Mgawadere Florence, Unkels Regine, Kazembe Abigail, van den Broek Nynke
Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
Kamuzu College of Nursing, University of Malawi, Zomba, Malawi.
BMC Pregnancy Childbirth. 2017 Jul 12;17(1):219. doi: 10.1186/s12884-017-1406-5.
The three delays model proposes that maternal mortality is associated with delays in: 1) deciding to seek care; 2) reaching the healthcare facility; and 3) receiving care. Previously, the majority of women who died were reported to have experienced type 1 and 2 delays. With increased coverage of healthcare services, we sought to explore the relative contribution of each type of delay.
151 maternal deaths were identified during a 12-month reproductive age mortality survey (RAMOS) conducted in Malawi; verbal autopsy and facility-based medical record reviews were conducted to obtain details about the circumstances surrounding each death. Using the three delays framework, data were analysed for women who had; 1) died at a healthcare facility, 2) died at home but had previously accessed care and 3) died at home and had not accessed care.
62.2% (94/151) of maternal deaths occurred in a healthcare facility and a further 21.2% (32/151) of mothers died at home after they had accessed care at a healthcare facility. More than half of all women who died at a healthcare facility (52.1%) had experienced more than one type of delay. Type 3 delays were the most significant delay for women who died at a healthcare facility or women who died at home after they had accessed care, and was identified in 96.8% of cases. Type 2 delays were experienced by 59.6% and type 1 delays by 39.7% of all women. Long waiting hours before receiving treatment at a healthcare facility, multiple delays at the time of admission, shortage of drugs, non-availability and incompetence of skilled staff were some of the major causes of type 3 delays. Distance to a healthcare facility was the main problem resulting in type 2 delays.
The majority of women do try to reach health services when an emergency occurs, but type 3 delays present a major problem. Improving quality of care at healthcare facility level will help reduce maternal mortality.
三延误模型提出，孕产妇死亡与以下三方面的延误相关：1）决定寻求医疗护理；2）抵达医疗机构；3）接受医疗护理。此前，据报告大多数死亡妇女经历了第1类和第2类延误。随着医疗服务覆盖范围的扩大，我们试图探究各类延误的相对影响。
在马拉维进行的一项为期12个月的育龄期死亡率调查（RAMOS）中确定了151例孕产妇死亡病例；通过口头尸检和基于医疗机构的病历审查来获取每例死亡情况的详细信息。使用三延误框架，对以下几类妇女的数据进行了分析：1）在医疗机构死亡的妇女；2）在家中死亡但此前曾接受过医疗护理的妇女；3）在家中死亡且未接受过医疗护理的妇女。
62.2%（94/151）的孕产妇死亡发生在医疗机构，另有21.2%（32/151）的母亲在医疗机构接受过护理后在家中死亡。在医疗机构死亡的所有妇女中，超过一半（52.1%）经历了不止一种类型的延误。对于在医疗机构死亡的妇女或在接受护理后在家中死亡的妇女，第3类延误是最显著的延误，在96.8%的病例中都有出现。所有妇女中有59.6%经历了第2类延误，39.7%经历了第1类延误。在医疗机构接受治疗前等待时间过长、入院时多次延误、药品短缺、缺乏熟练工作人员以及工作人员能力不足是第3类延误的一些主要原因。距离医疗机构较远是导致第2类延误的主要问题。
大多数妇女在紧急情况发生时确实会设法前往医疗服务机构，但第3类延误是一个主要问题。提高医疗机构层面的护理质量将有助于降低孕产妇死亡率。
