Every minute, a woman dies from complications related to pregnancy and childbirth [1]. According to a 2020 report by the World Health Organization, 800 women worldwide die every day from preventable causes related to pregnancy and childbirth. Of these, almost 70% of maternal deaths occurred in sub-Saharan Africa [2]. Women living in these countries are at higher risk of dying in childbirth than women in other regions. This can be prevented if women give birth in a health facility with qualified caregivers [2, 3]. Timely treatment and management of obstetric cases is key to preventing maternal mortality and narrowing the maternal mortality gap between developed and developing countries [4, 5].
Thaddues and Maine developed a three-delay model three decades ago to assess the circumstances of accessing appropriate emergency obstetric care [6]. These three delays have three components: the first component (first delay) is the delay in the decision to seek care from the individual or family; the second component (second delay) is the delay in reaching an appropriate healthcare facility; and the final component (third delay) is the delay in providing adequate care at the healthcare facility. Delay one is often influenced by negative past experiences, late recognition of the problem, and financial problems. Delay two is usually determined by the availability of transportation and facility accessibility. The third delay is related to suboptimal care after reaching the healthcare facility and is typically measured by the availability of trained healthcare providers, essential medical tools, initiation of early treatment, and follow-up [7–12]. The three-delay model has proven to be a widely accepted and very useful framework to account for delays in maternal emergency care management and their role in maternal mortality from the onset of complications. The model is also considered a comprehensive approach to examining barriers to seeking maternal care and preventing maternal mortality [13–15].
Evidence from developing countries suggests that six in ten women die from one of the three delays. Of the three delays, the third delay contributes the high maternal death and is responsible for 50% of maternal deaths. The second and third delays were 30 and 20 percent of maternal mortality in total maternal mortality, respectively [16]. Other study suggests that the first delay accounts for 33% of maternal deaths, followed by the second and third delays, which contribute 32% and 29% of maternal deaths, respectively [17]. Studies also reported that 36.1%, 27.6%, and 36.3% of maternal deaths were due to the first, second, and third delays, respectively [18].
The impact of these three delays is not limited to maternal mortality, but also affects neonatal mortality. Due to the three delays in maternal care, it becomes difficult to provide quality obstetric care that leads to favorable health conditions for the baby. Complications in the perinatal period occur in mothers with maternal delays [19, 20]. As indicated by the evidence, a third delay during delivery is 24 times more likely to have an adverse neonatal outcome [21]. Maternal delays are identified as the main contributing factors to maternal mortality in many developing countries, including Ethiopia. These delays contribute not only to maternal and neonatal mortality but also to maternal comorbidities, such as uterine rupture and prolapse, vaginal prolapse, postpartum sepsis, postpartum hemorrhage, retained placenta, and postpartum psychosis, which can cause unwanted physical, social, economic, emotional, and mental outcomes for respective families [22].
The literature indicates that the magnitude of the three maternal delays in utilizing maternal care varies across countries. In developing countries, the prevalence of women experiencing first, second, and third maternal delays was 71%, 40%, and 79%, respectively [23]. Studies from Brazil and Nigeria showed that 53% and 47.9% of mothers experienced all three delays, respectively [14, 24]. A study from Ethiopia showed that the number of mothers who experienced the first, second, and third delays in utilizing maternal care were 37.8%, 31.7%, and 30.7%, respectively [25].
Many efforts have been made to tackle the problem of unacceptably high maternal delays in Ethiopia through several initiatives to increase access and enhance community demand for greater service use. By expanding health extension worker programs like user-free exemption for institutional delivery, maternity waiting rooms, ambulance service to reach health facilities for childbirth, and community mobilization endeavors since 2005 [26–28]. Moreover, middle-level health cadres (Integrated Emergency Surgical Officers) are being trained to handle obstetric emergencies at a lower level. This is coupled with upgrading the existing health facilities to ensure the provision of comprehensive emergency obstetrics and newborn care. Despite all these efforts, however, the number of maternal deaths remains unacceptably high [29–31].
The three maternal delays (first, second, and third delay) are significantly influenced by various factors such as: lack of transportation, lack of accessibility to health facilities, rural location, drug supply, maternal awareness, education, occupation, family attitudes towards maternal care, quality of maternal care, availability of qualified professionals, lack of maternal awareness, lack of decision to seek care, poor quality of care, length of hospital stay, age of women, and distance from home to health facility [19] [20] [14] [28] [32] [33].
Although several individual studies have been conducted to identify three maternal delays and associated factors in mothers seeking maternal care in different regions of Ethiopia .There was no national data to support the overall prevalence of maternal delay. And the representativeness and results of a single study are neither conclusive nor consistent. Therefore, the purpose of this systematic review and meta-analysis was to assess the pooled prevalence of maternal delay and related factors in Ethiopia. The results of this study lead to general insights that help reduce maternal delays in women who use maternal care by helping to inform policy, design strategies, and improve maternal care utilization. This plays an important role in reducing maternal and neonatal mortality