The pathways to emergency obstetric care (EmOC) were diverse and broadly categorized into 4 major sequences based on the number of steps along an individual’s journey, with a majority of women going directly to a facility that provided the required care.

Women’s care-seeking pathways reflected potential inefficiencies in the referral system, including referrals from designated comprehensive EmOC facilities and direct referrals to the national referral hospital from lower-level facilities.

The majority of women seeking care for complications in Kampala resided in neighboring districts, with their pathways often involving 1 or more formal providers before the final care facility. In contrast, women living in Kampala often had more direct pathways.

Policymakers and program stakeholders should strengthen the urban health system’s capacity for quality EmOC by equitably expanding health care infrastructure, enhancing implementation of referral standards, implementing proven service delivery improvement models, and increasing private-sector contributions.

Policymakers and programmers should foster collaborative action among metropolitan districts to effectively meet the existing need for quality health care by establishing strong regulatory and accountability mechanisms and coordination systems.

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.

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.

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.

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.

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