Defined by the World Health Organization (WHO) as the death of a mother because of complications from pregnancy, up to and within 42 days following childbirth, maternal mortality (MM) has for decades remained a public health indicator of the quality of services offered by a health system.¹ According to the 2019 WHO global factsheet, there were roughly 295 000 largely preventable deaths among women during labour, delivery and the immediate puerperal period in the 2017.^1,2

According to global estimates, some 140 million births occur annually with the majority of these being vaginal deliveries among pregnant women. Most of these women do not present with identifiable risk factors at delivery. However, in situations where complications do arise during labour, the risk of morbidity and death becomes important for both mother and baby.³ The relevance of maternal and neonatal mortalities as global public health concerns is evident in the elaboration of the Millennium Development Goals (MDGs) of 2000 and later the Sustainable Development Goals (SDGs) of 2015, both of which were expounded upon by the countries worldwide during the United Nations General Assembly. Not surprisingly, target 3 of the SDG 3 aims at reducing the maternal mortality rate (MMR) to less than 70 deaths per 100 000 live births by 2030. Interventions included are the provision of evidence-based clinical and programmatic guidelines, setting global standards and providing technical support to member states on developing and implementing effective policy and programmes during pregnancy and childbirth.¹

Almost 94% of the approximately 295 000 preventable maternal deaths that occurred in 2017 were in low-resource settings. Disturbingly, 86% of these deaths occurred in sub-Saharan Africa and Southern East Asia alone.² It is worth noting that one-third of maternal deaths and pregnancy-related morbidities are accounted for by complications arising during labour, childbirth and the immediate postpartum period. Most of these deaths could largely be prevented if access to the health facility were readily feasible, pregnancies and deliveries were attended to by skilled health personnel having the right equipment and supplies and complicated cases were timely referred to equipped emergency obstetric units.^1,4

Despite global efforts, the situation remains deplorable in most developing lands. In Cameroon, WHO reported an alarming 529 MMR (per 100 000 live births) in 2016 while the neonatal mortality rate (NMR) was estimated at 24 deaths per 1000 live births.⁵ Not only does this place the country off target as far as attaining the ambitious SDGs, but it also puts the country well above global and regional values.^6,7 As a result, local policies have involved training health personnel, implementing the systematic utilisation of the partogram to follow up all deliveries and the implementation of regular surveillance meetings at district and regional levels to identify and redress any causes of evitable MM or morbidity. Nonetheless, with more equipped health services concentrated in major cities, women living in remote areas find it especially difficult to access emergency obstetric care for childbirth. This is compounded by the long travel distances, limited transport options, the absence of skilled staff and adequate drugs or equipment, all of which make hospital-based delivery services nearly as unsafe as deliveries carried out by unskilled traditional birth attendants in the community.⁸

Interestingly, several studies have evoked the impact of environmental and geographic factors as major determinants to the accessibility to healthcare delivery and hence the health outcomes.^{9,10,11,12,13,14,15} With a persistent gap in knowledge on the perceived impact of environmental and geographic factors on maternal and early neonatal healthcare services offered in most health facilities, there is an urgent need to understand the effect of these on the health status of these vulnerable groups and how and why certain strategies should be implemented. This should help rationalise programming decisions.^5,7,16 This is in line with a quantitative cross-sectional survey in Ghana where suboptimal access and utilisation of healthcare services during the maternal period was found to be influenced by the socio-economic characteristics of pregnant women.⁷ Therefore, it was considered that the results of this study will be beneficial in finetuning efforts aimed at improving upon healthcare utilisation by this vulnerable group in a bid to achieve global targets.

As outlined by the Health Belief Model (HBM),¹³ a woman’s perception on intrapartum care is critical to her health-seeking behaviour. The perceived distance in reaching the healthcare service, the estimated cost of care and perceptions on the quality of care affect decision making (first delay). Additionally, the second delay, that of reaching the health facility, is related to the distribution and site of health facilities capable of offering optimal maternal and neonatal care, as well as the availability and accessibility of transportation means to the health facilities.^{1,10,11,17,18,19,20}

In Cameroon where these factors weigh on the nation’s health system, very little has been done to identify and address the situation. This could partly be because of the absence of data to concretise knowledge on these gaps, resulting in limited policy inclusion. This hinders progress toward sustainable development and universal health coverage. It is in this light that the current study aimed to assess the effects of environmental factors, delivery outcomes and other characteristics such as geographical factors on the utilisation of hospital-based intrapartum care. This unique study conducted in the Ketté Health District will address the absence of substantial information on understanding the difficulties associated with the accessibility to healthcare services. In 2019, Cameroon began implementing the decentralisation process with the involvement of local communities and councils in service delivery. Hence, findings from this study will inform the decisions and implementation of developmental strategies through the country’s decentralisation plan to offer quality healthcare to its population.

