Transitioning from the “Three Delays” to a focus on continuity of care: a qualitative analysis of maternal deaths in rural Pakistan and Mozambique
Authors: Vidler Marianne , Kinshella Mai-Lei Woo , Sevene Esperanca , Lewis Gwyneth , von Dadelszen Peter , Bhutta Zulfiqar ,   the CLIP Working Group, Sevene Esperança , Macete Eusébio , Munguambe Khátia , Sacoor Charfudin , Vala Anifa , Boene Helena , Amose Felizarda , Pires Rosa , Nhamirre Zefanias , Macamo Marta , Chiaú Rogério , Matavele Analisa , Vilanculo Faustino , Nhancolo Ariel , Cutana Silvestre , Mandlate Ernesto , Macuacua Salésio , Bique Cassimo , Mocumbi Sibone , Gonçálves Emília , Maculuve Sónia , Biz Ana Ilda , Mulungo Dulce , Augusto Orvalho , Filimone Paulo , Nobela Vivalde , Tchavana Corsino , Nkumbula Cláudio , Qureshi Rahat , Bhutta Zulfiqar A. , Hoodbhoy Zahra , Raza Farrukh , Sheikh Sana , Memon Javed , Ahmed Imran , Hussain Amjad , Bellad Mrutunjaya B. , Charantimath Umesh S. , Goudar Shivaprasad S. , Katageri Geetanjali M. , Kavi Avinash J. , Revankar Amit P. , Mallapur Ashalata A. , Ramdurg Umesh Y. , Bannale Shashidhar G. , Dhamanekar Vaibhav B. , Mungarwadi Geetanjali I. , Honnungar Narayan V. , Kodkany Bhalachandra S. , Joshi Anjali M. , Kudachi Uday S. , Mastiholi Sphoorthi S. , Karadiguddi Chandrappa C. , Kengapur Gudadayya S. , Kamble Namdev A. , Chougala Keval S. , Bone Jeffrey , Dunsmuir Dustin T. , Drebit Sharla K. , Kariya Chirag , Lee Tang , Li Jing , Lui Mansun , Payne Beth A. , Sawchuck Diane , Sharma Sumedha , Tu Domena K. , V·Ukah Ugochi , Magee Laura A. , Ansermino JMark , Betrán Ana Pilar , Derman Richard , Dharamsi Shafik , Donnay France , Drebit Sharla , Dumont Guy , Engelbrecht Susheela M. , Fillipi Veronique , Firoz Tabassum , Grobman William , Knight Marian , Langer Ana , Lewin Simon , Mitton Craig , Schuurman Nadine , Shennan Andrew , Singer Joel , Thornton Jim , Wong Hubert , Adetoro Olalekan O. , Munguambe Khátia , Sotunsa John O. 
Published: October 2023

Abstract
Background
The Three Delays Framework was instrumental in the reduction of maternal mortality leading up to, and during the Millennium Development Goals. However, this paper suggests the original framework might be reconsidered, now that most mothers give birth in facilities, the quality and continuity of the clinical care is of growing importance.

Methods
The paper explores the factors that contributed to maternal deaths in rural Pakistan and Mozambique, using 76 verbal autopsy narratives from the Community Level Interventions for Pre-eclampsia (CLIP) Trial.

Results
Qualitative analysis of these maternal death narratives in both countries reveals an interplay of various influences, such as, underlying risks and comorbidities, temporary improvements after seeking care, gaps in quality care in emergencies, convoluted referral systems, and arrival at the final facility in critical condition. Evaluation of these narratives helps to reframe the pathways of maternal mortality beyond a single journey of care-seeking, to update the categories of seeking, reaching and receiving care.

Conclusions
There is a need to supplement the pioneering “Three Delays Framework” to include focusing on continuity of care and the “Four Critical Connection Points”: (1) between the stages of pregnancy, (2) between families and health care workers, (3) between health care facilities and (4) between multiple care-seeking journeys.

Trial registration
NCT01911494, Date Registered 30/07/2013.