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

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 socio-demographic, travel, and obstetric data. Extracted travel data was 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 3,278 births, there were 408 stillbirths (12.5%). Women with livebirths travelled a median distance of 7.3km (IQR 3.3–18.0) and over a median time of 24 mins (IQR 12–51). Those with stillbirths travelled a median distance of 8.5km (IQR 4.4-19.7) and over a median time of 30mins (IQR 16-60). Following adjustments, though no significant association with distance was found, odds of stillbirth were significantly higher for travel of 10-29mins (OR=2.25, 95%CI 1.40–3.63), 30-59mins (OR=2.30, 95%CI 1.22–4.34), and 60-119mins (OR=2.35, 95% CI 1.05–5.25). The adjusted odds ratio of stillbirth was significantly lower following booking (OR=0.37, 95%CI 0.28–0.49), obstetric complications with mother (obstructed labour (OR=0.11 (95% CI 0.07–0.17)) and haemorrhage (OR=0.30 (95%CI 0.20–0.46))). Odds were significantly higher with multiple gestations (OR=2.40, 95% CI1.57–3.69) and referral (OR=1.55, 95%CI 1.13–2.12). 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- and middle-income setting.