Assessing geographical distribution and accessibility of emergency obstetric care in sub-Saharan Africa: a systematic review

Has the Gratuité policy reduced inequities in geographic access to antenatal care in Burkina Faso? Evidence from facility-based data from 2014 to 2022

Background

Evidence shows that user fee exemption policies improve the use of maternal, newborn, and child health (MNCH) services. However, addressing the cost of care is only one barrier to accessing MNCH services. Poor geographic accessibility relating to distance is another. Our objective in this study was to assess the effect of a user fee exemption policy in Burkina Faso (Gratuité) on antenatal care (ANC) use, considering distance to health facilities.

Methods

We conducted a cross-sectional study with sub-analysis by intervention period to compare utilization of ANC services (outcome of interest) in pregnant women who used the service in the context of the Gratuité user fee exemption policy and those who did not, in Manga district, Burkina Faso. Dependent variables included were socio-demographic characteristics, obstetric history, and distance to the lower-level health facility (known as Centre de Santé et Promotion Sociale) in which care was sort. Univariate, bivariate, and multivariate analyses were performed across the entire population, within those who used ANC before the policy and after its inception.

Results

For women who used services before the Gratuité policy was introduced, those living 5-9 km were almost twice (OR = 1.94; 95% CI: 1.17-3.21) more likely to have their first ANC visit (ANC1) in the first trimester compared to those living <5 km of the nearest health facility. After the policy was introduced, women living 5-9 km and >10 km from the nearest facility were almost twice (OR = 1.86; 95% CI: 1.14-3.05) and over twice (OR = 2.04; 95% CI: 1.20-3.48) more likely respectively to use ANC1 in the first trimester compared to those living within 5 km of the nearest health facility. Also, women living over 10 km from the nearest facility were 1.29 times (OR = 1.29; 95% CI: 1.00-1.66) more likely to have 4+ ANC than those living less than 5 km from the nearest health facility.

Conclusions

Insofar as the financial barrier to ANC has been lifted and the geographical barrier reduced for the populations that live farther away from services through the Gratuité policy, then the Burkinabé government must make efforts to sustain the policy and ensure that benefits of the policy reach the targeted and its gains maximized.

Equity in prenatal healthcare services globally: an umbrella review

BACKGROUND

Timely, appropriate, and equitable access to quality healthcare during pregnancy is proven to contribute to better health outcomes of birthing individuals and infants following birth. Equity is conceptualized as the absence of differences in healthcare access and quality among population groups. Healthcare policies are guides for front-line practices, and despite merits of contemporary policies striving to foster equitable healthcare, inequities persist. The purpose of this umbrella review is to identify prenatal healthcare practices, summarize how equities/inequities are reported in relation to patient experiences or health outcomes when accessing or using services, and collate equity reporting characteristics.

METHODS

For this umbrella review, six electronic databases were searched (Medline, EMBASE, APA PsychInfo, CINAHL, International Bibliography of the Social Sciences, and Cochrane Library). Included studies were extracted for publication and study characteristics, equity reporting, primary outcomes (prenatal care influenced by equity/inequity) and secondary outcomes (infant health influenced by equity/inequity during pregnancy). Data was analyzed deductively using the PROGRESS-Plus equity framework and by summative content analysis for equity reporting characteristics. The included articles were assessed for quality using the Risk of Bias Assessment Tool for Systematic Reviews.

RESULTS

The search identified 8065 articles and 236 underwent full-text screening. Of the 236, 68 systematic reviews were included with first authors representing 20 different countries. The population focus of included studies ranged across prenatal only (n = 14), perinatal (n = 25), maternal (n = 2), maternal and child (n = 19), and a general population (n = 8). Barriers to equity in prenatal care included travel and financial burden, culturally insensitive practices that deterred care engagement and continuity, and discriminatory behaviour that reduced care access and satisfaction. Facilitators to achieve equity included innovations such as community health workers, home visitation programs, conditional cash transfer programs, virtual care, and cross-cultural training, to enhance patient experiences and increase their access to, and use of health services. There was overlap across PROGRESS-Plus factors.

CONCLUSIONS

This umbrella review collated inequities present in prenatal healthcare services, globally. Further, this synthesis contributes to future solution and action-oriented research and practice by assembling evidence-informed opportunities, innovations, and approaches that may foster equitable prenatal health services to all members of diverse communities.

