Emergency obstetrical complications in a rural African setting (Kayes, Mali): The link between spatial access and in-hospital mortality

Background: Mali has the eighth highest rate of maternal mortality in the world. In order to lower its high maternal mortality rate, the country has implemented reference systems to increase spatial access to emergency obstetrical care. We test the hypothesis that spatial access, proxied by travel time during the rainy and dry seasons, is associated with in-hospital maternal mortality in Kayes, Mali.

Methods: We conducted a matched case-control study on women who were treated at the regional hospital for obstetrical complications between 2005 and 2007. Key informant interviews provided exposure data on spatial access. The regional obstetrical monitoring system provided demographic and medical data.

Results: For all women treated at the regional hospital during the study period, case fatality rates increased with increasing travel time from the hospital. Average travel time was 80 minutes, but ranged from 15 minutes to >24 hours. The case-control study showed that inadequate spatial access to emergency obstetrical care was significantly associated with mortality in women four or more hours from the hospital (OR: 3.09; CI: 1.05-9.14). Major obstetric interventions had a borderline protective effect against mortality (OR: 0.42; CI: 0.17-1.06).

Conclusions: This study supports previous evidence demonstrating that poor spatial access leads to increased maternal mortality and shows that spatial access contributes to maternal mortality even in women who reached the hospital. Improving spatial access will help to assure that women arrive at the hospital in time to be treated and may increase the effectiveness of major obstetric interventions, such as caesarean section.