Three Delays Model

Three Delays Model


Distance and transport
In Zimbabwe up to 50% of the maternal deaths from haemorrhage can be attributed to the absence of emergency transport. [1]
Since a few years the so called ‘three delays model’ has been asserted as tool to identify problems in reaching a dropdown or MMR. The first level of delay is concerned with the decision to seek care. Problems in this phase can occur as a result of lacking knowledge, recognition, cultural believes and convictions or previous experiences with health systems and can be prevented by providing adequate and cultural sensitive education to women and their social environment concerning maternal health.

The second level of delay is related to reaching a health care facility. Safely and timely arriving at a centre can be impaired or endangered by issues like lacking (financial means for) transportation or unequal (or even absent) distribution of health care facilities. Especially the current unequal distribution of medical care within many developing countries reflects a highly problematic situation. Although four-fifth of India’s population lives in rural areas only one-fifth of the physicians are settled there. Hence, in many African countries the health care coverage is largely restricted to cities which results in lacking obstetric care in parts of the countries where most citizens are resided. (Post) conflict areas are also subject to specific distribution problems. Governmental fear that refugee camps will turn into small villages as refugees prolong their residence contribute to the resistance of implementing protracted and adequate obstetric facilities. The open air refugee camp in Khartoum, containing more than 38.000 refugees, is one of those camps lacking basic health care facilities. Those populations who seek refuge within the national borders are also, and sometimes even more directly, faced with lacking facilities. Reproductive health care for these so called internally displaced persons (IDP’s), has long time been neglected, despite the fact that this group exists currently out of almost 25 million people. One illustrative example is the case of Lebanon. Only one third of the IDP’s within Lebanon live in a refugee settlement[2]. This means that the remaining two third of this population lives unregistered and often far away from maternity services and obstetric care. Research has proven that the increase in negative maternal outcomes within this country is most strongly caused by a decrease in use of health services by pregnant women. Currently, Lebanon is flooded with Syrian refugees who, just as the IDP’s, seek refuge often in empty buildings or small communities difficult to reach and far away from healthcare facilities. Flexible facilities are therefore needed to reach all segments of the displaced populations and those living in rural and underdeveloped areas.
The third level of delay is problems related to the quality of the care provided to women and their infants. Shortages in supplies, equipment, lack of (trained) personnel and incompetence of staff are challenges headed under this third delay[3].
Most common barriers [4]

  • Inadequate skills
  • Staff shortages
  • Lack of equipment  
Research has shown that specifically shortages of power and water delayed the treatment and caused care to be severely substandard. Nevertheless, absence of skilled personnel and lacking skills of available personnel accounted for the most often reoccurring argument headed under the third delay, strongly contributing to an ongoing high average of maternal mortality. Although it is sometimes difficult to establish a causal link between skilled attended births and maternal mortality estimates suggest that 16% till 33% of the maternal deaths could have been prevented if skilled personnel would have been present[5]. Therefore, one of the identified key strategies to reduce maternal deaths is to increase the availability of skilled health professionals to supervise deliveries. The global target for 2015 is that at least 90% of the deliveries are supervised by a skilled birth attendant. Sadly, researchers have calculated that between 2011 and 2015 less than 50% of the deliveries will be attended by skilled personnel. 180 million deliveries within sub-Saharan Africa and South Asia will be unattended, with the largest amounts of unattended births, around 90%, taking place in rural areas. Hence, the quality of the staff that attends births is also a key factor. According to the WHO World Health Report 2005 access to good quality obstetric care could prevent between 50% and 70% of the global maternal deaths.  This short elaboration shows the ongoing importance to focus on all three of the delays but definitely on the second (access) and third (quality of the care provided) one.

[1] Ensor, T. & Cooper, S. (2004). Overcoming barriers to health service access: influencing the demand side. Health Policy and Planning 19, p. 69 – 79.  
[2] Kabakian-Khasholian, T., Shayboub, R. &  El-Kak, F. (2012). Seeking Maternal Care in Times of Conflict: The Case of Lebanon. Health Care for Women International, 34, p. 352 – 362.
[3] Knight, E. H., Self, A. & Kennedy, S. H. (2012). Why are Women Dying When They Reach Hospital On Time? A Systematic Review of the Third Delay. PLOS ONE, 8, p. 1 – 9.
[4] IRC. (2013). Syria: A Regional Crisis. Retrieved on July 11, 2013 from:
[5] Crowe, S., Utley, M., Costello, A. & Pagel, C. (2012). How many births in sub-Saharan Africa and
South Asia will not be attended by a skilled birth attendant between 2011 and 2015? BMC Pregnancy & Childbirth, 12, p. 1 – 9.