Commentary: Reasons for Persistently High Maternal and Perinatal Mortalities in Ethiopia: Part III–Perspective of the “Three Delays” Model

Abstract

From the experience of high-income countries, the occurrence of all obstetric complications may not be preventable but almost all are treatable before resulting in serious maternal and perinatal morbidity and mortality (1, 2). The interventions may start at preconception; however, providing optimal obstetric care for all pregnant women starting from early pregnancy up to the end of puerperium has paramount significance in the reduction of maternal and perinatal deaths. Specific to low and middle-income countries, improving the intrapartum monitoring and access to a cesarean section and blood transfusion were highly recommended as key interventions to reduce maternal and perinatal deaths (3, 4). According to the Federal Ministry of Health of Ethiopia 2011/2012 Health and Health Related Indicators report, however, the proportion of at least four visits antenatal care was 19%; total births attended by skilled health personnel were 16.6%; and the proportion of cesarean delivery was about 1% (5), while the WHO cesarean delivery recommendation is 5%–15% for the general population (6). These reports indicate the big gap in utilizing reproductive health services before and after conception. In addressing issues regarding maternal and perinatal death rates, the “three delay” model is frequently used to consider factors that may be obstacles for women receiving appropriate medical care. The three delay model was initially proposed by Thaddeus and Maine in 1990 (7). The components of this model include the delays of the decision to seek health care (8), the ability to get access to a health facility (9) and receiving medical care timely and appropriately once the facility is reached (10). It is generally recognized that diminished access to facilities providing emergency obstetric care contributes to increased maternal and perinatal mortality (11, 12). The purpose of this review was to look into the high maternal and perinatal mortality from the perspective of the three delays models and to show the complexity and interlink of predisposing factors for maternal and perinatal deaths. As discussed in other articles (13, 14), the factors for high maternal and perinatal mortality in the last three decades were multidimensional (the extremely low number of health facilities and health professionals, low adult literacy rate, low utilization of contraceptive methods, high total fertility rate, high early marriage and adolescent pregnancy, low antenatal care service, low skilled person attended deliveries, and rampant harmful traditional practices). The main focus of this review is the “Delay Model”. To summarize these complex and interlinked factors for the increased risk of maternal and perinatal deaths in Ethiopia, a simplified schematic presentation from the perspective of the “three delays” model (Figure 1). As a complimentary, two more schematic presentations were developed from the perspective of “etiologic” factors (Figure 2), and to show the multidimensional nature of maternal mortality (Figure 3). Open in a separate window Figure 1 Contextual factors that contribute to high maternal and perinatal mortality in Ethiopia, using the “Delay model”