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

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

doi:10.1136/bmjgh-2020-003943

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

BMJ Glob Health. 2020 Dec;5(12):e003943. doi: 10.1136/bmjgh-2020-003943.

Authors

Alex J van Duinen^{1

2}, Håvard A Adde³, Ola Fredin^{4

5}, Hampus Holmer⁶, Lars Hagander⁷, Alimamy P Koroma^{8

9}, Michael M Koroma^{8

9}, Andrew Jm Leather¹⁰, Arne Wibe^{3

2}, Håkon A Bolkan^{3

2}

Affiliations

¹ Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway aalke.j.v.duinen@ntnu.no.
² Department of Surgery, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway.
³ Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
⁴ Geological Survey of Norway, Trondheim, Norway.
⁵ Department of Geography, Norwegian University of Science and Technology, Trondheim, Norway.
⁶ Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
⁷ Centre for Surgery and Public Health, Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden.
⁸ Ministry of Health and Sanitation, Freetown, Sierra Leone.
⁹ Department of Obstetrics and Gynaecology, Princess Christian Maternity Hospital (PCMH), University Teaching Hospitals Complex, University of Sierra Leone, Freetown, Sierra Leone.
¹⁰ King's Centre for Global Health & Health Partnerships, King's College London, London, UK.

Abstract

Introduction: Longer travel times are associated with increased adverse maternal and perinatal outcomes. Geospatial modelling has been increasingly used to estimate geographic proximity in emergency obstetric care. In this study, we aimed to assess the correlation between modelled and patient-reported travel times and to evaluate its clinical relevance.

Methods: Women who delivered by caesarean section in nine hospitals were followed up with home visits at 1 month and 1 year. Travel times between the location before the delivery and the facility where caesarean section was performed were estimated, based on two models (model I Ouma et al; model II Munoz et al). Patient-reported and modelled travel times were compared applying a univariable linear regression analysis, and the relation between travel time and perinatal mortality was assessed.

Results: The median reported travel time was 60 min, compared with 13 and 34 min estimated by the two models, respectively. The 2-hour access threshold correlated with a patient-reported travel time of 5.7 hours for model I and 1.8 hours for model II. Longer travel times were associated with transport by boat and ambulance, visiting one or two facilities before reaching the final facility, lower education and poverty. Lower perinatal mortality was found both in the group with a reported travel time of 2 hours or less (193 vs 308 per 1000 births, p<0.001) and a modelled travel time of 2 hours or less (model I: 209 vs 344 per 1000 births, p=0.003; model II: 181 vs 319 per 1000 births, p<0.001).

Conclusion: The standard model, used to estimate geographical proximity, consistently underestimated the travel time. However, the conservative travel time model corresponded better to patient-reported travel times. The 2-hour threshold as determined by the Lancet Commission on Global Surgery, is clinically relevant with respect to reducing perinatal death, not a clear cut-off.

Keywords: geographic information systems; maternal health.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Cesarean Section*
Female
Humans
Infant, Newborn
Perinatal Death
Perinatal Mortality*
Pregnancy
Sierra Leone / epidemiology
Time Factors
Travel