Can navigation applications facilitate equity in geographical access to emergency obstetric care?
Authors: Michael C Ezeanochie, Ruth Jahonga
Journal: The Lancet Global Health (2024)

Although huge investments have been made to target the leading direct causes of maternal mortality, the default health system configuration in many low-income and middle-income country (LMIC) settings appears to limit the effect of these investments.1Souza JP Day LT Rezende-Gomes AC et al.A global analysis of the determinants of maternal health and transitions in maternal mortality.Lancet Glob Health. 2024; 12: e306-e316Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar Timely access to lifesaving emergency obstetric care can be affected by inequalities in the geographical distribution of emergency obstetric care facilities, the quality of services, and a paucity of proper transport networks to allow choice of facility in the referral pathway for emergency care. A third of maternal deaths in LMICs are thought to occur as a result of delays experienced while in transit to access emergency obstetric care services.2Tesfay N Tariku R Zenebe A Mohammed F Woldeyohannes F Area of focus to handle delays related to maternal death in Ethiopia.PLoS One. 2022; 17e0274909 Google Scholar, 3Chavane LA Bailey P Loquiha O Dgedge M Aerts M Temmerman M Maternal death and delays in accessing emergency obstetric care in Mozambique.BMC Pregnancy Childbirth. 2018; 18: 71Crossref PubMed Scopus (43) Google Scholar Therefore, detailed exploration of geographical accessibility factors that lead to inequalities in the coverage, access to, and the use of emergency obstetric care services in a high-burden LMIC is necessary. In The Lancet Global Health, Aduragbemi Banke-Thomas and colleagues4Banke-Thomas A Wong KLM Olubodun T et al.Geographical accessibility to functional emergency obstetric care facilities in urban Nigeria using closer-to-reality travel time estimates: a population-based spatial analysis.Lancet Glob Health. 2024; 12: e848-e858Google Scholar assessed the geographical accessibility, based on travel time, of the three nearest functional public and private comprehensive emergency obstetric care facilities for women aged 15–49 years in the 15 largest Nigerian cities. They calculated closer-to-reality travel time estimates relative to traditional model-based approaches, using Google Maps Platform's internal Directions Application Programming Interface, to map geocoded health facilities from both public and private sectors that were known to provide emergency obstetric care services. The median travel time to each facility was identified based on use of motorised transport under eight traffic scenarios covering weekdays and weekends and a range of daily time periods. Their research provides innovative information that will be relevant (eg, within the context of transportation infrastructure) to health system managers and public health practitioners on the dynamics involved in the journey to access emergency obstetric care by pregnant people. In addition, the spatial information provided can be layered onto other variables (eg, population density, poverty distribution, and the existence of informal settlements), which will improve understanding of barriers to the distribution and accessibility of emergency obstetric care across different socioeconomic and ecological strata within urban cities. The calculated median travel time estimates to functional emergency obstetric care facilities, in most of the scenarios they presented, fall within the WHO recommended 2-h intervals for accessing relevant services during obstetric emergencies.5Mubiri P Kajjo D Okuga M et al.Bypassing or successful referral? A population-based study of reasons why women travel far for childbirth in Eastern Uganda.BMC Pregnancy Childbirth. 2020; 20: 497Crossref Scopus (18) Google Scholar, 6Dotse-Gborgbortsi W Dwomoh D Alegana V Hill A Tatem AJ Wright J The influence of distance and quality on utilisation of birthing services at health facilities in Eastern Region, Ghana.BMJ Glob Health. 2020; 4e002020 Crossref PubMed Scopus (31) Google Scholar, 7WHOUNFPAUNICEFAverting Maternal Deaths and DisabilitiesMonitoring emergency 472 obstetric care: a handbook. WHO Press, Geneva, Switzerland2009Google Scholar Despite this apparently sufficient geographical accessibility, Nigeria remains a major contributor to maternal mortality globally, which is somewhat paradoxical.8WHOUNICEFUNFPAWorld Bank GroupUNDPTrends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. World Health Organization, Geneva2023: 1-86Google Scholar Mixed (ie, public and private) health-care systems exist in many LMIC settings where public and private sector providers coexist and provide care. The disaggregation of the health facilities in this study into either public or private facilities to assess their geographical accessibility reveals that public facilities were more sparsely distributed than private facilities, which limited their accessibility (with particular relevance to those with low incomes). This finding highlights a need for a closer integration of public and private sectors providing health-care services, to enable equitable geographical access to emergency obstetric care services, which is especially relevant in LMICs, where governments have fewer resources for adequate coverage than high-income countries. There is also need for multi-sectoral collaboration for health impact beyond the health system, such as in developing efficient road infrastructure. We recognise that, beyond geographic accessibility, other factors such as socioeconomic considerations influence access to health-care services especially for private health-care facilities where substantial user fees are charged. Therefore, consideration of the perspectives of health-care consumers are important to clearly understand the individual-level factors that influence decision making by pregnant people during emergencies. The information they provide can help to explain why people choose to bypass the nearest functional emergency obstetric care facility for a farther one during obstetric emergencies. The geographical distribution of health facilities clearly influences their accessibility. The use of navigation tools that model for the dynamics associated with the journey of patients to access care can provide more realistic closer-to-reality time estimates than traditional model-based approaches, better informing health system planning. However, these tools still do not adequately capture the complex interactions that occur between public and private health-care facilities when patients migrate their care from public to private, due to varying degrees of service integration. An intersection between the data on geographical accessibility and other determinants of access to health care could provide a more nuanced perspective and will be an interesting area for future research. We declare no competing interests. Geographical accessibility to functional emergency obstetric care facilities in urban Nigeria using closer-to-reality travel time estimates: a population-based spatial analysisBetter access to comprehensive emergency obstetric care is needed in Nigerian cities and solutions need to be tailored to context. The innovative approach used in this study provides more context-specific, finer, and policy-relevant evidence to support targeted efforts aimed at improving comprehensive emergency obstetric care geographical accessibility in urban Africa. Full-Text PDF Open Access