title: Why are women dying when they reach hospital on time? A systematic review of the 'third delay'.
abstract: BACKGROUND
  The 'three delays model' attempts to explain delays in women accessing emergency obstetric care as the result of: 1) decision-making, 2) accessing services and 3) receipt of appropriate care once a health facility is reached. The third delay, although under-researched, is likely to be a source of considerable inequity in access to emergency obstetric care in developing countries. The aim of this systematic review was to identify and categorise specific facility-level barriers to the provision of evidence-based maternal health care in developing countries.
  
  
  RESULTS
  Five electronic databases were systematically searched using a 4-way strategy that combined search terms related to: 1) maternal health care; 2) maternity units; 3) barriers, and 4) developing countries. Forty-three original research articles were eligible to be included in the review. Thirty-two barriers to the receipt of timely and appropriate obstetric care at the facility level were identified and categorised into six emerging themes (Drugs and equipment; Policy and guidelines; Human resources; Facility infrastructure; Patient-related and Referral-related). Two investigators independently recorded the frequency with which barriers relating to the third delay were reported in the literature. The most commonly cited barriers were inadequate training/skills mix (86%); drug procurement/logistics problems (65%); staff shortages (60%); lack of equipment (51%) and low staff motivation (44%).
  
  
  CONCLUSIONS
  This review highlights how a focus on patient-side delays in the decision to seek care can conceal the fact that many health facilities in the developing world are still chronically under-resourced and unable to cope effectively with serious obstetric complications. We stress the importance of addressing supply-side barriers alongside demand-side factors if further reductions in maternal mortality are to be achieved.
authors.affiliation: Nuffield Department of Obstetrics & Gynaecology, University of Oxford, Oxford, United Kingdom. hknight@rcog.org.uk
authors.forename: Hannah E
authors.initials: HE
authors.lastname: Knight
authors.forename: Alice
authors.initials: A
authors.lastname: Self
authors.forename: Stephen H
authors.initials: SH
authors.lastname: Kennedy
mesh_terms: D004632:Emergency Medical Services / Q000706:statistics & numerical data; D005260:Female; D006268:Health Facilities / Q000706:statistics & numerical data; D006291:Health Policy; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D008428:Maternal Mortality; D008962:Models, Theoretical; D004364:Pharmaceutical Preparations; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D012017:Referral and Consultation; D013997:Time Factors
chemical_list: D004364:Pharmaceutical Preparations