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

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Study Justification:
The study aimed to assess the influence of travel time and distance to the hospital of care on stillbirths in Lagos, Nigeria. This research is important because access to emergency obstetric care has been shown to significantly reduce stillbirths. However, before pregnant women can access this care, they need to travel to a health facility. Understanding the impact of travel time and distance on stillbirths can help inform strategies to improve access to timely and quality care, particularly in urban low-income and middle-income settings like Lagos.
Study Highlights:
– The study included a retrospective cross-sectional analysis of pregnant women who presented with obstetric emergencies over a year across all 24 public hospitals in Lagos, Nigeria.
– Data on sociodemographic, travel, and obstetric factors were extracted from clinical records.
– Travel data were exported to Google Maps to determine distance and travel time for each woman.
– The study found that travel time to the hospital was strongly associated with stillbirth. Odds of stillbirth were significantly higher for travel durations of 10-29 minutes, 30-59 minutes, and 60-119 minutes.
– Other factors associated with stillbirth included lack of booking, obstetric complications (obstructed labor and hemorrhage), multiple gestations, and referral.
– The study highlights the importance of efforts to improve access to quality care for pregnant women and to reduce travel time to hospitals.
Recommendations:
Based on the study findings, the following recommendations can be made:
1. Improve transportation infrastructure: Addressing poor road conditions, traffic congestion, and flooding during the rainy season can help reduce travel time and improve access to hospitals.
2. Enhance birth preparedness: Encourage pregnant women to book early and receive adequate antenatal care to reduce the risk of stillbirth.
3. Strengthen emergency obstetric care services: Ensure that hospitals have the capacity to provide timely and quality care for obstetric emergencies, including adequate staffing and resources.
4. Implement referral systems: Develop effective referral systems to ensure that pregnant women are promptly referred to appropriate facilities when needed.
5. Increase awareness and education: Conduct public awareness campaigns to educate pregnant women and their families about the importance of timely access to care and the risks associated with prolonged travel time.
Key Role Players:
1. Government health agencies: Responsible for implementing policies and programs to improve maternal and child health, including addressing transportation infrastructure and strengthening healthcare services.
2. Healthcare providers: Obstetricians, midwives, and other healthcare professionals play a crucial role in providing quality care and ensuring timely access to emergency obstetric services.
3. Community leaders and organizations: Engaging community leaders and organizations can help raise awareness, promote birth preparedness, and facilitate access to healthcare services.
4. Transportation authorities: Collaborating with transportation authorities can help address road infrastructure issues and improve transportation services for pregnant women.
5. Non-governmental organizations (NGOs): NGOs focused on maternal and child health can support advocacy efforts, provide resources, and implement interventions to improve access to care.
Cost Items for Planning Recommendations:
1. Infrastructure improvement: Budget for road repairs, maintenance, and upgrades to address poor road conditions and reduce travel disruptions.
2. Staffing and training: Allocate funds for hiring and training healthcare professionals to ensure adequate staffing in hospitals and enhance their skills in emergency obstetric care.
3. Equipment and supplies: Provide necessary medical equipment and supplies to hospitals to support the provision of quality care for obstetric emergencies.
4. Referral system development: Invest in the development and implementation of an effective referral system, including establishing communication channels and transportation arrangements.
5. Public awareness campaigns: Allocate funds for public education campaigns to raise awareness about the importance of timely access to care and promote birth preparedness.
Note: The above cost items are estimates and may vary based on the specific context and resources available.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study conducted a retrospective cross-sectional analysis of pregnant women in Lagos, Nigeria, and used multivariable logistic regression to assess the influence of distance and travel time on stillbirth. The study included a large sample size and adjusted for potential confounding variables. However, the study design is observational, which limits the ability to establish causality. To improve the strength of the evidence, future research could consider conducting a prospective study or a randomized controlled trial to assess the impact of interventions aimed at reducing travel time and improving access to emergency obstetric care.

Introduction Access 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. Methods We 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. Results Of 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). Conclusion Travel 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.

