ABSTRACT

The objective of this review is to summarize evidence available in the scientific literature from the applicability of the Three Delays Model in the context of maternal mortality in terms of causal factors and interventional measures. It is an integrative literature review, carried out with no time frame, in seven databases, with the descriptors Maternal Mortality, Pregnancy Complications, Maternal Death and the keyword Three Delays Model. 15 studies were selected for analysis. The first delay stood out as a determinant of maternal deaths, with the refusal to seek obstetric care in the health institution an initiative of the woman or family members. In the second delay, geographic factors and poor road infrastructure made access to health services difficult. In the third delay, the care conditions in the health institutions implied a reduced quality of care. The applicability of the model makes it possible to demonstrate the barriers faced by women in the search for obstetric care and to visualize contexts that need interventional actions to face the problem.

KEYWORDS
Maternal mortality; Pregnancy complications; Mortality; Models, theoretical; Cause of death

Introduction

The universal and opportune access to health care services in all stages of life cycle arises as a challenge for the global health care systems¹1 Pan American Health Organization. Strategy for universal access to health and universal health coverage. Proceedings of the 53rd Directing Council (CD53/5, Rev. 2). 2014. [acesso em 2019 out 31]. Disponível em: http://www.paho.org/hq/dmdocuments/2014/CD53-5-e.pdf.
http://www.paho.org/hq/dmdocuments/2014/... ,²2 Kassara SB, Melo AMC, Coutinho SB, et al. Determinants of neonatal death with emphasis on health care during pregnancy, childbirth and reproductive history. J. Pediatr. 2013; 89(3):269-77.. In the context of the pregnancy-puerperium cycle, the ensuring immediate and qualified access to the assistance constitutes determining factor of maternal-infant health, inasmuch as it congregates events with greater possibility of clinical and/or obstetric intercurrences³3 Parada CMGL. An evaluation of the prenatal and puerperal care provided in an upstate region of the State of São Paulo in 2005. Rev. Bras. Saúde Mater. Infant. 2008 [acesso em 2022 out 14]; 8(1):113-124. Disponível em: https://www.scielo.br/j/rbsmi/a/xQqxyNNCb-jFgsG9GdMJg8Nh/abstract/?lang=pt.
https://www.scielo.br/j/rbsmi/a/xQqxyNNC... ,⁴4 Silva ALS, Almeida LCG. Experience of women facing the pilgrimage for childbirth]. Rev. Eletrôn. Atualiza Saúde. 2015 [acesso em 2020 maio 8]; 2(2):7-19. Disponível em: http://atualizarevista.com.br/wp-content/uploads/2015/07/Viv%C3%AAncia-de-mulheres-frente-%C3%A0-peregrina%C3%A7%C3%A3o-para-o-parto-v.2-n.2.pdf.
http://atualizarevista.com.br/wp-content... .

When the health care systems are not sufficient or limited to meet women’s demands or the inequalities and barriers prevent their effective outreach, it leads to a journey throughout the health care services system in search of assistance, that may cause an aggravation of the clinical pictures and negative outcomes, such as near miss and maternal death³3 Parada CMGL. An evaluation of the prenatal and puerperal care provided in an upstate region of the State of São Paulo in 2005. Rev. Bras. Saúde Mater. Infant. 2008 [acesso em 2022 out 14]; 8(1):113-124. Disponível em: https://www.scielo.br/j/rbsmi/a/xQqxyNNCb-jFgsG9GdMJg8Nh/abstract/?lang=pt.
https://www.scielo.br/j/rbsmi/a/xQqxyNNC... ,⁴4 Silva ALS, Almeida LCG. Experience of women facing the pilgrimage for childbirth]. Rev. Eletrôn. Atualiza Saúde. 2015 [acesso em 2020 maio 8]; 2(2):7-19. Disponível em: http://atualizarevista.com.br/wp-content/uploads/2015/07/Viv%C3%AAncia-de-mulheres-frente-%C3%A0-peregrina%C3%A7%C3%A3o-para-o-parto-v.2-n.2.pdf.
http://atualizarevista.com.br/wp-content... . In spite the improvement of the indicators, the maternal mortality is yet considered high in developing countries, and many advancements are necessary to reach the targets of the 2030 Agenda⁵5 Souza JP. A mortalidade materna e os novos objetivos de desenvolvimento sustentável (2016-2030). Rev. Bras. Ginecol Obstet. 2015 [acesso em 2021 set 25]; 37(12):549-551. Disponível em: https://doi.org/10.1590/SO100-720320150005526.
https://doi.org/10.1590/SO100-7203201500... , especially in order to elucidate the causes of maternal mortality and to direct efforts for the proposition of interventions.

In this sense, in order to understand maternal deaths, theoretical approach⁶6 Rosenfield A, Maine D. Maternal mortality-a neglected tragedy: Where is the M in MCH?. The Lancet. 1985; 2(8446):83-5. that correlates this phenomenon to the use of health care services during pregnancy, childbirth or puerperium has revealed that the negative outcomes were associated to previous complications, to the delays in the women’s access to the institutions of reference and to the progression to potentially serious situations.

This theoretical model proposed in the nineties, named Three Delays Model⁶6 Rosenfield A, Maine D. Maternal mortality-a neglected tragedy: Where is the M in MCH?. The Lancet. 1985; 2(8446):83-5.,⁷7 Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Sm. Sci. Med. 1994; 38(8):1091-1110., when involving knowledge of different areas, such as Anthropology, Geography and Social Sciences, has become a reference to the analysis of the social causes that involve maternal deaths, since it highlighted not only its causal sequence, but, also, social and behavioral causes, related to individuals, to families and to communitarian contexts, correlating them to the access to health care systems⁸8 Kalter HD, Salgado R, Babille M, et al. Social autopsy for maternal and child deaths: a comprehensive literature review to examine the concept and the development of the method. Popul Health Metrics. 2011; (9):45..

The model is based on the identification and combination of factors and evidences related and grouped in three delays that may prevent women from receiving necessary maternal health care. The first delay refers to the decision of seeking for health care, the second is related to the path for reaching and obtaining care; and, finally, the third delay corresponds to the receiving of the adequate care in the access of health care services⁷7 Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Sm. Sci. Med. 1994; 38(8):1091-1110..

A synthesis of the evidences on the utilization of the Three Delays Model that included studies carried out in África, Ásia, Latin America and Caribbean described its potential in identifying barriers in the access to obstetric care in low and average-income countries, although with limited use in the triggering of preventive interventions⁹9 Danna VA, Bedwell C, Wakasiaka S, et al. Utility of the three-delays model and its potential for supporting a solution-based approach to accessing intrapartum care in low- and middle-income countries. Quality. Evid. Synth. 2020; 13(1):1819052..

Therefore, it is understood that the identification of the social, economic, reproductive and assistance conditions implied in the access to the obstetric services that result in predictive delays of maternal death represent an important dimension to subsidize the planning and the proposition of the intervention measures oriented to the qualification of the assistance offered and to the reduction of the maternal fatalities²2 Kassara SB, Melo AMC, Coutinho SB, et al. Determinants of neonatal death with emphasis on health care during pregnancy, childbirth and reproductive history. J. Pediatr. 2013; 89(3):269-77..

Objective

To summarize available evidence in the scientific literature resulting from the applicability of the Three Delays Model in the context of maternal mortality relating to the causal factors and to the intervention measures.

Material and methods

Type of study

Integrative review of the literature carried out through stages: 1) elaboration of the research question; 2) definition of the data basis and of the criteria for the inclusion and exclusion of studies; 3) definition of the information to be extracted from the selected studies; 4) evaluation of the studies included in the review; 5) interpretation of the results 6) presentation of the review/synthesis of the knowledge¹⁰10 Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs. 2005; 52(5):546-53..

Elaboration of the research question

Therefore, the research started based on the construction of the guiding question: which causal factors and intervention measures are available in the scientific literature resulting from the applicability of the Three Delays Model in the context of maternal mortality?

Establishment of inclusion and exclusion criteria

Were defined as inclusion criteria the scientific researches published in Portuguese, English, Spanish or French, that used the Three Delays Model to comprehend the factors directly implied in the ‘delays’ that cause maternal mortality. It was decided not to use the publishing time cutting, in order to reach greater amount of studies. Were excluded literature review articles, thesis, dissertations and studies that did not answer to the research question.

Data sources and search strategies

The paired search was carried out between June and August 2021, through the periodical portal of the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), in the databases Medical Literature Analysis and Retrieval System Online (MEDLINE) and Cumulative Index to Nursing And Allied Health (CINAHL) through EBSCO Information Services, Banco de Dados em Enfermagem (BDENF), Web of Science (WoS), Literatura da América Latina e do Caribe em Ciências da Saúde (LILACS), and Índice Bibliográfico Espanhol de Ciências da Saúde (IBECS) and virtual library Scientific Electronic Library Online (SciELO).

It was employed the advanced search form. And, as search strategy, the combination of controlled descriptors, chosen through the PCIo strategy – Population = pregnant women; Phenomenon of interest = complications in the course of pregnancy arising from an intervening factor, delay; and Context = maternal death. (Maternal Mortality, Pregnancy Complications, Maternal Death), contained in the structured vocabulary of the Medical Subject Heading (MeSH), a key-word (Three Delays Model). The crossing occurred through the boolean operator AND, resulting in three search keys: 1) Maternal Mortality AND Three Delays Model; 2) Pregnancy Complications AND Three Delays Model; e 3) Maternal Death AND Three Delays Model, in a standardized manner in all the databases.

