Critical comparative analysis of data sources toward understanding referral during pregnancy and childbirth: three perspectives from Nigeria

Obstetric referrals, complications and health outcomes in maternity wards of large hospitals during the COVID-19 pandemic: a mixed methods study of six hospitals in Guinea, Nigeria, Uganda and Tanzania

OBJECTIVES

The COVID-19 pandemic affected provision and use of maternal health services. This study describes changes in obstetric complications, referrals, stillbirths and maternal deaths during the first year of the pandemic and elucidates pathways to these changes.

DESIGN

Prospective observational mixed-methods study, combining monthly routine data (March 2019-February 2021) and qualitative data from prospective semi-structured interviews. Data were analysed separately, triangulated during synthesis and presented along three country-specific pandemic periods: first wave, slow period and second wave.

SETTING

Six referral maternities in four sub-Saharan African countries: Guinea, Nigeria, Tanzania and Uganda.

PARTICIPANTS

22 skilled health personnel (SHP) working in the maternity wards of various cadres and seniority levels.

RESULTS

Percentages of obstetric complications were constant in four of the six hospitals. The percentage of obstetric referrals received was stable in Guinea and increased at various times in other hospitals. SHP reported unpredictability in the number of referrals due to changing referral networks. All six hospitals registered a slight increase in stillbirths during the study period, the highest increase (by 30%-40%) was observed in Uganda. Four hospitals registered increases in facility maternal mortality ratio; the highest increase was in Guinea (by 158%), which had a relatively mild COVID-19 epidemic. These increases were not due to mortality among women with COVID-19. The main pathways leading to these trends were delayed care utilisation and disruptions in accessing care, including sub-optimal referral linkages and health service closures.

CONCLUSIONS

Maternal and perinatal survival was negatively affected in referral hospitals in sub-Saharan Africa during COVID-19. Routine data systems in referral hospitals must be fully used as they hold potential in informing adaptations of maternal care services. If combined with information on women's and care providers' needs, this can contribute to ensuring continuation of essential care provision during emergency.

Prevalence, influencing factors, and outcomes of emergency caesarean section in public hospitals situated in the urban state of Lagos, Nigeria

Background

Caesarean section (CS) performed in an emergency can be life-saving for both the pregnant woman and her baby. In Nigeria, CS rates have been estimated to be 2.7% nationally, with the highest regional rate of 7.0% reported in the South-West of the country. Our objective in this facility-based retrospective cross-sectional study was to describe patterns and assess factors, obstetric indications, and outcomes of emergency CS in Lagos, Nigeria.

Methods

Socio-demographic, travel, and obstetric data of pregnant women were extracted from case notes. Travel data was inputted in Google Maps to extract travel time from the pregnant women' home to the hospital. Univariate, bivariate and multivariable logistic regression analyses were conducted.

Results

Of the 3,134 included pregnant women, 1,923 (61%) delivered via emergency CS. The odds of an emergency CS were significantly higher among women who were booked (OR=1.97, 95%CI 1.64-2.35), presented with obstructed labour (OR=2.59, 95%CI 1.68-3.99), pre-eclampsia/eclampsia (OR=1.67, 95%CI 1.08-2.56), multiple gestations (OR=2.71, 95%CI 1.72-4.28) and travelled from suburban areas (OR=1.43, 95%CI 1.15-1.78). There was an increasing dose-effect response between travel time to the hospital and emergency CS.

Conclusion

Optimisation of CS rates requires a multi-pronged approach during pregnancy and childbirth, with particular emphasis on supporting pregnant women living in the suburbs.

The potential utility of an augmented data collection approach in understanding the journey to care of pregnant women for maternal and perinatal death surveillance and response

Background: The Maternal and Perinatal Death Surveillance and Response (MPDSR) proposed by the World Health Organization recognises the importance for health systems to understand the reasons underpinning the death of a pregnant woman or her newborn as an essential first step in preventing future similar deaths. Data for the surveillance component of the MPDSR process are typically collected from health facility sources and post-mortem interviews with affected families, though it may be traumatising to them. This brief report aimed to assess the potential utility of an augmented data collection method for mapping journeys of maternal and perinatal deaths, which does not require sourcing additional information from grieving family members. Methods: A descriptive analysis of maternal and perinatal deaths that occurred across 24 public hospitals in Lagos State, Nigeria, between 1 ^st November 2018 and 30 ^th October 2019 was conducted. Data on their demographic, obstetric history and complication at presentation, travel to the hospital, and mode of birth were extracted from their hospital records. The extracted travel data was exported to Google Maps, where driving distance and travel time to the hospital for the period of the day of travel were also extracted. Results: Of the 182 maternal deaths, most presented during the week (80.8%), travelled 5-10 km (30.6%) and 10-29 minutes (46.9%), and travelled to the nearest hospital to their places of residence (70.9%). Of the 442 pregnant women who had perinatal deaths, most presented during the week (78.5%), travelled <5 km (26.9%) and 10-29 minutes (38.0%). For both, the least reported travel data was the mode of travel used to care (>90.0%) and the period of the day they travelled (approximately 30.0%). Conclusion: An augmented data collection approach that includes accurate and complete travel data and closer-to-reality estimates of travel time and distance can be beneficial for MPDSR purposes.

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

Introduction

Prompt 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.

Methods

We 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.

Findings

Of 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.

Conclusion

Our 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.

