Emergency obstetric care access dynamics in Africa's cities: Analysis of women's self-reported care-seeking pathways in Kampala city, Uganda

The rapid urbanization, particularly in Africa has posed several challenges that affect provision and accessibility of healthcare. The complex mix of providers, socio-economic inequalities, and inadequate infrastructure have been found to limit clients ability to reach and utilize routine and emergency health services. A growing body of literature shows poor health outcomes in African cities, including high institutional maternal mortality, which reflect poorly performing health systems. Understanding care-seeking pathways is necessary for improving health service delivery and ultimately improving health outcomes. We describe typologies and attributes of care-seeking pathways, using self-reported data from a cross-sectional survey of 433 women (15-49 years) who had obstetric complications, from nine health facilities in Kampala city. Participants average age was 26 (SD=6) years, and 55% (237/433) lived in the city suburbs. We identified four broad pathway sequences based on number and location of steps: pathways with one step, directly to a facility that could provide required care (42%, 183/433); two steps, mostly including direct referrals from basic and comprehensive obstetric facilities (40%, 171/433); three steps, including potentially delayed referral trajectories as women first return home (14%, 62/433); and [≥]4 steps (4%, 17/433). Comprehensive obstetric facilities referred out 43% (79/184) of women who initially sought care in these facilities. Peripheral facilities referred 65% of women directly to the National Referral Hospital. Majority (60%, 34/57) of referred women first returned home before going to the final care facility. Our findings suggest that care pathways of women with obstetric complications in Kampala mostly comprise of at least two formal providers. This implies that efforts to strengthen urban health systems for maternal health should adopt broad or integrated approaches; and calls for improved inter-facility communication, streamlined referral processes and emergency transport availability. Future studies should investigate quality and experiences of care along the pathways. Key findingsO_LIThe pathways to care were multiple and varied by complication. Majority included at least two formal providers, giving insights into the dynamics surrounding obstetric referrals in the city such as time spent in a facility before referral and travel time between facilities. C_LIO_LIThe issues identified from the facility referral pathways were: referrals from comprehensive obstetric facilities, bypassing of referral hierarchies by peripheral facilities, and low utilization of ambulances by peripheral facilities. C_LIO_LIAdditionally, a notable percentage of referral pathway trajectories were interrupted and delays created therein, by women having to go back home after first seeking care from a formal provider. This was largely to obtain funds and other requirements. C_LIO_LIMajority of women seeking care for complications in Kampala city reside in neighboring suburbs. C_LI Key implicationsO_LIPolicy makers and program stakeholders need to develop strategies and design services/systems that align with the care-seeking behaviors of clients in urban areas, including a substantial reliance on peripheral facilities, high contribution of referrals and the complexity of delays as clients move across different types or levels of providers. C_LIO_LIPolicy makers should strengthen and expand coverage of comprehensive obstetric care to reduce unnecessary referrals or bypassing. Policy initiatives to facilitate access through private hospitals could contribute to improved access. C_LIO_LISubnational stakeholders in urban areas, with support from national stakeholders, need to develop effective strategies and plans such as networks of care or care pathways for organizing and monitoring service delivery in metropolitan areas, with proper accountability for outcomes and resources. C_LI