Objectives: To assess where the delays occur in the referral chain at most and maternal health outcomes based on the three delay model in Addis Ababa, Ethiopia.

Design: The study was a facility-based cross-sectional study

Setting:  Two public and tertiary hospitals in Addis Ababa

Participants: All pregnant women who were referred for only labor and delivery services after 28 weeks of gestation between December 2018 and February 2019 in Zewditu and Gandhi Memorial hospitals.

Primary and secondary outcome measures: The primary outcome was the type of delays from the three-delay model which met operationally defined time. Maternal health outcomes based on the three-delay model as a secondary outcome.   

Results: A total of 403 pregnant women referred for delivery to the study hospitals were included in the study. Three-fourth (301, 74.7%) of referred pregnant women had the third delay (delayed receiving appropriate care); (211, 52.4%) had a first delay (delay in making a decision to seek care). Overall 366(90.8%) pregnant women had experienced at least one of the three delays and 71(17.6%) had all the three delays. Twenty-nine (7.2%) referred women had severe maternal outcomes (SMO). The most leading causes/diagnosis of SMO were blood transfusion 17 (58.6%) followed by postpartum hemorrhage 15 (52%) then eclampsia 9 (31%). In addition, women who experienced severe maternal outcomes were 2.9 times more likely to have at least one of the three delays.

Conclusion & recommendation:  This study highlights the persistence of delays at all levels and especially delay three and its contribution to severe maternal outcomes. Strengthening health referral systems and addressing specific health system bottlenecks during labor and birth in order to ensure no mother will be endangered. We also recommend a qualitative method of study (focus group discussion and in-depth interview) and observing the tertiary hospitals set-up and readiness to manage obstetrics emergencies.

Data collection

After they gave birth, women were identified and interviewed from emergency OPD, labor ward, and in-patient wards every day before they discharged from the hospital by data collectors using pretested and structured questionnaires. 

The referral papers reviewed and date, time and diagnosis of referral was recorded for each mother. The triage paper and patient chart are also reviewed including mode of transportation, date and time of arrival, sources of referrals, obstetrics performances, the time taken to admit/get the service after arrival, diagnosis at receiving hospital, gestational age, place and mode of delivery, newborn outcomes, and severe maternal complications types and managements. Women interviewed on socio-demographic characteristics, time interval to seek medical advice and reason for the delay to seek the care (if there was). 

Data Process/analysis

Data were entered in epi-info version 7.2.2.6 and transported to SPSS Version-21 statistics software for cleaning and analysis. Descriptive statistics were used to present women by their socio-demographic characteristics, referral diagnosis, diagnosis at receiving hospitals, obstetrics characteristics, mode of delivery, newborn outcomes, the three delays, and severe maternal outcomes. Severe maternal outcomes were analyzed for the three delays. The relationship between the three delays and SMO were examined using the multivariate logistic regression. The goodness of the model was tested by the Hosmer-Lemeshow test for goodness-of-fit. Selected variables were included in the model to account for maternal characteristics differences other than delays in seeking and receiving care

File Information:

1. Conceptual frame work: how the study conducted on the three-delay models

2. Dx at receiving and referral: This excel sheet showed cases diagnosis
from referral centres and diagnosis in the two selected hospitals. It showed
also, the disparity of diagnosis based on the findings.

3. Latent stage of labor only SPSS sheet showed: Mother diagnosed below 4 cm
cervical dilation without any obstetrics/ and medical complications. On the
other hand,thus cases  don't need urgent admission.

4. Time interval for admission excel sheet showed: first part showed the
time it took to reach the hospitals after referrals. Second part showed:the
time duration the mother stayed in emergency OPD, after admission decided.