Assessing geographical distribution and accessibility of emergency obstetric care in sub-Saharan Africa: a systematic review

Background: In sub-Saharan Africa (SSA), over 200 000 women (66% of global figures) die annually due to complications of pregnancy and child-birth. Many of these deaths are preventable, especially if women have access to timely emergency obstetric care (EmOC). With poor roads and difficult topography in the region, access can be impeded. Based on United Nations EmOC assessment guidelines, minimum acceptable levels for geographical distribution of EmOC facilities have been defined (EmOC Indicator 2). We aimed to critically assess studies published in the peer-review literature that assessed EmOC geographical distribution and accessibility in SSA. METHODS: Two reviewers systematically searched multiple databases for articles published between January 2009 and June 2018. Both screened and selected studies based on the set inclusion criteria. Following quality assessments, data on study characteristics, process of data collection and analysis and findings reported were extracted. Extracted data were synthesised and presented in tables and charts. Narrative synthesis was used to summarise reported findings. RESULTS: 15 studies met the inclusion criteria, with varying assessed quality: high (7 studies), medium (4 studies) and low (4 studies). 8 studies were conducted at a national level while 7 were sub-national. 8 studies focused on assessing Indicator 2, while the others assessed multiple EmOC indicators. Only about half of the studies presented details of analysis for assessing geographical distribution, provided a map and interpreted their findings. Similarly, half of the studies used geographic information systems (GIS) for analyses. Of these, GIS was used to map EmOC facilities or relate facility numbers to 500 000 population (3), estimate straight-line distances between facilities and residences of women (2) and model travel scenarios (3). EmOC facilities in SSA are concentrated in capitals, central and urban areas and at least a third of women in the region cannot reach their nearest EmOC facility within the recommended two-hour time-frame. CONCLUSIONS: There is a limited number of studies that have assessed EmOC geographical distribution in SSA. When available, completeness and quality of analysis are questionable. Comprehensive assessments need to maximise recent advancements in mobile and GIS open-source technology to provide more realistic representation of EmOC access for service planners and policy-makers. PROSPERO REGISTRATION: CRD42018099882.