GSRHR course 2010 The Three Delays Model Pauline Binder, PhD student Medical anthropologist Women’s and Children’s Health Int’l Maternal and Child Health (IMCH)

Aims To explore the interval between the onset of obstetric complication and its outcome To help guide efforts to create programs aimed at the prevention of maternal mortality

Methods Multidisciplinary literature review Looking primarily from the social sciences as applied to the safe motherhood Emphasis of original article is in Africa

Conceptual framework Based on the findings from the literature review, three likely obstacles to providing and utilizing high-quality and timely care were identified: Phase I delay: Delay in deciding to seek care Phase II delay: Delay in reaching an adequate health facility Phase III delay: Delay in receiving adequate care once at the health facility

Phase I delay: Decision to seek care Delays can be from woman, the family, or both Discussed in the literature as ”barriers” or ”constraints” to health-seeking behavior Driven by the idea that increasing services does not necessarily increase use. What are the factors for under-utilization? Distance Cost Quality of care Socio-cultural factors

Distance Distance a problem (especially in rural areas): -barrier when attempting to reach health facility -also acts as a disincentive. Distance can be compounded by the severity of the condition and the reputation of the provider Impact of distance has been assessed in the literature by i. community-based interviews ii. analysis of facility records iii. comparing severity of condition hen patients arrive at hospital and relating it to how far they’ve traveled iv. physical proximity does not necessarily increase utilization

Cost Receives considerable attention Cost and distance are linked -receiving care (transportation, physician costs, facility fees) -medications and supplies -opportuity costs (longer distance = higher transport costs) -compared to other factors, cost of receiving care is not a major determinate in the decision to seek care Assessed in the literature via Interviews Surveys of users and non-users

Quality of care When patients are offered a choice, preference is more important than distance Preferences are dependent upon patient’s own experiences with service delivery Affects care-seeking via satisfaction/dis-satisfaction (primarily with institutional factors: procedures, staff attitudes, long waiting times)

Socio-cultural factors: identifying the problem Patient beliefs in relation to etiology of illness play a role in the decision to seek care. Beliefs have less of a role in an urban setting Characteristics of the illness as perceived by the patient relate to care-seeking and influence judgement of severity -Perception of a condition as normal or minor interacts with cost and distance Illness severity is just as important a factor as distance, cost or beliefs about illness causation Once the decision to seek care is justified by perceived severity, the choice of care is associated with the cause of the illness (defined by patient and family) Women’s status - Economic status - Educational status

Phase II delay: Reaching a medical facility Once the decision to seek care has been made, how accessible is the health care facility? Location of health facility Travel distribution because of location Transportation required to travel the distance

Identifying and reaching the medical facility General shortage of facilities in low-resource countries Most are concentrated around urban settings Distance is important because of travel time and the fact that outcome can occur during travel Transportation is relevant Costs are an issue when they exceed expectations or the ability to pay

Phase III delay: Receiving adequate treatment Delays in the delivery of care, as resulting from one or more of: Staff shortages Low access to essential equipment Shortages of supplies, drugs, blood Inadequate management Late or wrong diagnoses Incorrect action by staff

Obstacles that are faced in Phases II and III feedback into the decision-making of Phase I Assessing gravity of situation Despite proper identification, awareness of transport problems and facility failures still act as a barrier to care-seeking People do not seek care when they believe they will not be cured, or that they might die at hospital

Program strategies Factors that contribute to delays: distance – cost – care quality – illness – women’s status – economic status – educational status The paper identifies that most of these problems are out of the hands of individuals

Distance: What can be done? Maternity ward waiting homes Moving the care to the woman On-call doctors and midwives Training traditional birth attendants ?

Cost: What can be done? Paper proposes the development of women’s cooperatives that help pay for services “Creative experimentation” is called for ??

Quality of care: What can be done? Upgrade care facilities to provide obstetric first aid and treatment Increase services in established health centers Create local shops for the purchase of drugs or first-aid items Provide training programs Expand the role of midwives and nurses

Women’s status and educational status: Overcoming obstacles Lasting changes require policy amendments at the government level The paper proposes the development of health professional advocacy programs that target policy change

Illness characteristics: What can be done? Identification of severity has been established as a key factor in the choice to seek care Programs should harness this known fact and promote community education services for obstetric complications

Conclusion Cited in the literature 481 times (Google scholar) Assessing mortality in low and middle resource settings becomes possible, despite lack of medical records etc Your experiences??