The relationship between prolonged travel and mortality among women with complicated deliveries in rural Kenya

Background: In many low- and middle-income settings, deliveries often take place in primary health facilities that are not equipped to address life-threatening complications. Emergency referral systems seek to rapidly transport women and newborns facing complications but inevitably introduce delays. Estimating the mortality impact of these delays is challenging due to potential selection bias. As an alternative approach, we examine the relationship between delays and adverse outcomes among a sample that is less likely to exhibit selection effects: mothers who started at a low-level facility before transfer to a hospital equipped to provide definitive care (hospital-level). Methods: We leverage demographic, obstetric, and geodata collected through the parent study Service Delivery Reform for Maternal and Newborn Health in Kakamega County, Kenya to explore the relationship between intrapartum travel and whether there was a maternal death, neonatal death, or stillbirth (adverse health outcome). We conducted a series of logistic models estimating the relationship between longer travel distances and probability of an adverse health outcome, with analyses iteratively adjusted for sociodemographic and obstetric covariates. Results: Of the 39,052 mothers with full geodata, 1,928 (4.9%) reported visiting at least one low-level facility before visiting a high-level facility. After restricting to those who experienced upward movement in facility level during delivery and adjusting for relevant covariates, we find that those in the fourth quartile of travel distances (42-436 km) had a 2.60 times higher odds of an adverse health outcome relative to those in the first quartile (2-16 km). Conclusions: Our findings show that Phase 2 delays in the form of intrapartum journeys have a pronounced association with maternal and child mortality when the total distance travelled is long. These findings align with the prior evidence that delays in receiving appropriate and timely delivery care are related to maternal and child mortality and morbidity.