Fraud, Waste, and Abuse (FWA) detection is a significant yet challenging problem in the health insurance industry. An essential step in FWA detection is to check whether the medication is clinically reasonable with respect to the diagnosis. Currently, human experts with sufficient medical knowledge are required to perform this task. To reduce the cost, insurance inspectors tend to build an intelligent system to detect suspicious claims with inappropriate diagnoses/medications automatically.The aim of this study was to develop an automated method for making use of a medical knowledge graph to identify clinically suspected claims for FWA detection.First, we identified the medical knowledge that is required to assess the clinical rationality of the claims. We then searched for data sources that contain information to build such knowledge. In this study, we focused on Chinese medical knowledge. Second, we constructed a medical knowledge graph using unstructured knowledge. We used a deep learning–based method to extract the entities and relationships from the knowledge sources and developed a multilevel similarity matching approach to conduct the entity linking. To guarantee the quality of the medical knowledge graph, we involved human experts to review the entity and relationships with lower confidence. These reviewed results could be used to further improve the machine-learning models. Finally, we developed the rules to identify the suspected claims by reasoning according to the medical knowledge graph.We collected 185,796 drug labels from the China Food and Drug Administration, 3390 types of disease information from medical textbooks , and information from 5272 examinations as the knowledge sources. The final medical knowledge graph includes 1,616,549 nodes and 5,963,444 edges. We designed three knowledge graph reasoning rules to identify three kinds of inappropriate diagnosis/medications. The experimental results showed that the medical knowledge graph helps to detect 70% of the suspected claims.The medical knowledge graph–based method successfully identified suspected cases of FWA  from the claim documents, which helped to improve the efficiency of claim processing. Currently, claim processing is a labor-intensive task for health insurance companies. For each claim document, the insurance inspector, who is usually a trained medical professional, needs to check whether the claim is reasonable from a clinical perspective, such as to catch any irrationality between a drug and diagnosis, or to check whether the examination is suitable for the diagnosis or symptoms. Detecting any signs of Fraud, Waste, and Abuse (FWA) is akin to looking for a needle in a haystack through claim data. The insurance company needs to hire people with sufficient medical knowledge, which significantly increases its human resource cost. Besides, claim processors still need to consult textbooks or the drug labels periodically as it is quite hard to remember details for all types of diseases, drugs, and examinations, which reduces the efficiency of claim processing. To improve the efficiency of the labor-intensive claim processing task, domain experts have devised some rules to generate a warning for suspected claims automatically. However, as the claims are coming from various hospitals that use different terminologies for drugs, examinations, and diagnoses, the coverage of fixed rules established by domain experts is relatively low. Moreover, as the drug information continues to be updated, the rules need to be updated correspondingly. To handle these challenges, knowledge graph technology could be used to represent unstructured medical knowledge such that the computer could perform reasoning on top of the knowledge graph to determine whether the claim is clinically reasonable automatically. Moreover, a method to build the knowledge graph automatically or with low human labor cost is indispensable.Computational methods have been studied to detect FWA events -4. Howev<treat; drug, disease>, <interact; drug, drug>, and <check; disease, examination>.In this paper, we present a method to automatically build a medical knowledge graph for FWA detection in claim processing. To support FWA detection, a medical knowledge graph should cover the essential concepts such as diseases, drugs, examinations, symptoms, and the relationships between these concepts such as The main contributions of this study are as follows. First, we designed a medical knowledge graph schema for intelligent claim processing in health care insurance, and we collected recognized knowledge sources to support medical knowledge graph construction. Second, we built the medical knowledge graph using a deep learning–based method to extract entities and relationships from the knowledge sources automatically. We explored a human-machine collaboration to improve the quality of the medical knowledge graph. Finally, we applied the medical knowledge graph to empower claim processing in a health care insurance scenario.<interaction, drug, drug>).To build the knowledge graph, we first needed to define a knowledge graph schema  according to the requirements in claim processing. The above-required knowledge was collected from three sources: medical textbooks, drug labels, and clinical guidelines. We collected information on more than 3000 diseases and 1000 examinations from textbooks, 185,796 drug labels from the China Food and Drug Administration, and more than 2000 clinical guidelines from the Chinese Medical Association. In the following sections, we will introduce the algorithms used to identify the concepts and relationships from these sources.NER is used to detect medical entity mentions from unstructured data. As shown in Although there are many Chinese NER methods -17, thesOur model is an improved version based on conventional BiLSTM-CRF. We improved the model from the following aspects.First, we replaced the tokenizer and word embedding with BERT , which iSecond, we used a feature engineering approach. We included many additional handcrafted features to the model. Neural networks have a good reputation for automatically capturing features. However, in the case of industrial application, handcrafted features can help to improve the robustness of the model. We extracted the following features. We used a word segmentation tool to extract the word segmentation soft boundary in which we used a Begin-Middle-End segmentation tag for each character of the text and the label was mapped to a lowdimensional vector by a randomly initialized matrix. Radical features were extracted, as Chinese characters are hieroglyphic, which means that the shape of each character can represent its actual meaning to some extent. In the medical domain, a character consisting of the radical “疒” is usually related to a disease or symptom. Another typical case is “月,” which is relevant to a body structure. In addition, we extracted the prefix/suffix feature. In Chinese, a word typically consists of more than one character, and some characters play the role of a prefix or suffix. For instance, a disease name often has the suffix “病” and drugs often have suffixes such as “胶囊” or “冲剂.”Combining the predictions of a deep-learning NER model, manually developed rules, and dictionaries can be a difficult task. Results from the model and the dictionary can have conflicts, neither of which is always correct. After analyzing the results of the prediction of multiple experiments, we found that the most common mistakes that a model can make are inconsistent tagging, wrong entity type, and incomplete span. Inconsistent tagging means that a predicted entity instance is not tagged in the correct Beginning (B)-Inside (I)-Outside (O) format . A wrong entity type means the model gives out the wrong entity type. For example, it mistakes a disease for a drug, or it gives out an inconsistent entity type such as “B-Disease I-Drug I-Disease” for a disease entity. Incomplete span, the most frequently detected problem, means that the model predicts the “O” label for a part of the entity instance. For example, the model outputs a tagging sequence “B-Disease I-Disease I-Disease O O O” for the original sequence “帕金森综合症” (Parkinson disease). The above three problems can also co-occur. Thus, after we obtained the model prediction, we conducted the following adjustments. First, we checked whether the span is complete by checking whether after adding the surrounding words, the entity span is in the dictionary. If so, the longer span is accepted; otherwise, the span is accepted as is. Second, if the entity is in the dictionary, then the entity type suggested by the dictionary is used; otherwise, the entity type given by the model is accepted. If the model gives inconsistent entity types such as “BDisease IDrug IDisease,” the entity type that occurs more frequently in this entity instance is chosen . Finally, the tags are adjusted following the B-I-O format.The objective of property value extraction is to extract the property information corresponding to an entity from the unstructured text. In drug instructions, the properties we focused on mainly included the usage, frequency of administration, dosage, and treatment course, which are different when targeting different diseases or symptoms, or different populations ,21.To solve these problems, property value extraction for drug instructions is usually divided into two parts: property value recognition and property value combination. Property value recognition is used to locate boundaries and determine categories, and property value combination combines property values belonging to the same entity.Different property values require different methods. In addition to the model-based method for indication, the remaining property values are determined by the pattern-based method . The folThe properties of dose, frequency, duration, and population are similar in form and are a combination of numbers and units; thus, similar extraction methods can be used. Taking the dose as an example, the pattern is first used to extract all combinations of numbers and dosage units such as “gram” or “slice,” and then the context keywords are used to retain the combination so that context hit keywords form the property value of dosage. The population property value is considered since a description of the taboo property may exist, such as that the dosage is 2 times a day for children but prohibited for children under 1 year of age. Therefore, interference data should be filtered according to the context keyword (prohibited) instead of the reservation.Usage refers to the administration method of a drug such as “口服” . We developed a set of patterns, which are shown in An “indication” for a drug refers to the use of that drug for treating a disease. For example, diabetes is an indication for insulin. Following the previous section, we employed a BERT-BiLSTM-CRF model with manually designed features for indication detection, and the detected entities were linked to our medical knowledge graph.The property values of the same medication information entity need to be combined. In most cases, all types of property values for the same entity will appear in the same sentence. For a small number of the remaining cases, we aggregated