Open access Original research BMJ Open: first published as 10.1136/bmjopen-2020-045891 on 30 July 2021. Downloaded from National optimisation of accessibility to emergency obstetrical and neonatal care in Togo: a geospatial analysis Andrew Curtis,1,2 Jean- Pierre Monet,3 Michel Brun,3 Issa Abdou- Kérim Bindaoudou,4 Idrissou Daoudou,5 Marta Schaaf ,6 Yawo Agbigbi,7 Nicolas Ray 1,2 To cite: Curtis A, Monet J- ABSTRACT Strengths and limitations of this study P, Brun M, et al. National Objectives Improving access to emergency obstetrical optimisation of accessibility and neonatal care (EmONC) is a key strategy for reducing ► This is the first study presenting an improvement to emergency obstetrical maternal and neonatal mortality. Access is shaped and neonatal care in Togo: a of a network of emergency obstetrical and neonatal by several factors, including service availability and geospatial analysis. BMJ Open care (EmONC) facilities, based on the characteristics geographical accessibility. In 2013, the Ministry of Health 2021;11:e045891. doi:10.1136/ of these facilities and on realistic physical accessi- (MoH) of Togo used service availability and other criteria bmjopen-2020-045891 bility modelling. to designate particular facilities as EmONC facilities, ► Country- based experts estimated the modes and ► Prepublication history and facilitating efficient allocation of limited resources. In speeds of transport on the various road types and additional supplemental material 2018, the MoH further revised and rationalised this health for this paper are available off- road landcover categories, and associated un- facility network by applying an innovative methodology online. To view these files, certainty analyses assessing relative effect of travel using health facility characteristics and geographical please visit the journal online speeds were performed. accessibility modelling to optimise timely access to (http:// dx. doi. org/ 10. 1136/ ► The EmONC prioritisation approach succeeded in EmONC services. This study compares the geographical bmjopen- 2020- 045891). prioritising 73 out of the initial 109 EmONC facilities, accessibility of the network established in 2013 and the with only a marginal drop of population coverage. Received 15 October 2020 smaller network developed in 2018. This will enable efficient use of limited resources. Accepted 12 July 2021 Design We used data regarding travel modes and speeds, ► Only the physical accessibility to nearest designated geographical barriers and topographical and urban EmONC services was modelled, but potential finan- constraints, to estimate travel times to the nearest EmONC cial barriers and the fact that some patients could facilities. We compared the EmONC network of 109 http://bmjopen.bmj.com/ opt to bypass the nearest facility may also affect facilities established in 2013 with the one composed of 73 access to EmONC. facilities established in 2018, using three travel scenarios ► Travel was modelled only for the dry season condi- (walking and motorised, motorcycle- taxi and walking- only). tions, but degraded road conditions in certain parts Results When walking and motorised travel is considered, of the country during the wet season may affect our © Author(s) (or their the 2013 EmONC network covers 81% and 96.6% of the estimates of EmONC accessibility. employer(s)) 2021. Re- use population at the 1- hour and 2- hour limit, respectively. permitted under CC BY- NC. No These figures are slightly higher when motorcycle- taxis commercial re- use. See rights and permissions. Published by are considered (82.8% and 98%), and decreased to BMJ. 34.7% and 52.3% for the walking- only scenario. The (SDG3.2). One of the primary strategies for on October 2, 2021 by guest. Protected copyright. 1GeoHealth Group, Institute 2018 prioritised EmONC network covers 78.3% (1- hour) reducing maternal and neonatal mortality and 95.5% (2- hour) of the population for the walking and of Global Health, University of and morbidity is ensuring timely access to Geneva, Geneva, Switzerland motorised scenario. 