The stage relating to the databases search in the virtual library was carried out by two independent researchers. Initially, were identified 491 primary references. After sorting, carried out through the reading of the title and the summary and careful analysis based on inclusion and exclusion criteri, 15 articles composed the sample. During the process, when there was divergence in the selection of the studies, the researchers gathered in order to decide about the articles to be included.

It was employed the flowchart adapted from the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA)¹¹11 Page MJ, Moher D, Bossuyt PM, et al. PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ. 2021; (372):n160. in order to demonstrate the operationalization of the search and of the selection, according to figure 1.

Information extracted from the selected studies

An instrument for the extraction of data was elaborated, divided in three sections containing the items related to the articles´characterization data (authors, year, article’s title, database, journal); methodological characterization (delineation, sites, participants, study scenarios and data collection technique and, finally, aspects related to the phenomenon of maternal fatality and delays that guided the applicability of the Three Delays Model, the causes, the causal factors and the intervention measures) in the articles reviewed.

Evaluation of the studies included in the review

For the evaluation of the methodological quality of the studies included in the sample, was employed the evaluation by level of evidence, being: level I, the meta-analysis of multiple controlled studies; level II, the individual study with experimental design, level III, the study with quasi-experimental design, having as an example a study without randomization with single group pre-test and post-test, time series or case-control; level IV, the study with non-experimental design, descriptive correlacional research and qualitative or case studies; level V, case reports or data obtained in systematic way, of verifiable quality or program evaluation data; and, in the level VI, opinion of respected authorities based on clinical competence or opinion of committees of experts, including interpretation of information not based on researches¹²12 Galvão CM. Levels of evidence. Acta Paul. Enferm. 2006; 19(2):5-5..

Interpretation of results and presentation of the knowledge synthesis

For the analysis, it was employed the data reduction method¹⁰10 Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs. 2005; 52(5):546-53. that involved the division and the classification of the primary sources in subgroups through organization, codification and data gathering based on similarities and divergences, aiming to identify patterns, topics or connections which shall enable in a logical structure the data comparison, facilitating, thus, the analysis process. The results were interpretatively analyzed from the recurrent patterns that emerged and presented through descriptive synthesis and figures. And, finally, were discussed in conformity with the literature on the subject.

Results

In the data collected in table 1, lies the characterization of the studies that applied the Three Delays Model to comprehend the determining aspects of the delay to receive and/or to offer assistance in the context of maternal mortality.

In the researches analyzed, the African continent¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,¹⁶16 Laddunuri MM. Matern al mort alit y in rur al areas of Dodom a region, Tanzani a: a qualitative study. Journal of Nursing, Social Studies, Public Health and Rehabilitation. 2013 [acesso em 2019 out 10]; 1(2):75-82. Disponível em: http://casopis-zsfju.zsf.jcu.cz/journal-of-nursing-social-studies-public-health-and-rehabilitation/administrace/clanky-file/20130701134845253078.pdf.
http://casopis-zsfju.zsf.jcu.cz/journal-... ,¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.,¹⁹19 Pagalday-Olivares P, Sjöqvist BA, Beek JA, et al. Exploring the feasibility of eHealth solutions to decrease delays in maternal healthcare in remote communities of Ghana. BMC Med. Inform. Decis. Mak. 2017; 17(1):156.,²¹21 Nabieva J, Souares A. Factors influencing decision to seek health care: a qualitative study among labourmigrants’ wives in northern Tajikistan. BMC Pregnancy Childbirth. 2019 [acesso em 2022 out 14]; 19:7. Disponível em: https://bmcpregnancychildbirth.biomed-central.com/articles/10.1186/s12884-018-2166-6.
https://bmcpregnancychildbirth.biomed-ce... ,²³23 Ngoma T, Asiimwe AR, Mukasa J, et al. Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner. Glob. Health Sci. Pract. 2019; 7(1):S68-S84.,²⁶26 Mohammed MM, Gelany SE, Eladwy AR, et al. A ten year analysis of maternal deaths in a tertiary hospital using the three delays model. BMC Pregnancy and Childbirth. 2020; 20(1).,²⁷27 Aden JA, Ahmed HJ, Östergren PO. Causes and contributing factors of maternal mortality in Bosaso District of Somalia. A retrospective study of 30 cases using a Verbal Autopsy approach, Global Health Action. 2019; 12(1):1672314. obtained prominence in conducting the studies about the topic, and, regarding the developing countries, Malawi¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,¹⁶16 Laddunuri MM. Matern al mort alit y in rur al areas of Dodom a region, Tanzani a: a qualitative study. Journal of Nursing, Social Studies, Public Health and Rehabilitation. 2013 [acesso em 2019 out 10]; 1(2):75-82. Disponível em: http://casopis-zsfju.zsf.jcu.cz/journal-of-nursing-social-studies-public-health-and-rehabilitation/administrace/clanky-file/20130701134845253078.pdf.
http://casopis-zsfju.zsf.jcu.cz/journal-... and Zâmbia²¹21 Nabieva J, Souares A. Factors influencing decision to seek health care: a qualitative study among labourmigrants’ wives in northern Tajikistan. BMC Pregnancy Childbirth. 2019 [acesso em 2022 out 14]; 19:7. Disponível em: https://bmcpregnancychildbirth.biomed-central.com/articles/10.1186/s12884-018-2166-6.
https://bmcpregnancychildbirth.biomed-ce... ,²³23 Ngoma T, Asiimwe AR, Mukasa J, et al. Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner. Glob. Health Sci. Pract. 2019; 7(1):S68-S84., were prominent as research scenarios.

The central participants of the studies varied from family members close¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,¹⁶16 Laddunuri MM. Matern al mort alit y in rur al areas of Dodom a region, Tanzani a: a qualitative study. Journal of Nursing, Social Studies, Public Health and Rehabilitation. 2013 [acesso em 2019 out 10]; 1(2):75-82. Disponível em: http://casopis-zsfju.zsf.jcu.cz/journal-of-nursing-social-studies-public-health-and-rehabilitation/administrace/clanky-file/20130701134845253078.pdf.
http://casopis-zsfju.zsf.jcu.cz/journal-... ,¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.,¹⁹19 Pagalday-Olivares P, Sjöqvist BA, Beek JA, et al. Exploring the feasibility of eHealth solutions to decrease delays in maternal healthcare in remote communities of Ghana. BMC Med. Inform. Decis. Mak. 2017; 17(1):156.,²¹21 Nabieva J, Souares A. Factors influencing decision to seek health care: a qualitative study among labourmigrants’ wives in northern Tajikistan. BMC Pregnancy Childbirth. 2019 [acesso em 2022 out 14]; 19:7. Disponível em: https://bmcpregnancychildbirth.biomed-central.com/articles/10.1186/s12884-018-2166-6.
https://bmcpregnancychildbirth.biomed-ce... ,²³23 Ngoma T, Asiimwe AR, Mukasa J, et al. Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner. Glob. Health Sci. Pract. 2019; 7(1):S68-S84.,²⁶26 Mohammed MM, Gelany SE, Eladwy AR, et al. A ten year analysis of maternal deaths in a tertiary hospital using the three delays model. BMC Pregnancy and Childbirth. 2020; 20(1).,²⁷27 Aden JA, Ahmed HJ, Östergren PO. Causes and contributing factors of maternal mortality in Bosaso District of Somalia. A retrospective study of 30 cases using a Verbal Autopsy approach, Global Health Action. 2019; 12(1):1672314. to the woman who died, health care professionals¹³13 Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc. Sci. Med. 1998; 46(8):981-993.,¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,¹⁹19 Pagalday-Olivares P, Sjöqvist BA, Beek JA, et al. Exploring the feasibility of eHealth solutions to decrease delays in maternal healthcare in remote communities of Ghana. BMC Med. Inform. Decis. Mak. 2017; 17(1):156.,²²22 Kaiser JL, Fong RM, Hamer DH, et al. How a woman’s interpersonal relationships can delay care-seeking and access during the maternity period in rural Zambia: An intersection of the Social Ecological Model with the Three Delays Framework. Soc. Sci. and Med. 2019; (220):312-321.,²⁵25 Omer S, Zakar R, Zakar MZ, et al. The influence of social and cultural practices on maternal mortality: a qualitative study from South Punjab, Pakistan. Reprod. Health. 2021; (18):97.,²⁶26 Mohammed MM, Gelany SE, Eladwy AR, et al. A ten year analysis of maternal deaths in a tertiary hospital using the three delays model. BMC Pregnancy and Childbirth. 2020; 20(1). that cared for the woman any time before her death, midwives¹³13 Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc. Sci. Med. 1998; 46(8):981-993.,¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.,¹⁹19 Pagalday-Olivares P, Sjöqvist BA, Beek JA, et al. Exploring the feasibility of eHealth solutions to decrease delays in maternal healthcare in remote communities of Ghana. BMC Med. Inform. Decis. Mak. 2017; 17(1):156.,²²22 Kaiser JL, Fong RM, Hamer DH, et al. How a woman’s interpersonal relationships can delay care-seeking and access during the maternity period in rural Zambia: An intersection of the Social Ecological Model with the Three Delays Framework. Soc. Sci. and Med. 2019; (220):312-321.,²⁶26 Mohammed MM, Gelany SE, Eladwy AR, et al. A ten year analysis of maternal deaths in a tertiary hospital using the three delays model. BMC Pregnancy and Childbirth. 2020; 20(1)., and close neighbors¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.,²⁰20 Sheikh MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delas model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy Childbirth. 2019; (19):314.,²⁷27 Aden JA, Ahmed HJ, Östergren PO. Causes and contributing factors of maternal mortality in Bosaso District of Somalia. A retrospective study of 30 cases using a Verbal Autopsy approach, Global Health Action. 2019; 12(1):1672314.. Some data collections were carried out in the patient´s promptuary records¹⁴14 Mazza MM, Vallejo CM, Blanco MG. Mortalidad materna: análisis de las tres demoras. Rev. Obstet. Ginecol. Venezuela. 2012 [acesso em 2019 out 11]; 72(4):233-248. Disponível em: http://ve.scielo.org/scielo.php?script=sci_arttext&pid=S0048-77322012000400004.
http://ve.scielo.org/scielo.php?script=s... ,¹⁷17 Esscher A, Binder-Finnema P, Bødker B, et al. Sub-optimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the ‘migration three delays’ model. BMC Pregnancy Childbirth. 2014; (14):141.,²⁰20 Sheikh MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delas model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy Childbirth. 2019; (19):314.,²³23 Ngoma T, Asiimwe AR, Mukasa J, et al. Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner. Glob. Health Sci. Pract. 2019; 7(1):S68-S84.,²⁴24 Sk MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delays model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy and Childbirth. 2019; 19(1).,²⁶26 Mohammed MM, Gelany SE, Eladwy AR, et al. A ten year analysis of maternal deaths in a tertiary hospital using the three delays model. BMC Pregnancy and Childbirth. 2020; 20(1)..

