Using the 3-delays framework to prevent stillbirth: a mixed-methods study in Tanzania and Zambia

Using the 3-delays framework to prevent stillbirth: a mixed-methods study in Tanzania and Zambia

Tina Lavender (1), Rose Laisser (2), Chowa Tembo (3), Chris Sutton (4), Kieran Blaikie (4), Carol Bedwell (1)

(1) Division of Nursing Midwifery and Social Work, The University of Manchester, Manchester, UK, (2) The Catholic University of Health Sciences, Mwanza, Tanzania, (3) Ministry of Health, Lusaka, Zambia, (4) Centre for Biostatistics, The University of Manchester, Manchester, UK.

Background:
The Lancet Stillbirth Series highlighted the need for further research in LMICs to ensure that women and newborns receive appropriate care. However, effective intervention studies are likely to be multifaceted and challenging. The three-delays model has been proposed as a framework for understanding the complexities related to inadequate intrapartum care. Although predominantly used when researching maternal mortality, this model has the potential to support preventative interventions for stillbirth. Aim: To gain understanding of the complexities surrounding delays in effective intrapartum care in Tanzania and Zambia and to use this knowledge to develop and implement appropriate interventions to reduce stillbirths.

Methods:
This study, guided by pragmatism, took place in rural and urban facilities in Tanzania and Zambia. A convergent parallel design was adopted, including data collected by; a retrospective case note review (n=2000), in-depth interviews (n=166) and non-participant observations (n=36). Quantitative data was analysed using descriptive statistics and multiple logistic regression. Qualitative analysis followed grounded theory principles.

Results:
In the study period, included facilities reported stillbirth rates of 163/1000 in Tanzania and 102/1000 in Zambia. Defined delays (OR 1.69, 95%CI 1.06 to 2.76) and intrapartum transfer (OR 3.55, 95%CI 2.14 to 5.91) were identified as important joint predictors of stillbirth. The qualitative data offered multiple reasons for the 3 delays, including traditional beliefs, cultural constraints, lack of resources, seasonality, community constraints, fear of revealing HIV status and disrespectful care.

Conclusion:
In Sub-Saharan Africa stillbirth rates are unacceptably high; prevention is reliant on women receiving timely care. Using the 3-delays model is a useful way of exploring modifiable factors and intervention trigger points when designing further research and planning future care strategies.

Ethics Statement:
Ethical approval for this study was obtained from University of Manchester (UREC 2018-4446-6653), The Catholic University of Health Sciences, Tanzania (CREC/287/2018) and the Independent Research Board (IRB), Zambia (2018-Jun-029). For the qualitative element parent participants were identified and approached via clinical teams, for consent for contact by the research team. Following, verbal and written explanations and time to consider, written (or thumb print) consent was obtained. Interviews were conducted at a venue of participants choice with pseudonyms used to protect identity. A study-specific distress policy was adhered to at all times. All data were managed securely and adhered to GDP regulations.

Funding:
NIHR Global Health Group for the Prevention and Management of Stillbirth in Sub Saharan Africa

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