This was a quantitative cross-sectional, hospital-based survey, which was carried out at the Ketté District Hospital, a rural health district located in the East region of Cameroon. The locality is found at an altitude of 764 m above sea-level, having a savannah-type vegetation and a mixed population of 65 550 inhabitants, principally composed of the local ‘Gbaya’ community, the Fulani and an important refugee population from neighbouring Central African Republic.⁶ Roads linking health facilities within the district health area are earth roads, being barely accessible during the rainy season.

The study population included women of reproductive age, between 15 and 49 years, residing within the Ketté Health District area. For ethical reasons and in line with national standards, eligible participants were pregnant women aged between 18 and 49 years inclusive, who presented at term (i.e., at least completed 36 weeks of amenorrhoea) for antenatal consultation, for intrapartum or for early postpartum care (within the first 2 weeks following delivery, regardless of the delivery outcome) at the Ketté District Hospital and who voluntarily consented to participation. Persons who objected to participate or who did not meet the specific inclusion criteria were excluded from the study.

The G*power software (version 3.1.9.7) was used to do an a priori power analysis,²¹ and the findings showed that the sample size was adequate for valid results to identify small, medium and large effects. With a critical T value of 1.96 and a power of 0.8, alpha level of 0.05 and low effective size of 0.2, we were able to get the necessary sample size of 471 people.

The convenience sampling method was used. For this, an institution-based cross-sectional study at the Ketté District Hospital was conducted. To compensate for the passive exclusion of women not presenting at the retained health facility for peripartum care, all patients presenting at the waiting room of the hospital were notified by the data collectors of the ongoing research, its purpose, objectives, admission and exclusion criteria, the methodology and the potential benefits to the population. This was done as a public announcement. All eligible and willing participants were then given the opportunity to provide written consent at the end of their regular visit. Where necessary, questions were rephrased into the local language to ease understanding.

A structured closed-ended, self-administered questionnaire developed from literature review and published studies was the tool used for data collection. A pilot study was conducted to test the quality of the questionnaire and to ensure the internal integrity of the tool.^12,22 Data were then collected as primary data and were grouped based on environmental, socio-demographic, and obstetric and delivery characteristics. These were further categorised as exposure variables, outcome variable and covariates or confounders. Where applicable, a Likert scale was used to gauge opinions and attitudes.^9,22,23

Data were prepared and analysed using IBM Corp. (Released 2023, IBM SPSS Statistics for Windows, Version 29.0.2.0 Armonk, NY: IBM Corp statistics version 29.0).²⁴ Descriptive statistic such as frequencies and percentages were computed to summarise the nominal and ordinal variables, while means and standard deviations (s.d.) were used to describe the numerical variables. The Chi-square test was computed to evaluate the association between categorical determinants and the outcome variable(s). Logistic regression analysis was performed to identify significant predictors of suffering complications during delivery. A p < 0.05 was considered statistically significant.

The reliability of the data collection tool was ensured through a test-retest analysis, which was performed on 5% of the sample group. External validity was ensured by raising the sample size to a higher level as determined by the time frame. For internal validity, questions were proofread, translated into the local language and re-read by the supervisor and three different translators to ensure the use of simple understandable language, the absence of jargon or double-barrel questions.

For ethical considerations, the study proposal was submitted to and approved by the University of Johannesburg’s Higher Degree Committee (HDC) and the Research Ethics Committee (REC) while written authorisation was obtained from the Regional Delegate of Public Health for the East Region. The use of face masks, hand sanitisers, physical distancing of at least one meter between the interviewer and the participant was compulsory throughout the data collection process to ensure the application of standard barrier measures within the context of the coronavirus disease 2019 (COVID-19) pandemic.

The study’s data and findings are shown in this section. IBM-SPSS version 29.0²⁴ was used for data preparation and analysis. Data include respondents’ delivery and obstetric details, as well as environmental elements and demographics. Along with submitting the analysis, it talks about the outcomes by making predictions and looking for correlations.