the extracted information via three heuristic rules based on linguistic patterns in the drug instructions as follows: (1) usage, dosage, and duration usually appear at the end; (2) if a property value does not appear in the description of the current entity but appears in the previous entity, the property value is usually the same as the previous entity; (3) if the population changes, the disease, frequency, and duration will also change.Therefore, most of the property values in the same sentence can be directly combined. Otherwise, we manually combined the extracted information to ensure precision and improve performance.Medical relation extraction refers to the semantic relationship between medical entities defined in the medical knowledge graph schema . The maiWe use the DDI relation as an example to demonstrate how to use rules for relation extraction. The relationship between drugs defined in the schema of the medical knowledge graph is divided into three categories: promotion, contraindication, and none (no relationship). Promotion indicates that two drugs can promote the efficacy of each other, contraindication means that two drugs will cause adverse reactions when taken at the same time, and none is no interaction between the two drugs. Some representative examples and patterns are provided in We experimented with a series of models for our relation extraction tasks, including piecewise convolutional neural networks (PCNN) , BiLSTM Knowledge graph fusion can be regarded as an ontology alignment task in our workflow, which has been studied extensively in the literature -30. In tThe previous entity extraction step would introduce the entity mentions that are unknown terms in the existing medical knowledge graph. In this case, one must decide whether an entity mention is a variant of some term in the medical knowledge graph or a new entity, which requires a precise entity normalization system. To build such a system, three difficulties are encountered. First, typos or discrepancies in transliterations may occur in online documents; for example, “唐尿病” is a frequent typo of “糖尿病” (diabetes), akin to diabites (misspelling) and diabetes, and “咪康唑” (miconazole) and “密康唑” (miconazole) are both transliterations of miconazole. Second, some entity mentions look quite alike, but represent quite distinct entities; for example, “ii 型糖尿病” (type 2 diabetes) and “i 型糖尿病” (type 1 diabetes) are quite similar, but they are very different entities. Third, there can be some discrepancies in expressing the same component of an entity name; for example, “手部擦伤” (hand abrasion) can be easily expressed as “手擦伤” (hand abrasion) since “手部” and “手” both mean hand.The above three difficulties make it nontrivial to build a term canonicalization system, and previous systems have not addressed the above issues altogether -33. One To effectively address the above difficulties, we designed a multilevel fine-grained similarity score system. First, on the whole, we built a multilevel string matching algorithm, which we call ZhFuzzyED, considering three levels  so that the similarity score is less sensitive to typos and transliteration differences. Second, diving deeper into the components of entity names, we found that an entity mention such as a disease entity mention usually consists of semantic units such as body structure, negation, degree adverb, some adjective describing the type or stage, and the core term that defines the disease  to enable human-machine cooperation for knowledge graph fusion and knowledge graph quality control. The main design of the app is shown in In this step, when a new entity mention comes in, we first search in the medical knowledge graph  for a possible matched entity and then the candidates are reranked via the above similarity score system. If the best-scored candidate still obtains a low score, the entity mention is considered to be an unknown entity, waiting to be added or corrected manually by experts. Otherwise, it is considered a term for best-scored known entity. This process is equivalent to a cycle of a selflearning process since the new terms added to the medical knowledge graph can improve the accuracy of our workflow at the next round of iteration.In this section, we discuss how to use the medical knowledge graph to conduct automatic FWA detection in claim processing. Given a claim document, in the first step, we need to identify the diagnosis, examinations, and medications in the claims.As the medical entities in a claim are extracted by optical character recognition or from various hospital information systems, these terms may follow different terminologies and may contain errors. Thus, term normalization is the foundation. We first used the aforementioned multilevel string matching algorithm (ZhFuzzyED) to perform term normalization.After the entity mentions in a claim were linked to entities in the medical knowledge graph, we checked the following three suspicious scenarios.Fraud diagnosis is suspected when the disease does not match the indication of treatment. In this condition, the relation between a drug and disease can be used for detecting the mismatch case. There are three types of scenarios: (1) a drug does not have the disease as an indication; (2) the disease is a contraindication of the drug; and (3) no suitable drugs for treating the disease appear in this claim.Excess prescription refers to excessive medical care such as one disease corresponding to many drugs in a claim, which is not medically necessary.Drugs prescribed in a claim have interactions. If the drugs in a visit record have interactions, especially when the interaction is harmful, the claim is considered to be fraudulent.Inferring new facts from existing knowledge graphs is a form of an explainable reasoning process. The above scenarios could not be directly queried from the medical knowledge graph. Therefore, further reasoning on queries is required. Multihop knowledge graph reasoning was applied for our FWA detection. The graph reasoning rules are shown in For example, as shown in Our NER corpus was drawn from drug descriptions, encyclopedia pages for medical entities, and the literature so that the model trained can adapt to different scenarios. We prioritized documents that are related to entities that are common or medically important, which were split into 10,889 sentences. The annotation process followed the majority voting rule; that is, if two annotators did not agree on the annotation of the same sentence, then a senior annotator, who is a more experienced medical practitioner, made the final annotation. To save labor costs, our annotation is carried out in an active learning fashion as introduced by Chen et al . For exaThe relation extraction dataset was built on the same corpus. The preannotation takes advantage of the technique of distant supervision in addition to active learning . DistantThe annotated dataset was split into 8:2 training:test datasets. We compared three kinds of NER models: the deep-learning model only, the model with hand-crafted features, and the model with hand-crafted features and manually designed rules. Detailed results on the test set are shown in The annotated dataset was split into 8:2 training:test sets. For relation extraction, we conducted experiments to evaluate the effectiveness of the three models and report the performances on the test set in Finally, we built a medical knowledge graph that includes 1,616,549 nodes and 5,963,444 edges. To make it easier to explore the graph, we developed a web app to support the browsing on our medical knowledge graph on a website , which iWe collaborated with the insurance company in our PingAn group and obtained 214,107 claim documents. Every claim document contains a list of diagnoses (1.5 diagnoses on average) and a list of drugs (2.3 drugs on average). There are 2586 unique ICD-10 codes and 5307 unique common drug names in these claim documents. More information is shown in In the following, we report the performance of each step in the FWA detection process.As described above, the first step in FWA detection is to link the diagnosis and medications to the entities in our medical knowledge graph. Our proposed multilevel string matching algorithm ZhFuzzyED achieved 0.861 accuracy in linking the diagnosis to the ICD-10 coding system and 0.902 accuracy for drug normalization.For claim processing, 10% of claims are typically rejected for various reasons. The clinical unreasonable problem is only one of the reasons for rejection. We randomly selected 100 rejected claim documents and let the insurance inspector manually label the type of the rejected reasons. We then applied our proposed FWA detection method to identify the three types of frauds as described above. Our method could help detect around 70% of these events. This result is much better than the existing method that relies on only a human to check part of the claims randomly. Therefore, the existing method requires investing many professionals and spending a substantial amount of time to check each claim one by one.In this paper, we have proposed an automatic method to extract information from medical knowledge to build a medical knowledge graph specifically for FWA detection. First, our NER results showed that by integrating the hand-crafted features with the embeddings helps to improve the accuracy of medical entity recognition. In addition, when the domain-specific rules were added, the performance could be further improved as shown in Second, for medical relation extraction, the PCNN+AT model showed better performance as compared to CNN or PCNN. Third, we constructed a high-quality medical knowledge graph, including 1,616,549 nodes and 5,963,444 edges. Finally, we designed the rules on top of the medical knowledge graph to detect three kinds of FWAs in claim processing. The experimental results showed that our approach helps to detect 70% of these FWA events automatically. The medical knowledge graph–based method provided good interpretability of the results. The reasoning process on the medical knowledge graph can help the insurance inspector to quickly determine whether the claim should be rejected, which will contribute to substantial savings in the claim processing cost. Our system has already been deployed as a service to generate alerts of suspected claims for insurance inspectors within our PingAn group.Our medical knowledge graph and proposed rules could detect three kinds of FWA issues. However, there are still other types of FWA events such as medication overdose and medications that are not suitable for the population. Therefore, we need to integrate more information into our medical knowledge graph and design more rules to detect more types of FWA problems. In addition, our method still missed some FWA events. This is because we failed to extract some drug categories from the drug labels. Therefore, we need to further improve the recall of our information extraction method.In this study, we examined the effectiveness of building a medical knowledge graph to enhance FWA detection on claim data. Our method can help insurance inspectors to identify insurance claims worthy of attention from thousands of documents and ultimately reduce Medicare and Medicaid spending.


