distance and travel time data were extracted. Multivariable logistic regression was conducted to determine the relative influence of distance and travel time on maternal death.FindingsOf 4181 pregnant women with obstetrical emergencies, 182 (4.4%) resulted in maternal deaths. Among those who died, 60.3% travelled ≤10 km directly from home, and 61.9% arrived at the hospital ≤30 mins. The median distance and travel time to EmOC was 7.6 km (IQR 3.4–18.0) and 26 mins (IQR 12–50). For all women, travelling 10–15 km (2.53, 95% CI 1.27 to 5.03) was significantly associated with maternal death. Stratified by referral, odds remained statistically significant for those travelling 10–15 km in the non-referred group (2.48, 95% CI 1.18 to 5.23) and for travel ≥120 min (7.05, 95% CI 1.10 to 45.32). For those referred, odds became statistically significant at 25–35 km (21.40, 95% CI 1.24 to 36.72) and for journeys requiring travel time from as little as 10–29 min (184.23, 95% CI 5.14 to 608.51). Odds were also significantly higher for women travelling to hospitals in suburban (3.60, 95% CI 1.59 to 8.18) or rural (2.51, 95% CI 1.01 to 6.29) areas.ConclusionOur evidence shows that distance and travel time influence maternal mortality differently for referred women and those who are not. Larger scale research that uses closer-to-reality travel time and distance estimates as we have done, rethinking of global guidelines, and bold actions addressing access gaps, including within the suburbs, will be critical in reducing maternal mortality by 2030.

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Leveraging big data for improving the estimation of close to reality travel time to obstetric emergency services in urban low- and middle-income settings

“…Women living in urban areas have been assumed to have better physical access EmOC compared to their rural counterparts due to relatively shorter travel distances to health facilities (11). However, emerging evidence shows that this so called "urban advantage" is shrinking and, in some LMIC settings, almost non-existent partly because while travel distances might be shorter, travel time can get longer (9,12,13). In urban LMIC settings, typically characterized by poor spatial planning, haphazardly built environments, growing informal settlements, poor road infrastructure, and extreme traffic congestion prolong travel time, delay care-seeking, and aggravate the risk of long-term morbidity and mortality for women and their babies.…”

Use of motorised transport and pathways to childbirth care in health facilities: Evidence from the 2018 Nigeria Demographic and Health Survey

“…Delays in reaching an appropriately staffed and equipped health facility increase the risk of maternal mortality [8]. Research from Nigeria also shows long travel to care is associated with maternal mortality and stillbirths [9,10].…”