Three delay model


“I was very excited at the prospect of having my first child. I had carried him for nine months and deeply cared for him,” said 22 years’ old Alishba. She was just 19 when her first baby was delivered. Throughout her pregnancy, she had been going around choosing clothes and accessories for her baby.

“Whenever I was alone at home, I would talk to my baby for hours on end and he would respond through movements,”  said Alishba.

“My husband was very helpful and kind during the entire period. We discussed every aspect of our baby’s future life. My husband, however, was against the idea of delivery at any hospital or maternity care centre due to moral aversion to male doctors,” said Alishba. That is why we selected a private maternity care centre run by a lady doctor, she added.

“The maternity home was nearby and on the expected delivery date my sister-in-law accompanied me to the clinic. When I asked to see my child after birth, the doctor refused on the grounds that the baby was suffering from respiratory problems, and its life was in danger because of unavailability of oxygen at the clinic,” said Alishba.

The baby was rushed to a primary care centre, wherefrom he was referred to a tertiary care hospital (TCH), but died there after struggling for his life for a few hours. Unfortunately, newborn deaths are not limited to this case alone and many children and mothers lose their lives during emergencies related to childbirth due to insufficient and untimely maternal healthcare.

The World Health Organization (WHO) has developed a three-delay model of maternal healthcare to reduce mortality rates around the world. It identifies the factors contributing to maternal mortality and is focused on the three main factors that affect the outcome of emergency presentation during pregnancy.

These factors are defined, chronologically, as the lengths of the delays in the decision to access care, the identification of – and transport to – a medical facility, and the receipt of adequate and appropriate treatment, in that order. This so-called three-delay model illustrates that maternal mortality is not due solely to a lack of economic and human resources but is a product of numerous interwoven factors.

According to the WHO findings, Alishba and her baby suffered from first and third delays as she and her husband made a wrong decision to avoid a well equipped health facility and were therefore unable to get adequate and appropriate treatment.

Dr. Sadia Rehman, a senior medical officer at Hayatabad Medical Complex (HMC) told this scribe that expecting mothers and newborn are frequently brought to the hospital in critical condition at a stage where little can be done to save their lives. She suggested that expecting mothers visit well equipped health facilities for childbirth.

She added that rural folks preferred local maternity clinics for deliveries run by medical technicians, who often fail at handling the cases properly, and only refer the patients onward when the patients become critical.

The effective way to handle an emergency situation depends upon the patient’s or caregiver’s ability to recognize that the condition at hand is critical, that the condition has a level of severity warranting intervention and that an intervention is available to treat the condition. Any delays in the recognition of a potentially severe condition decreases the likelihood that appropriate care will be provided in a timely and effective fashion. For this purpose, expecting mothers need to be properly educated.

Child specialist Dr. Jamshed says, “Proper education imparted to the mother and guardian is very important for child health. In our society, people don’t pay the required attention to pregnant women and often assume that childbirth is a natural process that is likely to take place with or without medical care and assistance.”

He added that there is a network of lady health workers (LHWs) spread all over Pakistan. These LHWs visit door to door and if they come across pregnancy cases, it is their obligation to educate expecting mothers. Pregnant women should be well aware of the entire pregnancy process and frequently visit nearby health centres for check-ups, he added.

The second delay in identifying and reaching a medical facility is dependent upon the planning and organization of pre-hospital emergency services in the setting involved. Effective pre-hospital care – even in low-resource settings – improves survival by decreasing the time to treatment. Community-based first responders can reduce mortality and morbidity substantially, especially among trauma cases. If care delays are to be minimized, the individuals who provide pre-hospital services need to be able to identify the level of care that a patient requires and to take the patient directly to the nearest facility that offers that level of care.

The third delay in the receipt of appropriate care – after the patient has reached a health facility – may be broken down into three parts: the delay in the provision of appropriate care at the initial facility, the delay in the patient’s transfer to another facility for definitive care – if needed, and the delay in the provision of appropriate care at the secondary facility. Delay at any of these time points has been shown to worsen patient outcome.

“After the loss of our first baby, my husband and I decided that only a well equipped healthcare centre can save the life of a child. I rushed to the maternity care centre at once when my second baby was to be delivered. The doctors ensured a safe delivery and I feel it was one of the best decisions I ever made,” explained Alishba.

While prevention remains critical to the treatment concerning maternal health, emergency care requires not only that the patient or caregiver recognizes that a life-threatening or life-changing condition is occurring, and that there is a need to seek care, but also that timely access to adequate care is made available.

Given the unpredictable nature of health emergencies, there are few quick fixes. However, strong emergency systems can prevent delays during critical situations. Such systems do not require massive resource allocation but rather a cost-effective, informed approach that emphasizes the proven life-saving interventions that are appropriate to the context.

Improving access to emergency care, by minimizing the three main types of delays in the delivery of such care, has the potential to reduce mortality in every field, system and population.

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A media journalist, photographer and documentary film producer, Mr. Umer Farooq joined the Daily North West Frontier (English) as a reporter right after the completion of his master degree from the Department of Journalism & Mass Communication, University of Peshawar. During his time with the Daily North West Frontier, Mr Farooq produced excellent articles with a focus on the genuine educational issues of the Pakistani society. He is currently working with an online television, Maati-TV as a correspondent; he produced several short documentaries on different issues from Khyber Pakhtunkhwa. He is also working with the Independent Project for reporting (Project of Deutsche Gesellschaft für Internationale Zusammenarbeit GIZ) as a reporter and videographer.