Assessment of "Three Delays Model": An Experience at Public Sector MCH Hospital

Abstract

Background: Maternal Mortality is a strong indicator of human development that points towards health of the women, accessibility and the quality of the health services. Nearly two third of the maternal deaths all over the world are due to direct causes e.g hemorrhage, sepsis and eclampsia. Objective: To assess the role of three delays in maternal mortality at a public sector hospital. Study type, settings and duration: A descriptive cross sectional study was carried out at Holy Family Hospital, Rawalpindi, from October to December 2016. Methodology: Data concerning age, socioeconomic , demographic, parity, booking, referral center and cause of the three delays was collected on a structured questionnaire from 200 respondents by interviewing them, their relatives and history files. Data was analyzed in SPSS version 20 and the results were presented in tabular form as frequencies and percentages. Results: It was found that first delay was the most frequent one and faced by 70% respondents after the onset of labor pains. Total of 47% told that late decision of the husband to seek care was the reason for delay whereas 22% reported that midwives were responsible for this delay. For the second delay, the study reflected that almost 52% of respondents reached the facility within an hour while the remaining took longer because of distance, and volume of traffic. The third delay was faced by 35% because of heavy patient flow to the obstetrics emergency department where 83% were attended by doctors within 30 minutes after reaching the facility. Conclusion: This study findings concluded that delay in decision making to seek out care and delay in reaching a suitable health facility in time were mainly the contributors to maternal morbidity and mortality. Lack of knowledge and poor socioeconomic factors were also highlighted as the major reasons of these delays.

Full text

83 Pakistan Journal of Medical Research, 2019 (April - June)
Pak J Med Res
Vol. 58, No. 2, 2019
Assessment of „Three Delays Model‟: An
Experience at Public Sector MCH Hospital
Asif Mahmood Mattoo1, Saadia Hameed2, Asif Maqsood Butt3
Aero Hospital1, Hasanabdal, Holy Family Hospital2, Department of Medical Education, Rawalpindi
Medical University3, Rawalpindi.
Abstract
Background: Maternal Mortality is a strong indicator of human development that points towards health of the
women, accessibility and the quality of the health services. Nearly two third of the maternal deaths all over the
world are due to direct causes e.g hemorrhage, sepsis and eclampsia.
Objective: To assess the role of three delays in maternal mortality at a public sector hospital.
Study type, settings and duration: A descriptive cross sectional study was carried out at Holy Family Hospital,
Rawalpindi, from October to December 2016.
Methodology: Data concerning age, socio-economic, demographic, parity, booking, referral center and cause
of the three delays was collected on a structured questionnaire from 200 respondents by interviewing them,
their relatives and history files. Data was analyzed in SPSS version 20 and the results were presented in tabular
form as frequencies and percentages.
Results: It was found that first delay was the most frequent one and faced by 70% respondents after the onset
of labor pains. Total of 47% told that late decision of the husband to seek care was the reason for delay
whereas 22% reported that midwives were responsible for this delay. For the second delay, the study reflected
that almost 52% of respondents reached the facility within an hour while the remaining took longer because of
distance, and volume of traffic. The third delay was faced by 35% because of heavy patient flow to the
obstetrics emergency department where 83% were attended by doctors within 30 minutes after reaching the
facility.
Conclusion: This study findings concluded that delay in decision making to seek out care and delay in reaching a
suitable health facility in time were mainly the contributors to maternal morbidity and mortality. Lack of knowledge
and poor socio-economic factors were also highlighted as the major reasons of these delays.
Key words: Socio-demographic characteristics, delays, maternal mortality.
Introduction
aternal death is an important indicator of the
status of women, access to care,
acceptability and standard of healthcare in
developing countries. Complications in pregnancy
resulted in 10.7 million women deaths between
1990 and 2015 globally, the majority of which were
preventable.1 However, these reasons do not
usually cause maternal deaths in developed
countries. Therefore, few other factors like delays in
getting timely and suitable care in cause of a high
risk pregnancy have been put forward as a major
factor in maternal mortality. Thaddeus and Maine
introduced the concept of delays which can occur at
three different levels:
1. Delay in decision to seek out care.
2. Delay in reaching the suitable facility, and
3. Delay in receiving satisfactory care in the facility.
The reasons behind the first delay may be
late recognition of the situation, the enormous
hospital bills, fear of the hospital check-up or lack an
appropriate decision maker. The second delay is
usually initiated by difficulty in getting transport and
distance within time to travel to reach health facility
suitable to handle the situation. The third delay is
often due to difficulty in getting availability of trained
staff, doctor or nurse, blood supplies, proper
equipment and operation theatre facility.2 It is said
M
Corresponding Author:
Asif Maqsood Butt
Department of Medical Education
Rawalpindi Medical University, Rawalpindi.
Email: drasifrmc@gmail.com
Received: 31 May 2018, Accepted: 27 June 2019,
Published: 28 June 2019
Authors Contribution
AMM conceptualized the project & did the data collection,
drafting, revision & writing of manuscript. AMB did the
literature search. SH performed the statistical analysis.
Original Article