Obstetric fistulas are one of the most tragic injuries that occur after difficult, prolonged childbirth without timely intervention. These fistulas cause discomfort to patients and result in emotional, social, and even physical suffering. The present study aimed to explore the experiences of women with rectovaginal fistula in Kamyaran city, in Kurdestan province, west of Iran.In a phenomenological study, 16 patients, healthcare personnel, and patients’ families were investigated. Purposive sampling was performed and Study participants were interviewed in-depth semi-structured interviews. All interviews were audio-recorded, transcribed verbatim (word by word), and analyzed by Colaizzi’s method. For determining the validity of the study, Lincoln and Guba’s criteria, which include credibility, dependability, transferability, and confirmability, were considered.Five general themes and 10 sub-themes emerged after investigating interviews. Themes include religious harassment the sub-theme of being defiled), fail , consequence , and ultimately panic .The rectovaginal fistula is a complex and multifaceted problem with social, individual, familial, religious, and ethnic-environmental dimensions, so there is no simple solution to interact with this problem and there is a need to find a solution, considering the dimensions of the problem and plan for help these patients cope with their disease, and take steps to fully treat it. Maternal health refers to the health of mothers during pregnancy, childbirth, and postpartum childbirth. Each mother who wishes to have a baby, wants to have safe childbirth, care, and support during and after childbirth . ObstetrThe present study was conducted in the first 8 months of 2019. The timing of this problem in women has not been determined, but women in the study have reported problems for more than 5 months. When the study was approved by Kermanshah University of Medical Sciences Ethics Committee, 16 patients, healthcare personnel, and patients’ families were investigated using a descriptive phenomenology and Colaizzi’s method. This method allows the researcher to express the meaning and nature of phenomena in their language and to explore their understanding of the phenomenon. In this approach, the perception of each person is considered as a unique person, but the sum of them contributes to achieving a better understanding of the phenomenon.Purposive sampling was performed on 16 participants, including 14 patients, one midwife, and one family member (mother) in Kamyaran (western Iran). Study participants were coordinated for interviewing after obtaining written informed consent at their preferred location (often a clinic consultation room). Participants have known samples of rectovaginal fistula who referred to the clinic for follow-up treatment, could speak Persian or Kurdish Languages, and completed the consent form. The sample size was determined based on data saturation criteria so sampling continued until data saturation and the emergence of no new code . The preWhat is your experience with living with a rectovaginal fistula?What does a rectovaginal fistula mean to you?What is your understanding of living with a rectovaginal fistula?How others  reach your illness)?How do you cope with the rectovaginal fistula?The in-depth semi-structured interviews were used to collect data. In-depth interview used to explore and clarify the meaning of phenomena under study. The order of questions were related to participants’ responses . Before It should be noted that all patients spoke Kurdish.All interviews were audio-recorded, transcribed verbatim (word by word), and translated to English, where applicable. Pseudonyms were used to maintain anonymity. Data analysis was guided by that described by Colaizzi’s method. Two researchers examined all transcripts for accuracy and completeness against the original notes before data was ready for coding.The Colaizzi’s seven steps were followed step by step. They included: familiarizing, identifying significant statements, formulating meanings, clustering themes, developing an exhaustive description, producing the fundamental structure, and seeking verification of the fundamental structure . FinallyA total of 14 patients with rectovaginal fistula participated in the study, and the mother of one patient and one treatment staff (master of obstetrics) were interviewed to ensure maximum variability. Most participants had a low educational level, and all were housewives. The most important cause was difficult childbirth and sex. The age range was between 24 to 71 years , fail , consequence , and ultimately panic .“... Only since I have no control over my urine, defecation and, gas, my Wuzoo doesn’t remain intact for a long time. While I’m praying, I’m always afraid that it breaks my prayer....” (Participant 3).One of the main themes was the religious harassment theme. Study participants had difficulty performing their religious duties due to their illness, so they blamed themselves religiously and were not prepared to perform religious activities.Or they were afraid of polluting religious sites. “I do not go to the mosque because I am afraid to defile the mosque” (participant 11).Another important theme was to fail, which included two sub-themes of loss and negative attitude. Study participants often regarded the illness as the loss of everything and saw the future as bleak.“It’s very bad to be suffering from the filthiest thing. I am very angry in front of my eyes woe betide others and I pray that it will be treated” (Participant 13).In this regard, one participant said, “To be honest, the disease destroyed my life... let alone lacking control over your urine, defecation, and gas” (Participant 2).Some participants also regarded the disease as an unpleasant experience and were sometimes desperate. “I have nothing to say but well everything to me was contrary to my dreams and wishes up to this point. Only the first few years of my life were good and financial problems would not allow me to touch happiness at that time, but I wish people did not have all the pain at the same time” (Participant 5).“Well, the relationship is a two-way thing, and I must be content with it, but (he) always does its job and doesn’t care about anything” (Participant 7).“Both my husband and I hate sex” (Participant 9).“In the early course of the disease, as soon as my husband suggested me to have sex, I said that I’m on my period and have spots, and then I fought with him without planning. Now I have no sex with him once a month” (Participant 14).Another main theme of this study was disrupted sex. Participants were sometimes dissatisfied with their sex, and sometimes escaping it.“But my husband mocked me for expelling gas during sleeping a couple of times” (Participant 1).“I’m so embarrassed to fart, especially my children are boys” (Participant 6).“What can I say to my family, it’s hard for me to explain a bit” (Participant 4).“I’m not always worried that my daughter or my son will notice this” (Participant 2).Another main theme referred to by participants was panic and fear. Constant humiliation, secrecy, and fear are part of their lives. They always think no to be humiliated and ridiculed, and their name dragged through the mud because of the current situation.Another main theme of this study was the consequence. The consequence of this complication for patients in this study was isolation, sleep disturbances, and mental crises. Patients often fall asleep later than others, lest they expel gas at bedtime, in addition to being a light sleeper so that I can manage defecation if it happens. The consequences of the disease often made them nervous and were in a state of mental crisis. On the other hand, these patients have cut family relationships and have often been isolated.“At night, I always let my husband sleep, then I sleep, and I sleep after making sure he has slept” (Participant 1).“I try to control as far as I can, but I’m not satisfied. I’m tired of every single second of my life” (Participant 12).“I especially have to stay in the bathroom for a long time and get angry” (Participant 7).“And I always try to squeeze my legs if I’m standing next to somebody. Interestingly, the pressure continues until it’s expelled” (Participant 4).“I reached the stage between hope and hopelessness” (Participant 1).“It has a big impact on my commuting. I used to go to the village for a week and stayed at my mom’s house, but I don’t want to go now, and I feel like I’m in touch less frequently” (Participant 10).