Transitioning from the "Three Delays" to a focus on continuity of care: a qualitative analysis of maternal deaths in rural Pakistan and Mozambique

doi:10.1186/s12884-023-06055-w

. 2023 Oct 23;23(1):748.

doi: 10.1186/s12884-023-06055-w.

Transitioning from the "Three Delays" to a focus on continuity of care: a qualitative analysis of maternal deaths in rural Pakistan and Mozambique

Marianne Vidler^#¹, Mai-Lei Woo Kinshella^#², Esperanca Sevene^{3

4}, Gwyneth Lewis⁵, Peter von Dadelszen⁶, Zulfiqar Bhutta^{7

8}; CLIP Working Group

Collaborators, Affiliations

Collaborators

CLIP Working Group:
Esperança Sevene, Eusébio Macete, Khátia Munguambe, Charfudin Sacoor, Anifa Vala, Helena Boene, Felizarda Amose, Rosa Pires, Zefanias Nhamirre, Marta Macamo, Rogério Chiaú, Analisa Matavele, Faustino Vilanculo, Ariel Nhancolo, Silvestre Cutana, Ernesto Mandlate, Salésio Macuacua, Cassimo Bique, Sibone Mocumbi, Emília Gonçálves, Sónia Maculuve, Ana Ilda Biz, Dulce Mulungo, Orvalho Augusto, Paulo Filimone, Vivalde Nobela, Corsino Tchavana, Cláudio Nkumbula, Rahat Qureshi, Zulfiqar A Bhutta, Zahra Hoodbhoy, Farrukh Raza, Sana Sheikh, Javed Memon, Imran Ahmed, Amjad Hussain, Mrutunjaya B Bellad, Umesh S Charantimath, Shivaprasad S Goudar, Geetanjali M Katageri, Avinash J Kavi, Amit P Revankar, Ashalata A Mallapur, Umesh Y Ramdurg, Shashidhar G Bannale, Vaibhav B Dhamanekar, Geetanjali I Mungarwadi, Narayan V Honnungar, Bhalachandra S Kodkany, Anjali M Joshi, Uday S Kudachi, Sphoorthi S Mastiholi, Chandrappa C Karadiguddi, Gudadayya S Kengapur, Namdev A Kamble, Keval S Chougala, Jeffrey Bone, Dustin T Dunsmuir, Sharla K Drebit, Chirag Kariya, Tang Lee, Jing Li, Mansun Lui, Beth A Payne, Diane Sawchuck, Sumedha Sharma, Domena K Tu, Ugochi V Ukah, Laura A Magee, JMark Ansermino, Ana Pilar Betrán, Richard Derman, Shafik Dharamsi, France Donnay, Sharla Drebit, Guy Dumont, Susheela M Engelbrecht, Veronique Fillipi, Tabassum Firoz, William Grobman, Marian Knight, Ana Langer, Simon Lewin, Craig Mitton, Nadine Schuurman, Andrew Shennan, Joel Singer, Jim Thornton, Hubert Wong, Olalekan O Adetoro, Khátia Munguambe, John O Sotunsa

Affiliations

¹ Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, Canada. marianne.vidler@cw.bc.ca.
² Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, Canada.
³ Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique.
⁴ Centro de Investigação Em Saúde da Manhiça, Manhiça, Mozambique.
⁵ Bournemouth University, Poole, UK.
⁶ Department of Women & Children's Health, King's College London, London, UK.
⁷ Department of Pediatrics, Aga Khan University, Karachi, Pakistan.
⁸ Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada.

^# Contributed equally.

PMID: 37872504
PMCID: PMC10594808
DOI: 10.1186/s12884-023-06055-w

Transitioning from the "Three Delays" to a focus on continuity of care: a qualitative analysis of maternal deaths in rural Pakistan and Mozambique

Marianne Vidler et al. BMC Pregnancy Childbirth. 2023.

. 2023 Oct 23;23(1):748.

doi: 10.1186/s12884-023-06055-w.

Authors

Marianne Vidler^#¹, Mai-Lei Woo Kinshella^#², Esperanca Sevene^{3

4}, Gwyneth Lewis⁵, Peter von Dadelszen⁶, Zulfiqar Bhutta^{7

8}; CLIP Working Group

Collaborators

CLIP Working Group:
Esperança Sevene, Eusébio Macete, Khátia Munguambe, Charfudin Sacoor, Anifa Vala, Helena Boene, Felizarda Amose, Rosa Pires, Zefanias Nhamirre, Marta Macamo, Rogério Chiaú, Analisa Matavele, Faustino Vilanculo, Ariel Nhancolo, Silvestre Cutana, Ernesto Mandlate, Salésio Macuacua, Cassimo Bique, Sibone Mocumbi, Emília Gonçálves, Sónia Maculuve, Ana Ilda Biz, Dulce Mulungo, Orvalho Augusto, Paulo Filimone, Vivalde Nobela, Corsino Tchavana, Cláudio Nkumbula, Rahat Qureshi, Zulfiqar A Bhutta, Zahra Hoodbhoy, Farrukh Raza, Sana Sheikh, Javed Memon, Imran Ahmed, Amjad Hussain, Mrutunjaya B Bellad, Umesh S Charantimath, Shivaprasad S Goudar, Geetanjali M Katageri, Avinash J Kavi, Amit P Revankar, Ashalata A Mallapur, Umesh Y Ramdurg, Shashidhar G Bannale, Vaibhav B Dhamanekar, Geetanjali I Mungarwadi, Narayan V Honnungar, Bhalachandra S Kodkany, Anjali M Joshi, Uday S Kudachi, Sphoorthi S Mastiholi, Chandrappa C Karadiguddi, Gudadayya S Kengapur, Namdev A Kamble, Keval S Chougala, Jeffrey Bone, Dustin T Dunsmuir, Sharla K Drebit, Chirag Kariya, Tang Lee, Jing Li, Mansun Lui, Beth A Payne, Diane Sawchuck, Sumedha Sharma, Domena K Tu, Ugochi V Ukah, Laura A Magee, JMark Ansermino, Ana Pilar Betrán, Richard Derman, Shafik Dharamsi, France Donnay, Sharla Drebit, Guy Dumont, Susheela M Engelbrecht, Veronique Fillipi, Tabassum Firoz, William Grobman, Marian Knight, Ana Langer, Simon Lewin, Craig Mitton, Nadine Schuurman, Andrew Shennan, Joel Singer, Jim Thornton, Hubert Wong, Olalekan O Adetoro, Khátia Munguambe, John O Sotunsa

