The role of distance and transportation in decision making to seek emergency obstetric care among women of reproductive age in south–South Nigeria: A mixed methods study

Abstract Objective To explore the role of transportation in seeking emergency obstetric care among women with obstetric complications. Methods A mixed‐methods design. The study population comprised women aged 15–49 years who had experience direct obstetric complications and were attending the health facility for care at the time of this study. A total of 318 women completed the questionnaires, and in‐depth interviews were held for six women who were purposively selected from the 318 respondents. Both questionnaire and semi‐structured interviews were used in collecting data for this study. Quantitative data were analyzed using SPSS using both inferential and bivariate analysis, and a qualitative content analysis was carried out on the qualitative data. Results Of the 318 respondents, 290 (91.2%) accessed health facilities by motorized transport with 28 (8.8%) on foot. Mode of transportation was related to regularity at prenatal care (P = 0.003), with those who came on foot being regular attenders compared with those that came on motorized transport. Conclusion An efficient and suitable transport system as well as distance are key factors influencing women’s role in decision making to seek care.


| INTRODUC TI ON
Transport and health are interlinked on many levels, with transport directly and indirectly influencing health, and health status influencing transport options. Transportation is an important barrier to accessing obstetric care for many pregnant and postpartum women in developing countries, particularly in rural areas. 1 Transportation also facilitates the timely and reasonable delivery of basic health, education; it connects communities to trade and information with one another and can empower vulnerable groups. However, low-income countries such as Nigeria are yet to completely accept and understand the role of transport in accessing maternal healthcare services and improving poor people's health. Women in Nigeria are faced with long distances and significant transportation costs to access and use maternal healthcare services in health facilities. An effective transportation system plays an important role in responding to an emergency promptly and effectively. 2 Most maternal deaths from direct causes (such as obstructed labor, eclampsia, infection, hemorrhage, or unsafe abortions) could be prevented if women received timely care at critical moments. 3 Maternal mortality is a major public health problem, particularly in sub-Saharan Africa, where half (50.4%) of all maternal deaths worldwide occur. 4 In 2005, the maternal mortality ratio in sub-Saharan Africa was estimated at 900 maternal deaths per 100 000 live births, which was by far the highest in the world. 5 Most pregnancies of healthy mothers end with the birth of a live baby. However, in many cases, childbirth is not the joyous event it should be but a time of pain, fear, suffering, and even death. 6 Transportation costs have been reported as one of the factors shown as having influence on maternity care access and utilization. 3 Krasovec 7 revealed that the Ministry of Health and the introduction of a two-way radio system to link the hospital increased the number of women referred with major obstetric complications from 0.9 to 2.6 per month following the replacement of motorbikes for referral from primary health centers with a four-wheel drive vehicle.
Transport played some role in increasing women's access to effective care, although some of these effects may have been an indirect result of additional women using the referral facility because of its upgraded status. Transport may have more greatly helped the survival of women coming from longer distances, while enhanced treatment at the hospital had a greater role in improved outcomes for women living closer to the health facility. 7 The provision of care for women during pregnancy and childbirth is essential to ensure a healthy and successful outcome of pregnancy for the mother and her newborn. All pregnant women are at risk of obstetric complications. About 15% of pregnancies and childbirths need emergency obstetric care because of risks that are difficult to predict. 8 Most life-threatening complications occur during labor and delivery, and these cannot be predicted. Every pregnant woman needs access to facilities with capabilities to provide emergency obstetric care services. 8 Emergency obstetric care is one of the important components of Safe Motherhood programmes; it refers to services provided in cases that threaten the lives of the mother and fetus, and that require emergency intervention during pregnancy and during or after childbirth.
Emergency obstetric care consists of the speedy evaluation of pregnant women on admission, and the early treatment in the event of the mother or infant showing life-threatening signs or symptoms.
Furthermore, after calming the situation, if needed, emergency obstetric care involves transferring the mother/infant to higher-level health care and providing safe blood transfusion in healthcare facilities. 9 Neither effective prenatal care nor identifying risk will help women if emergency obstetric care is not accessible, or not used.

| Means of transportation
Respondents' means of transportation to the hospital shows that majority 291 (91.2%) of the respondents traveled to the health facility by motorised transport, while 8.8% representing 28 respondents came on-foot. Suggesting that a good transport system put in place for pregnant women by the government will allow the women to utilise the health facility more for their needed healthcare.