“But I’m scared to be in the public, and that fear has caused me living in a small family facing some difficulty in daily commute” (Participant 8).The results showed that the study participants were religiously harassed, are always in a state of fear and anxiety, and in addition to suffering from disrupted sexual health, reached a stage of despair and helplessness, and the disease consequences led them to isolation and mental crisis. Similar studies in different cultures have had similar narratives.Women with rectovaginal fistula are unable to express themselves. They are in different Ethno- Religious conditions because they feel ashamed and have been suffering from this problem for many years.Religious harassment was caused by disease interfering with the practice of religion, and unlike the Boscaglia’s study, which regarded religion and spirituality as a solution to women’s disease management , the disReligion has a positive effect on emotions, hence it is used for managing diseases and coping with stress. Religion provides ways to conduct people’s lifestyles and communicate in social groups. If they follow religion rules, its’ consequences would reduce stress and vice versa can increase strain. Religious beliefs may cause desertion from familial problems as a result of involving in religious activities .Sexual dysfunction in patients with fistula is a major concern and has been discussed in various studies, although the present study emphasized sexual dissatisfaction, pointed to escaping sex, and having stress during intercourse. In another study, escaping sex is called fear of the future lacking a partner, not getting married, and not getting pregnant were among concerns of the patients . Lack ofPatients with fistulas often think that their lives have come to an end and regard it as a failure. Having a negative attitude and feeling worthless bother them. The combination of the constant presence of problem and loss of role leads to feelings of worthlessness , and womPatients were in constant fear, and none of the patients in the present study disclosed their disease to non-family members and found it necessary to keep it a secret, which has been confirmed by various studies. This has led to psychological consequences in these patients , 30, 31.Although this phenomenological study seeks to explore the meaning of the phenomenon from the participants’ point of view, variables such as the cause of fistula formation, and social life require more attention. Marriage at an early age, especially in rural areas and lack of proper sexual education, exposes young girls to the rectovaginal fistula.Women getting married at early ages is related to several factors and can deprive them from achieving proper education, attaining a suitable job, and engaging in social relationships or activities , 33.Another cause of rectovaginal fistula is lengthy labour. Over 85% of rectovaginal fistula cases are caused by lengthy obstructed labour in developing countries. A rectovaginal fistula is attributed to obstructed and/or prolonged labour coupled with poor health-seeking behaviours, poor health referral systems, lack of awareness, poor transportation systems, lack of skillful birth attendants, and insufficient obstetric care services. As a result, the survivors of these complications may develop Rectovaginal fistula , 34.Sexuality is an important component of women’s overall well-being, with quality of life and sexual dysfunction contributing to personal and interpersonal stress; this could be especially important for women with genital tract injuries from either obstetric trauma or surgical interventions as one of the major causes of rectovaginal fistula . Given tBased on the causes of the rectovaginal fistula, steps can be taken to prevent the status. Hence, there are numerous causes for it, so it is possible to improve the situation with a comprehensive approach. This approach include taking place laws for marriage age over 18 years of old, sexual education for girls, better access to health facilities, surgery by expert and skillful midwife, improved referral system and improve access to the health care system.The rectovaginal fistula is a complex and multifaceted problem with social, individual, familial, religious, and ethnic-environmental dimensions, so there is no simple solution to interact with this problem and there is a need to find a solution, considering the dimensions of the problem and plan for help these patients cope with their disease, and take steps to fully treat it. Moreover, we should pay attention to the risk factor of this disorder and prevent early marriage while improving health facilities to prevent problems.


Into the World: The Movement of Patočka’s Phenomenology (Springer 2019) offers an important contribution to the debate and a long-awaited critical presentation of Patočka’s asubjective phenomenology as well as creative re-reading of Patočka's central doctrine of the movements of existence.The studies of the Czech phenomenologist Jan Patočka (1907–1977) has been flourishing recently. Martin Ritter’s book  Dasein. In this respect, Patočka struggles with a number of concepts throughout his professional career, beginning with inwardness (nitro) and life, later replaced by a phenomenological re-conceptualization of the Platonic Idea, and later still re-considered in relation to the world and the body, and finally arriving at a phenomenological-existentialist reinterpretation of the Aristotelian movement. In his critical-constructive engagement with Patočka, Ritter takes the movement of existence as the central and most promising part of Patočka’s phenomenological corpus as it is the concept which enables the overcoming of both subjectivism and objectivism; or, to use Ritter’s vocabulary, to materialize the intertwining between the objective and the spiritual.Recent years have been rich with studies of the Czech phenomenologist Jan Patočka 1907–1977). The past year alone has seen the publication of four monographs, each of which deals with Patočka’s thought from a different angle: a phenomenological reading is offered by Chiara Pesaresi,907–1977.Heretical Essays in the Philosophy of History offers a novel perspective on reading Patočka’s apparently varied and unsystematic body of work. Ritter’s interpretation complements that of Paul Ricoeur, who finds the twin foci of Patočka in his philosophy of history and the problem of the natural world. Ritter identifies the core of Patočka’s interest in the concept of life, or existence, which leads the Czech phenomenologist into his development of an a-subjective phenomenology, in which, nonetheless, the subject is certainly still present. The question is, “How does the subject come to itself?” Patočka is satisfied, Ritter suggests, neither with Husserl’s transcendentalism nor with Heidegger’s being-thrown-in-the-world without really moving in the world and explores the interaction of the subject with a phenomenal field that is not dependent on that subject.The device of following Patočka from the early years of his dissertation on the notion of evidence and his habilitation on the natural world, through the project of Negative Platonism, to mature writings such as The first part of Ritter’s book therefore serves as an introduction not only to Patočka, something previously missing in English, but also to a-subjective phenomenology. Nonetheless, it is the second part of the book, which scrupulously elaborates on the movement of existence, which I find worthy of special attention and further debate. Patočka’s doctrine recognizes the three movements of acceptance, defence, and transcendence, the last of which functions as the fully authentic movement and the completion of the previous two and transcends the sphere of the mere preservation of life.Körper over the Leib. Along the lines of Findlay’s research on Patočka,Ritter introduces the problem through the dialectic between the body and the soul. Against the ontogenetical reading that the body gives rise to subjectivity , Ritter interprets the body as the objective bearer of subjectivity, and thus gives preference to the objective processes in their, paradoxically, non-objective conditioning of appearing” (p. 131). If I understand correctly, Ritter is suggesting that these trans-subjective conditions through which the subject realizes itself may be the concepts of cultural techniques in media philosophy. This should, Ritter argues, allow for conceiving existence in terms of the decentred subject and at the same time soften Patočka’s harsh comments on the objectification of existence, although these should be understood in their proper context. Is this a way forward in unfolding the possibilities of a-subjective phenomenology? Time, perhaps, will tell. I believe Ritter’s turn to media philosophy is potentially helpful, but it appears in rather a random section of the book, well-structured but lacking in content, and especially lacking any explanation as to how the spiritual aspect of existence—the aspect that most interests Patočka—relates to technique as the medium of existence.I applaud Ritter for attempting to present a more balanced view, one which considers finitude, the objective body, and the performance of existence in the world while not losing Patočka’s own argument concerning a-subjectivity. In this respect, Ritter confirms the intuition of contemporary phenomenology  that phenomenological reflection has its limits and brings media philosophy into play in order to enrich it. This connection, however original and oft repeated it may be, remains somewhat vague. The goal is “to disclose, and elucidate, some polemos of being in the world. For Patočka, the world is in crisis because care for the soul, which also implies care for the polis, is replaced and even suppressed by the rule of Force (Gestell), that is, the objective manipulation of being, the subject, and relations. On the individual level, (self-)sacrifice breaks with this logic. Ritter is nevertheless more interested in the inter-subjective way of dealing with the crisis, namely Patočka’s ambiguous category of the solidarity of the shaken. One may expect Ritter to venture into political philosophy at this point, but he does not; rather, and this is to be welcomed, he patiently analyses the existential aspect: “What is it, actually, that ‘the shaken’ … have in common?” (p. 154) His answer suggests that shaken-ness is a general experience lived through the singularity of every human being. Chaos, meaninglessness, uncertainty, in a word, finitude, is always my finitude, although it is also a common experience between you and me. This negative affection, as Ritter calls it, shared inter-subjectively, has the potential to create the spiritual force of critical consciousness. Questions remain, however: Does Patočka’s thought offer more than warnings and prohibitions? Can shaken-ness serve as the foundation for something positive which bestows meaning?The argument in the final three chapters is much more coherent. Here Ritter develops the theme of “shaken” existence in the world and offers a constructive proposal for understanding existence and living through the ontological In providing an answer, Ritter returns to Patočka’s movements of existence and argues again against their division, or, more precisely, against the elevation of the third, historical movement at the expense of the other two, which Patočka deems a-historical. For Ritter, being rooted physically in the world and defending life in its everyday needs must be taken both positively and historically. Patočka is perhaps right to suggest that we need to go through the nihil to understand “what is going on in history.” Ritter adds, however, and rightly in my opinion, that this is only the first word, not the last.Omnia vincit amor, the title of the final chapter, suggests the direction Ritter will take in answering the question of how to think with Patočka beyond Patočka. Love is the way, perhaps the only viable way, to accept, defend and also transcend finite life without exiting the world and life as such: “One must seek to realize the infinite through accepting one’s own finitude” (p. 174). Love is inter-subjectivity, embodied and lived and happening between you and I. Love performs self-transcendence towards the other. Love establishes the kingdom of God among us and transcends the need to search for the “trans-human and singularly non-existent” (p. 177). Ritter suggests that ultimately Patočka falls prey to extra-terrestrial escapism, although paradoxically it is Patočka’s notion of the transubstantiation of life, of yielding unconditionally to others, which allows Ritter to argue against him. In short, Ritter is suggesting that love does not withdraw us from the world but transforms our being in the world.into the world. The question remains, however, is this apologia pro philosophia—the defence of human, all too human—vis-a-vis both Patočka’s thought and theological thought necessary? Is all theology looking for an extra-worldly solution to worldly—finite—existence? It seems as if there have been only bad theological responses to good philosophical questions. Who is responsible for this impasse reflected in the final pages of Ritter’s book? Theologians, for pretending to adopt the task of thinking while tacitly presupposing the answer before the questions are even asked? Or philosophers, who know about the poverty of much theology but pretend to know nothing about the kenotic tone of theological poverty? Perhaps we can, in fact, turn to Patočka for a two-fold lesson: That we must walk eternally on earth; but this does not prevent us from “touching the stars,” as Patočka writes in his very first published essay on theology and philosophy in 1929. The challenge applies both to theologians and to philosophers, who must alike embrace love as something which shows us, as Ritter touchingly writes, “that there is no greater thing than life” (p. 182).Ritter’s criticism of the theology in Patočka and of using Patočka’s phenomenological philosophy for theological ends is clear. His sudden recourse to Feuerbach in the final chapter should strengthen his rethinking existence in terms of diving


Journal of Autism and Developmental Disorders, 50(2), 691–693], we argue that the use of language in autism research has material consequences for autistic people including stigmatisation, dehumanisation, and violence. Further, that the debate in the use of person-first language versus identity-first language should centre first and foremost on the needs, autonomy, and rights of autistic people, so in to preserve their rights to self-determination. Lastly, we provide directions for future research.In response to Vivanti’s ‘Ask The Editor…’ paper [ In this article, we expand on the conversation regarding the use of person first language (PFL), and identity first language (IFL), by responding to the editorial by Vivanti . VivantiIn his ‘Ask the Editor’ piece, Vivanti  providesWe would first like to commend Vivanti for the positive contributions of his editorial. The very fact that the Journal of Autism and Developmental Disorders is addressing this sometimes-perplexing issue is most welcome. Above all, we were especially glad to see Vivanti recognise the real-world implications of language choice: how it can ‘influence societal perceptions, public policy, clinical practice and research directions’ Vivanti : 1. Lateliterature, regarding the most preferred language from autistic people—as alluded to by Vivanti  involves the noun (“person”) followed by “with + noun” (here: “autism”). Other nouns (or noun phrases) that may be substituted in the second position for “autism” include those such as “cancer”, “liver disease”, “a headache”, “Covid-19”, etc. This is common formulation used to signify the presence of some kind of pathology or illness. In the second case (“person on the spectrum/autism spectrum”) represents a far less common formula, and as such already carries fewer connotations. However, the “…on the spectrum” can be substituted with prepositional phrases such as “on the cricket team”, “on the engineering course”, or “on holiday”, etc. These substitutions all denote position of some sort and provide a means of both locating the subject (the “person”) and identifying them as a member of a smaller group of people (i.e. the members of the category “person” is far greater than those belonging to the category of “person on the forecourt”).where such a compromise is necessitated. In doing so, we reject the assertion by Vivanti that it is too early to reject PFL, if he means the continued use of “person with autism” because a not insubstantial body of literature is showing that this is both least preferred and most offensive, and there are more preferred, and less offensive alternatives available.We agree with Bottema-Beutel et al. : 3, thatAutism is both a “real” phenomenon, and constituted from social meaning, culture, language, and common understanding  is considered as an appropriate expression of this cultural shift [to a neurodiversity perspective] by many self-advocates and scholars, as it counteracts the risk that separating the individual from the diagnosis (as in the expression “person with autism”) perpetuates the societal view that something is wrong about the diagnosis, potentially leading to an internalization of inferiority for those who receive the diagnosis.Again, when returning to the discussion of appropriate language, Vivanti : 1 explaparadigmatic one  has similarly moved towards a legal understanding of vulnerability that moves away from it being an inherent condition  still implies vulnerability is linked to specific functional markers rather than social context. The term ‘minimally verbal’ is, itself, one that has a basis in linguistics research, such as that of Tager-Flusberg and Kasari . HoweverThe harm caused by stereotypes is addressed in Kenny  and is amore able (which is conflated with being less autistic). Instead of dismissing current testimony, we believe that the lack of representative evidence that involves a full spectrum of autistic people should be addressed by research approaches which are participatory or consensus building , but do not share agreement with his solutions. Researchers, practitioners, and clinicians discounting narratives of minorities in favour privileging their own perspectives is a danger often seen in minority-based work McKinnon  and disaThe participatory approach used by Nicolaidis et al.  indicatealways communicate verbally. Further, researchers often categorise a heterogenous group of autistic people together based on the perception of one function-normative verbal communication. Yet 75% of autistic children with co-occurring situational mutism do not have learning disabilities . Research could focus on the linguistic nuance in interpretation and meaning making of these formulations. What is arguably most important in these directions for future research is that it remains person centred. That is, research and practice are framed around the needs, wishes, and experiences of autistic individuals most particularly. Directions in how we talk about autism in research ought to follow the guidance of autistic people themselves. In the meantime, while further research is needed, it should certainly be heeded that the autistic community does not tend to favour “with autism”.Further research should also aim to understand identity first and PFL with more nuance—including There will not always be consensus on what autism is or how we should talk about autistic people—even among autistic people ourselves—but to ignore those autistic voices that have broken through into the academy lest they not be representative of every single autistic person is short-sighted. Linguistic framing, including the use of PFL, has material consequences for the autistic community, especially those who are non-speaking. The priority of research should be to centre autistic people  in the conversation around the language used to describe autism and autistic people. If current studies are not representative enough of the entire autistic population the solution is to conduct more research. We would urge Vivanti and contributors to the Journal of Autism and Developmental Disorders to engage more fully with critical autism studies and other autistic academic voices on all matters of autism research for the mutual benefit of the both the autistic and the research communities.