Lagos State in the southwestern part of Nigeria has diverse geographical terrains (including land and water) and settlement types (including its central megacity, suburbs, slums and towns). While principally urban, Lagos state has some rural parts in its extreme east and west. The state has 20 local government areas and a population of approximately 26 million (estimated in 2019).15 The most common means of travel in Lagos is by road. However, in many parts of the state, the road infrastructure is poor, evidenced by presence of multiple potholes that sometimes make roads impassable for commuters. Severe traffic congestions are a common feature, with flooding during the rainy season making road conditions even worse. Road renovations are at best a stopgap and sometimes cause even more travel disruptions.16–18 Our study was a statewide multifacility retrospective cross‐sectional study that identified pregnant women who presented with obstetric emergencies at one of the 24 public hospitals with capacity for 24/7 all provision of EmOC services in the state. These 24 public hospitals include 20 general hospitals which are secondary health facilities with either a general obstetric unit or a dedicated Maternal Childcare Centres and four teaching hospitals which are tertiary health facilities (Details of the hospitals are in online supplemental table 1). According to the Health Facility Monitoring and Accreditation Agency, there are 1329 accredited private hospitals in Lagos. However, government health facilities manage 42% of deliveries in the state, while private health facilities take up about 28%.19 Two studies that estimated institutional SBR in Nigerian public hospitals reported 39.6 and 61.8 per 1000 births, respectively.20 21 bmjgh-2021-007052supp001.pdf We collected data from all 24 public hospitals over a 6-month period. The data collection team comprised consultant obstetricians, resident doctors and medical officers who had clinical experience working in the obstetric units of the hospitals and were familiar with the patient records system in Lagos public health facilities. The data collection team members were all trained on the standard operations protocol to guide data collection and ensure consistency across the different hospitals, use of the pretested online data collection tool in Google Forms and the ethical procedures guiding the research. From clinical records of all pregnant women with gestational age of 28 weeks or more who presented with an obstetric emergency between 1 November 2018 and 30 October 2019, we obtained data on sociodemographic characteristics, obstetric history, travel to reach the health facility (including day of travel and period-of-day when journey to the facility commenced, street name of women’s self-reported place of residence, referral facilities if any, the destination facility (one of the 24 public hospitals)), obstetric complication managed, mode of delivery and pregnancy outcomes. All pregnant women who presented at the obstetric emergency room and had a live or stillbirth at or after gestational age of 28 weeks were included. For the outcome, stillbirth, we aligned with WHO’s definition applicable in many LMIC settings defining a stillbirth as a baby born with no signs of life at 28 weeks of pregnancy or more.4 We excluded 51 cases with perinatal deaths that occurred after the baby was born alive (early neonatal deaths), because these deaths may have more to do with quality of care, as opposed to travel to the health facility. We excluded a further 22 cases which had missing data regarding the outcome of the pregnancy or gestational age could not be established. All recorded data captured in Google Forms was subsequently exported as a Microsoft Excel file. Additional data gathering on distance and travel time were required to fully characterise the travel to reach the hospital. Studies that estimated distance and travel time of pregnant women to reach EmOC facilities in LMIC settings have mostly been based on women’s self-reports or spatial models,10 with the accuracy of both approaches questioned by several authors.22–25 Compared with spatial model estimates, distance and travel time estimates using global positioning satellite navigation software like Google Maps (Alphabet, Mountain View, California, USA) have been shown to be closer to reality in an LMIC urban setting.26 Building on this evidence, we georeferenced the place of residence, referral points and destination facility for each woman in Google Maps, based on the data extracted from their clinical records. For addresses that were not discoverable on Google Maps, we contacted local persons who were well acquainted with the neighbourhoods to check for any spelling errors and reattempted to locate the street. For pregnant women with traceable journeys (meaning location of the home address and all referral points were known), we extracted distance (in kilometres (km) and travel time (in minute (min) for their journeys from Google Maps using the ‘typical time of travel’ tool for the time and day that the woman commenced her journey to the hospital, as per data extracted from the clinical records. To collect travel time estimates for the period-of-day of travel, we used specific time slots (9:00, 15:00, 18:00 and 21:00 hours for morning, afternoon, evening or night journeys, respectively). In cases in which this data was not available (27% of the sample), we assumed the woman travelled in the afternoon (15:00 hours), as it was a midpoint estimate between the two known travel peak periods in Lagos (6:30 and 11:30 hours (morning peak period) and 15:00 and 19.30 hours (evening peak period)).27 For means of transport, we assumed that all pregnant women used motor vehicle, since private cars (25%) and taxis (21%) are the most popular means of transport to health facilities, emergency or otherwise, and is almost always the transport means used by pregnant women in emergency situations in Lagos, especially as motorcycles have been banned.9 28 In cases in which it was not possible to find specific points of travel of the women, we labelled the case as untraceable (4% of the sample). Following data cleaning in Microsoft Excel (Microsoft Corporation, Redmond, USA), we used the extracted geocoordinates to map and visually inspect places of origin of all women with stillbirths relative to the location of public hospitals and produced maps in ArcGIS 10.6 (Esri, Redlands, California, USA). We then conducted descriptive analysis for all theoretically relevant sociodemographic and obstetric characteristics, travel path to facility and mode of delivery, indicating frequencies and percentages for categorical variables. The mean and SD as well as median and IQR for distance and travel time were computed. For interpretation, priority was given to the median values as these are known to be robust to the outliers.29 All continuous variables were subsequently converted into categorical variables. We conducted bivariate logistic regression to test the null hypothesis that there is no statistically significant association between each of the independent variables and stillbirth. The stillbirths were subsequently categorised into fresh and macerated stillbirths as extracted from patient records, as we theorised that the fresh type was more likely related to travel, since these occurred after the onset of labour but before birth, when the woman would have been en route to a health facility.4 Where there were discrepancies in stillbirth classifications for multiple gestations (eg, one fresh and one macerated), the stillbirth status of the first baby was used in the classification. Finally, we conducted multivariate logistic regression to determine the relative influence of the independent variable categories on stillbirths while controlling for other variables. The logistic regression models were built stepwise incorporating variables that showed a statistically significant association with stillbirths as an outcome in the bivariate analysis. Four models were fitted. Model I incorporated only significant sociodemographic and obstetric variables, model II added travel distance to significant sociodemographic and obstetric variables, model III added travel time to significant socio-demographic and obstetric variables and model IV included both travel time and distance to significant sociodemographic and obstetric variables. We reported both p values and 95% CIs of ORs derived from regression coefficients to show strength of evidence and considered differences between observations as statistically significant when the p value was <0.05. We also conducted a subgroup analysis by referral status and by stillbirth category (fresh and macerated). Missing data were excluded from the analysis. We conducted all statistical analysis in STATA SE V.15.0 (StataCorp). Patients and/or the public were not involved in the design, conduct, reporting or dissemination of this research.

