Emergency Obstetric Care Access Dynamics in Kampala City, Uganda: Analysis of Women's Self-Reported Care-Seeking Pathways.

Introduction: Timely access to emergency obstetric care (EmOC) remains a challenge in sub-Saharan Africa, influenced by poor health care utilization and rapid urbanization. Studies show poor maternal health outcomes in African cities, reflecting weak health systems. Understanding care-seeking pathways is key to improving service delivery and health outcomes. We examined self-reported care-seeking pathways among women with obstetric complications in Kampala City, Uganda.

Methods: In this cross-sectional survey, we collected sequential data from 433 women (15-49 years) from 9 health facilities in Kampala City. We developed typologies of common pathways to EmOC and descriptively analyzed key attributes, including median time spent at each step, comparing pathways across complications and participant characteristics. Provider utilization and service delivery performance issues were also assessed.

Results: Participants' average age was 26 years (standard deviation=6), with 55% (237/433) living outside Kampala. We identified 4 common pathways based on number and location of steps: pathways with 1 step, directly to a facility that provided required care (42%, 183/433); 2 steps, mostly including direct facility referrals (40%, 171/433); 3 steps (14%, 62/433); and 4 or more steps (4%, 17/433). Comprehensive EmOC facilities referred elsewhere 43% (79/184) of women who initially sought care in these facilities. Peripheral facilities referred 65% of women directly to the national referral hospital. A majority (60%, 34/57) of referred women returned home before reaching the final care facility.

Conclusions: Our findings suggest that care pathways of women with obstetric complications in Kampala often involve at least 2 formal providers and reflect possible inefficiencies in the referral process, including potential delays and unnecessary steps. Efforts to strengthen urban health and referral systems should adopt multidisciplinary and integrated approaches, supported by clear policies and structures that facilitate effective interfacility and interdistrict care coordination. This should include streamlined care/referral pathways and equitable emergency transportation systems.