Travel time and perinatal mortality after emergency caesarean sections: an evaluation of the 2-hour proximity indicator in Sierra Leone

Duinen, Alex J. van; Adde, H A; Fredin, Ola; Holmer, Hampus; Hagander, Lars; Koroma, Alimamy P.; Koroma, Michael M.; Leather, Andrew J M; Wibe, Arne; Bolkan, Håkon A.

doi:10.1136/bmjgh-2020-003943

Cited by 23 publications

(36 citation statements)

References 30 publications

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“…This was significantly lower than the 60 min median travel time self-reported by over 1000 women who had an emergency caesarean birth in nine hospitals in Sierra Leone. 11 Evidence shows that estimates using Google Maps, like we have done in our study, are more reflective of reality compared with models. 26 On the other hand, self-reported travel time are usually higher than modelled estimates.…”

Section: Discussionsupporting

confidence: 53%

“…26 On the other hand, self-reported travel time are usually higher than modelled estimates. 11 While, methodological differences may explain the difference, it might also relate with road transport quality. Benchmarking with South Africa as highest quality (100), road transport quality index in…”

Section: Discussionmentioning

confidence: 99%

“…9 10 Until, only a few studies have looked at influence of travel including distance and travel time on perinatal outcomes in LMICs including one that focused specifically on stillbirths. [11][12][13][14] The one study that specifically assessed stillbirth was conducted in a hospital located in a north-eastern city of Nigeria and focused on travel time, not distance. 14 However, distance and travel time are both important considerations, especially in urban and periurban LMIC settings, where some pregnant women could travel for a long time despite living only a short distance from the health facility, due to traffic and vice versa, due to access to motorised transport.…”

Section: Bmj Global Healthmentioning

confidence: 99%

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

et al. 2021

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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.

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Section: Discussionsupporting

confidence: 53%

Section: Discussionmentioning

confidence: 99%

Section: Bmj Global Healthmentioning

confidence: 99%

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

et al. 2021

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“…Transport expenses were highest in the poorest quintile. In another manuscript, based on the same database, it was found that patients in the poorest quintile had a median reported travel time that was more than double that of the richest quintile (113 versus 45 minutes) [36]. Since October 2018, a National Emergency Medical Service has been established providing free transport for obstetric patients between primary health care units (PHUs) and hospitals [37].…”

Section: Plos Onementioning

confidence: 99%

Catastrophic expenditure and impoverishment after caesarean section in Sierra Leone: An evaluation of the free health care initiative

Duinen

Westendorp

Ashley³

et al. 2021

PLoS ONE

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Background Utilizing surgical services, including caesarean sections, can result in catastrophic expenditure and impoverishment. In 2010, Sierra Leone introduced the Free Health Care Initiative (FHCI), a national financial risk protection program for the most vulnerable groups. Aim of this study was to investigate catastrophic expenditure and impoverishment related to caesarean section in Sierra Leone and evaluate the impact of the FHCI. Methods Women who delivered by caesarean section in nine hospitals were followed up with home visits one month after surgery, and data on medical and non-medical expenditures were collected. Individual income was estimated based on household characteristics and used to determine catastrophic expenditure and impoverishment for each patient. The impact of the FHCI was assessed by comparing actual expenditure with counterfactual expenditures had the initiative not existed. Results For the 1146 patients in the study, the median expenditure was 23 (IQR 4; 56) international dollars (Int$). Patients in the poorest quintile spent a median Int$ 59 (IQR 28; 76), which was significantly more than patients in the richest quintile, who spent a median Int$ 17 (IQR 2; 38, p<0.001). Travel (32.9%) and food (28.7%) were the two largest expenses. Catastrophic expenditure was encountered by 12.0% and 4.0% (10% and 25% threshold, respectively) of the women. Without the FHCI, 66.1% and 28.8% of the women would have encountered catastrophic expenditure. Conclusion Many women in Sierra Leone face catastrophic expenditure related to caesarean section, mainly through food and travel expenses, and the poor are disproportionally affected. The FHCI is effective in reducing the risk of catastrophic expenditure related to caesarean section, but many patients are still exposed to financial hardship, suggesting that additional support is needed for Sierra Leone’s poorest patients.

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“…Our study shows a clear association between PT and risk of maternal and perinatal death during obstetric emergencies. While the association between PT and perinatal mortality is well studied in high-income countries, [31][32][33] only few studies evaluated the relationship between longer TT and adverse perinatal outcomes in low-income and low-middleincome countries, [34][35][36] and quantitative data on maternal risk of death are even less investigated. The high rates of perinatal deaths reported in our study concur with the results of van Duinen et al, 34 who reported a 19% perinatal mortality following emergency caesarian sections in Sierra Leone.…”

Section: Bmj Globalmentioning

confidence: 99%

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

et al. 2021

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IntroductionSierra 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.MethodsWe 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.ResultsAt 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%.ConclusionNEMS 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.

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Travel time and perinatal mortality after emergency caesarean sections: an evaluation of the 2-hour proximity indicator in Sierra Leone

Cited by 23 publications

References 30 publications

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

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

Catastrophic expenditure and impoverishment after caesarean section in Sierra Leone: An evaluation of the free health care initiative

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

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