The third delay: Why women are dying after reaching hospital doors

Every two minutes, a woman dies from pregnancy or childbirth complications somewhere in the world. These are not just statistics—they represent mothers, daughters, and families whose lives are shattered by preventable loss. 

Many other women experience life-altering complications like obstetric fistula, severe haemorrhage, or organ failure.

The impact extends far beyond the hospital—it affects families, drains resources, and robs communities of their future.

The tragedy is that most of these outcomes can be avoided. With timely, appropriate, and well-coordinated care, many of these women could survive and go on to raise their children and live fulfilling lives.

Also read: Failed by the system: Mothers we lost inside maternity wards

 Improving the quality and safety of obstetric care is not only the right thing to do—it is an essential strategy if we are to meet global goals like Universal Health Coverage and Sustainable Development Goal 3, which aims to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030.

Over the years, more women have gained access to healthcare facilities for childbirth. This is a positive step forward. However, increased access has not always translated into better outcomes. According to the World Health Organization, nearly half of maternal deaths in low- and middle-income countries are due to poor quality care, rather than a complete lack of access. Simply put, being in a hospital is not enough—the care provided must be safe, timely, effective, and respectful. Without quality, access means little.

Poor quality care doesn’t just cost lives—it erodes trust. When women feel they are not treated with dignity, or when they receive substandard care, they are less likely to seek medical help during future pregnancies. On the other hand, when mothers trust the health system, they are more likely to give birth in facilities where skilled personnel are available. This trust leads to more frequent and timely use of services, which in turn improves outcomes. It is a cycle, and one that we must reinforce by making quality and safety the standard, not the exception.

So, what does quality care look like in the context of maternal health? At its core, it includes well-equipped facilities, skilled and compassionate health workers, timely emergency responses, and a culture of respect and dignity. Care must be guided by the latest evidence and tailored to the individual needs of each woman. Every birth should be a moment of safety and celebration—not risk and fear.

Also read: The deadly inequality: Why African women face 25 times higher risk of pregnancy death

The leading causes of maternal deaths are well-known: postpartum haemorrhage, infections such as sepsis, high blood pressure disorders like eclampsia, obstructed labour, and complications from unsafe abortions. Fortunately, we have proven interventions that can prevent or treat these conditions. Administering oxytocin after delivery can reduce bleeding. Antibiotics can treat sepsis. Timely caesarean sections can resolve obstructed labour. Magnesium sulphate can prevent seizures in women with eclampsia. These interventions save lives—but only when they are used correctly, consistently, and in time.

This is where guidelines and protocols come into play. They ensure that essential interventions are not missed or delayed. Maternity units that follow up-to-date clinical guidelines consistently report better maternal and newborn outcomes. But even the best protocols won’t work if the people delivering care don’t have the support they need.

 Healthcare workers are at the heart of quality obstetric care, and they need more than knowledge—they need mentorship, regular training, and reasonable working conditions. A burned-out or overstretched obstetrician, midwife, nurse or clinician, no matter how skilled, may not be able to deliver optimal care. Investing in the well-being of healthcare providers is just as important as investing in infrastructure or technology.

Another often overlooked but critical factor is timeliness. In obstetric emergencies, minutes can make the difference between life and death. The "three-delay" model highlights three barriers that often lead to poor outcomes: delays in deciding to seek care, delays in reaching care, and delays in receiving appropriate care once at a facility. That last delay—within the health facility—is particularly dangerous and yet preventable. It often stems from inefficient triage, lack of clear emergency pathways, or under-resourced departments.

26 weeks of gestation

A simple but impactful change can be introduced to address this issue. All pregnant women beyond 26 weeks of gestation can be redirected directly to the maternity unit, bypassing the general triage. This ensures that they receive prompt assessment and care by skilled providers. Specialised triage tools such as the Maternal Foetal Triage Index can also help by ensuring that pregnant women are assessed and reviewed based on urgency, with clearly defined response times. These innovations show that sometimes, improving care doesn’t require major investment—just better design and coordination.

Lastly, there is a need for commitment among all stakeholders to do what is right and to build a strong foundation rooted in quality and safety, moving us toward a position where no mother dies or receives care that is not respectful. To ensure that these improvements are sustained, there is a need to incorporate monitoring and evaluation of services. As the saying goes: what is not measured is not improved. Selecting and tracking key indicators offers major insights into performance and helps identify areas for improvement. These indicators could include the length of stay, perineal tears following normal delivery, maternal mortality, adherence to clinical protocols—such as the proportion of patients in labour with documented and completed partographs—and, lastly, patient satisfaction. These metrics guide us on what is working, what isn’t, and where the gaps lie.

The development of a monitoring framework at the healthcare facility level not only highlights areas for improvement but also engrains a culture of continuous quality enhancement. Regular review of data boosts staff morale as they feel supported, enables better resource allocation, and allows leadership to make evidence-based decisions. Audits, such as those focusing on near misses, uncover systemic issues that, once addressed, can prevent future harm. Patient satisfaction, in particular, offers healthcare providers valuable insight into the quality of care from the client’s perspective, providing a more complete picture of the obstetric services delivered.

All these interventions can be implemented even in resource-constrained settings. We are all stakeholders in the effort to enhance the quality of care offered to mothers and newborns. As we embark on the journey to improve maternal health, we must constantly ask ourselves whether we are making a difference. With the right systems in place—and with robust monitoring and feedback mechanisms—we can confidently say that every intervention counts and brings us closer to a future where safe, high-quality obstetric care is the norm, not a privilege for a few.

Dr Nairuti is the quality advisor, Aga Khan University Hospital, Nairobi