Regarding the collection scenario, were prominent the health care institutions¹³13 Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc. Sci. Med. 1998; 46(8):981-993.,¹⁴14 Mazza MM, Vallejo CM, Blanco MG. Mortalidad materna: análisis de las tres demoras. Rev. Obstet. Ginecol. Venezuela. 2012 [acesso em 2019 out 11]; 72(4):233-248. Disponível em: http://ve.scielo.org/scielo.php?script=sci_arttext&pid=S0048-77322012000400004.
http://ve.scielo.org/scielo.php?script=s... ,¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,¹⁷17 Esscher A, Binder-Finnema P, Bødker B, et al. Sub-optimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the ‘migration three delays’ model. BMC Pregnancy Childbirth. 2014; (14):141.,¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.,¹⁹19 Pagalday-Olivares P, Sjöqvist BA, Beek JA, et al. Exploring the feasibility of eHealth solutions to decrease delays in maternal healthcare in remote communities of Ghana. BMC Med. Inform. Decis. Mak. 2017; 17(1):156.,²⁰20 Sheikh MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delas model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy Childbirth. 2019; (19):314.,²¹21 Nabieva J, Souares A. Factors influencing decision to seek health care: a qualitative study among labourmigrants’ wives in northern Tajikistan. BMC Pregnancy Childbirth. 2019 [acesso em 2022 out 14]; 19:7. Disponível em: https://bmcpregnancychildbirth.biomed-central.com/articles/10.1186/s12884-018-2166-6.
https://bmcpregnancychildbirth.biomed-ce... ,²³23 Ngoma T, Asiimwe AR, Mukasa J, et al. Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner. Glob. Health Sci. Pract. 2019; 7(1):S68-S84.,²⁴24 Sk MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delays model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy and Childbirth. 2019; 19(1).,²⁵25 Omer S, Zakar R, Zakar MZ, et al. The influence of social and cultural practices on maternal mortality: a qualitative study from South Punjab, Pakistan. Reprod. Health. 2021; (18):97.,²⁶26 Mohammed MM, Gelany SE, Eladwy AR, et al. A ten year analysis of maternal deaths in a tertiary hospital using the three delays model. BMC Pregnancy and Childbirth. 2020; 20(1).,²⁷27 Aden JA, Ahmed HJ, Östergren PO. Causes and contributing factors of maternal mortality in Bosaso District of Somalia. A retrospective study of 30 cases using a Verbal Autopsy approach, Global Health Action. 2019; 12(1):1672314. and the domiciles (communities) of the participants in the studies¹³13 Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc. Sci. Med. 1998; 46(8):981-993.,¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,¹⁶16 Laddunuri MM. Matern al mort alit y in rur al areas of Dodom a region, Tanzani a: a qualitative study. Journal of Nursing, Social Studies, Public Health and Rehabilitation. 2013 [acesso em 2019 out 10]; 1(2):75-82. Disponível em: http://casopis-zsfju.zsf.jcu.cz/journal-of-nursing-social-studies-public-health-and-rehabilitation/administrace/clanky-file/20130701134845253078.pdf.
http://casopis-zsfju.zsf.jcu.cz/journal-... ,¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.,²³23 Ngoma T, Asiimwe AR, Mukasa J, et al. Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner. Glob. Health Sci. Pract. 2019; 7(1):S68-S84.,²⁵25 Omer S, Zakar R, Zakar MZ, et al. The influence of social and cultural practices on maternal mortality: a qualitative study from South Punjab, Pakistan. Reprod. Health. 2021; (18):97.,²⁷27 Aden JA, Ahmed HJ, Östergren PO. Causes and contributing factors of maternal mortality in Bosaso District of Somalia. A retrospective study of 30 cases using a Verbal Autopsy approach, Global Health Action. 2019; 12(1):1672314..

