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

Introduction: Prompt access to emergency obstetric care (EmOC) reduces the risk of maternal mortality. We assessed institutional maternal mortality by distance and travel time for pregnant women with obstetric 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 1st November 2018 and 30th October 2019, we extracted socio-demographic, travel, and obstetric data. The extracted travel data was 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 4,181 pregnant women with obstetric emergencies, 182 (4·4%) resulted in maternal deaths. Among those who died, 60.3% travelled ≤10km directly from home, and 61·9% arrived at the hospital ≤30mins. The median distance and travel time to EmOC was 7·6km (IQR 3·4-18·0) and 26mins (IQR 12-50). For all women, travelling 10-15km (2·53, 95%CI 1·27-5·03) was significantly associated with maternal death. Stratified by referral, odds remained statistically significant for those travelling 10-15km in the non-referred group (2·48, 95%CI 1·18-5·23) and for travel ≥120min (7.05, 95%CI 1.10-45.32). For those referred, odds became statistically significant at 25-35km (21·40, 95%CI 1·24-36·72) and for journeys requiring travel time from as little as 10-29min (184.23, 95%CI 5.14-608.51). Odds were also significantly higher for women travelling to hospitals in suburban (3·60, 95%CI 1·59–8·18) or rural (2·51, 95%CI 1·01–6·29) 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.