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Objective The objective of the study was to review the evidence on interventions to improve obstetric emergency referral decision making, communication and feedback between health facilities in sub‐Saharan Africa (SSA). Methods A systematic search of PubMed, Embase, Cochrane Register and CINAHL Plus was conducted to identify studies on obstetric emergency referral in SSA. Studies were included based on pre‐defined eligibility criteria. Details of reported referral interventions were extracted and categorised. The Joanna Biggs Institute Critical Appraisal checklists were used for quality assessment of included studies. A formal narrative synthesis approach was used to summarise findings guided by the WHO's referral system flow. Results A total of 14 studies were included, with seven deemed high quality. Overall, 7 studies reported referral decision‐making interventions including training programmes for health facility and community health workers, use of a triage checklist and focused obstetric ultrasound, which resulted in improved knowledge and practice of recognising danger signs for referral. 9 studies reported on referral communication using mobile phones and referral letters/notes, resulting in increased communication between facilities despite telecommunication network failures. Referral decision making and communication interventions achieved a perceived reduction in maternal mortality. 2 studies focused on referral feedback, which improved collaboration between health facilities. Conclusion There is limited evidence on how well referral interventions work in sub‐Saharan Africa, and limited consensus regarding the framework underpinning the expected change. This review has led to the proposition of a logic model that can serve as the base for future evaluations which robustly expose the (in)efficiency of referral interventions.

IntroductionAccess 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.MethodsWe 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.ResultsOf 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).ConclusionTravel 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.

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.