International Journal of Gynecology and Obstetrics 106 (2009) 85–88

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International Journal of Gynecology and Obstetrics

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o

AVERTING MATERNAL DEATH AND DISABILITY

Perinatal audit using the 3-delays model in western Tanzania

Godfrey Mbaruku a,b, Jos van Roosmalen c,d,⁎, Iluminata Kimondo a, Filigona Bilango a, Staffan Bergström b,e
a
Department of Obstetrics and Gynaecology, Regional Hospital, Maweni, Kigoma, Tanzania
b
Division of International Health (IHCAR), Karolinska Institute, Stockholm, Sweden
c
Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
d
Section of Health Care and Culture, VU University Medical Centre, Amsterdam, The Netherlands
e
Mailman School of Public health, AMDD program, Columbia University, New York, USA

a r t i c l e i n f o a b s t r a c t

Keywords: Objective: To audit intrapartum fetal and early neonatal deaths of infants weighing ≥ 2000 g in a regional
Perinatal audit hospital in western Tanzania. Methods: The 3-delays methodology was applied to a cohort of perinatal deaths
Substandard care from July 2002 to July 2004. Results: The overall perinatal mortality rate in the hospital was 38 per 1000 live
Tanzania
births, and in just over half of these cases the birth weight was ≥ 2000 g. The leading clinicopathologic causes
3-delays model
of death were birth asphyxia (19.0%), prolonged or obstructed labor (18.5%), antepartum hemorrhage
(11.5%), and uterine rupture (9.0%). First delays occurred in 19.0% of the cases, second delays occurred in
21.5%, and third delays occurred in 72.5%. Conclusion: For women who delivered in this hospital, most of the
substandard care occurred after admission to the health facility. The improvement of institutional health care
may have a significant impact on the decision to attend health institutions and, thereby, reduce first delays.
© 2009 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction studies utilized the Baird, Wigglesworth, or Nordic–Baltic classifica-

Worldwide, approximately 7 million perinatal deaths occur each
year, of which 98% occur in low- and middle-income countries [1]. In
2000, 38% of deaths of infants younger than 5 years old occurred in the
neonatal period, and 4 million infants each year were estimated to die
in the first 4 weeks of life [2]. Three-quarters of these died in the first
week of life.
The measurement of perinatal mortality is error prone. Some early
neonatal deaths occur after discharge from hospital and are not reported
because registration of deaths at home is lacking in most low-income
countries [3]. Because of logistic challenges and the almost universal
practice of early discharge, very few studies have been conducted
involving both hospital and community settings. Where such studies
have been conducted, interesting results have been obtained. In
northwestern Tanzania, the perinatal mortality rate in the community
was found to be 68 per 1000 live births, compared with 96 per 1000 in
the nearby hospital [4]. The highest perinatal mortality rate, however,
was for high-risk births at home (167 per 1000 live births). Low-risk
births in hospital had the lowest mortality rate (14 per 1000 live births).
The rate for low-risk births at home (73 per 1000 live births) was similar
to the rate for high-risk births in hospital (82 per 1000 live births) [5].
Many studies have explored the causes of perinatal deaths and
have shed light on their etiologies in different settings [6–11]. These
⁎ Corresponding author. Department of Obstetrics, Leiden University Medical Centre,
Leiden, The Netherlands. Tel.: +31 71 5262872; fax: +31 71 5266741.
E-mail address: j.j.m.van_roosmalen@lumc.nl (J. van Roosmalen).
tions of perinatal deaths, all of which seem to be appropriate, even at
district level in low-income countries [12–15].
Many perinatal deaths could be avoided with appropriate maternal
and neonatal health care, and it has been estimated that up to half of
these deaths are the result of poorly managed deliveries [16]. Hospital-
based studies in low-income countries have identified suboptimal care
in 10%–77% of perinatal deaths [17]. Many conditions can be
appropriately treated without significant investment in health care
and, thus, can be managed in settings with limited resources [18,19].
In the UK, inquiries into maternal deaths have had a crucial role in
reducing the rate of such fatalities [20]. A similar audit approach has
been applied to perinatal deaths—a process that has been multi-
national [21,22]. Perinatal audit addresses the question of why a
perinatal death has occurred. This can be used to detect substandard
care and, thus, may promote improvement of the quality of care. The
aim of our perinatal audit was to use the “3-delays” model, developed
by Thaddeus and Maine to audit maternal deaths, for the analysis of
perinatal mortality in a regional hospital in western Tanzania [23].
2. Methods
The study population included all births in the Department of
Obstetrics of the Maweni Regional Hospital in Kigoma, Tanzania, from
July 2002 to July 2004. Maweni is the referral hospital for the Kigoma
region, which has 1.6 million inhabitants [24].
A detailed questionnaire was used for all perinatal deaths in
the hospital. The questionnaire included details of the mothers'

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86 G. Mbaruku et al. / International Journal of Gynecology and Obstetrics 106 (2009) 85–88

