Reaching health facilities in situations of emergency: Experiences of pregnant women in the largest megacity of Africa

Travel of pregnant women requiring emergency obstetric care (EmOC) to health facilities remains a black box of many unknowns to the health system, more so in megacities which are fraught with wide inequalities. This in-depth study on travel of pregnant women in the largest megacity of Africa is based on interviews conducted between September 2019 and January 2020 with 47 women and 11 of their relatives who presented at comprehensive EmOC facilities in situations of emergency, requiring some EmOC services. Despite recognising danger signs, pregnant women are often faced with conundrums on when, where and how to reach EmOC facilities. While the decision-making process is a shared activity amongst all women, the available choice-options vary depending on socio-economic status. Women preferred to travel to facilities deemed to have nicer health workers, even if these were farther from home. Reported travel time ranged from 5-240 minutes in daytime and 5-40 minutes at night. Many women reported facing remarkably similar travel experiences, with varied challenges faced in the daytime (traffic congestion) compared to night-time (security concerns and scarcity of public transportation). This was irrespective of their age, socio-economic background, or obstetric history. However, the extent to which this experience impacted on their ability to reach facilities depended on their agency and support systems. Travel experience was better if they had their personal vehicle for travel at night, support of relatives or direct/indirect connections with senior health workers at comprehensive EmOC facilities. Referral barriers between facilities further prolonged delays and increased cost of travel for many women. If the goal to leave no one behind remains a priority, in addition to other health systems strengthening interventions, referral systems need to be improved, advocacy on policies to encourage women to utilise nearby functional facilities when in situations of emergency and private sector partnerships should be explored.