Health facility assessment of small and sick newborn care in low- and middle-income countries: systematic tool development and operationalisation with NEST360 and UNICEF

BACKGROUND

Each year an estimated 2.3 million newborns die in the first 28 days of life. Most of these deaths are preventable, and high-quality neonatal care is fundamental for surviving and thriving. Service readiness is used to assess the capacity of hospitals to provide care, but current health facility assessment (HFA) tools do not fully evaluate inpatient small and sick newborn care (SSNC).

METHODS

Health systems ingredients for SSNC were identified from international guidelines, notably World Health Organization (WHO), and other standards for SSNC. Existing global and national service readiness tools were identified and mapped against this ingredients list. A novel HFA tool was co-designed according to a priori considerations determined by policymakers from four African governments, including that the HFA be completed in one day and assess readiness across the health system. The tool was reviewed by > 150 global experts, and refined and operationalised in 64 hospitals in Kenya, Malawi, Nigeria, and Tanzania between September 2019 and March 2021.

RESULTS

Eight hundred and sixty-six key health systems ingredients for service readiness for inpatient SSNC were identified and mapped against four global and eight national tools measuring SSNC service readiness. Tools revealed major content gaps particularly for devices and consumables, care guidelines, and facility infrastructure, with a mean of 13.2% (n = 866, range 2.2-34.4%) of ingredients included. Two tools covered 32.7% and 34.4% (n = 866) of ingredients and were used as inputs for the new HFA tool, which included ten modules organised by adapted WHO health system building blocks, including: infrastructure, pharmacy and laboratory, medical devices and supplies, biomedical technician workshop, human resources, information systems, leadership and governance, family-centred care, and infection prevention and control. This HFA tool can be conducted at a hospital by seven assessors in one day and has been used in 64 hospitals in Kenya, Malawi, Nigeria, and Tanzania.

CONCLUSION

This HFA tool is available open-access to adapt for use to comprehensively measure service readiness for level-2 SSNC, including respiratory support. The resulting facility-level data enable comparable tracking for Every Newborn Action Plan coverage target four within and between countries, identifying facility and national-level health systems gaps for action.

Socio-spatial equity analysis of relative wealth index and emergency obstetric care accessibility in urban Nigeria

BACKGROUND

Better geographical accessibility to comprehensive emergency obstetric care (CEmOC) facilities can significantly improve pregnancy outcomes. However, with other factors, such as affordability critical for care access, it is important to explore accessibility across groups. We assessed CEmOC geographical accessibility by wealth status in the 15 most-populated Nigerian cities.

METHODS

We mapped city boundaries, verified and geocoded functional CEmOC facilities, and assembled population distribution for women of childbearing age and Meta's Relative Wealth Index (RWI). We used the Google Maps Platform's internal Directions Application Programming Interface to obtain driving times to public and private facilities. City-level median travel time (MTT) and number of CEmOC facilities reachable within 60 min were summarised for peak and non-peak hours per wealth quintile. The correlation between RWI and MTT to the nearest public CEmOC was calculated.

RESULTS

We show that MTT to the nearest public CEmOC facility is lowest in the wealthiest 20% in all cities, with the largest difference in MTT between the wealthiest 20% and least wealthy 20% seen in Onitsha (26 vs 81 min) and the smallest in Warri (20 vs 30 min). Similarly, the average number of public CEmOC facilities reachable within 60 min varies (11 among the wealthiest 20% and six among the least wealthy in Kano). In five cities, zero facilities are reachable under 60 min for the least wealthy 20%. Those who live in the suburbs particularly have poor accessibility to CEmOC facilities.

CONCLUSIONS

Our findings show that the least wealthy mostly have poor accessibility to care. Interventions addressing CEmOC geographical accessibility targeting poor people are needed to address inequities in urban settings.

Postabortion care availability, readiness, and accessibility in Niger in 2022: results from linked facility-female cross-sectional data

BACKGROUND

Postabortion care (PAC), which is an essential element of emergency obstetric care, is underresearched in Niger. The study aims to assess the availability, readiness, and accessibility of facility-based PAC services in Niger.

METHODS

This study uses female and facility data from Performance Monitoring for Action Niger. The female data include a nationally representative sample of women aged 15-49 (n = 3,696). Using GPS coordinates, these female data were linked to a sample of public and private facilities (n = 258) that are expected to provide PAC. We assessed PAC availability and facility readiness to provide basic and comprehensive PAC using the signal functions framework, overall and by facility type. We then calculated the distance between women and their closest facility and estimated the proportion of women living within five kilometers (5 km) of a facility providing any PAC, basic PAC, and comprehensive PAC, overall and by women's background characteristics.

