“Three delays” model

and story of Mrs. X

Dr. Gati Ara Syed
MBBS, CEFM, FCPS
Assistant Professor
Dow Medical College
Dow University of Health Sciences
Learning Objectives

To
 Define reproductive health and its components
 Define maternal death
 Identify global causes of maternal death
 Classify causes of maternal mortality
 Analyze Three Delays Model
 Scrutinize the multifactorial issues affecting three delays
 Advise the strategies to prevent three delays
 Define the background and purpose of lecture/ movie: Why
did Mrs. X die?
 Describe the maternal death road of Mrs. X
 Propose basic elements of comprehensive and integrated
strategy for mothers survival
Reproductive health

“A state of complete physical, mental, social

and spiritual wellbeing, not merely the
absence of disease and infirmity in all matters
relating to the reproductive system and its
functions and processes. Reproductive health
therefore implies that people are able to have
a satisfying and safe sex life and that they
have a capability to reproduce and the
freedom to decide if, when and how often to
do so”
Components of Reproductive health

1. Safe motherhood
2. Prevention and control of reproductive tract infections
3. Sexually transmitted infections including HIV/AIDS
4. Sub- fertilify
5. Malignancies of reproductive tract
6. Newborn care
Key components:
a. Familiy planning
b. Sex health
c. Maternal health
Maternal Death

“Death of a woman while pregnant or within 42

days of termination of pregnancy, irrespective of
the site and duration of pregnancy, by causes
related to or aggravated by the pregnancy or its
management but NOT due to accidental or incidental
causes”
 Maternal mortality key facts
 Every day in 2020, almost 800 women died from preventable
causes related to pregnancy and childbirth.
 Between 2000 and 2020, the maternal mortality ratio (MMR,
number of maternal deaths per 100 000 live births) dropped by
about 34% worldwide.
 Almost 95% of all maternal deaths occurred in low and lower
middle-income countries in 2020.
 Care by skilled health professionals before, during and after
childbirth can save the lives of women and newborns.
 The global MMR in 2020 was 223 per 100,000 live births
 Global causes of maternal mortality
 Direct maternal death (direct obstetric death) that is the
result of a complication of the pregnancy, delivery, or management
of the two.
E.g. PPH, Sepsis, Eclampsia, Obstructed labor

 An Indirect maternal death (Indirect obstetric deaths) are

those maternal deaths “resulting from previous existing disease or
disease that developed during pregnancy and not due to direct
obstetric causes but were aggravated by the physiologic effects of
pregnancy”.
E.g. deaths due to aggravation (by pregnancy) of an existing
cardiac or renal disease.
Other definitions

 Latematernal death: death of a woman

from direct or indirect causes more than 42
days but less than one year after the
termination of pregnancy.
 Pregnancy related death: death of a
woman during or within 42 days of the
termination of pregnancy irrespective of the
cause of death.
 Indicators of maternal mortality

 Maternal
mortality Ratio: number of women dying in
pregnancy and child birth per 100,000 live births
 Maternalmortality rate: number of women dying in
pregnancy and childbirth per 100,000 women aged 15-
49 years
 Proportional
maternal death: proportion of adult female
deaths due to maternal causes.
 Lifetime
risk (L TR) of maternal death: LTR reflects the
chances of a woman dying from maternal causes over
her 35 year reproductive life span.
Global distribution of the causes of
maternal mortality
 How can women’s lives be saved?

 Severe bleeding after birth can kill a healthy woman within

hours if she is unattended. Injecting oxytocics immediately
after childbirth effectively reduces the risk of bleeding.
 Infection after childbirth can be eliminated if good hygiene
is practiced and if early signs of infection are recognized and
treated in a timely manner.
 Pre-eclampsia should be detected and appropriately
managed before the onset of convulsions (eclampsia) and
other life-threatening complications. Administering drugs
such as magnesium sulfate for pre-eclampsia can lower a
woman’s risk of developing eclampsia.
Sustainable Development Goal 3

 3.1. Maternal mortality

By 2030, reduce the global

maternal mortality ratio to less
than 70 per 100 000 live births,
with no country having a maternal
mortality rate of more than twice
the global average
 Three Delays Model
 Delays leading to maternal death are often multi-factorial.
 Deaths can be prevented by reducing delays at three points:

1.The decision to access care

2.The identification of – and transport to – a
healthcare facility
3.The receipt of adequate and appropriate
treatment.
Factors affecting the three delays
DELAY I: Delay in decision to
seek care

 The low status of women

 Socio cultural barriers
 Poor understanding of complications and risk
factors in pregnancy and when to seek medical
help
 Previous poor experience of health care
 Acceptance of maternal death
 How it can be prevented?
 Provide communities (men and women) with information on pregnancy,
childbirth and newborn healthcare so they know when to seek medical
help.