Asif Mahmood Mattoo, Saadia Hameed, Asif Maqsood Butt
84
Pakistan Journal of Medical Research, 2019 (April - June)
that these three delays are interrelated and are
among the major contributing factors of maternal
mortality.3
The three delays model was studied and
considered valuable for the identification of factors
causing maternal mortality. This model describes
that the first delay is to seek timely health care and
it occurs mostly because of poor socio-cultural
factors, the low status of women and previous bad
experience at health facilities. The second delay
results because of insufficient infrastructure or
access to transportation, long distances and
prolonged travelling time to a health facility where
pregnant women can receive emergency treatment
and management. The third delay is due to the
delay in receiving care at the health care facility or
hospital. This typically occurs when patient has to
wait in the obstetric emergency because of rush,
non-availability of doctor, wrong diagnosis or
treatment, delay to arrange blood for transfusions or
lifesaving medications.4
In most of the developing nations, death
rates due to pregnancy and labor were frequently
high and affect women of reproductive age.
Nevertheless, these mortalities could be avoided in
time.5 Women education, empowerment and family
planning could result in significant lessening of
maternal morbidity and mortality but that require
long term health education and training of
community.6 While comparing maternal mortality
rates of developing and developed countries, it was
seen that there was a huge difference between
Maternal mortality rate (MMR) of these countries
that depend upon the management of high risk
pregnancies which if left untreated could lead to
death.7 The importance of appropriate timings could
not be ignored in medical practice. In gynecological
emergencies, timely diagnosis and treatment was
the only key to avoid maternal deaths.8
Maternal mortality occurs as a result of a
complex and long events of delays. In the obstetric
emergency women try to reach medical center, but
the delays happens because of many obstacles.
Every postponement could be deadly to women with
high risk pregnancy. Rural women appear to abstain
from heading off to the doctor's due to dread of
discrimination, regional and financial obstructions
and diverse understanding of threat signs. However,
a woman at first planned for home delivery tries to
get help when complication develops. These issues
lead to many problems in reaching to proper care
within time. Absence of public transportation in rural
regions causes delays for the transportation of
pregnant and then deficiency in medical services
might be because of one or a sequence of events
as inadequate medical supplies, lack of proper
equipment, untrained health workers and ineptitude
of the accessible staff.9
According to the three-delay model, the
traditional concept of broad emergency services
was similar to obstetric emergencies, in terms of
service provision, time etc. Timely action is also
important in general emergency services besides
providing medical interventions. The delay factors
such as access to hospital, distance travelled, and
access to timely patient care were applicable to all
sorts of emergency care. It was an acceptable fact
that time taken for a pregnant woman to reach
medical care or health facility was affected by the
travelling distance from home to the facility and
quality of provision of services at that facility.
Efficient emergency service has a lot of
factors on which it depends. One of the prime factor
was seen as the ability of the patient‟s or health
caretaker where he/she could identify the
occurrence of any abnormal condition, which in turn
affects the health of the patient. An effective
treatment was required to cope with the condition. In
situations, where a delay occurs in the recognition
of a potentially serious condition, an appropriate
care would not be available in time. In emergency
situations the economic factor was of least
importance when compared to the utilization of
services.10
Poor planning and delay in recognition of
serious conditions in the basic health centers and
homes results in complications. These could only be
reduced if provided with basic treatment before
reaching a hospital. If delays in patients care were
to be avoided, the persons who provide pre hospital
services must be trained to recognize the level of
care required by the patient and to shift the patient
directly to the health facility that provides that level
of required care.11
The three delays model was designed to
understand the ways that create hindrances a
women health care. This model identifies and
highlights the importance of all the three delays,
instead of focusing on only one. It has been
recognized as a well-established tool for the
measurement of causes of maternal and child
mortality because of delays around the world. It
further makes it possible to get actual data for the
guidance to work for actual impact in the
improvement of maternal and infant mortality rates.
Pre-eclampsia or eclampsia, obstructed labor,
hemorrhage, ruptured uterus and postpartum sepsis
are the most important factor of maternal mortality
related to delays. These could be prevented with
health promotion, family education, decision
making, and improving socio-economic factors. The
high maternal mortality ratio (178 deaths/100,000
live births) could be reduced in Pakistan by the
application of this model at Primary and Secondary
Health levels and aiming to improve the health
promotion.