The consequences of delays in travel of pregnant women to reach facilities in emergency situations are well documented in literature. However, their decision-making and actual experiences of travel to health facilities when requiring emergency obstetric care (EmOC) remains a ‘black box’ of many unknowns to the health system, more so in megacities of low- and middle-income countries which are fraught with wide inequalities.This in-depth study on travel of pregnant women in Africa’s largest megacity, Lagos, is based on interviews conducted between September 2019 and January 2020 with 47 women and 11 of their relatives who presented at comprehensive EmOC facilities in situations of emergency, requiring some EmOC services. Following familiarisation, coding, and searching for patterns, the data was analysed for emerging themes.Despite recognising danger signs, pregnant women are often faced with conundrums on “when”, “where” and “how” to reach EmOC facilities. While the decision-making process is a shared activity amongst all women, the available choices vary depending on socio-economic status. Women preferred to travel to facilities deemed to have “nicer” health workers, even if these were farther from home. Reported travel time was between 5 and 240 min in daytime and 5–40 min at night. Many women reported facing remarkably similar travel experiences, with varied challenges faced in the daytime (traffic congestion) compared to night-time (security concerns and scarcity of public transportation). This was irrespective of their age, socio-economic background, or obstetric history. However, the extent to which this experience impacted on their ability to reach facilities depended on their agency and support systems. Travel experience was better if they had a personal vehicle for travel at night, support of relatives or direct/indirect connections with senior health workers at comprehensive EmOC facilities. Referral barriers between facilities further prolonged delays and increased cost of travel for many women.If the goal, to leave no one behind, remains a priority, in addition to other health systems strengthening interventions, referral systems need to be improved. Advocacy on policies to encourage women to utilise nearby functional facilities when in situations of emergency and private sector partnerships should be explored. Many pregnant women in sub-Saharan Africa experience huge challenges in accessing critical maternal health services when in situations of emergency. The challenges of accessing these critical services, otherwise known as emergency obstetric care, is even greater in highly populated cities like Lagos. In this study, we interviewed 47 pregnant women who presented at public hospitals in emergency situations, and 11 of their relatives, to understand their decision-making processes and experiences in such situations.We found that pregnant women mostly recognise pregnancy danger signs. However, they are often faced with conundrums on “when”, “where” and “how” to reach the hospital in an emergency. While the decision-making process is a shared activity amongst all women, the available options vary depending on their socio-economic status. Women preferred to travel to facilities deemed to have “nicer” health workers, even if these were farther from home. Reported travel time varied in daytime and at night. Many women reported facing remarkably similar travel experiences, with varied challenges faced in the daytime (traffic congestion) compared to night-time (security concerns and scarcity of public transportation). However, the extent to which this experience impacted on their ability to reach facilities depended on their capacity to make their own choices and support systems around them. Referral barriers between facilities further prolonged delays and increased cost of travel for many women.We concluded that reaching hospitals in emergency situations should not be left to chance. Deliberate efforts to empower women and strengthen hospital referrals will make a difference.Despite a 29% reduction in global maternal deaths from 1990 to 2015, maternal mortality remains a global health challenge, with about 280,000 women dying every year due to complications of pregnancy and childbirth . EmOC, aDelays in decision-making to seek care (first delay), travel to reach health facilities (second delay), and provision of appropriate care upon arrival at the facility (third delay) impede EmOC access and have long been associated with increased risk for maternal deaths . This thPregnant women in emergency situations may experience a complicated travel path to reach health facilities . This joIn SSA, two cities - Kinshasa, Democratic Republic of Congo and Lagos, Nigeria have emerged as megacities with population estimates of 12 and 21 million respectively . HoweverLagos State is the economic nerve centre of Nigeria and arguably the most industrialised part of the country. It is divided into 20 Local Government Areas (LGA). The coastal state has a mix of remote and built-up areas, metropolis and slums, land and riverine areas with a variety of travel options including road, water and rail. The most popular mode of travel is by road.As per the most recent National Demographic and Health Survey, in Lagos 77% of women deliver in health facilities . The staAll 24 government-owned  health facilities with capacity to provide CEmOC in Lagos were eligible to participate in this study . We verified these characteristics by reviewing case notes of the women along with the medical team before approaching them. We borrowed insights from studies conducted in Nigeria to classify women into low, medium or high SES, considering their level of education, employment status and family monthly income , 27. OurYoruba and Pidgin English), conducted the in-depth interviews (IDI). We employed IDIs for data collection as they are ideal for preserving confidentiality, especially for a sensitive and emotive issue as the one explored in our research and also allowed a robust exploration of each woman’s experience  means I am expecting a problem. I know that women can have emergencies in pregnancy, but I know my own cannot be like that. God knows why this one happened”. However, irrespective of age, SES, or parity, women generally acknowledged that they recognised symptoms such as sharp abdominal pain, bleeding, severe headache, fever, not feeling foetal movements, or appearance of foetal parts from the introitus as symptoms that meant they needed to get help. While those who had attended ante-natal clinic in some health facility (public or private) appeared to have a better sense of urgency, those who had not registered in a hospital before they found themselves in emergency situations (i.e. un-booked women) appeared slower in making the decision to travel to a facility. One relative of an un-booked woman said:“On her arrival, first day, second day, she told me to give her a cloth. I asked why and she said she was seeing something that looked like her menses coming from her vagina … On the third day, we were waiting by the roadside... she just suddenly saw blood and then she alerted me. So, I said she should go inside the house into the bathroom while I go get some water for her. Before I got back to her, the paint bucket that she sat on was filled with blood. Then she said she was feeling dizzy. So, I told her to allow me quickly purchase milk for her. Before I got back, she had already fainted. I thank God, after we poured water on her, screamed her name and also by the help of God, she regained consciousness (Sighs!) Then I started shouting, “Where is a hospital? Where do I take her to”? … ”. Relative (Sister) of 30-year-old woman, low SES, multipara, spontaneous abortion that had been managed by a traditional birth attendant out-of-state and now presented in the hospital with profuse bleeding [Facility M ].Women in our study did not typically make travel plans for emergencies that could occur in pregnancy before they found themselves in situations of emergency, irrespective of their ante-natal clinic attendance. Most of the reported lack of preparation for an emergency was founded on religious beliefs. One 30-year-old, middle SES, primiparous woman, who presented with increased blood pressure at Facility W  said, “I was at home and I was having severe pains from about 2 a.m. that morning. I woke my husband up immediately, but because of our concerns with safety at that time, we decided to leave for the hospital later at about 6 a.m. … ” 29-year-old, medium SES, multipara, with bleeding and abdominal pain [Facility H ]“However, if the emergency occurred late at night, or there were concerns about security and safety on the roads, some women who recognised that they were in an emergency situation needing facility-based care waited till daybreak to commence their journeys. Women who reported waiting till morning were typically those in early pregnancy (first trimester). However, despite safety concerns, women in later stages of pregnancy (second and third trimesters) reported being more focused on the need to be delivered of the baby than being concerned about security.My husband was saying it is too late and it would not be safe for us to be on the road. But as a pregnant woman, when you are in labour, you are not thinking about anything. You just want them to remove the thing [the baby]”. 