Factors associated with maternal mortality in Malawi: application of the three delays model

BMC Pregnancy Childbirth. 2017 Jul 12;17(1):219. doi: 10.1186/s12884-017-1406-5.


Background: 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.

Method: 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.

Results: 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.

Conclusion: 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.

Keywords: Contributing factors; Maternal death review; Maternal mortality; Three delays model.

MeSH terms

  • Adolescent
  • Adult
  • Cause of Death
  • Female
  • Health Facilities / statistics & numerical data*
  • Health Services Accessibility / statistics & numerical data*
  • Humans
  • Malawi
  • Maternal Death / etiology
  • Maternal Health Services / statistics & numerical data*
  • Maternal Mortality*
  • Middle Aged
  • Patient Acceptance of Health Care / statistics & numerical data*
  • Pregnancy
  • Surveys and Questionnaires
  • Young Adult