Assessment of ‘Three Delays Model’: An Experience at Public Sector MCH Hospital
85
Pakistan Journal of Medical Research, 2019 (April - June)
Methodology
A descriptive cross sectional study was
carried out in a tertiary care teaching hospital from
October to December 2016 with a sample size of
200 respondents. The study was conducted in Holy
Family, a tertiary care teaching hospital, providing
services as a referral center for the health facilities
in and around Rawalpindi. Sample size was
calculated at the confidence interval of 95% and
prevalence of 50% and convenient sampling was
used to enroll patients. .
Patients registered at any of the two units of
the department of Obstetrics and Gynecology of
Holy Family hospital outpatient department were
defined as Booked. Three Delays were defined as
by Thaddeus and Maine. Majority of the
respondents admitted as emergency cases to the
labor room were referred by different private or
public hospitals.
A structured questionnaire was used to
collect relevant information by means of both
interviewing the respondents and their relatives
regarding first and second delays whereas for third
delay data was collected from the history files. The
questionnaire was divided into four parts, the first
part comprised of demographic data whereas the
other three parts constituted questions about the
three delays. Socio-demographic characteristics,
parity, status of booking, source of referral, and data
on three delays were collected. The data was
analyzed using SPSS version 20, and the results
were presented in tabular form as frequencies and
percentages.
The study was approved by Ethical
Committee of Sarhad University, Peshawar.
Departmental permission to conduct the study was
obtained from Holy Family Hospital, Rawalpindi and
informed written consent was obtained from all
participants.
Results
The study was conducted on 200 post-natal
ward respondents participated with a mean age of
26.1 ± 3.5 years. The minimum age of sample
respondents was 16 and maximum 35 years. The
sample variance was 12. Total of 99.5% of the
respondents were
Table: Frequency distribution of respondents about causes of the three delays.
First delay n (%)
Second delay n (%)
Third delay n (%)
First Delay 140 (70)
Second Delay 25 (12)
Third Delay 35 (18)
Preparation of antenatal cards for regular check up
Booked 125 (63)
Non Booked 75 (37)
Delay due to Transportation
Car 83 (42)
Rickshaw 69 (35)
Bus 12 (06)
Wagon 36 (18)
First check-up after reaching hospital by
Doctor 195 (98)
Aya 5 (03)
Number of females decided late for checkup
Delayed 95 (48)
Not delayed 105 (52)
Delay due to distance
1 hour or less 103 (52)
1 to 2 hours 44 (22)
2 to 3hours 41 (21)
3 hours or more 12 (06)
Delay for late checkup
Doctor non-availability 18 (09)
Rush in ER 110 (55)
Blood arrangement 72 (36)
Reason for late checkup because of
Husband 93 (47)
Midwife delay 44 (22)
or poor counseling
Lack of self-awareness 30 (15)
Lack of health facility 19 (10)
Lack of finances 14 (07)
Time taken of checkup
Within 15-mins 109 (55)
16-30 minutes 56 (28)
31-60 minutes 15 (08)
More than 1hour 20 (10)
Advice to go to hospital
Self- 74 (37)
Husband 16 (08)
Family 41 (21)
Midwife 21 (11)
Private doctor 33 (17)
Government doctor 15 (08)
Complications due to delay arrival and
initiation of treatment
Yes 60 (30)
No 140 (70)
Checked-up before getting referral
Yes 107 (54)
No 93 (47)
Nature of complication
Fetal Distress 29 (48)
Baby breathing problem 13 (22)
Hemorrhage 18 (30)
Baby Death 2 (03)
Respondent brought to hospital by
Husband 134 (67)
Family 66 (33)