RESULTS

Only 36.4% and 14% of eligible facilities had all basic and comprehensive PAC signal functions, respectively. Oxytocics and laparotomy were the most missing signal function for basic and comprehensive PAC, respectively. Private facilities were the least ready to provide the full range of PAC services. While 47% of women lived within 5 km of a facility providing any PAC services, only 33.4% and 7.9% lived within 5 km of a facility providing all basic and all comprehensive PAC signal functions, respectively. Women who were divorced/widowed, had higher levels of education, and were living in urban areas had increased odds of living within 5 km of a facility with any or basic PAC. Women who were never married had increased odds of living within 5 km of a facility with comprehensive PAC, while urban residence was fully predictive of living within 5 km of a facility with comprehensive PAC.

CONCLUSIONS

This study found PAC availability and readiness to be insufficient in Niger, with inadequate and disparate accessibility to facilities providing PAC services. We recommended stakeholders ensure stock of essential commodities and availability of PAC services at primary facilities in order to mitigate the negative maternal health repercussions of unsafe abortion in this setting.

A geospatial database of close-to-reality travel times to obstetric emergency care in 15 Nigerian conurbations

Travel time estimation accounting for on-the-ground realities between the location where a need for emergency obstetric care (EmOC) arises and the health facility capable of providing EmOC is essential for improving pregnancy outcomes. Current understanding of travel time to care is inadequate in many urban areas of Africa, where short distances obscure long travel times and travel times can vary by time of day and road conditions. Here, we describe a database of travel times to comprehensive EmOC facilities in the 15 most populated extended urban areas of Nigeria. The travel times from cells of approximately 0.6 × 0.6 km to facilities were derived from Google Maps Platform's internal Directions Application Programming Interface, which incorporates traffic considerations to provide closer-to-reality travel time estimates. Computations were done to the first, second and third nearest public or private facilities. Travel time for eight traffic scenarios (including peak and non-peak periods) and number of facilities within specific time thresholds were estimated. The database offers a plethora of opportunities for research and planning towards improving EmOC accessibility.

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 "No bed syndrome" in Ghana - what, how and why? A literature, electronic and print media review

Objectives

"No bed syndrome" has become a familiar phrase in Ghana. Yet, there is very little in medical texts or the peer reviewed literature about it. This review aimed to document what the phrase means in the Ghanaian context, how and why it occurs, and potential solutions.

Design

A qualitative desk review using a thematic synthesis of grey and published literature, print and electronic media content covering the period January 2014 to February 2021. Text was coded line by line to identify themes and sub-themes related to the research questions. Analysis was manual and with Microsoft Excel to sort themes.

Setting

Ghana.

Participants and Intervention

Not applicable.

Results

"No bed syndrome" describes the turning away by hospitals and clinics of people seeking walk in or referral emergency care with the stated reasons "no bed available" or "all beds are full". There are reported cases of people dying while going round multiple hospitals seeking help and being repeatedly turned away because there is "no bed". The situation appears to be most acute in the highly urbanized and densely populated Greater Accra region. It is driven by a complex of factors related to context, health system functions, values, and priorities. The solutions that have been tried are fragmented rather than well-coordinated whole system reform.

Discussions and recommendations

The "no bed syndrome" describes the challenge of a poorly functioning emergency health care system rather than just the absence of a bed on which to place an emergency case. Many low and middle income countries have similar challenges with their emergency health care systems and this analysis from Ghana is potentially valuable in attracting global attention and thinking about emergency health systems capacity and reform in low and middle income countries. The solution to the "no bed syndrome" in Ghana requires reform of Ghana's emergency healthcare system that takes a whole system and integrated approach. All the components of the health system such as human resource, information systems, financing, equipment tools and supplies, management and leadership need to be examined and addressed together alongside health system values such as accountability, equity or fairness in the formulation, implementation, continuous monitoring and evaluation of policies and programs for system reform to expand and strengthen emergency healthcare system capacity and responsiveness. Despite the temptation to fall back on them as low hanging fruit, piecemeal and ad-hoc solutions cannot solve the problem.

