Did Saving Mothers, Giving Life Expand Timely Access to Lifesaving Care in Uganda? A Spatial District-Level Analysis of Travel Time to Emergency Obstetric and Newborn Care

Michelle M. Schmitz; Florina Serbanescu; Vincent Kamara; Joan Marie Kraft; Marc Cunningham; Gregory Opio; Patrick Komakech; Claudia Morrissey Conlon; Mary M. Goodwin

doi:10.9745/GHSP-D-18-00366

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FIGURE 1
Visual Representation of Data Sources Used in Health Care Accessibility Modeling Analysis
Abbreviation: WRA, women of reproductive age.
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FIGURE 2
Percentage of Women of Reproductive Age Living Within 2 Hours of CEmONC Facilities by Motorized Transportation and SMGL District
Abbreviations: CEmONC, comprehensive emergency obstetric and newborn care; SMGL, Saving Mothers, Giving Life.
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FIGURE 3
Distribution of Estimated Travel Time to EmONC Facilities, Walking or Bicycling and Walking
Abbreviation: EmONC, emergency obstetric and newborn care.
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FIGURE 4
Distribution of Estimated Travel Time to CEmONC Facilities, Walking or Bicycling and Walking
Abbreviation: CEmONC, comprehensive emergency obstetric and newborn care.
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FIGURE 5
Distribution of Estimated Travel Time to EmONC Facilities Using Motorized Transportation^a
^a Transportation defined as motorcycles or 4-wheeled vehicles.
Abbreviation: EmONC, emergency obstetric and newborn care.
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FIGURE 6
Distribution of Estimated Travel Time to CEmONC Facilities Using Motorized Transportation^a
^a Transportation defined as motorcycles or 4-wheeled vehicles.
Abbreviation: CEmONC, comprehensive emergency obstetric and newborn care.

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TABLE 1.

Demographic Factors, SMGL-Supported Districts in Uganda, 2016

District	Total Population, 2016^a	Number of WRA, 2016^a	Population Density (People/km²)^b	Urbanization Level (% Urban)^b
Kabarole	456,052	121,794	259	26.0
Kamwenge	392,501	101,650	177	5.5
Kibaale	818,176	206,596	185	7.9
Kyenjojo	428,451	108,666	179	15.4
Total	2,095,180	538,706	173	21.3

Abbreviations: km², kilometers squared; SMGL, Saving Mothers, Giving Life; WRA, women of reproductive age.
↵a Estimated from SMGL Reproductive Age Mortality Study, 2017.¹⁹
↵b 2014 National Census Main Report, Uganda Bureau of Statistics.³³

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TABLE 2.

Recommended and Observed Number of EmONC^a and CEmONC Facilities per Capita in SMGL-Supported Districts at Baseline (2012), Phase 1 (2013), and Endline (2016)

	Baseline				Phase 1				Endline
	Population^a	Recommended EmONC^b,^c	Observed EmONC^c,^d	Observed CEmONC^c,^e	Population^a	Recommended EmONC^b^,^c	Observed EmONC^c,^d	Observed CEmONC^c,^e	Population^f	Recommended EmONC^b,^c	Observed EmONC^d	Observed CEmONC^c,^e
Kabarole	415,600	5	3	3	421,700	5	8	6	456,052	5	8	6
Kibaale	681,300	7	3	3	717,500	8	5	5	818,176	9	7	5
Kamwenge	332,000	4	3	0	339,500	4	5	2	392,501	4	3	3
Kyenjojo	383,600	4	1	1	397,700	4	7	3	428,451	5	8	3
Total	1,812,500	20	10	7	1,876,400	21	25	16	2,095,180	23	26	17

Abbreviations: CEmONC, comprehensive emergency obstetric and neonatal care; EmONC, emergency obstetric and neonatal care; RAMOS, Reproductive Age Mortality Study; SMGL, Saving Mothers, Giving Life; WHO, World Health Organization.
↵a Estimated from SMGL RAMOS 2013.¹⁹
↵b EmONC encompasses facilities performing at least 7 lifesaving interventions within the past 3 months. CEmONC indicates those facilities providing 9 lifesaving interventions in the past 3 months.
↵c Uses the WHO minimum-recommended number of EmONC and CEmONC per 500,000 population (5 EmONC, including at least 1 CEmONC, per 500,000).
↵d Observed EmONC includes facilities that may not have provided assisted vaginal delivery in the past 3 months.
↵e Observed CEmONC includes facilities that may not have provided assisted vaginal delivery in the past 3 months; a few facilities reported shortage of blood in Phase 1 in the previous 3 months but were still classified as CEmONC facilities.
↵f Estimated from SMGL RAMOS 2017.¹⁹
Source: SMGL Uganda Health Facility Assessments, 2012, 2013, and 2016.

