Determinants of delays in travelling to an emergency obstetric care facility in Herat, Afghanistan: an analysis of cross-sectional survey data and spatial modelling.

Atsumi Hirose,Jonathan Cox,Ahmad Shah Alkozai,Veronique Filippi,Matthias Borchert

doi:10.1186/s12884-015-0435-1

Abstract

BackgroundWomen’s delays in reaching emergency obstetric care (EmOC) facilities contribute to high maternal and perinatal mortality and morbidity in low-income countries, yet few studies have quantified travel times to EmOC and examined delays systematically. We defined a delay as the difference between a woman’s travel time to EmOC and the optimal travel time under the best case scenario. The objectives were to model travel times to EmOC and identify factors explaining delays. i.e., the difference between empirical and modelled travel times.MethodsA cost-distance approach in a raster-based geographic information system (GIS) was used for modelling travel times. Empirical data were obtained during a cross-sectional survey among women admitted in a life-threatening condition to the maternity ward of Herat Regional Hospital in Afghanistan from 2007 to 2008. Multivariable linear regression was used to identify the determinants of the log of delay.ResultsAmongst 402 women, 82 (20%) had no delay. The median modelled travel time, reported travel time, and delay were 1.0 hour [Q1-Q3: 0.6, 2.2], 3.6 hours [Q1-Q3: 1.0, 12.0], and 2.0 hours [Q1-Q3: 0.1, 9.2], respectively. The adjusted ratio (AR) of a delay of the “one-referral” group to the “self-referral” group was 4.9 [95% confidence interval (CI): 3.8-6.3]. Difficulties obtaining transportation explained some delay [AR 2.1 compared to “no difficulty”; 95% CI: 1.5-3.1]. A husband’s very large social network (> = 5 people) doubled a delay [95% CI: 1.1-3.7] compared to a moderate (3-4 people) network. Women with severe infections had a delay 2.6 times longer than those with postpartum haemorrhage (PPH) [95% CI: 1.4-4.9].ConclusionsDelays were mostly explained by the number of health facilities visited. A husband’s large social network contributed to a delay. A complication with dramatic symptoms (e.g. PPH) shortened a delay while complications with less-alarming symptoms (e.g. severe infection) prolonged it. In-depth investigations are needed to clarify whether time is spent appropriately at lower-level facilities. Community members need to be sensitised to the signs and symptoms of obstetric complications and the urgency associated with them. Health-enhancing behaviours such as birth plans should be promoted in communities.

Highlights

Women’s delays in reaching emergency obstetric care (EmOC) facilities contribute to high maternal and perinatal mortality and morbidity in low-income countries, yet few studies have quantified travel times to EmOC and examined delays systematically
The period from the onset of signs and symptoms of complications to the receipt of EmOC is usually divided into three phases or “three delays” [1]: The first delay refers to the interval between the onset of obstetric complication and the decision to seek care; the second delay is the interval between the decision and the arrival in a health facility; and the third delay is between the arrival and the provision of adequate care
Sixty-two couples were excluded because the exact location of their village was unknown for various reasons: The male relative did not participate in the interview (33 women); nomads did not know where they were staying when complications were recognised (4 women); or the village name reported during the interview did not match any village in the AIMS database (25 women)

Summary

Introduction

Women’s delays in reaching emergency obstetric care (EmOC) facilities contribute to high maternal and perinatal mortality and morbidity in low-income countries, yet few studies have quantified travel times to EmOC and examined delays systematically. Women’s delay in reaching emergency obstetric care (EmOC) facilities contributes to a high burden of maternal and perinatal mortality and morbidity in low-income countries. Factors prolonging the second interval include travel distance [2,3], sparsely distributed EmOC health facilities ( in rural areas) [4], ineffective referrals [5,6], a lack of transportation means [3,6,7], the cost of transportation [8], and drivers’ unwillingness to transport women in labour. While many studies provide these factors as reasons for the second delay, few empirical studies have attempted to quantify travel distances and times for women needing EmOC [4,9]

Methods

Results

Discussion

Conclusion