Delayed access to emergency obstetrical care among preeclamptic and non-preeclamptic women in Port-Au-Prince, Haiti

Despite progress in reducing maternal mortality, Haiti still suffers from some of the worst maternal and neonatal health indicators in the Western Hemisphere. Hypertensive disorders of pregnancy, including preeclampsia and eclampsia, are particularly prevalent, [1, 2] and are the leading cause of pregnancy-related death in the region [3]. An understaffed, underfunded health system with few obstetric providers, exacerbated by several large natural disasters in the past decade, makes access to health care difficult. Although most hospitals and obstetric staff are concentrated in the capital city of Port-au-Prince, [4] access to emergency obstetric care is challenging even in this urban context.

Thaddeus and Maine’s Three Delays Model of maternal mortality describes how delays at home prior to deciding to seek care (the first delay); delays in finding and managing transport to a facility (the second delay); and delays in receiving appropriate treatment once at the facility (the third delay) contribute to maternal mortality [5]. The model was conceptualized to address the experiences of rural women, with the original article titled “Too Far to Walk.” Past studies utilizing the Three Delays Model have identified several factors associated with delays in various contexts, including distance to facility, [6‐8] cost, [8] educational level, [8] women’s status in the family, [9] perception of the gravity of the situation, [10] transportation options, [11] distribution of facilities, and perception of quality at the facility. [12, 13] Relatively few studies, [14‐17] however, have examined how women in urban contexts access emergency care, and the unique delays they encounter. One such study in Kenya examined how access and outcomes among urban poor women may be even worse than their rural counterparts [14]. Urban women who develop obstetric complications, such as preeclampsia and eclampsia, need timely access to high-quality obstetric care to prevent dangerous complications, but often face specific barriers to access that are unique to these settings. The goal of this study was to examine the delays faced by women with preeclampsia while accessing emergency obstetric care in urban Port-au-Prince, the relative importance of the factors associated with delays, and the relationship between those delays and maternal and neonatal health outcomes.

Urban, poor women in Haiti face dangerous delays to accessing emergency obstetric care. Preeclamptic and eclamptic women in this study experienced a delay in receiving appropriate medical treatment of more than fourteen hours, on average. Median delays were much shorter, reflecting the impact of a subset of women with exceptionally long delays. The vast majority of participants had accessed antenatal care, and yet few could identify any warning signs of preeclampsia. Almost one fifth of preeclamptic participants experienced a twenty-four-hour delay in accessing health care after symptoms started. These very long delays were primarily attributable to long first delays, over thirteen hours after symptoms developed, on average, for this group. Third (triage/health facility) delays were also significantly longer in this group, though that may have been attributable to so many in the non-preeclamptic group arriving at the hospital in advanced labor. Second (transport) delays were comparable in the two groups. Preeclamptic women did not have shorter delays to accessing care, even if they lived relatively close to the hospital. Large proportions of women experienced adverse clinical outcomes, including eclampsia and ICU admission for mothers, and NICU admission and stillbirth for newborns.

Few studies examining the Three Delays have attempted to quantify the length of time for each delay. Our findings are generally consistent with those from comparable prior studies. Researchers in India found an average first delay of eight hours among cases of maternal mortality, compared to a two-hour first delay among controls [7]. Researchers in The Gambia and Malawi found first delays among a minority of cases of maternal death, ranging from two days to a month. [22, 23] A recently published study from Ethiopia found very long delays, averaging more than five days, for women experiencing danger signs of preeclampsia [24].

Although we had expected to identify subgroups of women who were more likely to experience delays, we found no demographic factors associated with longer delays. This lack of association may reflect several possibilities unique to the Haitian context. The vast majority of women in this study were poor and lacked formal employment. Poverty creates an overwhelming barrier to access for all mothers, perhaps rendering other associations to longer delays less important. We found a trend towards shorter delay among preeclamptic women with better economic status (4.9 h versus 15.2 h), although this did not reach statistical significance, likely given the small number of women in our sample (n = 25) who reported faring well economically. Economic factors may have similarly limited access for the women in our study [14] even though geographic distances were relatively short.

