The influence of travel time to health facilities on stillbirths: A geospatial case-control analysis of facility-based data in Gombe, Nigeria

Access to quality emergency obstetric and newborn care (EmONC); having a skilled attendant at birth (SBA); adequate antenatal care; and efficient referral systems are considered the most effective interventions in preventing stillbirths. We determined the influence of travel time from mother’s area of residence to a tertiary health facility where women sought care on the likelihood of delivering a stillbirth. We carried out a prospective matched case-control study between 1st January 2019 and 31st December 2019 at the Federal Teaching Hospital Gombe (FTHG), Nigeria. All women who experienced a stillbirth after hospital admission during the study period were included as cases while controls were consecutive age-matched (ratio 1:1) women who experienced a live birth. We modelled travel time to health facilities. To determine how travel time to the nearest health facility and the FTHG were predictive of the likelihood of stillbirths, we fitted a conditional logistic regression model. A total of 318 women, including 159 who had stillborn babies (cases) and 159 age-matched women who had live births (controls) were included. We did not observe any significant difference in the mean travel time to the nearest government health facility for women who had experienced a stillbirth compared to those who had a live birth [9.3 mins (SD 7.3, 11.2) vs 6.9 mins (SD 5.1, 8.7) respectively, p = 0.077]. However, women who experienced a stillbirth had twice the mean travel time of women who had a live birth (26.3 vs 14.5 mins) when measured from their area of residence to the FTHG where deliveries occurred. Women who lived farther than 60 minutes were 12 times more likely of having a stillborn [OR = 12 (1.8, 24.3), p = 0.011] compared to those who lived within 15 minutes travel time to the FTHG. We have shown for the first time, the influence of travel time to a major tertiary referral health facility on the occurrence of stillbirths in an urban city in, northeast Nigeria

Potential impact of midwives in preventing and reducing maternal and neonatal mortality and stillbirths: a Lives Saved Tool modelling study

Background
Strengthening the capacity of midwives to deliver high-quality maternal and newborn health services has been highlighted as a priority by global health organisations. To support low-income and middle-income countries (LMICs) in their decisions about investments in health, we aimed to estimate the potential impact of midwives on reducing maternal and neonatal deaths and stillbirths under several intervention coverage scenarios.

Methods
For this modelling study, we used the Lives Saved Tool to estimate the number of deaths that would be averted by 2035, if coverage of health interventions that can be delivered by professional midwives were scaled up in 88 countries that account for the vast majority of the world’s maternal and neonatal deaths and stillbirths. We used four scenarios to assess the effects of increasing the coverage of midwife-delivered interventions by a modest amount (10% every 5 years), a substantial amount (25% every 5 years), and the amount needed to reach universal coverage of these interventions (ie, to 95%); and the effects of coverage attrition (a 2% decrease every 5 years). We grouped countries in three equal-sized groups according to their Human Development Index. Group A included the 30 countries with the lowest HDI, group B included 29 low-to-medium HDI countries, and group C included 29 medium-to-high HDI countries.

Findings
We estimated that, relative to current coverage, a substantial increase in coverage of midwife-delivered interventions could avert 41% of maternal deaths, 39% of neonatal deaths, and 26% of stillbirths, equating to 2·2 million deaths averted per year by 2035. Even a modest increase in coverage of midwife-delivered interventions could avert 22% of maternal deaths, 23% of neonatal deaths, and 14% of stillbirths, equating to 1·3 million deaths averted per year by 2035. Relative to current coverage, universal coverage of midwife-delivered interventions would avert 67% of maternal deaths, 64% of neonatal deaths, and 65% of stillbirths, allowing 4·3 million lives to be saved annually by 2035. These deaths averted would be particularly in the group B countries, which currently account for a large proportion of the world’s population and have high mortality rates compared with group C.

Interpretation
Midwives can help to substantially reduce maternal and neonatal mortality and stillbirths in LMICs. However, to realise this potential, midwives need to have skills and competencies in line with recommendations from the International Confederation of Midwives, to be part of a team of sufficient size and skill, and to work in an enabling environment. Our study highlights the potential of midwives but there are many challenges to the achievement of this potential. If increased coverage of midwife-delivered interventions can be achieved, health systems will be better able to provide effective coverage of essential sexual, reproductive, maternal, newborn, and adolescent health interventions.

Funding
New Venture Fund.