A rural ambulance service in Northern Togo improves access to emergency care for women with obstetric complications.

Background: Maternal mortality remains high in sub-Saharan Africa, with little progress made in the last 20 years. The provision of emergency obstetric care has been shown to have the greatest effect in reducing maternal mortality in countries with high maternal mortality ratios, especially when paired with an emergency transport service. Integrate Health has partnered with the Togolese Ministry of Health to improve maternal and child health via the integration of a free ambulance service into a pre-existing primary care model. In this study, we aim to describe the implementation of this service and assess its effectiveness on access to emergency obstetric care by estimating its coverage of women with obstetric complications.

Methods: This is a retrospective cross-sectional study using routinely collected data from ambulance logbooks. The study was restricted to pregnant or postpartum woman in four districts of Northern Togo. For each patient transported, the variables collected included date of transport, destination, patient information, kilometres travelled, and reason for transport. Complicated obstetric cases were defined by reason for transport and included maternal haemorrhage, complicated birth, and signs of danger. Estimated coverage of major obstetric complications was calculated using population estimates per fiscal year, the birth rate (3.7%) in Togo, and the assumption that 15% of pregnant women will have a complication.

Results: Between July 2020 and June 2023, there were 2926 maternal patients transported by the ambulance service. Of these, 1030 were reported as complicated obstetric cases. Estimated coverage of obstetric complications increased over time and as the programme expanded, from 18% in 2020 to 35.7% in 2021, and 66.5% in 2022.

Conclusions: Our findings demonstrate that implementing a rural ambulance service in a region with historically high maternal mortality rates may improve maternal access to emergency obstetric care. The success of our ambulance service was likely due to the fact that it is free, available 24/7, easily accessible, operated by trained staff and community members, and integrated into a pre-existing primary care programme with well-resourced health care centres.