Falling through the net: An adaptive assessment of the ‘Three Delays’ encountered by patients seeking emergency maternal and neonatal care within a remote health system on Lake Victoria, Kenya

ABSTRACT

In rural sub-Saharan Africa, preventable delays in accessing emergency care remain a dominant factor in maternal and neonatal deaths. The MOMENTUM study is a pragmatic cohort investigation designed to measure the “Three Delays”, i.e. delays in recognizing need for care (Type 1), reaching care (Type 2), and receiving care (Type 3) within a remote island health system on Lake Victoria, Kenya. The study utilizes an adaptive methodology to provide actionable data for a locally-directed “Health Navigation” intervention. We present analysis of 56 maternal and neonatal emergency cases occurring between January 2019 and February 2020. The mean Total Delay Interval (Type 1–3) reported was 39.3 ± 32.3hours. Notably, 18 cases in this cohort resulted in a neonatal (n = 16) or maternal death (n = 2). Sub-analysis indicates significant delay interval reductions associated with involvement of a “Health Navigator” in emergency care coordination for Type 2 Delay Intervals (0.5 ± 0.3 vs. 1.2 ±  1.1 hrs., p = 0.002) and Type 3 Delay Intervals (17.9 ± 14.1 vs. 32.9 ± 33.7 hrs., p = 0.030). Prolonged delays, complex barriers, and high mortality highlight the fraught nature of maternal emergencies in this remote setting. We discuss practical considerations for application of the Three Delays model, and avenues for further investigation.

KEYWORDS:

• Maternal health
• emergency care
• patient navigation
• Three Delays
• Kenya

Acknowledgments

The authors would like to acknowledge our international and local collaborators at the Mfangano Community Health Field Station, including the Ekialo Kiona Centre staff and volunteers, the Organic Health Response Board of Directors, the Mfangano Island Health Navigators and Community Health Volunteers, and the EK Community Advisory Group. We want to highlight the unwavering dedication and outstanding community service of the EK Emergency Boat Coxswains, Walter Opiyo and Oliver Ogutu, and the logistics coordination of Lavinah Chikamai. We thank the Kenyan Ministry of Health staff at participating facilities for their assistance in screening participants, and all Mfangano Island community members for their partnership over the years. The Ekialo Kiona Centre would like to thank all local and international partners who have supported the Health Navigation programme since its inception in 2014, particularly the timely COVID-19 support from the Improving Chances Foundation.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This study was supported by a ‘CGHSR Global Health Seed Grant’ of the University of Minnesota. Fieldwork was also supported in part by the Doris Duke International Clinical Research Fellows Program.