Did saving mothers, giving life expand timely access to lifesaving care in Uganda? A spatial district-level analysis of travel time to emergency obstetric and newborn care

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Study Justification:
The study aimed to assess the impact of the Saving Mothers, Giving Life (SMGL) initiative on timely access to emergency obstetric and newborn care (EmONC) in Uganda. The study justified the need to evaluate the effectiveness of the SMGL intervention in improving access to lifesaving care for pregnant women in SMGL-supported districts.
Highlights:
1. The number of EmONC facilities in the SMGL-supported districts almost tripled between 2012 and 2016, leading to increased geographic access to EmONC.
2. Travel time to EmONC facilities significantly decreased during the 5-year period, indicating improved access to care.
3. The proportion of women of reproductive age (WRA) able to access any EmONC facility within 2 hours by motorcycle increased by 18%, and access to comprehensive EmONC (CEmONC) increased by 37% from baseline to 2016.
4. Similar increases in timely access were observed for WRA using 4-wheeled vehicles and nonmotorized transportation such as walking and bicycling.
5. The study developed a geographic outline of facility accessibility using multiple types of transportation, providing valuable information for planners and policymakers.
Recommendations:
1. Increase the number and geographic distribution of EmONC facilities to further improve access to lifesaving care.
2. Complementary efforts should be made to make motorized transportation available, as it is necessary to achieve meaningful increases in EmONC access.
3. Use spatial travel-time analyses, along with other EmONC indicators, to estimate need and target underserved populations for further gains in EmONC accessibility.
Key Role Players:
1. Ministry of Health: Responsible for implementing and coordinating interventions to improve access to EmONC.
2. SMGL implementing partners: Involved in the expansion and upgrading of EmONC facilities.
3. Health facility staff: Provide EmONC services and play a crucial role in ensuring timely access to care.
4. Transportation authorities: Responsible for improving road infrastructure and ensuring availability of motorized transportation.
Cost Items for Planning Recommendations:
1. Construction and upgrading of EmONC facilities: Includes costs for building new facilities and renovating existing ones to meet EmONC standards.
2. Road infrastructure development: Budget for improving road networks, including paving roads and constructing bridges.
3. Procurement of motorized vehicles: Cost of acquiring motorcycles and 4-wheeled vehicles to facilitate transportation to EmONC facilities.
4. Training and capacity building: Investment in training healthcare providers and transportation personnel to ensure quality EmONC services and efficient transportation.
5. Monitoring and evaluation: Budget for monitoring the implementation of recommendations and evaluating the impact on access to EmONC.
Please note that the provided cost items are general categories and not actual cost estimates. Actual costs will vary based on the specific context and implementation strategies.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, as it presents a clear analysis of the changes in travel time to emergency obstetric and newborn care (EmONC) facilities in Uganda. The study compares travel-time estimates in 2012, 2013, and 2016, and shows a significant improvement in timely access to EmONC. The analysis includes multiple types of transportation and provides specific percentages of women of reproductive age (WRA) who can access EmONC facilities within 2 hours. The abstract also highlights the need for complementary efforts to make motorized transportation available. To improve the evidence, the abstract could provide more details on the methodology used for the travel-time analyses and the specific data sources used. Additionally, it would be helpful to include information on the sample size and representativeness of the districts included in the study.

Introduction: Interventions for the Saving Mothers, Giving Life (SMGL) initiative aimed to ensure all pregnant women in SMGL-supported districts have timely access to emergency obstetric and newborn care (EmONC). Spatial travel-time analyses provide a visualization of changes in timely access. Methods: We compared travel-time estimates to EmONC health facilities in SMGL-supported districts in western Uganda in 2012, 2013, and 2016. To examine EmONC access, we analyzed a categorical variable of travel-time duration in 30-minute increments. Data sources included health facility assessments, geographic coordinates of EmONC facilities, geolocated population estimates of women of reproductive age (WRA), and other road network and geographic sources. Results: The number of EmONC facilities almost tripled between 2012 and 2016, increasing geographic access to EmONC. Estimated travel time to EmONC facilities declined significantly during the 5-year period. The proportion of WRA able to access any EmONC and comprehensive EmONC (CEmONC) facility within 2 hours by motorcycle increased by 18% (from 61.3% to 72.1%, P < .01) and 37% (from 51.1% to 69.8%, P < .01), respectively from baseline to 2016. Similar increases occurred among WRA accessing EmONC and CEmONC respectively if 4-wheeled vehicles (14% and 31% increase, P 120 minutes). Instead of using AccessMod’s native Zonal Statistics module, we converted the raster into a shapefile of different travel-time zones in ArcGIS version 10.5. We mapped all travel-time zones to reach any EmONC and CEmONC services for each transportation mode. Combining the travel-time zones with georeferenced village population data, we estimated the number and proportion of WRA with access to EmONC and CEmONC services within each travel-time zone. We obtained the proportion of WRA within a travel-time zone by summing all WRA residing in villages located within each travel-time zone then dividing by the complete enumerated WRA population. We defined “adequate EmONC access” as the ability to reach an EmONC facility within 2 hours of travel time, and “poor EmONC access” as the inability to reach an EmONC facility within 2 hours. We assumed all travel to be from a woman’s home to a facility. We calculated the relative percentage change in the proportions of WRA residing within each travel-time zone and across each transportation mode, by subtracting the baseline percentage from the endline percentage and dividing by the baseline percentage. For the population percentages, z scores, based on the normal approximation to the binomial distribution, were used to calculate P values. The study protocol was reviewed and approved by recognized ethics committees in Uganda and complied with Ugandan Ministry of Health procedures for protecting human subjects. This study was reviewed and approved by the U.S. Centers for Disease Control and Prevention’s Center for Global Health Human Subject Review Board, which determined that it did not constitute human subjects research.