2Institute for Environmental Conclusions By factoring in geographical accessibility quality emergency obstetrical and neonatal 1 Sciences, University of Geneva, modelling to our iterative EmONC prioritisation process, care (EmONC). However, access to EmONC Geneva, Switzerland the MoH was able to decrease the designated number of is still a challenge in many low- income coun- 3 Technical Division, UNFPA, New EmONC facilities in Togo by about 30%, while still ensuring tries, especially in sub- Saharan Africa.2 York, New York, USA that a high proportion of the population has timely access 4 Because the physical distance to facilities has National Institute of Statistics to these services. However, the physical access to EmONC and Economic and Demographic long been recognised as an important compo- for women unable to afford motorised transport remains Studies, Lomé, Togo nent of timely access to care,3 4 an adequate 5 inequitable. Ministry of Health of Togo, geographical distribution of EmONC facili- Lomé, Togo 6Independent Consultant, ties is a prerequisite to minimise travel times Brooklyn, New York, USA INTRODUCTION for women in need of EmONC. The WHO 7 UNFPA- Togo, Lomé, Togo The Sustainable Development Goal 3 (SDG3) recommends a benchmark of no more than aims to better health outcomes for different 2 hours of travel time to reach the nearest Correspondence to 5 Professor Nicolas Ray; at risk groups, including pregnant women EmONC facility, as after 2 hours, an obstet- nicolas. ray@ unige. ch (SDG3.1) and children under 5 years of age rical haemorrhage can be fatal. Curtis A, et al. BMJ Open 2021;11:e045891. doi:10.1136/bmjopen-2020-045891 1 Open access Realistically modelling and measuring spatial acces- of approximately 7.9 million in 2018,22 and is bordered BMJ Open: first published as 10.1136/bmjopen-2020-045891 on 30 July 2021. Downloaded from sibility to health services is therefore very important for by Benin to the east, Ghana to the west and Burkina Faso adequate planning and improvement of access to quality to the north. More than 40% of the total population healthcare for pregnant women and newborns.6 Some live in the southern part of the country (in the region studies have used simple distance7 and time8 metrics, of Maritime and in the capital city of Lomé), with 42% as well as population-to- provider ratios.9 These metrics of this population living in urban areas.23 The 2017 have been popular for their ease of use and minimal Multiple Indicator Cluster Survey for Togo24 determined need for the input of spatial data layers, that is, data that that there is a strong correlation between poverty and both provide locations and describe characteristics of maternal mortality and morbidity. Indeed, the probability geographical features.10 of giving birth assisted by qualified personnel is found to However, these methods are not appropriate for model- be highly correlated to socioeconomic status and to place ling geographical accessibility in complex terrains where of residence. The aforementioned survey determined different modes of transport are potentially used for a single that 98% of women in the richest quintile are assisted trip, and when patients seeking care are facing an emer- at birth by skilled health personal, compared with only gency, where every minute of travel time is consequential. 52% of the poorest quintile. It also highlighted the fact In such cases, approaches based on least- cost path model- that 98% of women living in urban settings receive skilled ling (ie, finding the fastest route between locations based birth attendance, as compared with 65% of women living on various travel constraints) have proved useful to esti- in rural settings. Three- quarters of maternal deaths were mate time and routing to reach the nearest care providers, found to be due to direct obstetrical causes. This suggests and to model catchment areas of facilities.10 Applying this that access to timely EmONC is essential for reducing modelling approach, the AccessMod tool11 helps estimate maternal mortality in Togo. geographical accessibility by taking into consideration The 2017–2022 national plan for health sector devel- the modes of transport, their respective speeds of travel opment in Togo25 highlights that morbidity and mortality on roads and off- road on various landcover types and the rates for mothers and newborns are still very high, and influence of the topography and other barriers to move- notes that this is due to insufficient supply of obstet- ment. Studies assessing the accessibility of a variety of rical and neonatal care and by barriers to service access, healthcare destinations have used AccessMod in their anal- including financial barriers. Despite some progress over yses.12–19 Specific to accessibility to EmONC, Ebener and the last decades, maternal and newborn mortality are still colleagues20 have recently formalised and proposed new high in Togo, respectively, with 396 (80% CI: 270 to 557) indicators based on least- cost path modelling. maternal deaths per 100 000 live births in 201725 and 25 The main objective of this study was to realistically deter- neonatal deaths per 1000 live births in 2018.2 Improving mine and compare the overall geographical accessibility of access to quality EmONC services has been a priority for our target population (women with obstetrical complica- the government since the EmONC needs assessment of http://bmjopen.bmj.com/ tions in need of EmONC) to two