 Facilitate income generation schemes for women to enable them to

become financially independent and empowered to make decisions
about their own sexual and reproductive health and to become future
leaders

 Gender equity

 Couple empowerment, female empowerment

DELAY II. Delay in reaching
care
 Distance to health centres and hospitals
 Availability of and cost of transportation
 Poor roads and infrastructure
 Geography e.g. mountainous terrain, rivers
 Poor referral system
Mountainous terrains, poor road infrastructure
and lack of transport leading to Delay in
Reaching Care
 How it can be prevented ?

 Provision of health centres in rural and remote areas

as well as outreach healthcare workers visiting villages
to provide care.
 Building waiting houses next to health centres for
expectant mothers to stay in before their due date so
when they go into labour assistance is on site
 Provision of motorbike ambulances for mountainous
terrain to improve access to health centres
Motorbike ambulances and waiting
houses for expectant mothers.
DELAY III. Delay in receiving
adequate health care
 Poor facilities and lack of medical supplies
 Inadequately trained and poorly motivated
medical staff
 Inadequate referral systems
 Poor training/ lack of motivation of personnel
 Lack of finances
How it can be prevented?

 Training local midwives who will remain in rural

areas when qualified.
 Training nurses, doctors and healthcare
professionals to provide safe births.
 Ensuring health centres are suitably equipped to
provide safe deliveries and improving referral
systems between health centres and hospitals.
 Lesson:
This three-delay model illustrated that maternal
mortality was not due solely to a lack of economic
and human resources but was a product of
numerous interwoven factors.

A poor patient outcome is likely to result if any of

these factors contribute to an undue delay. For
example, an inability to recognize an emergency
may extend the delay in the decision to seek care.
 While the ability of the patient or a caregiver to
recognize an emergency is partially dependent
upon the patient’s or caregiver’s level of
education.

Studies have shown that true obstetric

emergencies may not be perceived as
emergencies in areas where they commonly
occur.

Additionally, in various cultures, women’s status

can affect both the ability of women to decide to
seek care and their subsequent ability to reach
care.
 Why did Mrs. X die?
 In 1988 the World Health Organization made a film based
on a lecture by the obstetrician professor Mahmoud Fathalla.
 Its aim was to raise awareness of the millions of women and babie
s dying each year from pregnancy and childbirth.
 The film told the story of one such mother--- Mrs. X.
It was called Why Did Mrs. X Die?
 Since then, there have been significant improvements in maternal
health, yet by no means enough.
 In some places, things have hardly changed-- women and their bab
ies are still dying needlessly.
 This is why the story of Mrs. X must be retold.
Why did Mrs. X die?
The maternal death road i
s still busy with this one way
traffic, and still several
hundreds of women, in the
prime of their lives, are to be
found lying dead by the side
or at the end of it every day.
Strategy for mothers’ survival
A comprehensive and integrated strategy for mothers survival should have the
following basic elements to address the maternal health needs of
 all women,
 all women in the reproductive age period,
 all pregnant women,
 all women in labour, women with high risk pregnancy, and
 women with obstetric life-threatening complications:

 Advancement of the status of women: for all women

 Birth planning: for all women in the reproductive age period
 Community-based prenatal services; for all pregnant women
 Delivery by a trained birth attendant: for all women in labour
 Essential obstetric functions: for women with high risk pregnancy
 Facilities for emergency transport: for women with obstetric life-
 All of us who believe in the beauty of the dream of safe motherhood f
or all
are not giving up hope.
 We are inspired by the success already achieved in several countries.
 We call upon all who care--
men and women from all over this world, rich or poor, in the North an
d South-- to join and play their part.
 Safe pregnancy and childbirth, joy, celebration, and pride for women
should be a basic human right and not a tragedy in a 21st century wo
rld.

Thank you.
References:

 Public Health and Community Medicine- Ilyas. 8th Edition Pg. 916-38
 Park’s textbook of Preventive and Social Medicine. 24th Edition. Pg.
521-99
 file:///C:/
Users/DUHS/Downloads/Why_did_Mrs_X_die_Launch_of_the_Safe_Mot.
pdf

 http
://apps.who.int/iris/bitstream/handle/10665/259947/WHO-RHR-18.02-
eng.pdf;jsessionid=8113365FD531F62F7E18F3585CC01880?sequenc
e=1#:~:
text=The%202016%20WHO%20ANC%20model,offers%20psychosoci
al%20and%20emotional%20support
 https://youtu.be/gS7fCvCIe1k
 https://