A rural district has high maternal mortality. An audit finds that most deaths occur in women who reached the facility in time but died waiting for blood products or surgical intervention. Which prevention level and bottleneck should the program prioritize?
APrimary prevention — the program should expand contraception access to reduce pregnancies in high-risk women
BSecondary prevention — the program should train more skilled birth attendants for community-level delivery
CTertiary prevention — the program should strengthen emergency obstetric care capacity at the facility (blood products, surgical capability)
DSecondary prevention — the program should improve prenatal screening to catch complications before labor
The three-delays model identifies three possible bottlenecks: delay in deciding to seek care, delay in reaching a facility, and delay in receiving adequate care once there. In this scenario, women are reaching the facility — so delays 1 and 2 are not the primary problem. Deaths are occurring because care at the facility is inadequate (missing blood products, no surgical capacity). This points directly to tertiary prevention — comprehensive emergency obstetric care (CEmOC). Interventions at the other prevention levels, however worthwhile in general, would not address the identified bottleneck and would likely not reduce mortality in this setting.
Question 2 Multiple Choice
What makes skilled birth attendance the highest-impact secondary prevention intervention for maternal mortality, compared to traditional birth attendants?
ASkilled birth attendants are more culturally trusted, increasing the likelihood that women choose facility delivery
BSkilled birth attendants can manage postpartum hemorrhage with oxytocin, recognize complications, and make timely referrals — capabilities traditional birth attendants lack regardless of experience
CSkilled birth attendants reduce the need for emergency obstetric care by preventing complications from occurring at all
DTraditional birth attendants are equally capable for normal deliveries; skill only matters for high-risk pregnancies identified in prenatal care
70–80% of maternal deaths occur during or immediately after delivery. The critical interventions at this moment — administering oxytocin for postpartum hemorrhage, recognizing obstructed labor, performing or facilitating emergency referral — require clinical training and equipment. Traditional birth attendants, regardless of experience, cannot provide these. Experience with normal deliveries does not substitute for clinical competency with complications. This is why traditional birth attendant training programs historically had limited impact on maternal mortality rates, while scale-up of skilled birth attendance consistently shows mortality reductions. The skill gap is not about familiarity — it's about clinical capability at the moment of crisis.
Question 3 True / False
Traditional birth attendants with extensive delivery experience can effectively substitute for clinically trained skilled birth attendants in resource-limited settings where skilled attendants are unavailable.
TTrue
FFalse
Answer: False
Evidence consistently shows that traditional birth attendants (TBAs), regardless of experience, cannot substitute for clinically trained skilled birth attendants in preventing maternal death. The interventions that avert maternal mortality at the time of delivery — managing postpartum hemorrhage with uterotonics, recognizing and responding to eclampsia, performing or arranging emergency obstetric procedures — require clinical training that TBA experience does not provide. Large-scale evaluations of TBA training programs found no significant reductions in maternal mortality. This doesn't mean TBAs are without value (they provide support, recognize the need for referral, and are often the only present care), but they cannot prevent the cascade of fatal complications that clinical skill can interrupt.
Question 4 True / False
Expanding access to contraception and family planning services constitutes primary prevention for maternal mortality because it reduces the incidence of the condition that causes death — pregnancy itself, specifically unintended or high-risk pregnancies.
TTrue
FFalse
Answer: True
Primary prevention prevents the disease or condition from occurring in the first place. Maternal death requires a pregnancy; therefore preventing unintended pregnancies, high-parity births, adolescent pregnancies, and short-interval pregnancies directly prevents the exposure. This is particularly important because unsafe abortion — itself a major cause of maternal mortality in settings with restricted access — is almost entirely a consequence of unintended pregnancy. Contraception access is often underfunded relative to clinical interventions, yet it carries high population-level impact per dollar. Understanding it as primary prevention — not just family planning — clarifies its role in the mortality reduction framework.
Question 5 Short Answer
Describe the three-delays model of maternal mortality and explain why identifying the dominant delay is essential before designing an intervention program.
Think about your answer, then reveal below.
Model answer: The three-delays model identifies three points where delay can convert a survivable obstetric complication into a death: (1) delay in deciding to seek care — due to financial barriers, lack of awareness of danger signs, cultural norms, or poor prior facility experiences; (2) delay in reaching a facility — due to distance, transport unavailability, or poor roads; and (3) delay in receiving adequate care once at the facility — due to absent staff, missing equipment, blood products, or surgical capacity. Each delay requires a different intervention: community education and financial support address delay 1; transport systems and maternity waiting homes address delay 2; facility capacity building addresses delay 3. Designing an intervention without identifying which delay dominates is why many programs fail — installing operating theatres in communities where women never reach them doesn't save lives, just as community mobilization in places where facilities lack blood products shifts deaths to a later point in the system.
The three-delays framework is a diagnostic tool as much as a classification system. Different settings have different bottleneck delays, and the same intervention bundle can succeed in one context and fail in another. Effective programs start with local data — auditing actual deaths to determine where the delay occurred — before selecting interventions.