Geographic access to critical maternal health services in an African megacity
Despite a 30% drop in global maternal deaths from 1990 to 2015, 280,000 women still die annually due to complications of pregnancy and childbirth. Sixty-six percent of these deaths occur in sub-Saharan Africa. It is well established that timely access to critical maternal health services can reduce deaths of pregnant women by 15-50%.
However, travel to reach hospitals that can provide this critical service remain a huge challenge for many pregnant women in sub-Saharan Africa. It is an even greater challenge in a megacity, like Lagos, Nigeria.
The challenges of emergency travel
In a study published in the journal Reproductive Health in March 2020, we explored in granular details the travel of pregnant women in emergency situations in Lagos. In it, we interviewed 47 pregnant women who presented at public hospitals in emergency situations, and 11 of their relatives.
We found that pregnant women are often faced with conundrums on "when," "where" and "how" to reach hospitals when in an emergency. While the decision-making is a shared activity among all women, the available options vary depending on their socioeconomic status.
Women preferred to travel to hospitals deemed to have "nicer" health workers, even if these were farther from home. Some women reported changing their course of travel because of connections with influential people at specific hospitals. Indeed, women, especially those of higher socioeconomic status, felt that they needed the perceived advantage that it provides. For them, this was a way of guaranteeing the quality of care they would receive.
Most women used some form of motorized transport—three or four wheelers, which was either privately owned, borrowed from family or friend, or publicly available. However, motorcycles were quite commonly used, especially for those in remote areas and areas prone to significant traffic.
The experiences of pregnant women
Irrespective of the choices that pregnant women made, their socioeconomic status or previous birthing experience, many women still reported facing significant challenges in traveling to hospitals. Though they faced varied challenges during the daytime and nighttime.
Women in our study reported they spent between 5 minutes and 4 hours to reach hospitals. They also reported that the heavy traffic combined with poor road conditions increased their travel time by two to six times. However, the extent to which the experience impacted on their ability to reach facilities depended on their capacity to make their own choices and support systems. For the urban poor in particular, increases in travel time was a strong deterrent to seeking maternal health services.
Referral barriers between facilities further prolonged delays, with many women left alone to find their way. Even when an ambulance service is available, it did not always guarantee quicker transit time. This was mostly because other road users did not give way to ambulances.
For night travel, security concerns were reported. However, no woman specifically reported this as part of their experience. Also, travel fares were significantly higher at night. This was seen as a form of exploitation especially for women who already found day fare rates as prohibitive.
In a 2017 study published in the Journal of Public Health in Africa, while the state government believed that hospitals with capacity to provide critical maternal health services have been strategically located across the state, several women reported difficulty in accessing facilities.
Efforts needed to improve travel experiences
Our research findings add credence to the challenges that women face in reaching hospitals in this megacity. These challenges force many pregnant women, rich and poor, to take risks when in emergency situations. Indeed, the experience of travel in Lagos fits the title of the first Mexican telenovela to be shown on Nigerian television, The Rich also Cry (known in Spanish as Los ricos también lloran).
Efforts need to be put in place to improve the travel experiences of women. While significant road-infrastructural improvements will be helpful to all aspects of state development, this will probably be cost-intensive.
Leveraging existing structures, such as establishing partnerships with specific taxi companies and tricycles, might offer a cost-effective and quick gains. However, the partial ban of tricycles in Lagos may need to be reconsidered, before this can be viable option. Indeed, tricycle riders and private taxi drivers can be trained on proper transfer of women in situations of emergency and integrated into the referral process.
Also, campaign for attitudinal change of drivers, as it relates to giving way for ambulances will be a helpful measure. However, this needs to be supported by legislation to ban misuse of such rights by ambulance drivers, ensuring that the siren is only used in emergency situations.
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