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The study titled “Influence of travel time and distance to the hospital of care on stillbirths: A retrospective facility-based cross-sectional study in Lagos, Nigeria” examines the impact of travel time and distance on stillbirth rates in Lagos, Nigeria. The study found that travel time to a hospital was strongly associated with stillbirth, highlighting the importance of timely access to emergency obstetric care.

Based on the findings of this study, here are some potential recommendations to improve access to maternal health and reduce stillbirth rates:

1. Mobile Clinics: Introduce mobile clinics equipped with necessary medical facilities to provide antenatal care, emergency obstetric care, and other essential maternal health services in remote or underserved areas. These clinics can travel to different locations, reducing the need for pregnant women to travel long distances to access healthcare.

2. Telemedicine and Teleconsultations: Implement telemedicine services to enable pregnant women to consult with healthcare professionals remotely. This can help address barriers related to travel time and distance, allowing women to receive medical advice, guidance, and support without the need for physical travel.

3. Community Health Workers: Train and deploy community health workers who can provide basic maternal health services, education, and support in local communities. These workers can conduct regular check-ups, provide health education, and identify high-risk pregnancies, ensuring timely referrals to healthcare facilities.

4. Transportation Support: Establish transportation support systems, such as subsidized or free transportation services, to assist pregnant women in reaching healthcare facilities quickly and safely. This can include partnerships with local transport providers or the use of ambulances for emergency cases.

5. Improving Road Infrastructure: Advocate for improvements in road infrastructure, particularly in areas with poor road conditions or frequent traffic congestion. This can involve collaborating with relevant authorities to repair roads, address flooding issues, and reduce travel disruptions.

6. Awareness and Education: Conduct awareness campaigns to educate pregnant women and their families about the importance of timely access to maternal healthcare services. Emphasize the potential risks associated with delayed or inadequate care and promote the available transportation options and support services.