The study aimed to identify the role of delayed access to care in poor clinical outcomes for mothers or babies. However, the association between long delays to care and poor clinical outcomes was not clearly evident from the data. Difficulties in assessing delay may have led to an under-reporting of delay for preeclamptic women. The study sample size may have been insufficient to find real associations that do exist. Additionally, the generally low economic status of participants and the difficulty they faced in finding health care may have minimized differences between the delayed and not delayed groups. Finally, neonatal death was not able to be accurately identified in this study, due to the inability to track neonatal outcomes after the time of survey administration. However, it is likely that neonatal deaths, even if accurately reported, would have been too rare to permit detection of major differences among the groups.

Long transportation delays were uncommon among both the preeclamptic and non-preeclamptic groups in our study. Prior studies of maternal mortality and the Three Delays Model in a rural context have focused on the distance between women’s homes and delivery facilities as a major factor in both first and second delays [5, 6, 11, 13, 22, 25‐27]. The long delays we found among preeclamptic women living relatively close to the hospital may improve understanding of how living short distances from a facility may, somewhat counter-intuitively, delay women’s decisions to leave home. Most women lived within two to five kilometers of a hospital; however, the effects of urban congestion, including traffic and transport difficulties may have contributed to longer delays. Some neighborhoods close to the CRUO hospital routinely experience high levels of violence, and travel may be too dangerous during nighttime hours, which also could have affected delays. However, some studies have found that women’s decisions to leave home for facility birth are unaffected by distance when health facilities are less than five kilometers away [13, 28].

If distance is not a main contributing factor, then what factors determine how urban women and their families make decisions about seeking emergency care? In addition to economic concerns, our study highlights the importance of prioritizing the quality of ANC to identify, treat, refer, and educate higher risk patients such as the preeclamptic mothers studied here, who reported little understanding of danger signs and the importance of seeking care. A lack of understanding of the gravity of their symptoms might explain many women’s long first delay at home prior to leaving to seek care. Other studies have found similarly low levels of knowledge of preeclampsia danger signs, [24, 29‐31] which contributed to delayed access to care [10, 23, 14]. Despite reporting at least four antenatal visits and a hypertension diagnosis, most preeclamptic women in this study were unaware of the specific symptoms that should prompt immediate medical attention. Given this lack of knowledge among the study population, our study identifies needs for improvement in ANC practices in Haiti and potentially in other low resource urban settings.

The measurement of delay represented the most important study limitation. As with all self-reported data, it is unclear to what extent study participants reported delays accurately. Although the interviewers attempted to clarify responses with participants, as well as to triangulate information with family members, it is possible that reported delays were not accurate. There were also challenges for participants in estimating the first delay. The onset of the first delay corresponds to the onset of the emergency, which is subjective and specific to the experience of each participant. For women without preeclampsia, who were in labor, the onset of the first delay typically corresponded with the onset of strong contractions, or when their water broke. Moreover, the non-preeclamptic women in our study were not an ideal comparison group as they were a select group of women in spontaneous labor who were admitted just prior to delivery. Fifteen participants in the normal group also stated that they had been diagnosed with preeclampsia during that pregnancy, and some of them had elevated blood pressure readings on admission. If these women were on the verge of delivering their infant, it is possible that staff did not have the time to distinguish between blood pressures that can be normally elevated during delivery, and those indicating preeclampsia. Misclassification of women by preeclampsia diagnosis could have biased the delays reported by these groups, by artificially lengthening delays in the normal group. It is unlikely that a misclassification of these fifteen participants would have affected the study outcomes. The non-preeclamptic women had shorter delays partly since they were, as a group, closer to delivery than their preeclamptic counterparts. Preeclamptic women’s lack of knowledge of danger signs meant that they were unable to identify the start of the delay, possibly leading to reporting artificially shorter delays.

In the more than twenty years since the seminal study proposing the Three Delays Model, the model has guided critical efforts to reduce maternal and neonatal mortality. Refining this model to include urban women, and the unique delays they face, will serve to include the essential experiences of these women who also sometimes face long delays to care. A renewed focus on the accessibility and quality of maternal health services, including newly published WHO guidelines on antenatal care, [32] provides an opportunity to improve quality and accessibility of these lifesaving services. This study reinforces the urgent need to ensure that urban poor women are included—and prioritized—in these efforts.