Unpacking pathways to emergency obstetric and newborn care and associated pregnancy outcomes: A cross-sectional spatial analysis in Benin City, Nigeria.

BACKGROUND: Travel time, referral, and waiting time at health facilities contribute to delays in receiving timely treatment for obstetric emergencies. This study assessed journeys to definitive obstetric emergency care and associations between journey characteristics and pregnancy outcomes. METHODS: A cross-sectional study of pregnant women in emergencies was conducted across four comprehensive emergency obstetric and newborn care (EmONC) facilities in Benin City from May to August 2024. Data on demographics, care-seeking journeys, symptoms, and pregnancy outcomes were collected through clinical records and interviews. Travel trajectories were reconstructed using geographic mapping and Google Maps-based time estimates. Total time to care was disaggregated into time spent on the road, referral facility, and waiting for definitive care at a comprehensive EmONC facility. Adjusted generalised linear models were used to assess associations between journey features and maternal death or stillbirth. RESULTS: Among 531 women, 308 (58.0%) went directly to definitive care. Median total time to definitive care was 57 min (IQR: 32-170), with median travel time being 25 min (15-40), and 15 min waiting at definitive care facilities (5-33). Travel time doubled with referrals, and if referred, median duration of admission at referral facilities was 510 min (120-1200). Maternal deaths (n = 11; 2.0%) or stillbirths (n = 57; 10.7%) were statistically associated with making ≥1stop before definitive care (adjusted odds ratio = 2.58, 95%CI: 1.28-5.20, p = 0.008). CONCLUSION: In Benin City, delays in care appeared to be largely due to time spent at health facilities, emphasising the need for a more integrated and efficient referral system to improve outcomes.