By implementing these recommendations, it is possible to improve access to maternal health services, reduce travel time and distance barriers, and ultimately decrease stillbirth rates in Lagos, Nigeria.
AI Innovations Description
The study titled “Influence of travel time and distance to the hospital of care on stillbirths: A retrospective facility-based cross-sectional study in Lagos, Nigeria” provides valuable insights into the impact of travel time and distance on stillbirth rates in Lagos, Nigeria. The study found that travel time to a hospital was strongly associated with stillbirth, highlighting the importance of timely access to emergency obstetric care.

Based on the findings of this study, a recommendation to improve access to maternal health and reduce stillbirth rates could be the development and implementation of innovative transportation solutions. Here are some potential recommendations:

1. Mobile Clinics: Introduce mobile clinics equipped with necessary medical facilities to provide antenatal care, emergency obstetric care, and other essential maternal health services in remote or underserved areas. These clinics can travel to different locations, reducing the need for pregnant women to travel long distances to access healthcare.

2. Telemedicine and Teleconsultations: Implement telemedicine services to enable pregnant women to consult with healthcare professionals remotely. This can help address barriers related to travel time and distance, allowing women to receive medical advice, guidance, and support without the need for physical travel.

3. Community Health Workers: Train and deploy community health workers who can provide basic maternal health services, education, and support in local communities. These workers can conduct regular check-ups, provide health education, and identify high-risk pregnancies, ensuring timely referrals to healthcare facilities.

4. Transportation Support: Establish transportation support systems, such as subsidized or free transportation services, to assist pregnant women in reaching healthcare facilities quickly and safely. This can include partnerships with local transport providers or the use of ambulances for emergency cases.

5. Improving Road Infrastructure: Advocate for improvements in road infrastructure, particularly in areas with poor road conditions or frequent traffic congestion. This can involve collaborating with relevant authorities to repair roads, address flooding issues, and reduce travel disruptions.

6. Awareness and Education: Conduct awareness campaigns to educate pregnant women and their families about the importance of timely access to maternal healthcare services. Emphasize the potential risks associated with delayed or inadequate care and promote the available transportation options and support services.

By implementing these recommendations, it is possible to improve access to maternal health services, reduce travel time and distance barriers, and ultimately decrease stillbirth rates in Lagos, Nigeria.
AI Innovations Methodology
The methodology used in the study titled “Influence of travel time and distance to the hospital of care on stillbirths: A retrospective facility-based cross-sectional study in Lagos, Nigeria” involved a retrospective cross-sectional study design. The study collected data from pregnant women who presented with obstetric emergencies over a one-year period across all 24 public hospitals in Lagos, Nigeria.

The researchers reviewed clinical records and extracted sociodemographic, travel, and obstetric data. The travel data, including distance and travel time, were exported to Google Maps to obtain accurate estimates. The study used multivariable logistic regression to determine the relative influence of distance and travel time on stillbirth rates.

The study included a total of 3,278 births, with 408 stillbirths (12.5%). The median distance traveled by women with live births was 7.3 km, while those with stillbirths traveled a median distance of 8.5 km. The median travel time for women with live births was 24 minutes, compared to 30 minutes for women with stillbirths.

After adjusting for other factors, the study found that travel time was strongly associated with stillbirth rates. Women who traveled for 10-29 minutes had 2.25 times higher odds of stillbirth, while those who traveled for 30-59 minutes had 2.30 times higher odds, and those who traveled for 60-119 minutes had 2.35 times higher odds.

The study also identified other factors associated with stillbirth, including booking for antenatal care, obstetric complications (such as obstructed labor and hemorrhage), multiple gestations, and referral status.

To simulate the impact of the main recommendations on improving access to maternal health, a possible methodology could involve implementing the recommendations in selected areas or communities and comparing the outcomes with a control group where the recommendations were not implemented. The study could collect data on stillbirth rates, travel time, and distance to healthcare facilities before and after the implementation of the recommendations. This would allow for an assessment of the impact of the recommendations on improving access to maternal health and reducing stillbirth rates. Statistical analysis, such as logistic regression, could be used to determine the association between the implementation of the recommendations and the outcomes of interest.

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