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

In Nigeria, 59% of pregnant women deliver at home, despite evidence about the benefits of childbirth in health facilities. While different modes of transport can be used to access childbirth care, motorised transport guarantees quicker transfer compared to non-motorised forms. Our study uses the 2018 Nigeria Demographic and Health Survey (NDHS) to describe the pathways to childbirth care and the determinants of using motorised transport to reach this care. The most recent live birth of women 15-49 years within the five years preceding the NDHS were included. The main outcome of the study was the use of motorised transport to childbirth. Explanatory variables were women's socio-demographic characteristics and pregnancy-related factors. Descriptive, crude, and adjusted logistic regression analyses were conducted to assess the determinants of use of motorised transport. Overall, 31% of all women in Nigeria used motorised transport to get to their place of childbirth. Among women who delivered in health facilities, 77% used motorised transport; among women referred during childbirth from one facility to another, this was 98%. Among all women, adjusted odds of using motorised transport increased with increasing wealth quintile and educational level. Among women who gave birth in a health facility, there was no difference in the adjusted odds of motorised transport across wealth quintiles or educational status, but higher for women who were referred between health facilities (aOR = 8.87, 95% CI 1.90-41.40). Women who experienced at least one complication of labour/childbirth had higher odds of motorised transport use (aOR = 3.01, 95% CI 2.55-3.55, all women sample). Our study shows that women with higher education and wealth and women travelling to health facilities because of pregnancy complications were more likely to use motorised transport. Obstetric transport interventions targeting particularly vulnerable, less educated, and less privileged pregnant women should bridge the equity gap in accessing childbirth services.

Patterns, travel to care and factors influencing obstetric referral: Evidence from Nigeria's most urbanised state

The criticality of referral makes it imperative to study its patterns and factors influencing it at a health systems level. This study of referral in Lagos, Nigeria is based on health records of 4181 pregnant women who presented with obstetric emergencies at one of the 24 comprehensive emergency obstetric care (EmOC) facilities in the state between November 2018 and October 2019 complemented with distance and time data extracted from Google Maps. Univariate, bivariate, and multivariate analyses were conducted. About a quarter of pregnant women who presented with obstetric emergencies were referred. Most referrals were from primary health centres (41.9 %), private (23.5 %) and public (16.2 %) hospitals. Apart from the expected low-level to high-level referral pattern, there were other patterns observed including non-formal, multiple, and post-delivery referrals. Travel time and distance to facilities that could provide needed care increased two-fold on account of referrals compared to scenarios of going directly to the final facility, mostly travelling to these facilities by private cars/taxis (72.8 %). Prolonged/obstructed labour was the commonest obstetric indication for referral, with majority of referred pregnant women delivered via caesarean section (52.9 %). After adjustment, being married, not being registered for antenatal care at facility of care, presenting at night or with a foetus in distress increased the odds of referral. However, parity, presentation in the months following the commissioning of a new comprehensive EmOC facility or with abortion reduced the likelihood of being referred. Our findings underscore the need for health systems strengthening interventions that support women during referral and the importance of antenatal care and early booking to aid identification of potential pregnancy complications whilst establishing robust birth preparedness plans that can minimise the need for referral in the event of emergencies. Indeed, there are context-specific influences that need to be addressed if effective referral systems are to be designed.

Influence of travel time and distance to the hospital of care on stillbirths: a retrospective facility-based cross-sectional study in Lagos, Nigeria

INTRODUCTION

Access to emergency obstetric care can lead to a 45%-75% reduction in stillbirths. However, before a pregnant woman can access this care, she needs to travel to a health facility. Our objective in this study was to assess the influence of distance and travel time to the actual hospital of care on stillbirth.

METHODS

We conducted a retrospective cross-sectional study of pregnant women who presented with obstetric emergencies over a year across all 24 public hospitals in Lagos, Nigeria. Reviewing clinical records, we extracted sociodemographic, travel and obstetric data. Extracted travel data were exported to Google Maps, where typical distance and travel time for period-of-day they travelled were extracted. Multivariable logistic regression was conducted to determine the relative influence of distance and travel time on stillbirth.

RESULTS

Of 3278 births, there were 408 stillbirths (12.5%). Women with livebirths travelled a median distance of 7.3 km (IQR 3.3-18.0) and over a median time of 24 min (IQR 12-51). Those with stillbirths travelled a median distance of 8.5 km (IQR 4.4-19.7) and over a median time of 30 min (IQR 16-60). Following adjustments, though no significant association with distance was found, odds of stillbirth were significantly higher for travel of 10-29 min (OR 2.25, 95% CI 1.40 to 3.63), 30-59 min (OR 2.30, 95% CI 1.22 to 4.34) and 60-119 min (OR 2.35, 95% CI 1.05 to 5.25). The adjusted OR of stillbirth was significantly lower following booking (OR 0.37, 95% CI 0.28 to 0.49), obstetric complications with mother (obstructed labour (OR 0.11, 95% CI 0.07 to 0.17) and haemorrhage (OR 0.30, 95%CI 0.20 to 0.46)). Odds were significantly higher with multiple gestations (OR 2.40, 95% CI 1.57 to 3.69) and referral (OR 1.55, 95% CI 1.13 to 2.12).

CONCLUSION

Travel time to a hospital was strongly associated with stillbirth. In addition to birth preparedness, efforts to get quality care quicker to women or women quicker to quality care will be critical for efforts to reduce stillbirths in a principally urban low-income and middle-income setting.