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

Maternal and perinatal mortality remain huge challenges globally, particularly in low- and middle-income countries (LMICs) where >98% of these deaths occur. Emergency obstetric care (EmOC) provided by skilled health personnel is an evidence-based package of interventions effective in reducing these deaths associated with pregnancy and childbirth. Until recently, pregnant women residing in urban areas have been considered to have good access to care, including EmOC. However, emerging evidence shows that due to rapid urbanization, this so called “urban advantage” is shrinking and in some LMIC settings, it is almost non-existent. This poses a complex challenge for structuring an effective health service delivery system, which tend to have poor spatial planning especially in LMIC settings. To optimize access to EmOC and ultimately reduce preventable maternal deaths within the context of urbanization, it is imperative to accurately locate areas and population groups that are geographically marginalized. Underpinning such assessments is accurately estimating travel time to health facilities that provide EmOC. In this perspective, we discuss strengths and weaknesses of approaches commonly used to estimate travel times to EmOC in LMICs, broadly grouped as reported and modeled approaches, while contextualizing our discussion in urban areas. We then introduce the novel OnTIME project, which seeks to address some of the key limitations in these commonly used approaches by leveraging big data. The perspective concludes with a discussion on anticipated outcomes and potential policy applications of the OnTIME project.

Effect of emergency obstetric care and proximity to comprehensive facilities on facility-based delivery in Malawi and Haiti

Proximity of households to comprehensive obstetric care is a key determinant for preventing maternal mortality due to obstetric emergencies. The relationship between proximity to comprehensive care and facility delivery is further complicated by the use of varied methods in measuring facility obstetric capacity-which may misrepresent the real scenario of obstetric care availability in a service environment. We investigated the joint effects of proximity and two emergency obstetric care assessment (EmOC) methods on women's place of delivery in Malawi and Haiti. Household level and health facility data were obtained from the 2013-2018 Demographic and Health Surveys and Service Provision Assessment surveys. Records of women aged 15 to 49 years who had a childbirth in the last 5 years were linked to obstetric facilities within 5km, 10km and 15km from their households using Kernel Density Estimation. Log-binomial models were fitted to estimate the joint effects of proximity to comprehensive facilities on place of delivery and two EmOC methods (1. the facility's recent performance of signal functions only, and 2. a composite index of obstetric care), and whether this varied by urban/rural setting. Proximity to comprehensive facilities was significantly associated with facility delivery in Malawi among women living 5km of a comprehensive facility (using EmOC method 2), in addition, living further (15km) from facilities with high capacity of EmOC was associated with reduced likelihood for facility delivery in urban settings in stratified analyses. In contrast, positive associations were present in Haiti in both urban and rural settings, with the likelihood of facility delivery being higher with greater proximity of women to comprehensive facilities, regardless of methods to define EmOC. Women living within 5km of a comprehensive facility in Haiti were the most likely to deliver in facilities based on EmOC method 1 (APR: 1.81, 95% CI 1.56, 2.09). Findings from Malawi elucidates the relevance of context and suggests the need for research in diverse settings.

Association between ambulance prehospital time and maternal and perinatal outcomes in Sierra Leone: a countrywide study

INTRODUCTION

Sierra Leone, one of the countries with the highest maternal and perinatal mortality in the world, launched its first National Emergency Medical Service (NEMS) in 2018. We carried out a countrywide assessment to analyse NEMS operational times for obstetric emergencies in respect the access to timely essential surgery within 2 hours. Moreover, we evaluated the relationship between operational times and maternal and perinatal mortality.

METHODS

We collected prehospital data of 6387 obstetric emergencies referrals from primary health units to hospital facilities between June 2019 and May 2020 and we estimated the proportion of referrals with a prehospital time (PT) within 2 hours. The association between PT and mortality was investigated using Poisson regression models for binary data.

RESULTS

At the national level, the proportion of emergency obstetric referrals with a PT within 2 hours was 58.5% (95% CI 56.9% to 60.1%) during the rainy season and 61.4% (95% CI 59.5% to 63.2%) during the dry season. Results were substantially different between districts, with the capital city of Freetown reporting more than 90% of referrals within the benchmark and some rural districts less than 40%. Risk of maternal death at 60, 120 and 180 min of PT was 1.8%, 3.8% and 4.3%, respectively. Corresponding figures for perinatal mortality were 16%, 18% and 25%.

CONCLUSION

NEMS operational times for obstetric emergencies in Sierra Leone vary greatly and referral transports in rural areas struggle to reach essential surgery within 2 hours. Maternal and perinatal risk of death increased concurrently with operational times, even beyond the 2-hour target, therefore, any reduction of the time to reach the hospital, may translate into improved patient outcomes.

