1. GSRHR course 2010 The Three Delays Model Pauline Binder, PhD student
Medical anthropologist
Women’s and Children’s Health Int’l Maternal and Child Health (IMCH)

2. Aims
To explore the interval between the onset of obstetric complication and its outcome
To help guide efforts to create programs aimed at the prevention of maternal mortality

3. Methods Multidisciplinary literature review
Looking primarily from the social sciences as applied to the safe motherhood
Emphasis of original article is in Africa

4. Conceptual framework
Based on the findings from the literature review, three likely obstacles to providing and utilizing high-quality and timely care were identified:
Phase I delay: Delay in deciding to seek care
Phase II delay: Delay in reaching an adequate health facility
Phase III delay: Delay in receiving adequate care once at the health facility

5. Phase I delay: Decision to seek care
Delays can be from woman, the family, or both
Discussed in the literature as ”barriers” or ”constraints” to health-seeking behavior
Driven by the idea that increasing services does not necessarily increase use. What are the factors for under-utilization?
Distance
Cost
Quality of care
Socio-cultural factors

6. Distance Distance a problem (especially in rural areas):
-barrier when attempting to reach health facility
-also acts as a disincentive.
Distance can be compounded by the severity of the condition and the reputation of the provider
Impact of distance has been assessed in the literature by
i. community-based interviews
ii. analysis of facility records
iii. comparing severity of condition hen patients arrive at hospital and relating it to how far they’ve traveled
iv. physical proximity does not necessarily increase utilization

7. Cost Receives considerable attention Cost and distance are linked
-receiving care (transportation, physician costs, facility fees)
-medications and supplies
-opportuity costs (longer distance = higher transport costs)
-compared to other factors, cost of receiving care is not a major determinate in the decision to seek care
Assessed in the literature via
Interviews
Surveys of users and non-users

8. Quality of care
When patients are offered a choice, preference is more important than distance
Preferences are dependent upon patient’s own experiences with service delivery
Affects care-seeking via satisfaction/dis-satisfaction (primarily with institutional factors: procedures, staff attitudes, long waiting times)

9. Socio-cultural factors: identifying the problem
Patient beliefs in relation to etiology of illness play a role in the decision to seek care. Beliefs have less of a role in an urban setting
Characteristics of the illness as perceived by the patient relate to care-seeking and influence judgement of severity
-Perception of a condition as normal or minor interacts with cost and distance
Illness severity is just as important a factor as distance, cost or beliefs about illness causation
Once the decision to seek care is justified by perceived severity, the choice of care is associated with the cause of the illness (defined by patient and family)
Women’s status - Economic status - Educational status

10. Phase II delay: Reaching a medical facility
Once the decision to seek care has been made, how accessible is the health care facility?
Location of health facility
Travel distribution because of location
Transportation required to travel the distance

11. Identifying and reaching the medical facility
General shortage of facilities in low-resource countries
Most are concentrated around urban settings
Distance is important because of travel time and the fact that outcome can occur during travel
Transportation is relevant
Costs are an issue when they exceed expectations or the ability to pay

12. Phase III delay: Receiving adequate treatment
Delays in the delivery of care, as resulting from one or more of:
Staff shortages
Low access to essential equipment
Shortages of supplies, drugs, blood
Inadequate management
Late or wrong diagnoses
Incorrect action by staff

13. Obstacles that are faced in Phases II and III feedback into the decision-making of Phase I
Assessing gravity of situation
Despite proper identification, awareness of transport problems and facility failures still act as a barrier to care-seeking
People do not seek care when they believe they will not be cured, or that they might die at hospital

14. Program strategies Factors that contribute to delays:
distance – cost – care quality – illness – women’s status – economic status – educational status
The paper identifies that most of these problems are out of the hands of individuals

15. Distance: What can be done?
Maternity ward waiting homes
Moving the care to the woman
On-call doctors and midwives
Training traditional birth attendants ?

16. Cost: What can be done?
Paper proposes the development of women’s cooperatives that help pay for services
“Creative experimentation” is called for ??

17. Quality of care: What can be done?
Upgrade care facilities to provide obstetric first aid and treatment
Increase services in established health centers
Create local shops for the purchase of drugs or first-aid items
Provide training programs
Expand the role of midwives and nurses

18. Women’s status and educational status: Overcoming obstacles
Lasting changes require policy amendments at the government level
The paper proposes the development of health professional advocacy programs that target policy change

19. Illness characteristics: What can be done?
Identification of severity has been established as a key factor in the choice to seek care
Programs should harness this known fact and promote community education services for obstetric complications

20. Conclusion Cited in the literature 481 times (Google scholar)
Assessing mortality in low and middle resource settings becomes possible, despite lack of medical records etc
Your experiences??