The Six Delays Model
Expanding the three delays model with evidence from Madagascar for maternal referrals in LMICs
Bibliographic Data
| ID | 21880477 |
|---|---|
| Authors | Mara Anna Franke (0000-0001-7548-4423, Charité - Universitätsmedizin Berlin), Gybel Iata Pasteur (Madagascar Biodiversity Partnership) |
| Year | 2026 |
| Volume | 11 |
| Issue | 2 |
| Pages | e020936 |
| Publication date | 2026-02-01 |
| Peer Reviewed | Yes |
| Open Access | Yes |
| Type | ARTICLE |
| Venue | BMJ Global Health (JOURNAL) |
| Journal identifiers | ISSN: 2059-7908 • E-ISSN: 2059-7908 |
| Publisher | BMJ (PUBLISHER • GB) |
| DOI | 10.1136/bmjgh-2025-020936 |
| PMID | 41702636 |
| OpenAlex | W7129776477 |
| Language | EN |
| References cited | 63 |
Maternal mortality remains disproportionately high in low-income and middle-income countries, where pyramidal health systems and inadequate referral processes often delay access to emergency obstetric care. The Three Delays Model has long been used to analyse delays in maternal care globally, but it fails to capture the full complexity of referral-related delays within pyramidal health systems. Drawing on the example of Madagascar, this paper reviews the limitations of the traditional model and proposes a revised ‘Six Delays Model’. This model expands the traditional three delays to include the following six stages: ‘delay in seeking initial care’, ‘delay in reaching initial care’, ‘delay in receiving initial care’, ‘delay in seeking referral care’, ‘delay in reaching referral care’, ‘delay in receiving referral care’. This revised model improves granularity, integrates patient-provider and inter-provider dynamics that influence referral decisions and reflects both individual and community-level factors that influence decision-making. By mapping delays accurately along the patient journey, the revised model provides a more actionable model for policymakers and implementers seeking to reduce maternal mortality. While more complex, the expanded model offers necessary nuance and adaptability for pyramidal health systems and supports targeted intervention design to address systemic barriers to timely and adequate obstetric care
Adaptability · Health care · Maternal health · Maternal morbidity · Referral · Global Health and Surgery · Global Maternal and Child Health · Maternal and fetal healthcare
Global causes of maternal death
Reframing the Three Delays framework
Why do women not adhere to advice on maternal referral in rural Tanzania? Narratives of women and their family members
Utility of the three-delays model and its potential for supporting a solution-based approach to accessing intrapartum care in low- and middle-income countries. A qualitative evidence synthesis
Community-based referral transportation system for accessing emergency obstetric services in the Rohingya refugee camp during the Covid-19 pandemic in Bangladesh
Conducting an audit to improve the facilitation of emergency maternal and newborn referral in northern Ghana
Non-professional health practitioners and referrals to facilities
Out-of-pocket costs for facility-based maternity care in three African countries
Too far to walk
How a woman's interpersonal relationships can delay care-seeking and access during the maternity period in rural Zambia
Maternity referral systems in developing countries
| Citation velocity | historical |
|---|---|
| Highly cited | No |