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.

An assessment of geographical access and factors influencing travel time to emergency obstetric care in the urban state of Lagos, Nigeria

Previous efforts to estimate the travel time to comprehensive emergency obstetric care (CEmOC) in low- and middle-income countries (LMICs) have either been based on spatial models or self-reported travel time, both with known inaccuracies. The study objectives were to estimate more realistic travel times for pregnant women in emergency situations using Google Maps, determine system-level factors that influence travel time and use these estimates to assess CEmOC geographical accessibility and coverage in Lagos state, Nigeria. Data on demographics, obstetric history and travel to CEmOC facilities of pregnant women with an obstetric emergency, who presented between 1st November 2018 and 31st December 2019 at a public CEmOC facility were collected from hospital records. Estimated travel times were individually extracted from Google Maps for the period of the day of travel. Bivariate and multivariate analyses were used to test associations between travel and health system-related factors with reaching the facility >60 minutes. Mean travel times were compared and geographical coverage mapped to identify ‘hotspots’ of predominantly >60 minutes travel to facilities. For the 4005 pregnant women with traceable journeys, travel time ranges were 2–240 minutes (without referral) and 7–320 minutes (with referral). Total travel time was within the 60 and 120 minute benchmark for 80 and 96% of women, respectively. The period of the day of travel and having been referred were significantly associated with travelling >60 minutes. Many pregnant women living in the central cities and remote towns typically travelled to CEmOC facilities around them. We identified four hotspots from which pregnant women travelled >60 minutes to facilities. Mean travel time and distance to reach tertiary referral hospitals were significantly higher than the secondary facilities. Our findings suggest that actions taken to address gaps need to be contextualized. Our approach provides a useful guide for stakeholders seeking to comprehensively explore geographical inequities in CEmOC access within urban/peri-urban LMIC settings.

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.

"In cities, it's not far, but it takes long": comparing estimated and replicated travel times to reach life-saving obstetric care in Lagos, Nigeria

BACKGROUND

Travel time to comprehensive emergency obstetric care (CEmOC) facilities in low-resource settings is commonly estimated using modelling approaches. Our objective was to derive and compare estimates of travel time to reach CEmOC in an African megacity using models and web-based platforms against actual replication of travel.

METHODS

We extracted data from patient files of all 732 pregnant women who presented in emergency in the four publicly owned tertiary CEmOC facilities in Lagos, Nigeria, between August 2018 and August 2019. For a systematically selected subsample of 385, we estimated travel time from their homes to the facility using the cost-friction surface approach, Open Source Routing Machine (OSRM) and Google Maps, and compared them to travel time by two independent drivers replicating women's journeys. We estimated the percentage of women who reached the facilities within 60 and 120 min.

RESULTS

The median travel time for 385 women from the cost-friction surface approach, OSRM and Google Maps was 5, 11 and 40 min, respectively. The median actual drive time was 50-52 min. The mean errors were >45 min for the cost-friction surface approach and OSRM, and 14 min for Google Maps. The smallest differences between replicated and estimated travel times were seen for night-time journeys at weekends; largest errors were found for night-time journeys at weekdays and journeys above 120 min. Modelled estimates indicated that all participants were within 60 min of the destination CEmOC facility, yet journey replication showed that only 57% were, and 92% were within 120 min.

CONCLUSIONS

Existing modelling methods underestimate actual travel time in low-resource megacities. Significant gaps in geographical access to life-saving health services like CEmOC must be urgently addressed, including in urban areas. Leveraging tools that generate 'closer-to-reality' estimates will be vital for service planning if universal health coverage targets are to be realised by 2030.

Reaching health facilities in situations of emergency: qualitative study capturing experiences of pregnant women in Africa's largest megacity

Background

The consequences of delays in travel of pregnant women to reach facilities in emergency situations are well documented in literature. However, their decision-making and actual experiences of travel to health facilities when requiring emergency obstetric care (EmOC) remains a ‘black box’ of many unknowns to the health system, more so in megacities of low- and middle-income countries which are fraught with wide inequalities.

Methods

This in-depth study on travel of pregnant women in Africa’s largest megacity, Lagos, is based on interviews conducted between September 2019 and January 2020 with 47 women and 11 of their relatives who presented at comprehensive EmOC facilities in situations of emergency, requiring some EmOC services. Following familiarisation, coding, and searching for patterns, the data was analysed for emerging themes.

