This model identifies individual decision making, access to affordable services, and the provision of skilled personnel as the main factors which can delay access to effective interventions to prevent maternal mortality
Three Delays Model
Phase 1 delay. Delay in decision to seek care
- Failure to recognise complications
- Acceptance of maternal death
- Low status of women
- Socio-cultural barriers to seeking care: women’s mobility, ability to command resources, decision-making abilities, beliefs and practices surrounding childbirth and delivery, nutrition and education
Phase 2 delay. Delay in reaching care
- Poor roads, mountains, islands, rivers – poor organisation
Phase 3 delay. Delay in receiving care
- Inadequate facilities, supplies, personnel
- Poor training and demotivation of personnel
- Lack of finances
The true-life vignette below, taken from Thaddeus and Maine’s monograph provides a poignant illustration of Phase 3 delay:
By the time… deadly delay
Today, Mary, the lady who helps in the house, came late to work. I told her off for being late and asked why. She said that one of her townswomen had died in the hospital while giving birth to a baby. This was her fifth delivery. She was not from a far off village but from Sokoto city itself. She had not gone too late to the hospital but rather gone on time. By the time they found a vehicle to go to hospital, by the time they struggled to get her to an admission ward, by the time she was admitted, by the time her file was made up, by the time the midwife was called, by the time the midwife had finished eating, by the time the midwife came, by the time the midwife examined the woman, by the time the bleeding started, by the time the doctor was called, by the time the doctor could be found, by the time the ambulance went to find the doctor, by the time the doctor came, by the time the husband went out to buy drugs, IV set, drip and bottle of ether, by the time the husband went round to look for blood bags all over town, by the time the husband found one, by the time the husband begged the pharmacist to reduce the prices since he had already spent all his money on swabs, dressings, drugs and fluids, by the time the haematologist was called, by the time the haematologist took blood from the poor tired husband, by the time the day and night nurses changed duty, by the time the midwife came again, by the time the doctor was called, by the time the doctor could be found, by the time the doctor came, by the time the t’s had been properly crossed and all the I’s dotted and the husband signed the consent form, the woman died. Today the husband wanted to sell the drugs and other things they never used to be able to carry the body of his wife back to their village, but he could never trace [the body] again in the hospital.
In practice these three phases of delay rarely operate in isolation, and delay leading to maternal death is often multifactorial. Indeed the factors are likely to be interactive and multiplicative. Thus barriers and poor care encountered at Phase 2 and 3 feed back into subsequent decision-making at Phase 1. Interventions to reduce maternal mortality must address each of the Three Delays in order to have the greatest effect.
Koblinsky MA, CAMPBELL OMR & Harlow SD (1993). ‘Mother and more: a broader perspective on women’s health’ in Koblinsky M, Timyan J & Gay J (eds). The health of women: a global perspective. Boulder, CO: Westview: 33-62.
WHO (2005) The World Health Report 2005: Make Every Mother and Child Count. Geneva, WHO.
Maine D: Studying maternal mortality in developing countries. A guidebook: rates and causes. Geneva. WHO 1987 (FHE 87.7).
Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med 1994;38:1091-1110.
Tahzib F. College of Health Sciences, University of Sokoto, Nigeria, personal communication, 21 Mar 1989, from Thaddeus and Maine