Asif Mahmood Mattoo, Saadia Hameed, Asif Maqsood Butt
86
Pakistan Journal of Medical Research, 2019 (April - June)
house wives and 0.5% were working women and
majority belonging to a lower and few to middle
socioeconomic class. Among all, 13% were illiterate
and had never received any formal education, 13%
studied up to middle classes, 11% were under
matric, 32% matric and 33% above matric. Out of
all, 54% respondents were booked and had
received regular antenatal care throughout
pregnancy, 63% from private setups, 29% from mid-
wives and only 8% from government health care
center.
Table shows the reasons for the three
delays. First delay was most frequent and was
faced by 70% respondents after the onset of labor
pains while 47% told that late decision of the
husband for seeking care was the reason for delay
and in 22% of cases midwife was held responsible
for this delayed decision. For the second delay, the
study reflected that almost 52% of respondents
reached the facility within an hour and remaining
had a longer travelling time because of distance,
rush in traffic causing delay in reaching the facility.
The third delay was faced by 35% because of rush
in the obstetrics emergency department and 83%
were attended by doctors within 30 minutes after
reaching the facility.
Discussion
To best of our knowledge, this study on the
„three delays model‟ is the first study conducted in
the region of Rawalpindi and also among the few
studies conducted on this subject in Pakistan. It was
found in this study that the most common delay was
first (70%), then third (18%) and least was the
second (12%). The decision to seek out mother‟s
healthcare was seen mostly because of
socioeconomic factors, culture and low education of
women. Lack of awareness and limited knowledge
about antenatal checkup played a key role in delay
in timely recognition of complications of pregnancy.
Literacy in both husband and wife played a
key role in making quick decisions and getting early
medical advices during pregnancy was also noted.
Education of women empowers to make decision for
the health and wellbeing of their families. However it
was revealed in the study that most of the decisions
were made by the relatives without asking the
women. It was also supported by the results of the
study that literate males made better decisions for
their families.
First delay was found as the major
contributors of delays and it was further
strengthened by a similar study conducted in
Karachi highlighting that the first delay was because
of two main reasons as was seen in this study too.
Husband plays key role in all decision making and it
depends upon his knowledge on this subject. The
second factor highlighted was the advice of
midwives in decision making.12 A similar study of
Lahore also highlighted first delay and major
obstacle to seek out care was played by husband,
mother in-law and midwife in making decisions.13
It was observed in this study that literacy
rate played an important role irrespective of socio-
cultural and demographic aspects. A similar study
conducted in Nigeria concluded that formal
education have a significant role and to reduce
MMR adult women, literacy rate must be
improved.14 A study conducted in Karachi also
suggested that majority of women suffering from
first and second delays were because of poor socio-
demographic factors and was a major reason of
high MMR in Pakistan.2 A study from Egypt reported
that there was a high prevalence of MMR because
of delayed access to good quality health facilities of
women. The study also revealed that there was a
reduction of MMR because of improvements seen in
the sociocultural factors of the country.15
Delay in reaching the suitable facility was
the second delay and was due to lack of getting in
time transport, long distance or late referrals. The
study just like many other similar studies highlighted
that majority of the respondents‟ hired or used a
public transport to reach the hospital and wasting
the precious time because of difficulty in getting
proper transport and rush on the roads. A study
conducted in Tigray, Ethiopia reported that poor
system of transportation and preventable factors like
hospital service delay of care seeking contributed as
the leading cause of MMR. These could be avoided
to reduce maternal deaths.16
Suitably equipped health facilities with fully
trained available staff have a critical role to play
when a patient arrives in serious condition. This was
established from the study that increased work load
and lesser number of duty doctors results in long
waiting time in the obstetric emergency department
results as third delay. The non-booked cases were
other main factor that caused delay because of
difficulty in getting the arrangement of blood and
other medical supplies after reaching the hospital.
Our study was supplemented by a Karachi based
study highlighting un-booked and delayed referrals
as major reasons for third delay. Similarly lack of
management protocols, lack of medical audits, poor
conditions of labor rooms, and non-availability of
adequate blood in blood banks being the major
factors for third delay were also generally noticed in
both studies.17

Assessment of ‘Three Delays Model’: An Experience at Public Sector MCH Hospital
87
Pakistan Journal of Medical Research, 2019 (April - June)
In the light of the present study, the
following recommendations have been compiled to
minimize the factors affecting delays. Districts
should compile detailed Information Education
Communication (IEC) plans about health education
and awareness on maternal health issues. It should
be communicated through seminars, workshops,
medical camps and media by health and community
workers and social activists. Key objective of
Information, Education, and Communication (IEC)
campaigns should be to ensure that the community
in need of awareness and communication behavior
changes be aimed to improve health seeking.
All booked pregnant women visiting public
or private hospitals should be given separate
educational lectures and handouts, so that they
understand the hazards, risks and vulnerabilities
that they will face if prompt actions are not taken.
Quality of health services and facilities
should be ensured through regular and efficient
monitoring system.
Pregnant females should be encouraged on
at least three routine antenatal check-ups during a
pregnancy.
Early recognition of complications of
pregnant women should be done at each level and
health workers should rule out high risk pregnancies
timely so that timely referral to facilities offering
specialized health services.
This study findings concluded that delay in
decision making to seek out care and delay in
reaching a suitable health facility in time were the
main contributors to maternal morbidity and
mortality in the study area. Lack of knowledge and
poor socio-economic factors were also highlighted
as the major reasons of these delays.
Conflict of interest: None declared.
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