Transitioning from the “Three Delays” to a focus on continuity of care: a qualitative analysis of maternal deaths in rural Pakistan and Mozambique
Vidler M., Kinshella MLW., Sevene E., Lewis G., von Dadelszen P., Bhutta Z., Sevene E., Macete E., Munguambe K., Sacoor C., Vala A., Boene H., Amose F., Pires R., Nhamirre Z., Macamo M., Chiaú R., Matavele A., Vilanculo F., Nhancolo A., Cutana S., Mandlate E., Macuacua S., Bique C., Mocumbi S., Gonçálves E., Maculuve S., Biz AI., Mulungo D., Augusto O., Filimone P., Nobela V., Tchavana C., Nkumbula C., Qureshi R., Bhutta ZA., Hoodbhoy Z., Raza F., Sheikh S., Memon J., Ahmed I., Hussain A., Bellad MB., Charantimath US., Goudar SS., Katageri GM., Kavi AJ., Revankar AP., Mallapur AA., Ramdurg UY., Bannale SG., Dhamanekar VB., Mungarwadi GI., Honnungar NV., Kodkany BS., Joshi AM., Kudachi US., Mastiholi SS., Karadiguddi CC., Kengapur GS., Kamble NA., Chougala KS., Bone J., Dunsmuir DT., Drebit SK., Kariya C., Lee T., Li J., Lui M., Payne BA., Sumedha Sharma DS., Tu DK., Ukah UV., Magee LA., Ansermino JM., Betrán AP., Derman R., Dharamsi S., Donnay F., Dumont G., Engelbrecht SM., Filippi V., Firoz T., Grobman W., Knight M., Langer A., Lewin S., Mitton C., Schuurman N., Shennan A., Singer J., Thornton J., Wong H., Adetoro OO., Sotunsa JO.
Background: The Three Delays Framework was instrumental in the reduction of maternal mortality leading up to, and during the Millennium Development Goals. However, this paper suggests the original framework might be reconsidered, now that most mothers give birth in facilities, the quality and continuity of the clinical care is of growing importance. Methods: The paper explores the factors that contributed to maternal deaths in rural Pakistan and Mozambique, using 76 verbal autopsy narratives from the Community Level Interventions for Pre-eclampsia (CLIP) Trial. Results: Qualitative analysis of these maternal death narratives in both countries reveals an interplay of various influences, such as, underlying risks and comorbidities, temporary improvements after seeking care, gaps in quality care in emergencies, convoluted referral systems, and arrival at the final facility in critical condition. Evaluation of these narratives helps to reframe the pathways of maternal mortality beyond a single journey of care-seeking, to update the categories of seeking, reaching and receiving care. Conclusions: There is a need to supplement the pioneering “Three Delays Framework” to include focusing on continuity of care and the “Four Critical Connection Points”: (1) between the stages of pregnancy, (2) between families and health care workers, (3) between health care facilities and (4) between multiple care-seeking journeys. Trial registration: NCT01911494, Date Registered 30/07/2013.