In this blog, the authors discuss the findings of their study, “Influence of travel time and distance to the hospital of care on stillbirths: a retrospective facility-based cross-sectional study in Lagos, Nigeria”, which assesses the influence of distance and travel time to the actual hospital of care on stillbirth.
From the onset of pregnancy, even though there is still a nine-month wait, every woman yearns to hear the cry of her baby. Indeed, beyond 28 weeks of pregnancy, it is well known that the baby’s chances of survival outside the womb increases significantly. Babies that die after this cut-off week are known as stillbirths. A report by the United Nations Inter-Agency Group on Child Mortality Estimation estimated that despite some progress that has been observed since year 2000, the rate of decline of stillbirths globally has been slower compared to maternal mortality. In 2019, almost two million stillbirths were delivered worldwide. Three-quarters of these deaths occurred in sub-Saharan Africa and South Asia. Nigeria alone contributed almost a tenth of the global burden, a proportion only higher in India and Pakistan.
It is widely recognised that many stillbirths are preventable, especially if the mother can get to a facility with skilled personnel that can provide critical maternal health services, that have been shown to reduce as much as three-quarters of stillbirths that might occur while a pregnant woman is already in labour. Before the expectant mother can access this care, she needs to first travel to the health facility and in an emergency, she needs to get there in quick time. In many parts of sub-Saharan Africa, this might involve travelling long distances from rural areas or for unprecedented length of time due to traffic congestion in urban areas.
Very little is known at a health system level about the experience of women in travelling to a hospital when in an emergency setting, and no study has tried to understand the influence of the pregnant woman’s journey on the survival of her unborn child on a health system. Indeed, the only way to comprehensively understand the influence of distance and travel time on stillbirths is to assess it from the lens of multiple health facilities within a specified geographical area.
What we did
In a study published in the BMJ Global Health, we reviewed hospital records of all pregnant women with a pregnancy of 28 weeks or longer who presented with an emergency at one of the 24 public hospitals in Lagos, Nigeria, from November 2018 to October 2019. From their records, we extracted data on their sociodemographic characteristics, obstetric history, travel to reach the health facility (including day of travel and period-of-day when journey to the facility commenced, street name of women’s residential address, referral facilities if any, the facility in which she received care (one of the 24 public hospitals)), obstetric complication managed, mode of delivery and pregnancy outcomes. Using the location data extracted from records, we mapped the journeys of expectant mothers with obstetric emergencies from their home to health facilities where they delivered using Google Maps, which has been shown to provide closer-to-reality estimate of travel distances and time.
What we found
We found that pregnant women who travelled more than 10 minutes to a hospital were more than two times to have a stillbirth compared to those who travelled less than 10 minutes. Our findings also showed that pregnant women who had stillbirths travelled longer distances and took a longer time to get to a hospital than women whose babies were born alive. The distance travelled was even more pronounced for women who had a stillbirth when in labour compared to those who had not started labour. Some other factors including if she was referred from some health facility to a hospital also increased the likelihood of her having a stillbirth.
Before the expectant mother can access this care, she needs to first travel to the health facility and in an emergency, she needs to get there in quick time. In many parts of sub-Saharan Africa, this might involve travelling long distances from rural areas or for unprecedented length of time due to traffic congestion in urban areas
We know from a previous study that pregnant women face significant challenges in travelling to hospitals when in situations of emergency, with reported journey times to a hospital ranging from 5 minutes to as much as 4 hours. Pregnant women also reported that the bumper-to-bumper traffic in Lagos combined with the deplorable road conditions in many parts of the state increased their time of travel to a hospital by between two to six times. Delays in referral between health facilities further prolonged the time before they can access care. Of these, those who were referred from lower facilities or private clinics were mostly left on their own or with their relatives to find their way to a hospital. Those referred from one public hospital to another sometimes had access to an ambulance, but this did not always guarantee an expedited travel, because the roads, traffic, and the fact that many road users do not give way to ambulances. Clearly, as our new study has now shown, one significant consequence of all these delays is increased likelihood of a stillbirth.
What needs to be done
As our study has shown, a high number of stillbirths still occur among women who make it to a hospital. In addition, every minute counts when it comes to stillbirths. If any significant progress is to be made in reducing stillbirths, then planning for travel in the event of an emergency needs to commence before the emergency itself occurs. Health care providers should have this discussion with pregnant women as part of birth preparedness plans during routine antenatal clinics.
In addition to travel time, we also found that some previously known factors that had been associated with stillbirth were significant in our study. For example, carrying a twin pregnancy and not being seen previously by a health care provider during the pregnancy. Interestingly, our data showed that babies of women who had more overt complications like bleeding were less likely to die compared to babies whose mothers had no complication themselves. While support for all women should be the goal, these groups of women identified from our study need to be especially prioritised.
Governments should make all possible efforts in getting quality care quicker to pregnant women or pregnant women quicker to quality care. This will entail strengthening referral systems and implementing robust ambulance services supported by community orientation on the need to give way for ambulances carrying emergencies. This needs to be done while making consideration for both pregnant women who are poor and those who live far away from hospitals, remembering that our study did not include women who did not make it to a hospital. There is also a case for governments to help in ensuring ease with physical access to hospitals with full capacity to provide critical maternal health services for pregnant women in emergency situations. Any public investments to address these issues need to be done with clear recognition for assuring value for money in maternal and newborn health and guaranteeing the sustainability of outcomes.
If you truly want to leave no one behind, the time to act is now!
The views expressed in this post are those of the author and in no way reflect those of the Global Health Initiative blog or the London School of Economics and Political Science.