The Three Delays of Maternal Mortality

pregnant woman  seeking medical care
Photograph information - 2579-6 Nepal - Credit: (c) 1997 CEDPA/Nepal, Courtesy of Photoshare

“Most people aren’t even aware about how to identify complications, and men as heads of households aren’t aware of the importance of referring their wives, or they are too poor and don’t have the means.”

Approximately 560,000 women die in pregnancy and childbirth every year. These deaths are preventable. There are many factors affecting whether or not women will be able to access the treatment necessary to save their lives. This photo essay explores the ‘three delays’ approach related to maternal death.

Rita is expelled from school
411-4 Zimbabwe - Credit: (c) 1988 Media for Development International, Courtesy of Photoshare

In the 1990s an important article by D. Maine was published entitled “Too Far to Walk: Maternal Mortality in Context”. By looking at cases of maternal death, the researcher was able to identify three delays that often determine life or death for a woman experiencing complications in child birth. This conceptual framework has been important in understanding why women die of treatable pregnancy related complications.

The delays are determined as:
  1. The delay to seek care
  2. The delay to reach proper medical services
  3. The delay in accessing quality care at a health care facility
A man pushes a pregnant woman in a wheelbarrow
433-10 Lusaka, Zambia - Credit: (c) 2001 CCP, Courtesy of Photoshare
A man pushes a pregnant woman in a wheelbarrow on an emergency visit to a clinic in Zambia.

It is recognized that the faster each delay is dealt with, the greater chances that mother and baby will survive and be able to live free of any long-term injuries.

Making the decision to seek medical care when complications arise during childbirth can be more complicated than it seems. First, the birthing mother, attendant or family member must have the ability to recognize an obstetric complication. Knowing that there is help and treatment for problems that arise may also pose a challenge.

Woman on donkey in Afganistan
Photo M. Crangle

Even if the birthing mother or attendant acknowledges the need for medical attention, accessing care outside the home may not be the birthing woman’s choice to make. Cultural and societal factors may complicate the process. A woman may not hold much power in the family; she may need the permission of her husband, mother-in-law or senior co-wives to access care. There may also be deeply engrained societal norms or expectations about childbirth, for example, women are expected to be silent during labour.

“She can’t decide herself to come to the hospital because of family pressure,” Sadou said. “Her parents might refuse to listen to her when the contractions are underway. Traditionally, she must not show the pain, and her babies die, and she is injured.”

Dimol’s Director, Salamatou Traoré

the delay to reach proper medical services

The second delay is the delay to reach proper medical services. Once the decision has been made to access quality care, arriving at a location or contacting a skilled health provider can present an enormous challenge. Communication and transportation are significant barriers in enabling women to access life saving care.

“I tried to get together enough people to carry her to the clinic, but there was no one around,” her husband said. “After she died, I felt sad for a long time. I could not work. The children suffered too. We survived on handouts from the church.”

Bumpy road

It may be night time; roads are often treacherous with limited transportation options. Weather is also a factor, particularly in countries that experience monsoons, heavy snow fall and extreme heat. Horses and donkeys, bicycles with attached carts, walking, and being carried by family and friends are all common ways that women in low-resource countries, particularly in rural areas, may arrive to receive medical care. Financial constraints can also make it difficult for a family to obtain the necessary transportation to reach a medical facility.

Women sit on a bed without a mattress
426-15 Uganda - Credit: (c) 2001 Harvey Nelson, Courtesy of Photoshare
Buwenge Health Center in the Jinja District of Uganda

"She started pouring blood late in the evening just after evening prayers [5:00 pm]....we took her to the main road [tarred road] to look for transport. We were there [main road] up to twelve midnight but couldn't get transport. All the vehicles that came were full. We went back home and woke up early morning the following day to catch the first transports".

medical personnel

After deciding to access care and arriving at a medical centre, accessing quality care at a health care facility is another life threatening delay. This depends on a number of factors, such as the number and skill level of staff; the availability of drugs, supplies and blood; and the general condition of the facility. Women have also reported prejudice and maltreatment on the part of medical personnel; this contributes to their reluctance in visiting medical centres.


Other delays may be due to an overworked staff that is unable to treat the woman in a timely manner and a delay in accessing the appropriate medical care. Staff may not know the proper treatment; there may be a lack of hospital protocols. In resource-poor settings and in conflict zones, hospitals may not have regular access to clean water and electricity. Many patients in rural settings would need to be transported to an urban area for procedures such as blood transfusions or caesarean sections. Upon arrival they may find the medical centre closed, a lack of personnel, or a lack of blood or other essential medical supplies. Patients are often expected to purchase their medications and blood. This may be impossible for a family that has spent what little savings they have on arriving at a medical centre. Even when a family has the funds, they may find shortages or that the pharmacy is closed when the supplies are needed.

Transport in truck

"She was pouring blood at home so we took her to the health centre. There we were told she urgently needed blood but blood bags were not available. She was then transferred to the hospital [60 km away]. At the hospital blood bags were finished. She was in the hospital from mid-day up to the following day in the evening but had not received blood. Late at night she died".


"We took her to the health centre in the village... she was examined by the nurse who later transferred her to another health centre [44 km away]. There she spent the night and the following morning she was again transferred to the hospital [36 km away]. On our way to the hospital we had to cross the river at two different crossing points. Immediately after we reached the hospital she died".

The patient came to the health centre at around 4:00 pm... she cannot be managed here because she may need an operation [caesarean section]. We planned to evacuate her to the hospital but our ambulance had a breakdown a week ago. We looked for transport in the village throughout the night but could not get one. The following morning we went to the agricultural department to look for transport but their vehicle had already left for trek. It returned around 11:00 am and thereafter it came to transport the patient to the hospital".