Reframing the Three Delays framework: factors influencing referrals to facilities by matrones in rural Haiti

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Abstract

In Haiti, there has been limited research on the experiences of traditional birth attendants/matrones when they decide to refer and accompany pregnant women to the facility for giving birth. Understanding this contextualised experience could help to strengthen programming aimed at improving maternal, neonatal, and child health (MNCH) outcomes in rural Haiti. This paper describes the qualitative findings from seven focus group discussions (FGDs) with matrones regarding their experience of referring pregnant women to facilities in Haiti’s Central Plateau. Each FGD was conducted in Haitian Kreyol and audio recorded. Recordings were transcribed, translated to English, and thematically analysed. A conceptual model visualising factors influencing matrone decision-making was then developed using an adapted version of the Three Delays framework. Findings from this study show that matrones face a complex, multilayered web of intertwining factors related to attitudes and beliefs around their role, resource availability, and perceptions around quality of care and treatment. Each factor corresponds to a delay in the Three Delays framework. The factors can occur at the same time or each can occur individually at different times, and influence the decision to refer. The complexity of factors identified reflects the need to reassess the Three Delays framework so that it accounts for the intertwining, cyclical complexities faced by those trying to access the facility amidst the backdrop of both time and the community/social contexts. Results further reflect the need for strengthened health systems that better facilitate matrone facility-based referrals, improving outcomes for all parties involved and bridging the gap between homes/ communities and facilities. This calls for better integration of the matrones into the formal health system to systematically strengthen the continuum of MNCH health services provided from home to facility.

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Most cited references 42

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Code Saturation Versus Meaning Saturation: How Many Interviews Are Enough?

Bonnie N. Kaiser, Monique M. Hennink, Vincent C. Marconi (2017)

Saturation is a core guiding principle to determine sample sizes in qualitative research, yet little methodological research exists on parameters that influence saturation. Our study compared two approaches to assessing saturation: code saturation and meaning saturation. We examined sample sizes needed to reach saturation in each approach, what saturation meant, and how to assess saturation. Examining 25 in-depth interviews, we found that code saturation was reached at nine interviews, whereby the range of thematic issues was identified. However, 16 to 24 interviews were needed to reach meaning saturation where we developed a richly textured understanding of issues. Thus, code saturation may indicate when researchers have "heard it all," but meaning saturation is needed to "understand it all." We used our results to develop parameters that influence saturation, which may be used to estimate sample sizes for qualitative research proposals or to document in publications the grounds on which saturation was achieved.

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Too far to walk: Maternal mortality in context

Sereen Thaddeus, Deborah Maine (1994)

The Prevention of Maternal Mortality Program is a collaborative effort of Columbia University's Center for Population and Family Health and multidisciplinary teams of researchers from Ghana, Nigeria and Sierra Leone. Program goals include dissemination of information to those concerned with preventing maternal deaths. This review, which presents findings from a broad body of research, is part of that activity. While there are numerous factors that contribute to maternal mortality, we focus on those that affect the interval between the onset of obstetric complication and its outcome. If prompt, adequate treatment is provided, the outcome will usually be satisfactory; therefore, the outcome is most adversely affected by delayed treatment. We examine research on the factors that: (1) delay the decision to seek care; (2) delay arrival at a health facility; and (3) delay the provision of adequate care. The literature clearly indicates that while distance and cost are major obstacles in the decision to seek care, the relationships are not simple. There is evidence that people often consider the quality of care more important than cost. These three factors--distance, cost and quality--alone do not give a full understanding of decision-making process. Their salience as obstacles is ultimately defined by illness-related factors, such as severity. Differential use of health services is also shaped by such variables as gender and socioeconomic status. Patients who make a timely decision to seek care can still experience delay, because the accessibility of health services is an acute problem in the developing world. In rural areas, a woman with an obstetric emergency may find the closest facility equipped only for basic treatments and education, and she may have no way to reach a regional center where resources exist. Finally, arriving at the facility may not lead to the immediate commencement of treatment. Shortages of qualified staff, essential drugs and supplies, coupled with administrative delays and clinical mismanagement, become documentable contributors to maternal deaths. Findings from the literature review are discussed in light of their implications for programs. Options for health programs are offered and examples of efforts to reduce maternal deaths are presented, with an emphasis on strategies to mobilize and adapt existing resources.

