Conceptualising the prevention of adverse obstetric outcomes among immigrants using the 'three delays' framework in a high-income context

Soc Sci Med. 2012 Dec;75(11):2028-36. doi: 10.1016/j.socscimed.2012.08.010. Epub 2012 Aug 21.


Women from high-mortality settings in sub-Saharan Africa can remain at risk for adverse maternal outcomes even after migrating to low-mortality settings. To conceptualise underlying socio-cultural factors, we assume a 'maternal migration effect' as pre-migration influences on pregnant women's post-migration care-seeking and consistent utilisation of available care. We apply the 'three delays' framework, developed for low-income African contexts, to a high-income western scenario, and aim to identify delay-causing influences on the pathway to optimal facility treatment. We also compare factors influencing the expectations of women and maternal health providers during care encounters. In 2005-2006, we interviewed 54 immigrant African women and 62 maternal providers in greater London, United Kingdom. Participants were recruited by snowball and purposive sampling. We used a hermeneutic, naturalistic study design to create a qualitative proxy for medical anthropology. Data were triangulated to the framework and to the national health system maternity care guidelines. This maintained the original three phases of (1) care-seeking, (2) facility accessibility, and (3) receipt of optimal care, but modified the framework for a migration context. Delays to reciprocal care encounters in Phase 3 result from Phase 1 factors of 'broken trust, which can be mutually held between women and providers. An additional factor is women's 'negative responses to future care', which include rationalisations made during non-emergency situations about future late-booking, low-adherence or refusal of treatment. The greatest potential for delay was found during the care encounter, suggesting that perceived Phase 1 factors have stronger influence on Phase 3 than in the original framework. Phase 2 'language discordance' can lead to a 'reliance on interpreter service', which can cause delays in Phase 3, when 'reciprocal incongruent language ability' is worsened by suboptimal interpreter systems. 'Non-reciprocating care conceptualisations', 'limited system-level care guidelines', and 'low staff levels' can additionally delay timely care in Phase 3.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Africa / ethnology
  • Cultural Characteristics
  • Emigrants and Immigrants / psychology*
  • Female
  • Health Services Accessibility / statistics & numerical data*
  • Humans
  • London
  • Maternal Health Services / standards
  • Maternal Health Services / statistics & numerical data*
  • Middle Aged
  • Patient Acceptance of Health Care / statistics & numerical data*
  • Practice Guidelines as Topic
  • Pregnancy
  • Pregnancy Complications / prevention & control*
  • Qualitative Research
  • Risk Factors
  • Socioeconomic Factors
  • Time-to-Treatment / statistics & numerical data*
  • Young Adult