Results

Despite recognising danger signs, pregnant women are often faced with conundrums on “when”, “where” and “how” to reach EmOC facilities. While the decision-making process is a shared activity amongst all women, the available choices vary depending on socio-economic status. Women preferred to travel to facilities deemed to have “nicer” health workers, even if these were farther from home. Reported travel time was between 5 and 240 min in daytime and 5–40 min at night. Many women reported facing remarkably similar travel experiences, with varied challenges faced in the daytime (traffic congestion) compared to night-time (security concerns and scarcity of public transportation). This was irrespective of their age, socio-economic background, or obstetric history. However, the extent to which this experience impacted on their ability to reach facilities depended on their agency and support systems. Travel experience was better if they had a personal vehicle for travel at night, support of relatives or direct/indirect connections with senior health workers at comprehensive EmOC facilities. Referral barriers between facilities further prolonged delays and increased cost of travel for many women.

Conclusion

If the goal, to leave no one behind, remains a priority, in addition to other health systems strengthening interventions, referral systems need to be improved. Advocacy on policies to encourage women to utilise nearby functional facilities when in situations of emergency and private sector partnerships should be explored.

Measuring the availability and geographical accessibility of maternal health services across sub-Saharan Africa

BACKGROUND

With universal health coverage a key component of the 2030 Sustainable Development Goals, targeted monitoring is crucial for reducing inequalities in the provision of services. However, monitoring largely occurs at the national level, masking sub-national variation. Here, we estimate indicators for measuring the availability and geographical accessibility of services, at national and sub-national levels across sub-Saharan Africa, to show how data at varying spatial scales and input data can considerably impact monitoring outcomes.

METHODS

Availability was estimated using the World Health Organization guidelines for monitoring emergency obstetric care, defined as the number of hospitals per 500,000 population. Geographical accessibility was estimated using the Lancet Commission on Global Surgery, defined as the proportion of pregnancies within 2 h of the nearest hospital. These were calculated using geo-located hospital data for sub-Saharan Africa, with their associated travel times, along with small area estimates of population and pregnancies. The results of the availability analysis were then compared to the results of the accessibility analysis, to highlight differences between the availability and geographical accessibility of services.

RESULTS

Despite most countries meeting the targets at the national level, we identified substantial sub-national variation, with 58% of the countries having at least one administrative unit not meeting the availability target at province level and 95% at district level. Similarly, 56% of the countries were found to have at least one province not meeting the accessibility target, increasing to 74% at the district level. When comparing both availability and accessibility within countries, most countries were found to meet both targets; however sub-nationally, many countries fail to meet one or the other.

CONCLUSION

While many of the countries met the targets at the national level, we found large within-country variation. Monitoring under the current guidelines, using national averages, can mask these areas of need, with potential consequences for vulnerable women and children. It is imperative therefore that indicators for monitoring the availability and geographical accessibility of health care reflect this need, if targets for universal health coverage are to be met by 2030.

Improving geographical accessibility modeling for operational use by local health actors

BACKGROUND

Geographical accessibility to health facilities remains one of the main barriers to access care in rural areas of the developing world. Although methods and tools exist to model geographic accessibility, the lack of basic geographic information prevents their widespread use at the local level for targeted program implementation. The aim of this study was to develop very precise, context-specific estimates of geographic accessibility to care in a rural district of Madagascar to help with the design and implementation of interventions that improve access for remote populations.

METHODS

We used a participatory approach to map all the paths, residential areas, buildings and rice fields on OpenStreetMap (OSM). We estimated shortest routes from every household in the District to the nearest primary health care center (PHC) and community health site (CHS) with the Open Source Routing Machine (OSMR) tool. Then, we used remote sensing methods to obtain a high resolution land cover map, a digital elevation model and rainfall data to model travel speed. Travel speed models were calibrated with field data obtained by GPS tracking in a sample of 168 walking routes. Model results were used to predict travel time to seek care at PHCs and CHSs for all the shortest routes estimated earlier. Finally, we integrated geographical accessibility results into an e-health platform developed with R Shiny.

RESULTS

We mapped over 100,000 buildings, 23,000 km of footpaths, and 4925 residential areas throughout Ifanadiana district; these data are freely available on OSM. We found that over three quarters of the population lived more than one hour away from a PHC, and 10-15% lived more than 1 h away from a CHS. Moreover, we identified areas in the North and East of the district where the nearest PHC was further than 5 h away, and vulnerable populations across the district with poor geographical access (> 1 h) to both PHCs and CHSs.