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An intervention involving traditional birth attendants and perinatal and maternal mortality in Pakistan.

Abdul Jokhio, Michael Winter, Kar Keung Cheng (2005)

There are approximately 4 million neonatal deaths and half a million maternal deaths worldwide each year. There is limited evidence from clinical trials to guide the development of effective maternity services in developing countries. We performed a cluster-randomized, controlled trial involving seven subdistricts (talukas) of a rural district in Pakistan. In three talukas randomly assigned to the intervention group, traditional birth attendants were trained and issued disposable delivery kits; Lady Health Workers linked traditional birth attendants with established services and documented processes and outcomes; and obstetrical teams provided outreach clinics for antenatal care. Women in the four control talukas received usual care. The primary outcome measures were perinatal and maternal mortality. Of the estimated number of eligible women in the seven talukas, 10,114 (84.3 percent) were recruited in the three intervention talukas, and 9443 (78.7 percent) in the four control talukas. In the intervention group, 9184 women (90.8 percent) received antenatal care by trained traditional birth attendants, 1634 women (16.2 percent) were seen antenatally at least once by the obstetrical teams, and 8172 safe-delivery kits were used. As compared with the control talukas, the intervention talukas had a cluster-adjusted odds ratio for perinatal death of 0.70 (95 percent confidence interval, 0.59 to 0.82) and for maternal mortality of 0.74 (95 percent confidence interval, 0.45 to 1.23). Training traditional birth attendants and integrating them into an improved health care system were achievable and effective in reducing perinatal mortality. This model could result in large improvements in perinatal and maternal health in developing countries. Copyright 2005 Massachusetts Medical Society.

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Author and article information

Journal

Journal ID (nlm-ta): BMJ Glob Health

Journal ID (iso-abbrev): BMJ Glob Health

Journal ID (hwp): bmjgh

Journal ID (publisher-id): bmjgh

Title: BMJ Global Health

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Electronic): 2059-7908

Publication date Collection: 2023

Publication date (Electronic): 15 November 2023

Volume: 8

Issue: 11

Electronic Location Identifier: e011957

Affiliations

[1 ] departmentDepartment of Health Behavior , Ringgold_41474The University of North Carolina at Chapel Hill Gillings School of Global Public Health , Chapel Hill, North Carolina, USA

[2 ] departmentMedical Direction , Hopital Universitaire de Mirebalais , Mirebalais, Haiti

[3 ] departmentStrategic Health Information System (SHIS) , Partners In Health - Sierra Leone , Freetown, Sierra Leone

[4 ] departmentMaternity , Ringgold_452660Hôpital Universitaire de Mirebalais , Mirebalais, Haiti

Author notes

[Correspondence to ] Milenka Jean-Baptiste; milenka@ 123456email.unc.edu

Author information

Milenka Jean-Baptiste http://orcid.org/0000-0001-6773-7689

Meredith Casella Jean-Baptiste http://orcid.org/0000-0002-5082-2841

Article

Publisher ID: bmjgh-2023-011957

DOI: 10.1136/bmjgh-2023-011957

PMC ID: 10693684

PubMed ID: 37967901

SO-VID: 8e20a8bd-6522-4575-94e7-51e84719d7d9

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This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

History

Date received : 06 February 2023

Date accepted : 01 October 2023

Funding

Funded by: Nursing Center of Excellence (NCOE);

Funded by: FundRef http://dx.doi.org/10.13039/100005708, EMC;

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Keywords: maternal health,public health,qualitative study,health systems

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Keywords: maternal health, public health, qualitative study, health systems

Reframing the Three Delays framework: factors influencing referrals to facilities by matrones in rural Haiti

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Most cited references 42

Code Saturation Versus Meaning Saturation: How Many Interviews Are Enough?

Too far to walk: Maternal mortality in context

An intervention involving traditional birth attendants and perinatal and maternal mortality in Pakistan.

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