Why are women dying when they reach hospital on time? A systematic review of the 'third delay'

PLoS One. 2013 May 21;8(5):e63846. doi: 10.1371/journal.pone.0063846. Print 2013.


Background: The 'three delays model' attempts to explain delays in women accessing emergency obstetric care as the result of: 1) decision-making, 2) accessing services and 3) receipt of appropriate care once a health facility is reached. The third delay, although under-researched, is likely to be a source of considerable inequity in access to emergency obstetric care in developing countries. The aim of this systematic review was to identify and categorise specific facility-level barriers to the provision of evidence-based maternal health care in developing countries.

Methods and findings: Five electronic databases were systematically searched using a 4-way strategy that combined search terms related to: 1) maternal health care; 2) maternity units; 3) barriers, and 4) developing countries. Forty-three original research articles were eligible to be included in the review. Thirty-two barriers to the receipt of timely and appropriate obstetric care at the facility level were identified and categorised into six emerging themes (Drugs and equipment; Policy and guidelines; Human resources; Facility infrastructure; Patient-related and Referral-related). Two investigators independently recorded the frequency with which barriers relating to the third delay were reported in the literature. The most commonly cited barriers were inadequate training/skills mix (86%); drug procurement/logistics problems (65%); staff shortages (60%); lack of equipment (51%) and low staff motivation (44%).

Conclusions: This review highlights how a focus on patient-side delays in the decision to seek care can conceal the fact that many health facilities in the developing world are still chronically under-resourced and unable to cope effectively with serious obstetric complications. We stress the importance of addressing supply-side barriers alongside demand-side factors if further reductions in maternal mortality are to be achieved.

Publication types

  • Meta-Analysis
  • Research Support, Non-U.S. Gov't
  • Review
  • Systematic Review

MeSH terms

  • Emergency Medical Services / statistics & numerical data
  • Female
  • Health Facilities / statistics & numerical data
  • Health Policy
  • Hospitals / statistics & numerical data*
  • Humans
  • Maternal Mortality*
  • Models, Theoretical
  • Pharmaceutical Preparations
  • Practice Guidelines as Topic
  • Pregnancy
  • Referral and Consultation
  • Time Factors


  • Pharmaceutical Preparations

Grants and funding

The authors have no support or funding to report.