The predominant data collection technique was documental¹⁴14 Mazza MM, Vallejo CM, Blanco MG. Mortalidad materna: análisis de las tres demoras. Rev. Obstet. Ginecol. Venezuela. 2012 [acesso em 2019 out 11]; 72(4):233-248. Disponível em: http://ve.scielo.org/scielo.php?script=sci_arttext&pid=S0048-77322012000400004.
http://ve.scielo.org/scielo.php?script=s... ,¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,¹⁷17 Esscher A, Binder-Finnema P, Bødker B, et al. Sub-optimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the ‘migration three delays’ model. BMC Pregnancy Childbirth. 2014; (14):141.,¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.,²⁰20 Sheikh MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delas model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy Childbirth. 2019; (19):314.,²³23 Ngoma T, Asiimwe AR, Mukasa J, et al. Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner. Glob. Health Sci. Pract. 2019; 7(1):S68-S84.,²⁶26 Mohammed MM, Gelany SE, Eladwy AR, et al. A ten year analysis of maternal deaths in a tertiary hospital using the three delays model. BMC Pregnancy and Childbirth. 2020; 20(1).,²⁷27 Aden JA, Ahmed HJ, Östergren PO. Causes and contributing factors of maternal mortality in Bosaso District of Somalia. A retrospective study of 30 cases using a Verbal Autopsy approach, Global Health Action. 2019; 12(1):1672314., associated to the verbal autopsy¹³13 Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc. Sci. Med. 1998; 46(8):981-993.,¹⁶16 Laddunuri MM. Matern al mort alit y in rur al areas of Dodom a region, Tanzani a: a qualitative study. Journal of Nursing, Social Studies, Public Health and Rehabilitation. 2013 [acesso em 2019 out 10]; 1(2):75-82. Disponível em: http://casopis-zsfju.zsf.jcu.cz/journal-of-nursing-social-studies-public-health-and-rehabilitation/administrace/clanky-file/20130701134845253078.pdf.
http://casopis-zsfju.zsf.jcu.cz/journal-... ,¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.,²⁰20 Sheikh MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delas model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy Childbirth. 2019; (19):314.,²¹21 Nabieva J, Souares A. Factors influencing decision to seek health care: a qualitative study among labourmigrants’ wives in northern Tajikistan. BMC Pregnancy Childbirth. 2019 [acesso em 2022 out 14]; 19:7. Disponível em: https://bmcpregnancychildbirth.biomed-central.com/articles/10.1186/s12884-018-2166-6.
https://bmcpregnancychildbirth.biomed-ce... ,²³23 Ngoma T, Asiimwe AR, Mukasa J, et al. Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner. Glob. Health Sci. Pract. 2019; 7(1):S68-S84.,²⁴24 Sk MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delays model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy and Childbirth. 2019; 19(1).,²⁶26 Mohammed MM, Gelany SE, Eladwy AR, et al. A ten year analysis of maternal deaths in a tertiary hospital using the three delays model. BMC Pregnancy and Childbirth. 2020; 20(1).,²⁷27 Aden JA, Ahmed HJ, Östergren PO. Causes and contributing factors of maternal mortality in Bosaso District of Somalia. A retrospective study of 30 cases using a Verbal Autopsy approach, Global Health Action. 2019; 12(1):1672314.. Among the delays regarding the Three Delays Model analyzed in the primary studies, it was evidenced that the second delay¹³13 Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc. Sci. Med. 1998; 46(8):981-993.,¹⁴14 Mazza MM, Vallejo CM, Blanco MG. Mortalidad materna: análisis de las tres demoras. Rev. Obstet. Ginecol. Venezuela. 2012 [acesso em 2019 out 11]; 72(4):233-248. Disponível em: http://ve.scielo.org/scielo.php?script=sci_arttext&pid=S0048-77322012000400004.
http://ve.scielo.org/scielo.php?script=s... ,¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,¹⁶16 Laddunuri MM. Matern al mort alit y in rur al areas of Dodom a region, Tanzani a: a qualitative study. Journal of Nursing, Social Studies, Public Health and Rehabilitation. 2013 [acesso em 2019 out 10]; 1(2):75-82. Disponível em: http://casopis-zsfju.zsf.jcu.cz/journal-of-nursing-social-studies-public-health-and-rehabilitation/administrace/clanky-file/20130701134845253078.pdf.
http://casopis-zsfju.zsf.jcu.cz/journal-... ,¹⁷17 Esscher A, Binder-Finnema P, Bødker B, et al. Sub-optimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the ‘migration three delays’ model. BMC Pregnancy Childbirth. 2014; (14):141.,¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.,¹⁹19 Pagalday-Olivares P, Sjöqvist BA, Beek JA, et al. Exploring the feasibility of eHealth solutions to decrease delays in maternal healthcare in remote communities of Ghana. BMC Med. Inform. Decis. Mak. 2017; 17(1):156.,²⁰20 Sheikh MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delas model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy Childbirth. 2019; (19):314.,²¹21 Nabieva J, Souares A. Factors influencing decision to seek health care: a qualitative study among labourmigrants’ wives in northern Tajikistan. BMC Pregnancy Childbirth. 2019 [acesso em 2022 out 14]; 19:7. Disponível em: https://bmcpregnancychildbirth.biomed-central.com/articles/10.1186/s12884-018-2166-6.
https://bmcpregnancychildbirth.biomed-ce... ,²²22 Kaiser JL, Fong RM, Hamer DH, et al. How a woman’s interpersonal relationships can delay care-seeking and access during the maternity period in rural Zambia: An intersection of the Social Ecological Model with the Three Delays Framework. Soc. Sci. and Med. 2019; (220):312-321.,²³23 Ngoma T, Asiimwe AR, Mukasa J, et al. Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner. Glob. Health Sci. Pract. 2019; 7(1):S68-S84. was prominent in the studies, followed by the first¹³13 Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc. Sci. Med. 1998; 46(8):981-993.,¹⁴14 Mazza MM, Vallejo CM, Blanco MG. Mortalidad materna: análisis de las tres demoras. Rev. Obstet. Ginecol. Venezuela. 2012 [acesso em 2019 out 11]; 72(4):233-248. Disponível em: http://ve.scielo.org/scielo.php?script=sci_arttext&pid=S0048-77322012000400004.
http://ve.scielo.org/scielo.php?script=s... ,¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,¹⁶16 Laddunuri MM. Matern al mort alit y in rur al areas of Dodom a region, Tanzani a: a qualitative study. Journal of Nursing, Social Studies, Public Health and Rehabilitation. 2013 [acesso em 2019 out 10]; 1(2):75-82. Disponível em: http://casopis-zsfju.zsf.jcu.cz/journal-of-nursing-social-studies-public-health-and-rehabilitation/administrace/clanky-file/20130701134845253078.pdf.
http://casopis-zsfju.zsf.jcu.cz/journal-... ,¹⁷17 Esscher A, Binder-Finnema P, Bødker B, et al. Sub-optimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the ‘migration three delays’ model. BMC Pregnancy Childbirth. 2014; (14):141.,¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.,¹⁹19 Pagalday-Olivares P, Sjöqvist BA, Beek JA, et al. Exploring the feasibility of eHealth solutions to decrease delays in maternal healthcare in remote communities of Ghana. BMC Med. Inform. Decis. Mak. 2017; 17(1):156.,²⁰20 Sheikh MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delas model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy Childbirth. 2019; (19):314.,²¹21 Nabieva J, Souares A. Factors influencing decision to seek health care: a qualitative study among labourmigrants’ wives in northern Tajikistan. BMC Pregnancy Childbirth. 2019 [acesso em 2022 out 14]; 19:7. Disponível em: https://bmcpregnancychildbirth.biomed-central.com/articles/10.1186/s12884-018-2166-6.
https://bmcpregnancychildbirth.biomed-ce... ,²²22 Kaiser JL, Fong RM, Hamer DH, et al. How a woman’s interpersonal relationships can delay care-seeking and access during the maternity period in rural Zambia: An intersection of the Social Ecological Model with the Three Delays Framework. Soc. Sci. and Med. 2019; (220):312-321.,²⁴24 Sk MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delays model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy and Childbirth. 2019; 19(1).,²⁶26 Mohammed MM, Gelany SE, Eladwy AR, et al. A ten year analysis of maternal deaths in a tertiary hospital using the three delays model. BMC Pregnancy and Childbirth. 2020; 20(1). and by the third¹³13 Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc. Sci. Med. 1998; 46(8):981-993.,¹⁴14 Mazza MM, Vallejo CM, Blanco MG. Mortalidad materna: análisis de las tres demoras. Rev. Obstet. Ginecol. Venezuela. 2012 [acesso em 2019 out 11]; 72(4):233-248. Disponível em: http://ve.scielo.org/scielo.php?script=sci_arttext&pid=S0048-77322012000400004.
http://ve.scielo.org/scielo.php?script=s... ,¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,¹⁶16 Laddunuri MM. Matern al mort alit y in rur al areas of Dodom a region, Tanzani a: a qualitative study. Journal of Nursing, Social Studies, Public Health and Rehabilitation. 2013 [acesso em 2019 out 10]; 1(2):75-82. Disponível em: http://casopis-zsfju.zsf.jcu.cz/journal-of-nursing-social-studies-public-health-and-rehabilitation/administrace/clanky-file/20130701134845253078.pdf.
http://casopis-zsfju.zsf.jcu.cz/journal-... ,¹⁷17 Esscher A, Binder-Finnema P, Bødker B, et al. Sub-optimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the ‘migration three delays’ model. BMC Pregnancy Childbirth. 2014; (14):141.,¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.,¹⁹19 Pagalday-Olivares P, Sjöqvist BA, Beek JA, et al. Exploring the feasibility of eHealth solutions to decrease delays in maternal healthcare in remote communities of Ghana. BMC Med. Inform. Decis. Mak. 2017; 17(1):156.,²⁰20 Sheikh MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delas model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy Childbirth. 2019; (19):314.,²²22 Kaiser JL, Fong RM, Hamer DH, et al. How a woman’s interpersonal relationships can delay care-seeking and access during the maternity period in rural Zambia: An intersection of the Social Ecological Model with the Three Delays Framework. Soc. Sci. and Med. 2019; (220):312-321.,²⁴24 Sk MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delays model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy and Childbirth. 2019; 19(1).,²⁶26 Mohammed MM, Gelany SE, Eladwy AR, et al. A ten year analysis of maternal deaths in a tertiary hospital using the three delays model. BMC Pregnancy and Childbirth. 2020; 20(1)..

Among the factors related to the first delay, it was observed that the decision-making of not seeking for a health care institution came, mainly from the woman¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,¹⁷17 Esscher A, Binder-Finnema P, Bødker B, et al. Sub-optimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the ‘migration three delays’ model. BMC Pregnancy Childbirth. 2014; (14):141.,²⁰20 Sheikh MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delas model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy Childbirth. 2019; (19):314.,²⁴24 Sk MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delays model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy and Childbirth. 2019; 19(1).,²⁷27 Aden JA, Ahmed HJ, Östergren PO. Causes and contributing factors of maternal mortality in Bosaso District of Somalia. A retrospective study of 30 cases using a Verbal Autopsy approach, Global Health Action. 2019; 12(1):1672314., was decided by the spouse/partner¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,²²22 Kaiser JL, Fong RM, Hamer DH, et al. How a woman’s interpersonal relationships can delay care-seeking and access during the maternity period in rural Zambia: An intersection of the Social Ecological Model with the Three Delays Framework. Soc. Sci. and Med. 2019; (220):312-321. and/or father/mother-in-law²¹21 Nabieva J, Souares A. Factors influencing decision to seek health care: a qualitative study among labourmigrants’ wives in northern Tajikistan. BMC Pregnancy Childbirth. 2019 [acesso em 2022 out 14]; 19:7. Disponível em: https://bmcpregnancychildbirth.biomed-central.com/articles/10.1186/s12884-018-2166-6.
https://bmcpregnancychildbirth.biomed-ce... ,²²22 Kaiser JL, Fong RM, Hamer DH, et al. How a woman’s interpersonal relationships can delay care-seeking and access during the maternity period in rural Zambia: An intersection of the Social Ecological Model with the Three Delays Framework. Soc. Sci. and Med. 2019; (220):312-321. or influenced by other members of the family group¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090., neighbors and close friends¹³13 Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc. Sci. Med. 1998; 46(8):981-993.,¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090..

In the community, the custom of having the home birth (and they occur with no intercurrences)²⁴24 Sk MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delays model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy and Childbirth. 2019; 19(1).,²⁶26 Mohammed MM, Gelany SE, Eladwy AR, et al. A ten year analysis of maternal deaths in a tertiary hospital using the three delays model. BMC Pregnancy and Childbirth. 2020; 20(1). and the beliefs constituted an important agent in this decision-making process, considering that the alternative care offered, especially by healers, were more widely accepted by the population than the assistance offered by health care institutions¹³13 Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc. Sci. Med. 1998; 46(8):981-993.,¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.,²⁰20 Sheikh MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delas model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy Childbirth. 2019; (19):314.,²¹21 Nabieva J, Souares A. Factors influencing decision to seek health care: a qualitative study among labourmigrants’ wives in northern Tajikistan. BMC Pregnancy Childbirth. 2019 [acesso em 2022 out 14]; 19:7. Disponível em: https://bmcpregnancychildbirth.biomed-central.com/articles/10.1186/s12884-018-2166-6.
https://bmcpregnancychildbirth.biomed-ce... ,²²22 Kaiser JL, Fong RM, Hamer DH, et al. How a woman’s interpersonal relationships can delay care-seeking and access during the maternity period in rural Zambia: An intersection of the Social Ecological Model with the Three Delays Framework. Soc. Sci. and Med. 2019; (220):312-321.,²⁴24 Sk MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delays model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy and Childbirth. 2019; 19(1)., since it was believed that the chances of cure were higher, because the healers invoked spiritual entities.

