The fourth delay and community-driven solutions to reduce maternal mortality in rural Haiti: a community-based action research study

Abstract

BackgroundIn Haiti, the number of women dying in pregnancy, during childbirth and the weeks after giving birth remains unacceptably high. The objective of this research was to explore determinants of maternal mortality in rural Haiti through Community-Based Action Research (CBAR), guided by the delays that lead to maternal death. This paper focuses on socioecological determinants of maternal mortality from the perspectives of women of near-miss maternal experiences and community members, and their solutions to reduce maternal mortality in their community.MethodsThe study draws on five semi-structured Individual Interviews with women survivors of near-misses, and on four Focus Group Discussions with Community Leaders and with Traditional Birth Attendants. Data collection took place in July 2013. A Community Research Team within a resource-limited rural community in Haiti undertook the research. The methods and analysis process were guided by participatory research and CBAR.ResultsParticipants identified three delays that lead to maternal death but also described a fourth delay with respect to community responsibility for maternal mortality. They included women being carried from the community to a healthcare facility as a special example of the fourth delay. Women survivors of near-miss maternal experiences and community leaders suggested solutions to reduce maternal death that centered on prevention and community infrastructure. Most of the strategies for action were related to the fourth delay and include: community mobilization by way of the formation of Neighbourhood Maternal Health/Well-being Committees, and community support through the provision/sharing of food for undernourished women, offering monetary support and establishment of a communication relay/transport system in times of crisis.ConclusionsFinding sustainable ways to reduce maternal mortality requires a community-based/centred and community-driven comprehensive approach to maternal health/well-being. This includes engagement of community members that is dependent upon community knowledge, political will, mobilization, accountability and empowerment. An engaged/empowered community is one that is well placed to find ways that work in their community to reduce the fourth delay and in turn, maternal death. Potentially, community ownership of challenges and solutions can lead to more sustainable improvements in maternal health/well-being in Haiti.

Utility of the three-delays model and its potential for supporting a solution-based approach to accessing intrapartum care in low- and middle-income countries. A qualitative evidence synthesis

“…The synthesis included twenty-five studies which were conducted in Democratic Republic of Congo [ 41 ], Ethiopia [ 32 ], The Gambia [ 33 , 40 ], Ghana [ 7 ], Kenya [ 43 , 46 ], Liberia [ 47 ], Malawi [ 15 , 34 ], Nigeria [ 9 ], Rwanda [ 31 ], Tanzania [ 14 , 44 ], India [ 35 , 37 , 42 ], Timor-Leste [ 30 ], Colombia [ 36 ], Haiti [ 29 , 45 ] and Mexico [ 39 ]. One of the multi-country papers involved Ethiopia, India, Indonesia, Nigeria, Tanzania, Uganda and Nepal [ 38 ]; the other one included Indonesia and Burkina Faso [ 6 ].…”

A longitudinal study of near-miss and maternal mortality at a tertiary centre in rural Uttarakhand: addressing the fourth delay

“…This observation was similar to many other studies in the past. 13 Complications due to obstetric haemorrhage, if identified in time are largely preventable. Non-availability of blood and blood products, especially at rural regions is another important contributing factor.…”

“…Another important delay we found in our study was failure of the community to take the responsibility of women's health (delay 4). 13 Women are not given a right to decide about their fertility and family planning options. Unwanted pregnancy and unsafe and repeated abortions both are a major factor adversely affecting woman's health and later contributing to morbidity.…”

Improving Birth Preparedness and Complication Readiness Through an Integrated Microfinance and Health Literacy Program:Evidence From Rural India

“…In most instances in rural India, decision-making among households during maternal emergencies is in uenced by past experiences with the health system and a tendency to follow traditional cultural beliefs (29,31,32). Previously delays in care-seeking have been explained using the widely validated three-delays framework as an approach to develop interventions to improve care-seeking steps (19,24,31,(33)(34)(35). The framework identi es the recognition of danger signs in the household as the rst type of delay, delays in reaching an appropriate facility as the second delay and lastly, delays in receiving adequate care in the health facility (35).…”