CONCLUSION

Our study demonstrates how to improve geographical accessibility modeling so that results can be context-specific and operationally actionable by local health actors. The importance of such approaches is paramount for achieving universal health coverage (UHC) in rural areas throughout the world.

Incidence of maternal near miss among women in labour admitted to hospitals in Ethiopia

OBJECTIVES

To assess the incidence of maternal near miss and contributing factors among hospitals in Ethiopia. The study also assessed the ability of hospitals to provide signal functions of emergency obstetric care and its regional distribution.

DESIGN

A national dataset accessed from the Ethiopian Public Health Institute were analysed to assess the incidence of maternal near miss and mortality index among women admitted to hospitals with obstetric complications.

SETTING

Maternal health indicators including obstetric complications, maternal deaths and births conducted at all hospitals available in Ethiopia were included.

MEASUREMENTS

The maternal near miss incidence ratio, which is the number of near miss cases per 1,000 live births, and the mortality index were presented descriptively. Chi-squared test at p value ≤ 0.05 was used to assess the presence of significant regional differences of the provision of signal functions of emergency obstetric care.

RESULTS

In 2015, 78,195 women were admitted to hospitals with both the direct (68,002) and indirect (10,193) causes of maternal mortality. Of women who experienced the direct causes, 435 died which means there were 67,567 maternal near miss cases. In the same year, 323,824 live births were reported in hospitals, making the crude maternal near miss incidence ratio of 20.8% (9.1-38.8%) and mortality index of 0.64% (435/68,002) for the direct causes of maternal mortality. A significant regional variation was observed with regard to incidence of maternal near miss, mortality index and the provision of signal functions of emergency obstetric care. Administration of parenteral antibiotics was the most frequently practiced signal function of emergency obstetric care while blood transfusion was the least provided signal function.

CONCLUSIONS

In Ethiopian hospitals, the incidence of maternal near miss was unacceptably high. A significant regional variation was detected with regard to maternal near miss incidence ratio, mortality index and the provision of signal functions of emergency obstetric care. The Ethiopian government needs to work on equitable resource distribution and quality improvement initiatives in order to close the detected regional variations.

IMPLICATIONS FOR PRACTICE

The Ethiopian government needs to practice evidence-based maternal health strategies, including capacity building of the regional hospitals in order to improve the distribution of resources and quality of maternal health.

Survey on available treatment for acute kidney injury in the Southern African Development Community and Nigeria: are we ready for zero deaths by 2025 in sub-Saharan Africa?

OBJECTIVES

The International Society of Nephrology (ISN) has called for zero deaths by 2025. This survey aimed to determine the preparedness of Southern African Development Community (SADC) countries and Nigeria to heed this call.

SETTING

A questionnaire was emailed to facilities, where renal replacement therapy is available; to determine type of services available; quality of care and identify clinicians involved.

PARTICIPANTS

Clinicians and administrators involved in the care of patients with acute kidney injury (AKI) completed the questionnaire.

RESULTS

Completed questionnaires were received from 12 of the 15 SADC countries and Nigeria, covering 48 service providers. The government provided partial funding for dialysis in 41.7% of services. There was no funding for acute dialysis in two countries. Interdisciplinary teams in 72.9% of hospitals covered the intensive care units (ICUs), which included at least one nephrologist in 75%. Only 77% were able to provide dialysis in ICU. Intermittent haemodialysis was the most common modality available (91.7% of facilities), sustained low-efficiency dialysis in 50%, continuous therapies in 35% and peritoneal dialysis in 33.3%. Almost half (47.9%) of the sites were limited to one mode of dialysis and unable to care for severely ill patients. The clinical status was used to initiate and monitor dialysis, with very few sites having clear written standard operating procedures.

CONCLUSION

In the 16 countries surveyed, the majority had limited ability to provide comprehensive dialysis programmes for patients with AKI due to lack of facilities and government funding. Additionally, nephrologists are scarce; modes of dialysis are limited; as is the care for severely ill patients and lack of standard operating procedures. Resources, training and funding need to be made available to create universal coverage of dialysis for AKI. The ISN goal of providing renal replacement therapy to all by 2025 is unlikely to be achieved in SADC and Nigeria.