Maternal and neonatal vulnerability in a flood-prone area: a mixed-methods study in Agbétiko canton, Togo

Kossi Mitronougna KOUMI 

Flooding is increasingly recognised as a determinant of maternal and neonatal health in low-resource settings, yet the mechanisms by which it disrupts access to obstetric care remain poorly documented in West Africa. This mixed-methods study examined whether the flood season constitutes a period of heightened vulnerability for obstetric care access in the rural canton of Agbétiko, Togo. A retrospective analysis of 547 obstetric records from three peripheral health units (2020- 2024) was combined with a parallel ethnographic survey in the same localities. Exposure was defined by season (flood season, July-October, versus the rest of the year) and by an exploratory inter-annual classification of flood intensity. The main indicator of restricted access was delivery outside a health facility. Overall obstetric activity remained stable during the flood season (rate ratio 0.91, 95% confidence interval (CI) 0.76–1.09). Out-of-facility deliveries did not differ significantly by season (4.2% versus 5.4%; OR 0.78, 95% CI 0.27–2.23) or by inter-annual flood intensity. However, 17 of 18 out-of-facility deliveries occurred in the catchment area of one health unit (Agbétiko) despite both highly flood-exposed units serving comparable populations, pointing to marked village-level heterogeneity. Low birthweight was slightly, though not significantly, more frequent during the flood season (12.7% versus 10.7%; OR 1.21, 95% CI 0.69–2.14). Interviews highlighted mobility constraints, limited household financial reserves, and gendered decision-making delays as plausible contributors to this heterogeneity. In Agbétiko, flooding was not associated with a uniform disruption of obstetric care at facility level; vulnerability instead appears concentrated at village level, shaped by proximity, mobility and household economic resources rather than by service availability alone. Interventions calibrated to village-level access barriers may be more effective than broader supply-side responses.