33-year-old, high SES, multipara, labour not progressing [Facility H ]“we had to go pick my mother-in-law at [her place] before we started coming to this place [hospital]”. Similarly, another 33-year-old, low SES, multipara, presenting with heavy bleeding [Facility T ] said, “Before I came, I went to market to buy a few things that I thought I needed [in the hospital], before coming here [the hospital]. When I got here, they said they can never let me go, that my BP [blood pressure] was so high at 250 plus [systolic pressure]”.The choice on when to commence travel did not appear to be influenced by which facility they intended to visit or where it was located. However, there were a few women who knew that they were in an emergency situation but decided to make stopovers along the way to pick up “experienced”, “needed” or “helpful” relatives like mothers and mothers-in-law or go for shopping for items needed for their hospital admission. The choice to do this did not appear to be dependent on SES or parity. A 28-year-old, medium SES, multipara, who presented with prolonged labour said, “My sister had a baby here and she recommended it … So, I did not mind registering here. Secondly, this place is near to my house, so just in case something happened, I can quickly get here. And you see, I needed it”. However, for many women in our sample, perception trumped proximity. For such women, the negative perceptions that they had of specific facilities prevented them from attempting to travel to nearer facilities in situations of emergency. A 24-year-old, middle SES, primiparous who presented with high blood pressure in pregnancy [Facility B ] said, “[Facility D ] was closer to me, but I heard that they exchange people’s babies when they are born … So, me I said, I am not going there”. A positive perception made women in situations of emergency travel further because another facility was deemed to “be better”, “provide good care”, or as having “caring staff”. The case for going to a farther hospital was reinforced when influential relatives (husbands and mothers-in-law) or associates (leaders in religious organisations) recommend those facilities. One 25-year-old, low SES, primiparous, bleeding and abdominal pains [Facility U ] said, “It was my mother-in-law that suggested that we use this hospital. She told me that is the hospital she uses, and other relatives also deliver here. And that I will receive good care”. When probed further, we found that there were three closer facilities that were alternatives to her. Another woman said:It was my husband and brother that brought me here … we passed some [three] hospitals before we got here, but everyone knows that the people here are very caring”. 33-year-old, high SES, multipara, feeling faint and sharp upper abdominal pain [Facility J ]“For the decision on where to go in situations of emergency, women reported that several factors were considered. For some women, the decision on where to go in situations of emergency was made a priori based on the CEmOC facility where they received antenatal care (ANC). For such women, their choice of facility was principally based on proximity as well as community or a relative’s perception of the facility. One 29-year-old, medium SES, primipara, who presented with bleeding as a result of an ectopic pregnancy [Facility Y ] noted that, “My husband and I agreed that I should do my antenatal at [Facility E ]. But when my husband called his boss that night, he advised that we are better going to [Facility I]. He knew the ògá [i.e. medical director] there, and he will call them, so that we get the necessary care.” 27-year-old, high SES, multipara, not feeling baby movement [Facility I ]“Health insurance coverage in specific facilities was an additional reason given by women in deciding where to go. One 32-year-old, medium SES, multiparous, who presented with dizziness and was managed for pre-eclampsia, lost her baby while going to a more distant facility where her health insurance would be accepted. In addition, women talked about having connections (i.e. privileged access) to senior health workers in the facility as a deciding factor. In fact, pregnant women in situations of emergency reported altering their initial choice of where to go while in transit based on advice received from influential people. The underlying motivation appeared to be the reassurance that they would receive the emergency care that they needed urgently upon their arrival at the facility. Use of connections was particularly reported amongst high and medium SES women. In a respondent’s words:“I prefer kękę, it is safer than okada. You know it is emergency. So, with kękę, at least there is cover, because someone can still fall from okada, while dizzy”.Women in our study did not report their ‘how to travel’ i.e. mode of transportation as a matter of choice; it was a given based on availability. For those who owned cars, this was used in all instances. Some who did not have their own cars relied on partners to first make a trip to loan a car from relatives or friends or to hail a taxi through mobile apps, direct calls to known taxi drivers or through roadside taxis. However, for those who could not access any of the aforementioned means, the next two popular options were public “kękę”  and “okada” , with general preference for the former. A 26-year-old, low SES, primipara, who presented with high blood pressure and severe headache [Facility O] said, The only way to come here was to first take boat to the other side and then take kękę from there. We don’t have hospital on our side. My husband has his own boat that he uses for fishing. So, with the help of his brother, they brought me to this hospital … ”. 32-year-old, low SES, multipara, with fever and not feeling foetal movement [Facility F ].“However, for some who live in riverine areas, the sole mode of transportation was by boat - either one that they owned or one that was used by the public. Nevertheless, this mode of transport still needed to be combined with land travel to reach facilities in situations of emergency.Normally that journey will take maybe 20 minutes, because it is a highway, but my husband said it took us over 45 minutes … It is under construction at the moment”.The deplorable conditions of the roads only further prolonged travel. One 23-year-old, low SES, primiparous woman who presented at a facility located in a non-slum town with raised blood pressure [Facility F ] said that, “I took taxi... I was worried when I was being transported on the roads. There were so many potholes. I was just holding myself. Even though it was just a short journey, maybe like six minutes, from my house to the hospital. But I felt like I was going to die.” 39-year-old, low SES, multiparous, obstructed labour [Facility B ]“Another woman who travelled to reach a facility in a suburb, slum area said:… This was now after 11 p.m. When the doctor came, he said they could not handle it and then referred me to this hospital. We looked for kękę, we couldn’t find. When we finally found one, we got on the road but there were so many policemen on the road stopping us. Though they let us go when they saw me. We got here at about 1 a.m. the next morning. The gate was locked, but when my husband knocked, they let us enter. Thank God for my life. I could have died. It is the water that poured, the container did not break”. 37-year-old, low SES, multipara, with a footling breech [Facility B ]“ Women who travelled at night in towns and suburbs reported difficulty in finding transportation options, being stopped by police en route and the facility gate being closed upon arrival and only opened after beckoning to the security persons at the gate.“We spent ₦200 (US$0.55) from the house to the bus stop in kękę. Then from the bus stop to the main stop in the area of the hospital on a 30-minute bus ride, ₦200 (US$0.55) and then okada to the hospital, ₦100 ($0.27) per person”. Thirty-three of the 47 women in our study who took public transport reported spending between ₦300 ($0.82) and ₦7,500 ($20.60) to reach facilities in Lagos. When disaggregated, women who travelled within towns or suburbs to reach CEmOC facilities in cities using public transport appeared to spend more compared to those who travelled within the cities. Twenty-seven of the women who reside in suburbs spent between ₦1,200 ($3.30) and ₦7,500 ($20.60) while six of their counterparts who reside in urban areas spent between ₦300 ($0.82) and N2,500 ($6.87). Irrespective of settlement type, women reported that drivers hiked fares if they were carrying luggage with them or if they were travelling at night.We took taxi to [this hospital] when I started having problems … It would have been ₦2,000 ($5.49) in the morning but at that time of the night they said ₦5,000 ($13.74). He even said he could have charged us more but because he is of the same ethnicity as my husband, he allowed us pay less”. 32-year-old, low SES, multiparous, with bleeding [Facility D ]“Travel with personal cars was described by women as being “at no additional cost, except for the petrol purchased”. However, for low SES women, many complained about the expensive cost of travel, for which they had to sometimes “borrow money”, “plead with the driver”, “take okada” (which was deemed cheaper), or “walk some distance to save money”. It was not unusual for women to use multiple transport means to reach facilities. A relative (mother) of a 21-year-old, low SES, primiparous, who presented with bleeding as a result of antepartum haemorrhage [Facility O ] submitted that, The experience of getting to this place was terrible. I first went to a private hospital. From my house to that hospital, typically one hour no traffic. But we needed to be in hurry, we had to take the BRT [Bus Rapid Transit] lane. A policeman stopped us but the church member who was carrying me explained to him that he was carrying a pregnant woman, he then let us pass. But the traffic was still too much. We had to turn back on the road to drive ‘one-way’ to reach this hospital.” 35-year-old, medium SES, multipara, with obstructed labour [Facility S ].“In other instances, women reported using motorcycles which allowed them “beat the traffic”. However, they highlighted the discomfort and additional pain they had to endure with this mode of travel, compounded by the deplorable conditions of many of the roads. This road condition concern was shared by women irrespective of the time of the day that they travelled, the length of the trip or the location of the facility. One woman who presented at a facility located in a suburb and non-slum area said:I had to take okada from my house to the primary health centre, because I knew this would be faster, especially as the road is not tarred and there is usually plenty traffic on it. In all, the journey was about 30 minutes.... On my way going, when the bike enters a pothole, I will shout because I was in pain. But I didn’t have a choice!” 