Affiliations

¹ Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, Canada. marianne.vidler@cw.bc.ca.
² Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, Canada.
³ Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique.
⁴ Centro de Investigação Em Saúde da Manhiça, Manhiça, Mozambique.
⁵ Bournemouth University, Poole, UK.
⁶ Department of Women & Children's Health, King's College London, London, UK.
⁷ Department of Pediatrics, Aga Khan University, Karachi, Pakistan.
⁸ Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada.

^# Contributed equally.

PMID: 37872504
PMCID: PMC10594808
DOI: 10.1186/s12884-023-06055-w

Abstract

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.

Keywords: Cause of death; Continuity of patient care; Developing countries; Maternal health; Maternal mortality; Narrative analysis; Postnatal period; Quality of health care.

PubMed Disclaimer

Conflict of interest statement

The authors declare no competing interests.

Figures

**Fig. 1**
The Continuity of Care Framework

See this image and copyright information in PMC

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References

1. Kassebaum NJ, et al. Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1775–1812. doi: 10.1016/S0140-6736(16)31470-2. - DOI - PMC - PubMed
1. Rizvi A, Bhatti Z, Das JK, Bhutta ZA. Pakistan and the Millennium Development Goals for Maternal and Child Health: progress and the way forward. Paediatr Int Child Health. 2015;35:287–297. doi: 10.1080/20469047.2015.1109257. - DOI - PubMed
1. Loquiha O, et al. Mapping maternal mortality rate via spatial zero-inflated models for count data: A case study of facility-based maternal deaths from Mozambique. PLoS One. 2018;13:e0202186. doi: 10.1371/journal.pone.0202186. - DOI - PMC - PubMed
1. Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med. 1994;1982(38):1091–1110. doi: 10.1016/0277-9536(94)90226-7. - DOI - PubMed
1. Rosenfield A, Maine D. Maternal mortality- a neglected tragedy. Lancet. 1985;326:83–85. doi: 10.1016/S0140-6736(85)90188-6. - DOI - PubMed

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[1] Kassebaum NJ, et al. Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1775–1812. doi: 10.1016/S0140-6736(16)31470-2. - DOI - PMC - PubMed

[2] Kassebaum NJ, et al. Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1775–1812. doi: 10.1016/S0140-6736(16)31470-2. - DOI - PMC - PubMed

[3] Rizvi A, Bhatti Z, Das JK, Bhutta ZA. Pakistan and the Millennium Development Goals for Maternal and Child Health: progress and the way forward. Paediatr Int Child Health. 2015;35:287–297. doi: 10.1080/20469047.2015.1109257. - DOI - PubMed

[4] Rizvi A, Bhatti Z, Das JK, Bhutta ZA. Pakistan and the Millennium Development Goals for Maternal and Child Health: progress and the way forward. Paediatr Int Child Health. 2015;35:287–297. doi: 10.1080/20469047.2015.1109257. - DOI - PubMed

[5] Loquiha O, et al. Mapping maternal mortality rate via spatial zero-inflated models for count data: A case study of facility-based maternal deaths from Mozambique. PLoS One. 2018;13:e0202186. doi: 10.1371/journal.pone.0202186. - DOI - PMC - PubMed

[6] Loquiha O, et al. Mapping maternal mortality rate via spatial zero-inflated models for count data: A case study of facility-based maternal deaths from Mozambique. PLoS One. 2018;13:e0202186. doi: 10.1371/journal.pone.0202186. - DOI - PMC - PubMed

[7] Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med. 1994;1982(38):1091–1110. doi: 10.1016/0277-9536(94)90226-7. - DOI - PubMed

[8] Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med. 1994;1982(38):1091–1110. doi: 10.1016/0277-9536(94)90226-7. - DOI - PubMed

[9] Rosenfield A, Maine D. Maternal mortality- a neglected tragedy. Lancet. 1985;326:83–85. doi: 10.1016/S0140-6736(85)90188-6. - DOI - PubMed

[10] Rosenfield A, Maine D. Maternal mortality- a neglected tragedy. Lancet. 1985;326:83–85. doi: 10.1016/S0140-6736(85)90188-6. - DOI - PubMed

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Transitioning from the "Three Delays" to a focus on continuity of care: a qualitative analysis of maternal deaths in rural Pakistan and Mozambique

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Affiliations

Transitioning from the "Three Delays" to a focus on continuity of care: a qualitative analysis of maternal deaths in rural Pakistan and Mozambique

Authors

Collaborators

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Abstract

Conflict of interest statement

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