In the cultural aspects, were prominent the factors related to the customs rooted in the patriarchate centralized in the decisions of the male figure. Therefore, the woman, at times, was prevented by her spouse, partner or even father-in-law from seeking for hospital assistance, remaining as her only option to rely on care from a midwife. Bearing in mind that many were from the community, the men would not have to pay for transport or assistance. The midwives were considered by the community as holders of more experience and better dexterity for the handling of the childbirth and its possible complications¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.,²¹21 Nabieva J, Souares A. Factors influencing decision to seek health care: a qualitative study among labourmigrants’ wives in northern Tajikistan. BMC Pregnancy Childbirth. 2019 [acesso em 2022 out 14]; 19:7. Disponível em: https://bmcpregnancychildbirth.biomed-central.com/articles/10.1186/s12884-018-2166-6.
https://bmcpregnancychildbirth.biomed-ce... ,²²22 Kaiser JL, Fong RM, Hamer DH, et al. How a woman’s interpersonal relationships can delay care-seeking and access during the maternity period in rural Zambia: An intersection of the Social Ecological Model with the Three Delays Framework. Soc. Sci. and Med. 2019; (220):312-321..

Among the socieconomic factors, were prominent the poor financial condition, the scarce resources (poverty)¹³13 Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc. Sci. Med. 1998; 46(8):981-993.,¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,¹⁷17 Esscher A, Binder-Finnema P, Bødker B, et al. Sub-optimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the ‘migration three delays’ model. BMC Pregnancy Childbirth. 2014; (14):141.,¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.,²⁴24 Sk MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delays model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy and Childbirth. 2019; 19(1).,²⁶26 Mohammed MM, Gelany SE, Eladwy AR, et al. A ten year analysis of maternal deaths in a tertiary hospital using the three delays model. BMC Pregnancy and Childbirth. 2020; 20(1).,²⁷27 Aden JA, Ahmed HJ, Östergren PO. Causes and contributing factors of maternal mortality in Bosaso District of Somalia. A retrospective study of 30 cases using a Verbal Autopsy approach, Global Health Action. 2019; 12(1):1672314., and the low education level¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,²⁰20 Sheikh MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delas model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy Childbirth. 2019; (19):314., demonstrating that, the lower were the income and the educational level, more scarce was also the option and/or search for professional help and greater was the refusal of the treatments offered.

The bad experiences lived previously in health care institutions by the women themselves¹³13 Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc. Sci. Med. 1998; 46(8):981-993.,¹⁴14 Mazza MM, Vallejo CM, Blanco MG. Mortalidad materna: análisis de las tres demoras. Rev. Obstet. Ginecol. Venezuela. 2012 [acesso em 2019 out 11]; 72(4):233-248. Disponível em: http://ve.scielo.org/scielo.php?script=sci_arttext&pid=S0048-77322012000400004.
http://ve.scielo.org/scielo.php?script=s... ,¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.,¹⁹19 Pagalday-Olivares P, Sjöqvist BA, Beek JA, et al. Exploring the feasibility of eHealth solutions to decrease delays in maternal healthcare in remote communities of Ghana. BMC Med. Inform. Decis. Mak. 2017; 17(1):156.,²⁰20 Sheikh MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delas model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy Childbirth. 2019; (19):314.,²⁶26 Mohammed MM, Gelany SE, Eladwy AR, et al. A ten year analysis of maternal deaths in a tertiary hospital using the three delays model. BMC Pregnancy and Childbirth. 2020; 20(1). or by close relatives or friends¹³13 Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc. Sci. Med. 1998; 46(8):981-993.,¹⁴14 Mazza MM, Vallejo CM, Blanco MG. Mortalidad materna: análisis de las tres demoras. Rev. Obstet. Ginecol. Venezuela. 2012 [acesso em 2019 out 11]; 72(4):233-248. Disponível em: http://ve.scielo.org/scielo.php?script=sci_arttext&pid=S0048-77322012000400004.
http://ve.scielo.org/scielo.php?script=s... ,¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.,¹⁹19 Pagalday-Olivares P, Sjöqvist BA, Beek JA, et al. Exploring the feasibility of eHealth solutions to decrease delays in maternal healthcare in remote communities of Ghana. BMC Med. Inform. Decis. Mak. 2017; 17(1):156.,²⁰20 Sheikh MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delas model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy Childbirth. 2019; (19):314., the quality of the care offered perceived as ineffective or bad quality¹³13 Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc. Sci. Med. 1998; 46(8):981-993.,¹⁷17 Esscher A, Binder-Finnema P, Bødker B, et al. Sub-optimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the ‘migration three delays’ model. BMC Pregnancy Childbirth. 2014; (14):141.,¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.,²²22 Kaiser JL, Fong RM, Hamer DH, et al. How a woman’s interpersonal relationships can delay care-seeking and access during the maternity period in rural Zambia: An intersection of the Social Ecological Model with the Three Delays Framework. Soc. Sci. and Med. 2019; (220):312-321.,²⁶26 Mohammed MM, Gelany SE, Eladwy AR, et al. A ten year analysis of maternal deaths in a tertiary hospital using the three delays model. BMC Pregnancy and Childbirth. 2020; 20(1)., the lack of autonomy of the woman in deciding about going to the health care institution¹⁴14 Mazza MM, Vallejo CM, Blanco MG. Mortalidad materna: análisis de las tres demoras. Rev. Obstet. Ginecol. Venezuela. 2012 [acesso em 2019 out 11]; 72(4):233-248. Disponível em: http://ve.scielo.org/scielo.php?script=sci_arttext&pid=S0048-77322012000400004.
http://ve.scielo.org/scielo.php?script=s... and the lack of supporters²²22 Kaiser JL, Fong RM, Hamer DH, et al. How a woman’s interpersonal relationships can delay care-seeking and access during the maternity period in rural Zambia: An intersection of the Social Ecological Model with the Three Delays Framework. Soc. Sci. and Med. 2019; (220):312-321., were, also, impediments to the search for health care.

The women´s scarce knowledge about the obstetric risks¹⁴14 Mazza MM, Vallejo CM, Blanco MG. Mortalidad materna: análisis de las tres demoras. Rev. Obstet. Ginecol. Venezuela. 2012 [acesso em 2019 out 11]; 72(4):233-248. Disponível em: http://ve.scielo.org/scielo.php?script=sci_arttext&pid=S0048-77322012000400004.
http://ve.scielo.org/scielo.php?script=s... ,¹⁹19 Pagalday-Olivares P, Sjöqvist BA, Beek JA, et al. Exploring the feasibility of eHealth solutions to decrease delays in maternal healthcare in remote communities of Ghana. BMC Med. Inform. Decis. Mak. 2017; 17(1):156.,²⁰20 Sheikh MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delas model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy Childbirth. 2019; (19):314.,²⁵25 Omer S, Zakar R, Zakar MZ, et al. The influence of social and cultural practices on maternal mortality: a qualitative study from South Punjab, Pakistan. Reprod. Health. 2021; (18):97.,²⁶26 Mohammed MM, Gelany SE, Eladwy AR, et al. A ten year analysis of maternal deaths in a tertiary hospital using the three delays model. BMC Pregnancy and Childbirth. 2020; 20(1).,²⁷27 Aden JA, Ahmed HJ, Östergren PO. Causes and contributing factors of maternal mortality in Bosaso District of Somalia. A retrospective study of 30 cases using a Verbal Autopsy approach, Global Health Action. 2019; 12(1):1672314. and their relatives’¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090. and about the need to seek for health care assistance were decisive factors for the later progress of the clinical condition and of the impossibility of reversion.

Regarding the geographic location, it was perceived the correlation between the aggravation of the health clinical condition due to the distance traveled between the woman´s home and the health care institution¹³13 Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc. Sci. Med. 1998; 46(8):981-993.,¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,¹⁷17 Esscher A, Binder-Finnema P, Bødker B, et al. Sub-optimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the ‘migration three delays’ model. BMC Pregnancy Childbirth. 2014; (14):141.,¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.,²⁰20 Sheikh MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delas model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy Childbirth. 2019; (19):314., highlighting that, the higher were the distances and barriers to reach care, lower were the possibilities of reversion of the clinical condition.

It was observed, yet, that the seeking for emergency obstetric care was prevented, mainly, by the elevated cost¹³13 Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc. Sci. Med. 1998; 46(8):981-993.,¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090., and the refusal to the treatment offered was justified by the lack of reliability on the procedures carried out, by the unreliability on the health care professional, perception of reduced dexterity of the professional that would perform the health care or abbreviated knowledge of the health care professional¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,¹⁷17 Esscher A, Binder-Finnema P, Bødker B, et al. Sub-optimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the ‘migration three delays’ model. BMC Pregnancy Childbirth. 2014; (14):141.,¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219..