31-year-old, medium SES, primipara, with prolonged labour [Facility H ]“Women and their relatives reported varying experiences when they set out to CEmOC facilities. Experiences varied with the time of travel, as well as the terrain navigated to reach the facility. Irrespective of whether the facility was located in a town, suburb or city, women who lived within one or two streets away from CEmOC facilities had about 5–10 min of travel using taxis or their personal cars. Across the entire sample of 47 women, estimated time of travel was between 5 min to almost 4 h in daytime and between five and 40 min at night. At night, there did not appear to be much variation in travel time to reach facilities based in towns, suburbs or cities, irrespective of how close or far women lived from the facilities. Neither was there much variation in reported travel time to reach facilities serving mostly non-slum (5–30 min) and slum (15–40 min) populations. Women reported that time of travel in the afternoon could be between two and six times more if there was heavy traffic. In such conditions, women reported resorting to the use of extreme measures, including driving on illegal lanes, facing oncoming vehicles or abandoning the cars they were in to flag down a motorcycle. One particular woman’s experience trying to reach a facility located in a suburb, non-slum area captures some of these extremes:“She definitely does not know how she got here. She was gone [unconscious]! I had to put a spoon in her mouth [a local technique done to unconscious patients based on the belief that clenching of teeth signifies end of life]”.Women highlighted that having relatives with them along the way to reach CEmOC facilities was “very helpful”, “important”, and “most needed”. Relatives reported that they had to try all they could to support and manage their loved ones in situations of emergency and in some cases, they had to treat them any way that they knew. A relative (husband) of a 23-year-old, low SES, primiparous, who presented unconscious at Facility F  said, I registered with one matron in my community and I was placed on blood pressure medications. But the baby was still small and needed incubator. So, she referred me to [Facility D ] … But when I got to that facility, the doctor said, they don’t have any space for incubator, so they now referred me here [Facility B]”.Seventeen women required referral to a CEmOC facility, as the BEmOC or CEmOC facility they initially presented to could not provide the necessary care. Service delivery limitations included lack of bed space or incubators for their newborns. Some of these women had to move through multiple facilities in order to access the required care. A 24-year-old, medium SES, primipara, who presented with high blood pressure and pre-term delivery in Facility B  stated “The road was free … maybe 15 minutes max to reach here. It (the ambulance) had all I needed – oxygen, life support, everything! And then I have never been here in my life, so not like I even know my way to this place. It was a smooth process!” 33-year-old, high SES, multiparous, with complications post-caesarean [Facility R ]“They used their ambulance, which they told me to pay for. I paid ₦3,000 ($8.25). I left the hospital at 4 p.m. and I got here around 9 p.m. The traffic was really bad that day!! The ambulance did not help us to get here faster. Even people in their private car were dragging the road with us. They don’t even want to know if somebody is dying or something … If it was in my state, people will give way to ambulance”. 24-year-old, single, primipara, with incomplete abortion [Facility E ]“Ambulances, which are expected to be available in all state-owned CEmOC facilities, are typically used to transport patients from facility to facility in situations of emergency. When available and not in use and if there was no traffic, women referred in hospital ambulances found it to be advantageous, irrespective of urban settlement type. The reason given by women for such perception was that an ambulance provides supportive equipment and hospital drivers are more conversant with the directions to the referral hospital. However, some women reported that even though they had to pay to be transported in the hospital ambulance, it did not help to reach the referral facility any quicker. The women attributed this to the lack of regard for ambulances by other road users; there does not appear to be a culture of motorists giving way to ambulances on Lagos roads.“They did not even mention ambulance. So, my husband had to get taxi. We travelled for almost three hours from the health centre to get here”.Some women were also referred to state-owned CEmOC facilities from primary health care facilities or private hospitals. However, ambulance use for referral in these facilities was variable. In many instances, women were referred and expected to figure out on their own how to reach the referral facility. One 27-year-old, medium SES, primiparous, who was referred from a health centre with her newborn requiring incubator [Facility R ] said, This study set out to critically explore the factors influencing and experiences of travel of pregnant women in situations where they are attempting to access EmOC in Africa’s largest megacity, Lagos. Findings showed that after pregnant women have identified an emergency situation, they are still faced with real conundrums on “when”, “where” and “how” to travel to reach appropriate facilities. While this decision-making is a shared activity amongst all women, the options and the process vary. Our interviews revealed remarkably similar experiences of travel, irrespective of women’s age, socio-economic background, or obstetric history. Nevertheless, the extent to which travel experiences impacted their ability to reach EmOC facilities depended on individual agency and support systems. Due to service delivery limitations, some women had to be further referred, which further prolonged travel and increased cost.Women in our study recognised danger signs, regardless of their age, SES, obstetric history and presenting complaint. Our findings also showed that being aware of danger signs does not necessarily translate to responding to the urgency of the situation. It is difficult to conclude that decision on when to travel was made more quickly amongst those of higher SES compared to low SES in our study. Though a similar qualitative study conducted in Ghana found that women who lack formal education (a component of SES) tend to delay in recognising danger signs . Our finThe choice of ‘where’ to go was influenced by proximity for some women, especially when they resided close to facilities. However, for many women, proximity was trumped by family or community perception of the facility, health insurance coverage, connections with highly placed individuals within the health system and the advice of influential people. While a previous study showed that there is a general “positive perception” by women of public CEmOC facilities in Lagos, especially as it relates to the availability of technically sound skilled health personnel , concernWe found that decision-making on “how” to travel was based on availability. For women of high and medium SES who owned a car, had a relative nearby who owned a car, or had access to and could afford taxis, vehicles were the preferred mode of transport in an emergency. In other LMIC settings, lack of vehicles has been reported as a barrier to accessing EmOC , 37–39. Irrespective of the choices that women made, their socio-economic status or obstetric history, many women in our study reported facing significant challenges in travelling to health facilities, with different challenges faced during the daytime (traffic congestion) and night-time (security concerns and scarcity of public transportation). The deplorable conditions of many of the roads was a huge challenge, regardless of the time of day. A 2015 review reported travel time between 10 min and 1 day . Women iFor night travel, security concerns reported by women is shared by the Lagos population. However, no woman in our study specifically reported this as part of her experience in trying to reach a health facility. The price hike at night is not a unique experience in Lagos. Pregnant women in Ethiopia and Nepal have previously reported feeling financially exploited by transporters . Such exAs previously reported in the literature , our stuThere are clear implications for policy and practice based on our findings, which support the need for governments to target both health systems and the overall SES of women to improve EmOC access. Firstly, the practice of birth preparedness and complications readiness (BPCR) as part of routine ante-natal care in Lagos hospitals  needs toSecondly, there is a need to standardise costs to women for receiving EmOC, expand health insurance coverage and ensure respectful maternity care  in publiTo our knowledge, this is the first qualitative study that rigorously describes issues around travel of pregnant women in situations of emergency in a LMIC megacity. By seeking to maximise the heterogeneity of the sampled facilities and speaking to different women with varying characteristics within each facility, this study reflects multiple experiences of travel and the effect that the various characteristics could have on travel to reach facilities in an emergency. Nevertheless, this study also has limitations. Firstly, we only focused on women who made it to the facility, excluding those who had emergencies but never made it to the facility. Future studies need to engage with women and their relatives within the community, in order to identify such women and capture their experiences. Secondly, there could have been interviewer bias from the multiple interviewers who engaged the women. However, the use of a standard operating protocol to guide conduct and debriefing sessions minimised such occurrences. In addition, reported time estimates were based on recollection of the women or their relatives, many of whom were in duress while traveling to reach facilities and as such the reliability of their estimates is questionable. However, efforts were made during the interviews to verify travel time estimates by rephrasing travel time related questions in many ways and asking both women and relatives where possible.Our study revealed that the delay in travel to health facilities is a real experience of pregnant women in situations of emergency even in a megacity like Lagos. For pregnant women, reaching a facility in emergency situations is usually a matter of life and death. However, the ability to reach such facilities should not be based on chance, connections, or capacity. Every woman in such situation needs to have a fair opportunity to reach a facility and receive the necessary care at such critical moments. If the goal remains to leave no one behind, then in addition to other health system strengthening interventions, referral systems need to be improved, advocacy to encourage women to use their nearest facilities when in situations of emergency and partnerships with private sector need to be explored.Additional file 1. Completed checklist.