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TABLE 3.

Estimated Proportion of WRA Within Each Travel-Time Zone in SMGL-Supported Districts in Uganda (2012–2016), by Transportation Mode

Transportation Mode^a	EmONC Facilities					CEmONC Facilities
Transportation Mode^a	Baseline, 2012 (%)	Phase 1,2013 (%)	Endline, 2016 (%)	% Change^b	Sig.Level^c	Baseline, 2012 (%)	Phase 1, 2013 (%)	Endline, 2016 (%)	% Change^b	Sig.Level^c
Walking, minutes
0–30	1.4	2.4	2.6	+88	***	1.2	1.9	1.9	+55	***
31–60	1.5	3.5	3.5	+131	***	1.4	2.4	2.7	+96	***
61–90	2.0	4.0	4.4	+124	***	1.7	3.0	3.1	+89	***
91–120	1.8	4.3	4.5	+152	***	1.5	3.2	3.3	+118	***
≤120	6.7	14.2	15.0	+125	***	5.8	10.5	11.1	+91	***
>120	93.3	85.8	85.0	−9	***	94.2	89.5	88.9	−6	***
Bicycle, minutes
0–30	3.7	6.3	6.5	+77	***	3.4	4.8	5.0	+45	***
31–60	4.0	8.6	8.5	+113	***	3.5	6.6	6.8	+96	***
61–90	4.8	10.4	11.0	+129	***	3.6	7.7	7.9	+118	***
91–120	5.4	10.8	11.6	+115	***	3.8	9.2	9.4	+150	***
≤120	17.9	36.0	37.6	+110	***	14.3	28.2	29.1	+103	***
>120	82.1	64.0	62.4	−24	***	85.7	71.8	70.9	−17	***
Motorcycle, minutes
0–30	11.6	21.3	21.9	+89	***	10.6	16.9	17.2	+62	***
31–60	15.7	22.3	22.5	+44	***	12.2	22.3	23.2	+91	***
61–90	19.7	16.8	16.8	−15	***	15.7	17.6	17.7	+13	***
91–120	14.3	10.7	10.9	−24	***	12.7	12.0	11.7	−7	***
≤120	61.3	71.2	72.1	+18	***	51.1	68.7	69.8	+37	***
>120	38.7	28.8	27.9	−28	***	48.9	31.3	30.2	−38	***
4-wheeled vehicles, minutes
0–30	13.7	24.7	25.4	+85	***	12.3	20.2	20.6	+68	***
31–60	19.4	23.5	23.2	+20	***	15.8	24.1	25.2	+60	***
61–90	20.1	15.1	15.4	−23	***	15.8	16.3	15.9	+1	NS
91–120	11.9	10.2	10.2	−15	***	11.4	10.7	10.6	−7	***
≤120	65.1	73.4	74.1	+14	***	55.2	71.3	72.3	+31	***
>120	34.9	26.6	25.9	−26	***	44.8	28.7	27.7	−38	***

Abbreviations: CEmONC, comprehensive emergency obstetric and newborn care; EmONC, emergency obstetric and newborn care; SMGL, Saving Mothers, Giving Life; Sig. level, Significance level; WRA, women of reproductive age.
↵a Walking mode includes walking alone. Bicycle mode includes walking to a road and use of a bicycle. Motorized transportation modes (motorcycle, 4-wheeled vehicles) include walking to the road and use of a motorized transportation thereafter.
↵b Relative % change (% change) is calculated by the formula, ((p2-p1)/p1)*100.
↵c Asterisks indicate significance level of the % change between baseline and endline, calculated using z scores: *** P<.01, ** P<.05, NS = not significant.