Some interventions were described for the resolution or reduction of those issues related to the first delay, such as the promotion of education in health for women and their relatives in order to improve the decision-making problem¹³13 Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc. Sci. Med. 1998; 46(8):981-993.,¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,²³23 Ngoma T, Asiimwe AR, Mukasa J, et al. Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner. Glob. Health Sci. Pract. 2019; 7(1):S68-S84.; the designing of programs turned to the implementation of improvements in the health care institutions in the care for the obstetric urgency and emergency situations, especially the emergency childbirths¹³13 Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc. Sci. Med. 1998; 46(8):981-993.,²³23 Ngoma T, Asiimwe AR, Mukasa J, et al. Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner. Glob. Health Sci. Pract. 2019; 7(1):S68-S84., with the availability of health care professionals trained to manage possible complications; unification and improvement of the referring systems²³23 Ngoma T, Asiimwe AR, Mukasa J, et al. Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner. Glob. Health Sci. Pract. 2019; 7(1):S68-S84., in order to allow the woman to, when arriving at the health care institution, she would already have a team ready to welcome her. It was observed, yet, that the managers concern relating to the need to improve the infrastructure of the roads, of the equipments of the health care institutions and with the health care professionals qualification²³23 Ngoma T, Asiimwe AR, Mukasa J, et al. Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner. Glob. Health Sci. Pract. 2019; 7(1):S68-S84..

On figure 2, it is presented a synthesis of the causal factors and of the intervention measures related to the first delay.

The tough geographic accessibility was mentioned as one of the main causal factors of the second delay, due to the poor distribution of the health care institutions in the territory, especially in areas close to the community¹³13 Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc. Sci. Med. 1998; 46(8):981-993.,¹⁶16 Laddunuri MM. Matern al mort alit y in rur al areas of Dodom a region, Tanzani a: a qualitative study. Journal of Nursing, Social Studies, Public Health and Rehabilitation. 2013 [acesso em 2019 out 10]; 1(2):75-82. Disponível em: http://casopis-zsfju.zsf.jcu.cz/journal-of-nursing-social-studies-public-health-and-rehabilitation/administrace/clanky-file/20130701134845253078.pdf.
http://casopis-zsfju.zsf.jcu.cz/journal-... ,¹⁹19 Pagalday-Olivares P, Sjöqvist BA, Beek JA, et al. Exploring the feasibility of eHealth solutions to decrease delays in maternal healthcare in remote communities of Ghana. BMC Med. Inform. Decis. Mak. 2017; 17(1):156.,²³23 Ngoma T, Asiimwe AR, Mukasa J, et al. Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner. Glob. Health Sci. Pract. 2019; 7(1):S68-S84., which can cause the increasing of the distance of the health care institution from the woman´s home, the lack of health care institutions in some communities¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.,²⁴24 Sk MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delays model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy and Childbirth. 2019; 19(1).,²⁷27 Aden JA, Ahmed HJ, Östergren PO. Causes and contributing factors of maternal mortality in Bosaso District of Somalia. A retrospective study of 30 cases using a Verbal Autopsy approach, Global Health Action. 2019; 12(1):1672314., reduced infrastructure of the roads¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.,¹⁹19 Pagalday-Olivares P, Sjöqvist BA, Beek JA, et al. Exploring the feasibility of eHealth solutions to decrease delays in maternal healthcare in remote communities of Ghana. BMC Med. Inform. Decis. Mak. 2017; 17(1):156., geographic barriers (such as mountains¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090., rivers¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.), in addition to the bad quality of the road network¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219..

In the aspect related to the displacement, the delay occurred, mainly, due to the lack¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219. or unavailability of transport¹³13 Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc. Sci. Med. 1998; 46(8):981-993.,¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,¹⁶16 Laddunuri MM. Matern al mort alit y in rur al areas of Dodom a region, Tanzani a: a qualitative study. Journal of Nursing, Social Studies, Public Health and Rehabilitation. 2013 [acesso em 2019 out 10]; 1(2):75-82. Disponível em: http://casopis-zsfju.zsf.jcu.cz/journal-of-nursing-social-studies-public-health-and-rehabilitation/administrace/clanky-file/20130701134845253078.pdf.
http://casopis-zsfju.zsf.jcu.cz/journal-... ,¹⁷17 Esscher A, Binder-Finnema P, Bødker B, et al. Sub-optimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the ‘migration three delays’ model. BMC Pregnancy Childbirth. 2014; (14):141.,¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.,¹⁹19 Pagalday-Olivares P, Sjöqvist BA, Beek JA, et al. Exploring the feasibility of eHealth solutions to decrease delays in maternal healthcare in remote communities of Ghana. BMC Med. Inform. Decis. Mak. 2017; 17(1):156.,²⁰20 Sheikh MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delas model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy Childbirth. 2019; (19):314.,²³23 Ngoma T, Asiimwe AR, Mukasa J, et al. Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner. Glob. Health Sci. Pract. 2019; 7(1):S68-S84. and ambulances¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.. Due to elevated costs¹⁶16 Laddunuri MM. Matern al mort alit y in rur al areas of Dodom a region, Tanzani a: a qualitative study. Journal of Nursing, Social Studies, Public Health and Rehabilitation. 2013 [acesso em 2019 out 10]; 1(2):75-82. Disponível em: http://casopis-zsfju.zsf.jcu.cz/journal-of-nursing-social-studies-public-health-and-rehabilitation/administrace/clanky-file/20130701134845253078.pdf.
http://casopis-zsfju.zsf.jcu.cz/journal-... ,¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.,²⁰20 Sheikh MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delas model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy Childbirth. 2019; (19):314.,²¹21 Nabieva J, Souares A. Factors influencing decision to seek health care: a qualitative study among labourmigrants’ wives in northern Tajikistan. BMC Pregnancy Childbirth. 2019 [acesso em 2022 out 14]; 19:7. Disponível em: https://bmcpregnancychildbirth.biomed-central.com/articles/10.1186/s12884-018-2166-6.
https://bmcpregnancychildbirth.biomed-ce... ,²²22 Kaiser JL, Fong RM, Hamer DH, et al. How a woman’s interpersonal relationships can delay care-seeking and access during the maternity period in rural Zambia: An intersection of the Social Ecological Model with the Three Delays Framework. Soc. Sci. and Med. 2019; (220):312-321.,²³23 Ngoma T, Asiimwe AR, Mukasa J, et al. Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner. Glob. Health Sci. Pract. 2019; 7(1):S68-S84. and to the necessity of a long time journey for the woman´s transfer¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.,²¹21 Nabieva J, Souares A. Factors influencing decision to seek health care: a qualitative study among labourmigrants’ wives in northern Tajikistan. BMC Pregnancy Childbirth. 2019 [acesso em 2022 out 14]; 19:7. Disponível em: https://bmcpregnancychildbirth.biomed-central.com/articles/10.1186/s12884-018-2166-6.
https://bmcpregnancychildbirth.biomed-ce... ,²³23 Ngoma T, Asiimwe AR, Mukasa J, et al. Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner. Glob. Health Sci. Pract. 2019; 7(1):S68-S84..

Were observed, in the decision-making delay, failures in the woman’s referral¹⁴14 Mazza MM, Vallejo CM, Blanco MG. Mortalidad materna: análisis de las tres demoras. Rev. Obstet. Ginecol. Venezuela. 2012 [acesso em 2019 out 11]; 72(4):233-248. Disponível em: http://ve.scielo.org/scielo.php?script=sci_arttext&pid=S0048-77322012000400004.
http://ve.scielo.org/scielo.php?script=s... ,¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,¹⁶16 Laddunuri MM. Matern al mort alit y in rur al areas of Dodom a region, Tanzani a: a qualitative study. Journal of Nursing, Social Studies, Public Health and Rehabilitation. 2013 [acesso em 2019 out 10]; 1(2):75-82. Disponível em: http://casopis-zsfju.zsf.jcu.cz/journal-of-nursing-social-studies-public-health-and-rehabilitation/administrace/clanky-file/20130701134845253078.pdf.
http://casopis-zsfju.zsf.jcu.cz/journal-... ,¹⁷17 Esscher A, Binder-Finnema P, Bødker B, et al. Sub-optimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the ‘migration three delays’ model. BMC Pregnancy Childbirth. 2014; (14):141.,²⁰20 Sheikh MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delas model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy Childbirth. 2019; (19):314.,²³23 Ngoma T, Asiimwe AR, Mukasa J, et al. Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner. Glob. Health Sci. Pract. 2019; 7(1):S68-S84. by the health care professional for a specialized health care service, in order to allow her to have treatment in opportune time for the reversion of her clinical condition.

Were outlined as strategies for the reduction of the causal factors of the second delay the construction and/or the improvement of the health care institutions near the communities¹³13 Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc. Sci. Med. 1998; 46(8):981-993.,²³23 Ngoma T, Asiimwe AR, Mukasa J, et al. Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner. Glob. Health Sci. Pract. 2019; 7(1):S68-S84., the designing of more effective systems for the displacement of the women and the communication between health care teams involved. and the improvement of the transport fleet with the acquisition of ambulances, motorcycles and communication equipments, such as two-way radios¹³13 Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc. Sci. Med. 1998; 46(8):981-993.,²³23 Ngoma T, Asiimwe AR, Mukasa J, et al. Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner. Glob. Health Sci. Pract. 2019; 7(1):S68-S84..

It was also noticed the need to repair or to build roads used as access to the health care institutions; of implementation of support programs to the pregnant women with high risk pregnancies in the reference health care institutions; of establishing district transport committees to regularize the forwarding system and the coordination of ambulances for the referencing²³23 Ngoma T, Asiimwe AR, Mukasa J, et al. Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner. Glob. Health Sci. Pract. 2019; 7(1):S68-S84.; and of more training of the health care teams inserted in the communities for the accompaniment of the childbirth and of the puerperium in a secure manner²³23 Ngoma T, Asiimwe AR, Mukasa J, et al. Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner. Glob. Health Sci. Pract. 2019; 7(1):S68-S84..

On figure 3, there is a synthesis of the causal factors and of the intervention measures related to the second delay.