This study articulated the effect of environmental factors on hospital-based intrapartum care tendencies in a rural setting of Cameroon with findings being similar to several other studies.^15,38,39,40 As regard to socio-demographic indicators, participants with a family size of 1–2 persons were less likely to have had maternal complications, a finding concordant with those obtained earlier.⁴¹ This seems logical as the financial capacity to afford for healthcare services is diluted by an increase in family size, a predisposition to intrapartum complications as opposed to a lower likelihood for maternal complications when the family size is smaller.⁴² Not surprisingly, unemployed participants were more likely to have had maternal complications, as was the case in other studies.^15,43,44

Women above 35 years showed more responsible behaviour and were more confident and influential in decision-making as opposed to younger women, resulting in an increased utilisation of ANC services and lesser odds for maternal complications. Similar observations from other studies revealed that single mothers were more likely to have had maternal complications, possibly because of the increased exposure to lesser financial support.^10,39,41 As with some studies, no statistically significant association was identified between religious affiliation and the likelihood for delivery complications.¹⁰ Consistent with findings made by other researchers was the relationship between a limited level of education and maternal complications.^{10,40,42,45,46} This suggests that increased maternal education has a positive effect on complication preparedness, hence reducing the risk of maternal complications.^39,41,47,48

No significant relationship was found in this study between gestational age and delivery complications. This contradicts results from other studies where an increase in gestational age after 40 weeks was strongly associated with greater odds for maternal complications because of placental insufficiency, macrosomia, meconial aspiration and decreased amniotic fluid.^42,49 In this study, only 31 participants (6.6%) had attended at least 4 ANC visits as opposed to the required minimum of 8 ANC visits. These findings correlate with an earlier study¹⁵ in which only 9.1% of participants had attended at least 4 visits with a significant correlation between number of ANC and delivery complications. It has been established that the lesser the number of ANC attended, the greater the likelihood for maternal complications because of a lower likelihood for an early detection and management of evitable risks and complications related to delivery.^9,39,45

Participants who had been pregnant just once or thrice were less likely to have had maternal complications. This is consistent with previous findings^10,45,46 as an increase in parity (4 or more pregnancies) has been found to have a significantly negative effect on the health-seeking behaviour during the intrapartum period as well as a higher tendency for maternal complications. Also, multiparous women (4 or more pregnancies) were more likely to rely on experience rather than seek medical care with a resultant increase in the likelihood for maternal complications.^10,45 Participants whose deliveries were assisted by traditional birth attendants were more likely to have had maternal complications with as much as 237 (50.7%) participants having had their deliveries assisted by traditional birth attendants (TBAs). The finding from this study concords with results obtained in other studies.^9,15 This is plausible as an increased familiarity with a TBA – if the last delivery went well – lowers the tendency to opt for medicalised care, resulting in a higher predisposition for maternal complications.¹⁰ More so, participants whose babies suffered from neonatal complications were more likely to have had maternal complications. This finding also concurs with results obtained from earlier studies.^49,50,51 The occurrence of complications such as gestational diabetes, macrosomia, malformations, intrauterine growth retardation and still births have been shown to increase the risk for other intrapartum complications.^50,52,53

In this study, a strong relationship between maternal outcomes and socio-demographic and environmental determinants as determined by the use of hospital-based intrapartum health services in a rural community of Cameroon was established. This study showed that a smaller family size, walkable distance to the health facility or a low number of deliveries were predictive for poor maternal outcomes with a strong correlation between the means of transportation used, travel distance or time, season or road quality at the time of delivery and maternal outcomes. Consequently, an increased likelihood for maternal complications was found when environmental factors were not viewed as satisfactory. These findings corroborate with those observed in several other studies and highlight the need for an improved accessibility to health facilities in a bid to promote their usage, thus reducing the risks for maternal and neonatal complications especially during the intrapartum period. It is therefore essential that cost-effective and sustainable measures such as regular road maintenance, especially of secondary and tertiary roads, and the provision of motorised means of transportation to ease medical interventions be envisaged, especially in rural communities. Also, the provision of referral advice to women of child-bearing age and the training of community health workers and TBAs on first aid skills, danger signs identification and management, recommended health practices and referral could greatly improve maternal outcomes.