| Delays to getting to the hospital
One hundred and five (33.0%) respondents reported having difficulties associated with transportation. Respondents provided various reasons associated with difficulty in transportation, 77 (58.8%) 2 respondents claimed that too far a distance was the major difficulty associated with transportation, when compared with 4 (3.1%) respondents that reported high transportation cost as difficulty associated with transportation (Table 2).

| Transportation, distance and time as a determining factor to health care utilization
Women face numerous problems in accessing appropriate maternity care during pregnancy and delivery. Women reported that limited or lack of public transport services and police stops make maternal healthcare service use difficult. The timing of the transport and distance to the facility added further difficulty and costs to the use of services, particularly during the emergency period at night. One of the aspects that affected the belief structure of Nigerian women remains access to reproductive healthcare services. Analysis of the narratives indicated that the logistics of the health systems of Nigeria have a lot of barriers in the form of transport services due to unavailability of an ambulance within the health systems to assist in moving patients from one facility to another.
One of the study participants has this to say: I was referred to this hospital from a private clinic for delivery, but I was not provided with an ambulance or other form of transport services for my referral. My husband and I had to get a taxi from the private clinic where we were referred from to this facility and the cost was high. The situation was so discouraging.-(P1).
Transportation problems were reported to be worse at night due to bad roads, most drivers were not in operation during such hours, and this made transportation difficult during emergencies.
Most drivers do not want to operate at nights due to  Table 3 shows socio-economic factors associated with maternal decision to use maternity healthcare services. Results show that mode of transportation was related to regularity at prenatal care (P = 0.003), with those women who came on foot being regular attenders at prenatal care compared with those women how came by motorized transport. Travel time to the facility was significantly related to prenatal care attendance (P = 0.001), those who traveled for up to 30 minutes were more likely to report regularly to prenatal care compared with those who traveled for more than 30 minutes (Table 3).

| Costs (medical/ transportation)
Costs due to lack of medical equipment to carry out the required tests were also mentioned by most of the participants in the indepth interview. Mothers were often asked to go to local chemists/ laboratories/pharmacies to carry out prescribed tests and buy rec- The participants expressed concern about the poor state of their transportation system and how this has contributed to non-use of skilled birth attendants. The side of the cost issue became clear during the interviews. Even though the cost of medical treatment might be a concern as well, the traveling costs, moving from one facility to another to buy medications and carry out laboratory tests often made the visit unaffordable for poor patients.

Characteristics Frequency (n) Percentage
Mode of transportation to health facility stated that transport-related costs could be a primary factor in deterring patients from seeking treatment even when a vehicle can be obtained, cost can be prohibitive and not even related to distance.
The present study also revealed that women who visited the health facility on foot were more regular attenders at prenatal care.
This again might have been due to the closeness of the respondents' place of residence to the nearest health facility. Rose et al. 13  In conclusion, the present study suggested that the respondents' efficient, reasonable, and suitable means of transport plays a key role in empowering pregnant/nursing mothers in decision making to seek the desired health care. The strongest difficulty associated with transportation was lack of transportation service, and regular attendance at prenatal care was higher (92.9%) among women who visited the health facility on foot. Emergency access to obstetric care is crucial because many pregnancy-related complications are unpredictable, and many pregnant women spend a disproportionate time trying to get to a health facility with the ability to treat obstetric complications. As a result, public transportation and on foot remain the major modes of transportation for pregnant women, thereby cruelly limiting their capacity to reach needed care. To reduce the barriers that women face while accessing maternity care, governments and non-governmental organizations should work with communities to identify barriers to transport and the most appropriate ways to dismantle these barriers. Building and improving the existing transportation system by the government to meet the needs of women who desire to use health facilities for care is desirable.

CO N FLI C T O F I NTE R E S T
There is no conflict of interest.

ACK N OWLED G M ENT
We wish to acknowledge Professor Caro Bond for the supervision of the thesis.

AUTH O R CO NTR I B UTI O N S
EMS and SL conceived and designed the study; EMS and DM prepared the manuscript; and LS and DM supervised the study and contributed to paper editing.

DATA AVA I L A B I L I T Y S TAT E M E N T
Research data are not shared.