We assessed geographical accessibility to facility-based childbirth care in Grand Nokoué metropolitan area using localised and context-specific travel speeds. We explored inequalities by disaggregating travel time estimates by wealth quintiles and urbanicity. Travel time to the nearest childbirth care facility in Grand Nokoué was relatively short (8 min) under average travel conditions. This increased substantially to 106 min for women needing public hospital care traveling at slowest speeds. Women from poorer households had five times longer travel times compared to their wealthier counterparts. Our work builds on and improves upon previous assessments of spatial access in Benin [4, 5, 18, 20,21,22,23]. We contextualise these findings and their value to health system planning by identifying where patterns may inform evidence in Grand Nokoué.

Travel time to the most advanced and affordable care provided in public hospitals—33 min in the average scenario, 106 min in the slowest speed scenario—was within the global threshold of 2 h [6]. However, these durations still poses a risk as delays of 10 to 30 min have been associated with stillbirths and maternal mortality [7]. Overall, the travel time estimates in Grand Nokoué was slightly longer compared to other SSA cities where similar analyses were conducted [25, 26]. Slow speeds and consequently long travel times in Grand Nokoué could be due to traffic congestion leading to long delays for women needing to access CEmONC. The actual time to accessing care for many women would be even longer, accounting for time to find transport, securing fees, reaching from the entrance of a health facility to the maternity ward, and additional time if referral to another facility is required.

Within Grand Nokoué travel time varied at arrondissement level, with 21 arrondissements where travel time was longer than 60 min at slowest speeds. Travel time was substantially shorter in Cotonou and Porto-Novo, two cities which are part of large settlements in the urbanization continuum, due to the high density of road networks and health facilities (70% of hospitals in Grand Nokoué are located in these two cities). On the other hand, Ouidah and its immediate neighbourhood (Djègbadji, Houakpe-Daho, Avélékété, Pahou, and Bossito) had relatively longer travel times as the area has fewer facilities and a lower density of road network and some parts have water, flooded vegetation and trees, which limits movement.

Eight out of ten women in Grand Nokoué were within 30 min of any facility offering childbirth services at slowest speed. However, this declined to two out of ten within a half hour of a (public) hospital under the minimum speed, making geographic accessibility to hospital care, especially in critical situations, a significant barrier. Arrondissements like Avelekete, Hèvié, Pahou, Ouèdo, Bossito, had a geographic coverage of less than 15% of WoCBA within 2 h. These arrondissements would benefit from targeted policy interventions to reduce women’s geographic marginalization from hospital-based childbirth care. Actions such as upgrading lower-level facilities to hospitals, improving of roads or providing alternative means of transport such as ambulances [18] would enhance the geographical coverage in the most affected arrondissements. In this line, the Grand Nokoué sustainable urban mobility project aims to improve urban mobility, accessibility, and safety along selected corridors and urban areas of the Grand Nokoué. This includes improving transport infrastructure (Abomey-Calavi–Cotonou and Ouidah–Sèmè-Podji), providing efficient and affordable bus-based public transport services along the main urban mobility corridor [27]. When the public transport system is better-organized, it will help reduce road congestion and, consequently, travel times especially for the slowest speed scenario.

Our findings support the literature on the impacts of socio-economic status on access to childbirth care in SSA, whereby pro-rich inequalities have been documented in major cities [26, 33]. The health inequalities in the country are exacerbated by socio-economic factors [17, 19], considering that two-fifths of Beninese health expenditures are out-of-pocket [34]. Within Grand Nokoué, women from the poorest household wealth quintile travelled on average five times longer than those in the richest quintile to the nearest hospital. These pro-rich inequalities are due to a high distribution of hospitals in Cotonou and Porto-Novo, which also have households of relatively higher wealth. Almost half of the hospitals in Grand Nokoué are in Cotonou as a result of governmental efforts to improve access to healthcare. However, the population of Cotonou is reducing over time, as populations move toward other areas such as Abomey-Calavi and Sèmè-Kpodji. These peri-urban areas have a lower density of hospitals, and therefore, approaches to decentralize, restructure, or build new hospitals in these areas should be explored.

Although the private sector can be more expensive, it constitutes a vital alternative when public infrastructure is under pressure or takes too long to access. The private sector provides 45% of healthcare services in Benin [34], and up to 71% of childbirth services are from private providers in Grand Nokoué. Neglecting the private sector in estimates of accessibility to care can underestimate the actual healthcare options available to the population and our analysis shows that travel time reduced significantly when comparing access to public facilities versus all (public and private) facilities.

Our findings highlight substantial disparities in geographical access to childbirth services according to level of urbanization as previously reported in Benin [21]. Travel time is shorter in large and medium settlements than peripheral areas containing small settlements, low density, and almost uninhabited areas. The large and medium settlements areas are characterized by high population densities, well-maintained roads, efficient public transportation, and proximity to vital services. Conversely, peripheral areas have poor transportation infrastructure and fewer public transportation options.

The spatial metrics of travel time generated in this study relied heavily on travel speeds across different road types. Some road types saw a diverse traffic mix, including cars, cyclists, and pedestrians, requiring slower speed limits for safety reasons. Most of these were interurban roads where people live, such as in Abomey-Calavi-Allada. Additionally, during the data collection period, road construction and resurfacing work was underway in Grand Nokoué, which led to diverting road users and reducing the speed of vehicles in some areas. The speeds recorded in Grand Nokoué were similar to those recorded in Grand Conakry, Guinea [26], but are much slower than the generic speeds where major roads are assigned 100 km/hr [4, 5]. Therefore, it is likely that previous studies have overestimated geographic accessibility especially in urban settings when generic speeds have been used.