Impact of travel time to health facilities on perinatal outcomes: a systematic review with narrative synthesis and meta-analysis

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Abstract
Evidence-based global guidance on safe travel time for small or sick newborns who require transfer to health facilities after birth is lacking. A two-hour threshold is frequently cited in low- and middle-income countries (LMICs), while 30 minutes is commonly used in high-income countries (HICs). Although these thresholds are widely referenced, their empirical basis and consistency across levels of newborn care and journey types have not been systematically examined. This study synthesises the evidence linking travel time and perinatal outcomes. We conducted a systematic review with narrative synthesis and meta-analysis to assess the impact of travel time or distance (home-to-facility or interfacility) on stillbirth, perinatal mortality, and neonatal mortality. We searched Embase, MEDLINE, and Cochrane Central Register of Controlled Trials for published studies from 2014 to 2023. Given substantial methodological heterogeneity, we used narrative synthesis as the primary analytical approach and conducted random-effects meta-analyses where studies were sufficiently comparable (≥2 with similar definitions and outcome windows), pooling effect estimates for travel time thresholds of 30 minutes, 1 hour, or 2 hours and travel distances of 5, 10, and 15 km. We assessed bias using the Newcastle-Ottawa Scale for cohort and case-control studies. Of 8317 screened records, 166 were eligible for full-text review, with 37 studies meeting the inclusion criteria- All but two had low or moderate risk of bias. Most studies (n = 26) came from LMICs and documented higher perinatal survival with shorter journeys. Studies from HICs demonstrated lower out-of-hospital birth, lower morbidity, and lower mortality with shorter journeys though associations were weaker. Across the narrative synthesis, shorter travel times were consistently associated with better outcomes. Exploratory pooling suggested a greater than 3-fold higher odds of survival for interfacility journeys under 30 minutes (odds ratio (OR) = 3.25; 95% confidence interval (CI) = 1.90-5.57) and over 2-fold higher odds of survival for journeys from any location to hospitals at all thresholds (OR = 2.06; 95% CI = 1.60-2.65 for 2 hours; OR = 2.20; 95% CI = 1.46-3.33 for 1 hour; OR = 1.92; 95% CI = 1.10-3.34 for 30 minutes), though prediction intervals were wide, reflecting methodological and contextual diversity. We found that shorter journeys were associated with better perinatal outcomes, with the highest survival rates observed for journeys under 30 minutes to the hospital. Due to substantial contextual and methodological heterogeneity, pooled estimates should be interpreted as illustrative, rather than definitive. A travel time norm of 30 minutes or one hour is preferable to the two-hour threshold currently used in LMICs. To safeguard perinatal survival rates, any travel-time standard should be balanced with corresponding quality of care standards. PROSPERO: CRD42023460423.

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