Among the causal factors of the third delay, were highlighted the failures in the decision-making process by the health care professionals, such as: not forwarding in opportune moment still effective for the woman to have her condition reverted in a specialized health care institution, with the possibility to have a higher complexity care¹³13 Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc. Sci. Med. 1998; 46(8):981-993.,¹⁷17 Esscher A, Binder-Finnema P, Bødker B, et al. Sub-optimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the ‘migration three delays’ model. BMC Pregnancy Childbirth. 2014; (14):141.,²⁰20 Sheikh MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delas model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy Childbirth. 2019; (19):314.,²³23 Ngoma T, Asiimwe AR, Mukasa J, et al. Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner. Glob. Health Sci. Pract. 2019; 7(1):S68-S84.,²⁶26 Mohammed MM, Gelany SE, Eladwy AR, et al. A ten year analysis of maternal deaths in a tertiary hospital using the three delays model. BMC Pregnancy and Childbirth. 2020; 20(1).; forwarding several times¹⁴14 Mazza MM, Vallejo CM, Blanco MG. Mortalidad materna: análisis de las tres demoras. Rev. Obstet. Ginecol. Venezuela. 2012 [acesso em 2019 out 11]; 72(4):233-248. Disponível em: http://ve.scielo.org/scielo.php?script=sci_arttext&pid=S0048-77322012000400004.
http://ve.scielo.org/scielo.php?script=s... ; reference systems and communication deficits between health care teams¹⁹19 Pagalday-Olivares P, Sjöqvist BA, Beek JA, et al. Exploring the feasibility of eHealth solutions to decrease delays in maternal healthcare in remote communities of Ghana. BMC Med. Inform. Decis. Mak. 2017; 17(1):156.; wrong diagnosis¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,¹⁷17 Esscher A, Binder-Finnema P, Bødker B, et al. Sub-optimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the ‘migration three delays’ model. BMC Pregnancy Childbirth. 2014; (14):141.,¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219., imprecise¹³13 Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc. Sci. Med. 1998; 46(8):981-993. and late¹⁴14 Mazza MM, Vallejo CM, Blanco MG. Mortalidad materna: análisis de las tres demoras. Rev. Obstet. Ginecol. Venezuela. 2012 [acesso em 2019 out 11]; 72(4):233-248. Disponível em: http://ve.scielo.org/scielo.php?script=sci_arttext&pid=S0048-77322012000400004.
http://ve.scielo.org/scielo.php?script=s... ,¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.,²⁰20 Sheikh MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delas model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy Childbirth. 2019; (19):314.; and inadequate care offered¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,¹⁷17 Esscher A, Binder-Finnema P, Bødker B, et al. Sub-optimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the ‘migration three delays’ model. BMC Pregnancy Childbirth. 2014; (14):141.,²⁰20 Sheikh MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delas model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy Childbirth. 2019; (19):314.,²⁴24 Sk MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delays model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy and Childbirth. 2019; 19(1).; and delay in the decision-making, by the professional, for the women´s care when she can reach the health care institutionsaúde¹⁶16 Laddunuri MM. Matern al mort alit y in rur al areas of Dodom a region, Tanzani a: a qualitative study. Journal of Nursing, Social Studies, Public Health and Rehabilitation. 2013 [acesso em 2019 out 10]; 1(2):75-82. Disponível em: http://casopis-zsfju.zsf.jcu.cz/journal-of-nursing-social-studies-public-health-and-rehabilitation/administrace/clanky-file/20130701134845253078.pdf.
http://casopis-zsfju.zsf.jcu.cz/journal-... ,¹⁷17 Esscher A, Binder-Finnema P, Bødker B, et al. Sub-optimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the ‘migration three delays’ model. BMC Pregnancy Childbirth. 2014; (14):141.,¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.,²⁰20 Sheikh MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delas model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy Childbirth. 2019; (19):314.,²⁴24 Sk MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delays model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy and Childbirth. 2019; 19(1)..

Regarding the management of material resources, it was highlighted the lack of medication¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,²⁰20 Sheikh MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delas model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy Childbirth. 2019; (19):314.,²⁶26 Mohammed MM, Gelany SE, Eladwy AR, et al. A ten year analysis of maternal deaths in a tertiary hospital using the three delays model. BMC Pregnancy and Childbirth. 2020; 20(1)., specifically, magnesium sulfate¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219., hydralazine¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090. antibiotics¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.. Lack of supplies¹⁴14 Mazza MM, Vallejo CM, Blanco MG. Mortalidad materna: análisis de las tres demoras. Rev. Obstet. Ginecol. Venezuela. 2012 [acesso em 2019 out 11]; 72(4):233-248. Disponível em: http://ve.scielo.org/scielo.php?script=sci_arttext&pid=S0048-77322012000400004.
http://ve.scielo.org/scielo.php?script=s... , such as blood¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,¹⁶16 Laddunuri MM. Matern al mort alit y in rur al areas of Dodom a region, Tanzani a: a qualitative study. Journal of Nursing, Social Studies, Public Health and Rehabilitation. 2013 [acesso em 2019 out 10]; 1(2):75-82. Disponível em: http://casopis-zsfju.zsf.jcu.cz/journal-of-nursing-social-studies-public-health-and-rehabilitation/administrace/clanky-file/20130701134845253078.pdf.
http://casopis-zsfju.zsf.jcu.cz/journal-... ,¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.,²⁰20 Sheikh MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delas model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy Childbirth. 2019; (19):314.,²²22 Kaiser JL, Fong RM, Hamer DH, et al. How a woman’s interpersonal relationships can delay care-seeking and access during the maternity period in rural Zambia: An intersection of the Social Ecological Model with the Three Delays Framework. Soc. Sci. and Med. 2019; (220):312-321.,²⁶26 Mohammed MM, Gelany SE, Eladwy AR, et al. A ten year analysis of maternal deaths in a tertiary hospital using the three delays model. BMC Pregnancy and Childbirth. 2020; 20(1). and scarcity of materials¹⁴14 Mazza MM, Vallejo CM, Blanco MG. Mortalidad materna: análisis de las tres demoras. Rev. Obstet. Ginecol. Venezuela. 2012 [acesso em 2019 out 11]; 72(4):233-248. Disponível em: http://ve.scielo.org/scielo.php?script=sci_arttext&pid=S0048-77322012000400004.
http://ve.scielo.org/scielo.php?script=s... for the trivial procedures in the maternities, such as gloves¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219., equipments in general¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219.,²⁰20 Sheikh MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delas model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy Childbirth. 2019; (19):314., and ITU beds¹³13 Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc. Sci. Med. 1998; 46(8):981-993.,¹⁴14 Mazza MM, Vallejo CM, Blanco MG. Mortalidad materna: análisis de las tres demoras. Rev. Obstet. Ginecol. Venezuela. 2012 [acesso em 2019 out 11]; 72(4):233-248. Disponível em: http://ve.scielo.org/scielo.php?script=sci_arttext&pid=S0048-77322012000400004.
http://ve.scielo.org/scielo.php?script=s... .

The ineffective management of the human resources and the insufficiency of professionals were pointed out as causal factors of failures in the assistance¹³13 Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc. Sci. Med. 1998; 46(8):981-993.,¹⁴14 Mazza MM, Vallejo CM, Blanco MG. Mortalidad materna: análisis de las tres demoras. Rev. Obstet. Ginecol. Venezuela. 2012 [acesso em 2019 out 11]; 72(4):233-248. Disponível em: http://ve.scielo.org/scielo.php?script=sci_arttext&pid=S0048-77322012000400004.
http://ve.scielo.org/scielo.php?script=s... ,¹⁹19 Pagalday-Olivares P, Sjöqvist BA, Beek JA, et al. Exploring the feasibility of eHealth solutions to decrease delays in maternal healthcare in remote communities of Ghana. BMC Med. Inform. Decis. Mak. 2017; 17(1):156.,²⁰20 Sheikh MIK, Paswan B, Anand A, et al. Praying until death: revisiting three delas model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC Pregnancy Childbirth. 2019; (19):314.. The inadequate or insufficient communication between members of the team or of those with the patient and/ or relatives were highlighted as gaps in the assistance offered¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,²²22 Kaiser JL, Fong RM, Hamer DH, et al. How a woman’s interpersonal relationships can delay care-seeking and access during the maternity period in rural Zambia: An intersection of the Social Ecological Model with the Three Delays Framework. Soc. Sci. and Med. 2019; (220):312-321., as well as the inadequate communication due to the language¹⁷17 Esscher A, Binder-Finnema P, Bødker B, et al. Sub-optimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the ‘migration three delays’ model. BMC Pregnancy Childbirth. 2014; (14):141..