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The recommendation to improve access to maternal health based on the study is to focus on expanding the number and geographic distribution of emergency obstetric and newborn care (EmONC) facilities. The study found that the number of EmONC facilities almost tripled between 2012 and 2016, resulting in improved access to EmONC services.

To further enhance access, it is suggested to make motorized transportation available, such as motorcycles and 4-wheeled vehicles, especially in areas with challenging topography and limited road infrastructure. This would enable pregnant women to reach EmONC facilities more quickly and easily.

Additionally, efforts should be made to improve nonmotorized transportation options, such as walking and bicycling, to ensure that women in remote areas can still access EmONC services.

The study also highlights the importance of using spatial travel-time analyses, along with other EmONC indicators, to estimate the need for services and target underserved populations. This information can be used by planners and policymakers to make informed decisions and allocate resources effectively to further improve access to EmONC care.
AI Innovations Description
The recommendation to improve access to maternal health based on the study is to focus on expanding the number and geographic distribution of emergency obstetric and newborn care (EmONC) facilities. The study found that the number of EmONC facilities almost tripled between 2012 and 2016, resulting in improved access to EmONC services.

To further enhance access, it is suggested to make motorized transportation available, such as motorcycles and 4-wheeled vehicles, especially in areas with challenging topography and limited road infrastructure. This would enable pregnant women to reach EmONC facilities more quickly and easily.

Additionally, efforts should be made to improve nonmotorized transportation options, such as walking and bicycling, to ensure that women in remote areas can still access EmONC services.

The study also highlights the importance of using spatial travel-time analyses, along with other EmONC indicators, to estimate the need for services and target underserved populations. This information can be used by planners and policymakers to make informed decisions and allocate resources effectively to further improve access to EmONC care.
AI Innovations Methodology
The methodology used in the study involved several steps to simulate the impact of the main recommendations on improving access to maternal health:

1. Data Collection: The study collected data from various sources, including health facility assessments, geographic coordinates of EmONC facilities, population estimates of women of reproductive age (WRA), road network data, and land cover data.

2. Analysis of EmONC Facilities: The study analyzed the number and geographic distribution of EmONC facilities in the SMGL-supported districts in western Uganda. The functionality of these facilities was assessed based on a core set of lifesaving interventions known as “signal functions.”

3. Travel Time Estimation: The study used the AccessMod Accessibility module to estimate travel times to EmONC facilities. The module calculated the quickest way of traveling between two points, taking into account different transportation modes such as walking, bicycling, motorcycles, and 4-wheeled vehicles. Travel speeds for each mode were determined based on direct observation and published sources.

4. Categorization of Travel Time Zones: The continuous travel-time estimates were categorized into incremental 30-minute travel-time zones (0-30 minutes, 31-60 minutes, 61-90 minutes, 91-120 minutes, and >120 minutes). This allowed for the identification of areas with different levels of access to EmONC facilities.

5. Estimation of Proportions of WRA with Access: The study combined the travel-time zones with population data to estimate the number and proportion of WRA with access to EmONC facilities within each zone. Adequate EmONC access was defined as the ability to reach a facility within 2 hours of travel time.

6. Comparison of Baseline and Endline Data: The study compared the proportions of WRA with access to EmONC facilities at baseline and endline to assess the impact of the recommendations. The relative percentage change in the proportions was calculated, and statistical analysis was conducted to determine the significance of the changes.

By following this methodology, the study was able to simulate the impact of expanding the number and geographic distribution of EmONC facilities, as well as improving transportation options, on improving access to maternal health in the SMGL-supported districts of Uganda. The findings of the study demonstrated significant improvements in timely access to EmONC services.

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