Maternal mortality in developing countries; the three delay model

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INTRODUCTION

What is maternal mortality or maternal death?

It is when a woman dies while she's pregnant or a woman dies within the 6 weeks after the pregnancy was terminated.
This is not dependent on how long the pregnancy lasted or the site e.g even a pregnancy of 2 weeks can be classified as maternal mortality, an ectopic pregnancy is also classified as maternal mortality
However for the death to be classified as maternal mortality, it should be due to causes related to or worsened by her state of being pregnant e.g bleeding, obstructed labour and not incidental or accidental causes like road traffic accidents or car crashes.
Now we have a grasp of what maternal mortality is. Let's look at the causes

What are the causes of maternal mortality?

Causes could be direct or indirect

Direct causes

Pregnancy, child birth or management of these two could have complications. When these complications cause the mother to die. It's classed under the direct causes.

Examples

• Bleeding or hemorrhage
• Infections (sepsis)
• Obstructed labour
• Hypertensive disorders of pregnancy
• Postpartum hemorrhage
• Abortion and it's complications

Indirect causes

When a pregnant woman has preexisting disease or newly developed disease that gets worsened by the pregnancy or a disease that's unrelated to the pregnancy but her pregnant state worsened the illness. When this leads to death, it's classed under indirect causes:

• Malaria
• Anaemia
• HIV/AIDS
• Jaundice in pregnancy
• Hepatitis

QUICK FACTS

• Everyday, close to 830 women die while pregnant or during childbirth

• In developing countries, maternal deaths are the second leading cause of deaths in women of reproductive age with HIV being the leading cause

• The key factor responsible for maternal deaths is lack of access to quality health care

• Two thirds of maternal deaths occur in subsaharan africa

• Many more pregnancies occur in women in less developed countries than women in developed countries, thus their lifetime probability of maternal death is higher

• Most maternal deaths are preventable

The Three delay model

The three delays model proposes that there are 3 delays that are responsible for maternal mortality. On the other hand, there are direct and indirect causes which have the potential of causing death but the three delays serve as a "vehicle conveying the causes to the destination which is death"
For instance, a woman bleeding after childbirth is a potential cause of death if not attended to. It may not necessarily cause her to die but when the three delays are present, the probability of death is increased by ten fold.
The three D's include:

Delay in decision making to seek appropriate medical care

Before we dive in...
What is appropriate care?
Appropriate care refers to intervention(s) that is most likely to produce the best outcome for the patient. Care can be effective but not appropriate for the patient.
Delay in decision making occurs due to any of the following factors:

Ignorance and low educational status
Ignorance of the mother of the child or even the father. When they are not able to recognise that there is a problem which is an emergency and requires prompt treatment. Sometimes they are aware of the seriousness of the problem but fail to seek "appropriate" care because they don't even know the best care suitable for the woman because they are not well informed or educated

Beliefs and cultural practices
In communities where there is patriarchy dominance, there are beliefs and cultural practices that the man is the head of the family and should make decisions first. So when there's a severe life threatening condition that can cause maternal death and the father isn't around, because of the pre existing mentality in her head, she fails to seek care without approval of her husband. It may seem archaic but this is quite commoner than we think it is.
There's also the issue of cultural stigma for example cases of complications of abortion.

Low socio-economic status and Financial constraints
This is the commonest factor responsible for this delay. The cost of healthcare is relatively expensive in developing countries. Also, people hardly utilise health insurance schemes and they are not available in some health care institutions too. So 90% of the time, payment for heath care is out of pocket.
When there are financial constraints, there's a delay in seeking care because the people involved have to go and source for funds first. Or perhaps the funds are not sufficient to pay for "appropriate care" so they settle for less.
For instance,

Miss A, a 20 year old lady just terminated a 5 week pregnancy 2 months ago by taking pills. She's still bleeding and the bleeding has worsened since onset.
The most appropriate care she needs is to see a specialist doctor who would admit her, carry out investigations like an ultrasound scan which would suggest the best line of treatment. But because of the money she'd spend in going to a specialist clinic. She delays in seeking this care appropriate for her and goes to a nearby chemist who prescribes antibiotics and hematinics (blood drugs) and she goes home

Of course, this intervention would definitely not address Miss A's issue so it would keep worsening until it finally leads to death due to shock or severe infection (sepsis)

SOLUTIONS

Health education
Education isn't restricted to only females but also males because of ignorance of the "baby daddy" can also contribute. When a woman is empowered, she would be able to recognise when there's a problem and also have a high index of suspicion relative to an uneducated woman. Information about pregnancy, childbirth, child care.
Education also improves the status of the woman and gives her more opportunities in the job market

Provison of jobs and employment opportunities
Because poverty is a constraint and can contribute to delay in making decision. Jobs and other means of generating revenue can ameliorate this delay.
The government should create more employment opportunities for people.
There should be regular payment of salaries and wages to workers.

Development of national health insurance schemes
To ensure there's equity in distribution of health and to ensure that health care is accessible to even the poorest person in the community. Informing people about insurance schemes as most people are not aware that there's something called health insurance.

Delay in transport to the hospital

This delay arises due to factors arising from the roads or vehicles.
Some areas are so underdeveloped, roads are not available. Even if they are, the roads are bad and vehicles can't ply these roads. The geography of a region may unfavour car transport.
The transport systems may not be efficient so transport to health centres are relatively difficult.
Distance of the health from residential areas
Lack of good roads
Traffic jam

SOLUTIONS

• Good roads
• Extra lanes for emergency cases
• Birth preparedness during antenatal care, the pregnant woman should already have planned the vehicle that would be transporting her and have the driver on speed dial. A backup transport system should also be planned out.
  Hospitals should be cited close to residential areas and not remotely
• Outreaches in rural communities, if Mohammed doesn't go to the mountain, the mountain would go to him
  Providing free health care and drugs in the process, problems could be detected incidentally
• Provision of more ambulances to rapidly convey pregnant women
• Use of bikes in terrains that don't favour the plying of vehicles

Delay in Instituting treatment at the health centre or hospital

This may be due to various factors such as:

• Non chalant attitudes of health workers
  maybe due to various factors like poor payment of salary and wages

• Inadequate health care facilities and poor infrastructure

• Inadequate referral systems

SOLUTIONS

• Train health care workers, midwives to handle emergency situations
• Training traditional birth attendants because you can't really take them away completely from village
• Employment of more doctors. Patient to doctor ratio is high.

REFERENCES

• https://www.who.int/features/factfiles/maternal_health/maternal_health_facts/en/
  https://www.maternityworldwide.org/what-we-do/three-delays-model/

• https://www.who.int/en/news-room/fact-sheets/detail/maternal-mortality

• https://pubmed.ncbi.nlm.nih.gov/9579750/#:~:text=The%20%22Three%20Delays%22%20model%20proposes,when%20a%20facility%20is%20reached.

• https://en.m.wikipedia.org/wiki/Maternal_death#:~:text=Maternal%20death%20or%20maternal%20mortality,its%20management%20but%20not%20from