Were evidenced, also, the absence of qualified human resources¹³13 Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc. Sci. Med. 1998; 46(8):981-993.,¹⁴14 Mazza MM, Vallejo CM, Blanco MG. Mortalidad materna: análisis de las tres demoras. Rev. Obstet. Ginecol. Venezuela. 2012 [acesso em 2019 out 11]; 72(4):233-248. Disponível em: http://ve.scielo.org/scielo.php?script=sci_arttext&pid=S0048-77322012000400004.
http://ve.scielo.org/scielo.php?script=s... ,¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,¹⁶16 Laddunuri MM. Matern al mort alit y in rur al areas of Dodom a region, Tanzani a: a qualitative study. Journal of Nursing, Social Studies, Public Health and Rehabilitation. 2013 [acesso em 2019 out 10]; 1(2):75-82. Disponível em: http://casopis-zsfju.zsf.jcu.cz/journal-of-nursing-social-studies-public-health-and-rehabilitation/administrace/clanky-file/20130701134845253078.pdf.
http://casopis-zsfju.zsf.jcu.cz/journal-... , professionals with limited technical abilities¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090.,¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219., precarious structural conditions of the health care institutions¹³13 Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc. Sci. Med. 1998; 46(8):981-993.,¹⁴14 Mazza MM, Vallejo CM, Blanco MG. Mortalidad materna: análisis de las tres demoras. Rev. Obstet. Ginecol. Venezuela. 2012 [acesso em 2019 out 11]; 72(4):233-248. Disponível em: http://ve.scielo.org/scielo.php?script=sci_arttext&pid=S0048-77322012000400004.
http://ve.scielo.org/scielo.php?script=s... ,¹⁵15 Thorsen VC, Sundby J, Malata A. Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited. PLos ONE. 2012; 7(12):e52090., lack o guidelines for the treatment¹⁸18 Mgawadere F, Unkels R, Kazembre A, et al. Factors associated with maternal mortality in Malawi: application of the three delas model. BMC Pregnancy Childbirth. 2017; 17(1):219. and unsatisfactory management of professionals and hospital administration¹⁹19 Pagalday-Olivares P, Sjöqvist BA, Beek JA, et al. Exploring the feasibility of eHealth solutions to decrease delays in maternal healthcare in remote communities of Ghana. BMC Med. Inform. Decis. Mak. 2017; 17(1):156. as factors that influence the women’s care.

As intervention measures, were mentioned strategies such as: the designing of protocols and assistance forms directed to the standardization of the care in the emergency services and the improvement of the distribution of the equipments in the different health care institutions²³23 Ngoma T, Asiimwe AR, Mukasa J, et al. Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner. Glob. Health Sci. Pract. 2019; 7(1):S68-S84.. On figure 4, it is presented a synthesis of the causal factors and of the intervention measures related to the third delay.

Discussion

The occurrence of maternal losses results from biological, social, economic, cultural and behavioral interactions. Those are more significant in developing countries, especially in the average and low income social classes, resulting from the associating of contributing factors to its occurrence²⁸28 Moyer CA, Johnson C, Kaselitz E, et al. Using social autopsy to understand maternal, newborn, and child mortality in lowresource settings: a systematic review of the literature. Glob Health Action. 2017; 10(1):1413917..

The delays in the obstetric assistance are directly connected to the unfavorable maternal outcomes. The occurrence of maternal fatality results in a destructuring for the familiar nucleus, especially when she is the provider, and evidences the necessity to comprehend the existing limitations in the health care systems, in order to eliminate the barriers that contribute to this delays.

It is highlighted that the lower social classes, in addition to having precarious life conditions, have less accessibility to the health care services, due to the lack of knowledge, precarious roads, transport or even limited financial conditions. Therefore, some of the factors contributing to the occurrence of delays that lead to maternal death include educational, financial geographic of quality nd availability of transport, roads and health care services barriers²⁹29 Serbanescu F, Goodwin MM, Binzen S, et al. Addressing the First Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Approaches and Results for Increasing Demand for Facility Delivery Services. Glob. Health Sci. Pract. 2019; 7(supl1):548-67..

The limited access to education, to the labour market or to the adequate resources prevent women from obtaining the necessary obstetric care³⁰30 Kumari K, Srivastava RK, Srivastava M, et al. Maternal Mortality in Rural Varanasi: Delays, Causes, and Contributing Factors. Indian J. Community Med. 2019 [acesso em 2019 out 9]; 44(1):26-30. Disponível em: http://pubmed.ncbi.nlm.nih.gov/30983709/.
http://pubmed.ncbi.nlm.nih.gov/30983709/... . Women who can reach the health care services, at times, do not get proper assistance, which prevents the identification of the risks at the appropriate moment, besides pushing them away from the health care services, thus they do not see the assistance offered as effective²⁹29 Serbanescu F, Goodwin MM, Binzen S, et al. Addressing the First Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Approaches and Results for Increasing Demand for Facility Delivery Services. Glob. Health Sci. Pract. 2019; 7(supl1):548-67..

Therefore, the quality perceived by the woman or by her supporters regarding the health care influences directly the decision of seeking for care³¹31 Iyaniwura CA, Yussuf Q. Utilization of antenatal care and delivery services in Sagamu, South Western Nigeria. Afr. J. Reprod. Health. 2009 [acesso em 2019 out 7]; 13(3):111-22. Disponível em: http://pubmed.ncbi.nlm.nih.gov/20690266/.
http://pubmed.ncbi.nlm.nih.gov/20690266/... ,³²32 Kucho B, Mekonnen N. Delivery at home and associated factors among women in child bearing age, who gave birth in the preceding two years in Zala Woreda, southern Ethiopia. J Public Health Epid. 2017 [acesso em 2019 out 11]; 9(6):177-88. Disponível em: http://pdfs.semanticscholar.org/33a6/642a12a75f08e1635b5f2178af25024cef8a.pdf.
http://pdfs.semanticscholar.org/33a6/642... .

To face the high maternal mortality taxes, the actions shall be coordinated and integrated between the woman, the family/ communal nucleus, the State, the health care services and the community. Therefore, the access of the population to obstetric care shall be universal, integral and equal, however, it is perceived that this continues to be a challenge in many countries²⁹29 Serbanescu F, Goodwin MM, Binzen S, et al. Addressing the First Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Approaches and Results for Increasing Demand for Facility Delivery Services. Glob. Health Sci. Pract. 2019; 7(supl1):548-67..

Beliefs, culture, practices and customs of a determined place are direct influencers in the search for professional health care. Imposed patriarchal values present in daily life restrict women in decision-making to seek for health care, and the lack of autonomy delays the receiving of opportune health care²⁸28 Moyer CA, Johnson C, Kaselitz E, et al. Using social autopsy to understand maternal, newborn, and child mortality in lowresource settings: a systematic review of the literature. Glob Health Action. 2017; 10(1):1413917.,³³33 Geleto A, Chojenta C, Musa A, et al. Barriers to access and utilization of emergency obstetric care at health facilities in sub-Saharan Africa: a systematic review of literature. Syst. Rev. 2018; (7):183..

Exist, yet, institutional barriers when the woman reaches the services, such as the lack of properly qualified health care professionals to conduce or to revert aggravated clinical conditions is fundamental in order to assure prevention of maternal mortality, a phenomenon that constitutes a public health problem. Therefore, the quantitative and qualitative characterization of the maternal mortality becomes relevant, bearing in mind the necessity to to recognize the diverse particularities that involve this phenomenon in varied regions of the world³⁴34 Oliveira AS, Lima DJJ, Menezes NC. Epidemiological profile of maternal death cases in the city of Manaus by: cause, class, schooling and race, in the period of 2011 to 2015. REAS/EJCH. 2019; (supl23):e424..

Thus, measures that aim to improve the formation of health care professionals that care for the expectant mothers; parturients and recently given births, aiming to avoid maternal fatality by assuring a secure assistance are necessary. Wide and articulated actions that aim an effective change of the current care model of the obstetric assistance are essential, considering the difficulties highlighted in the obstetric care and the high number of avoidable fatalities³⁵35 Souza JP. Maternal mortality in Brazil: the need for strengthening health systems. Rev. Bras. Ginecol. Obstet. 2011 [acesso em 2019 set 4]; 33(10):273-9. Disponível em: http://www.scielo.br/pdf/rbgo/v33n10/01.pdf.
http://www.scielo.br/pdf/rbgo/v33n10/01....

Thus, the use of scientific parameters, such as applicability of a model, allows to estimate which are the factors involved and how they interact for the adverse result for that life, thus the reduction of the fatalities will only be reached when the actions visualize the particularities of the social problems, the diverse cultures, the health care systems and the different realities experienced by women, bearing in mind that the analysis of the delays provides data about the determinants implied in maternal deaths.

Study limitations

The limitations of the study are associated to the terms employed in the search strategy, considering that the non-existence of specific controlled descriptors that would represent the model being studied and the adoption of key-word for the search may have interfered in the results. Besides that, the adoption of eligibility criteria related to the language and the specific database group of the health care area may have limited the scope of the search.

Contributions for the health care area or public policy

From the Three Delays Model presented, this study provides subsides for the discussion and planning of the proposals, strategies and/or intervention measures, that aim the reorientation of the policies and the implementation of effective practices capable of tightening relations between legislation, public policies and assistance offered, turned to the confrontation of the problematic associated to the access to the health care services that result in unfavorable maternal-infant outcomes, especially in the context of developing countries.

Final considerations

This review allowed to synthesize contexts, barriers and consequences associated to the delays for the access to the services, offer and obtaining of health care in the context of maternal mortality. It was highlighted that the application of the Three Delays Model occurs more often in the first delay, that embraces the decision to seek for care. The causal factors of the first delay are more elucidated, in contrast, the intervention measures described associated to the third delay, that embraces the receiving of adequate health care are scarce.

This model has proven to be a valuable instrument for the analysis of the phenomenon of maternal mortality in different realities of health care, inasmuch as it helps to comprehend the factors associated to mortalities which the origins do not come only from obstetric complications, however for a complex net of delays coming from the community and from the reality of health care in which that woman is inserted.

Therefore, the comprehension of those factors, through an integrated approach, allows to know better the phenomenon and, through strategies and public policies, to direct efforts for confronting the barriers imposed to women in the access to the obstetric services, making then possible, the offer of a secure qualified assistance through the pregnant and puerperal cycle.

References

Publication Dates

History