backgrounds (age, marital status, and place of residence) and com-
plete medical, obstetric, family, and social histories. To ascertain the
duration of labor, attention was paid to the details of parturition that
took place prior to admission to the regional hospital. Attention was
also paid to fetal viability on admission and the care given from the
onset of labor. Information included the time taken to get from home
to the institution after the onset of labor, the type and cost of tran-
sport, whether the mother was referred from a lower-level health
facility, and the diagnosis made at the lower-level health facility (if
applicable). The care provided during labor was noted, including
institutional delays, type of attendant, decisions on management,
mode of delivery, complications, and resuscitation. Partogram use was
also assessed. All neonates were examined immediately after birth in
the hospital and details were recorded, including weight, sex, pre-
sence of congenital anomalies, and most importantly whether fetal
death had occurred prior to or during labor. All neonatal deaths (up to
7 days) that occurred in the hospital were recorded; no autopsies
were performed. Sick neonates received standard care according to
the hospital protocols.
The questionnaire was filled in by one of the authors (CK) after
interviewing the mother and checking the records. Counterchecking
was done by another author (GM). In addition to the completed
questionnaires, prenatal cards and clinical records were studied in
detail when available. The data were analyzed by a local team
consisting of a consultant obstetrician, a consultant pediatrician,
2 medical officers, and 2 nurse–midwives.
All intrapartum fetal and early neonatal deaths in which the birth
weight was ≥2000 g were audited using the 3-delays methodology.
This methodology classifies delays as follows: (1) first delay refers to
the time spent at home before a decision is made to seek health care;
(2) second delay refers to the inability to get to a health facility after
having made the decision to go there (due to problems with transport,
money, or poor roads); and (3) third delay refers to the time spent
waiting for adequate management after arrival at a health facility. In
addition to the Thaddeus and Maine model, we considered “misman-
agement or incorrect treatment” as a third delay in that it delayed
appropriate management.
For each perinatal death, a “process audit” was undertaken,
whereby actual practice was compared with standard practice, based
on evidence or expert consensus. Fetal monitoring was conducted
mainly through intermittent auscultation, and resuscitation of
asphyxiated neonates involved clearing the airway, simple drying,
ventilation with bag and mask, and immediate skin-to-skin contact
with the mother. Neonatal care comprised use of the “Kangaroo
method,” breastfeeding and close observation of early signs and
symptoms of infection. Sick neonates were seen by a consultant
pediatrician.
The research protocol was approved by the Ethics Committee of
the Karolinska Institute in Sweden and the National Institute of
Table 1
Clinicopathologic causes of intrapartum fetal and early neonatal deaths in which birth
weight was ≥ 2000 g (n = 200).
Table 2
First delaysa among intrapartum fetal and early neonatal deaths in which birth weight
was ≥2000 g (n = 200).
First delays No. (%)
Wanted to deliver at home, attended after complication occurred 26 (13.0)
Advised to have hospital delivery, but attended only after 9 (4.5)
complication occurred
Refused intervention 2 (1.0)
No prenatal care 1 (0.5)
Total 38 (19.0)
a
Thaddeus and Maine [23].
Medical Research in Tanzania. Written consent was obtained from
each participant.
3. Results
During the study period, 385 perinatal deaths occurred in 10 200
hospital births (38 per 1000 live births). Birth weight was less than
2000 g in 185 (48%) of these cases, leaving 132 intrapartum fetal deaths
and 68 early neonatal deaths in which the birth weight was ≥2000 g
(52%) to be included in the audit. The leading cause of death was birth
asphyxia (n= 38; 19.0%); followed by prolonged or obstructed labor
(n = 37; 18.5%); antepartum hemorrhage (n = 23; 11.5%); uterine
rupture (n = 18; 9.0%); cord prolapse (n = 15; 7.5%); and breech
delivery (n= 14; 7.0%) (Table 1). Congenital anomalies accounted for
only 7 cases (3.5%). Most infants (n= 161; 80.5%) weighed ≥2500 g.
There was 1 set of twins, and 3 mothers out of 199 (1.5%) died.
Analysis of the care received in terms of the 3-delays model is
provided in the following sections.
3.1. First delays
First delays occurred in 38 cases (19.0%) (Table 2). Most women
were admitted for delivery only after labor had started. Nine women
who had been advised to deliver in hospital attended only after com-
plications had occurred at home. In another 38 cases, pregnancy was
unwanted and its prevention could have avoided these perinatal
deaths.
3.2. Second delays
Second delays occurred in 43 cases (21.5%) (Table 3). The major
issues here were unspecified problems with transport after labor had
started (27 cases). Six women had long waiting times before em-
barking on a boat, 5 were transported on a stretcher, and 3 arrived by
bus or lorry. In 1 case, a car breakdown caused serious delay and
another woman had no money for transport.
An example of first and second delays was the case of a grand-
multiparous woman with 5 previous stillbirths (1 after cesarean
delivery). She had a 13-hour first stage of labor at home, experienced

Cause of death No. (%) Table 3

Birth asphyxia 38 (19.0) Second delaysa among intrapartum fetal and early neonatal deaths in which birth
Prolonged or obstructed labor 37 (18.5) weight was ≥2000 g (n = 200).
Antepartum hemorrhage 23 (11.5)
Uterine rupture 18 (9.0) Second delays No. (%)
Cord prolapse 15 (7.5) Unspecified transport problems 27 (13.5)
Breech delivery 14 (7.0) Long wait before embarking on a boat 6 (3.0)
Malpresentation 10 (5.0) Transported on stretcher 5 (2.5)
(Pre-)Eclampsia 9 (4.5 Transported on bus or truck 3 (1.5)
Sepsis 9 (4.5) Car breakdown 1 (0.5)
Congenital anomalies 7 (3.5) No money 1 (0.5)
Shoulder dystocia 2 (1.0) Total 43 (21.5)
Unknown causes 18 (9.0) a
Thaddeus and Maine [23].
 G. Mbaruku et al. / International Journal of Gynecology and Obstetrics 106 (2009) 85–88
6 hours of transport delays, and sustained uterine rupture on arrival at
the hospital.
3.3. Third delays
Third delays occurred in 145 cases (72.5%) (Table 4). Cesarean
delivery was performed in 67 cases (33.5%). In 19 cases, no fetal
heartbeat could be heard at the time of the decision to operate. In 13
women, the indication was for so-called “obstructed” labor, although
the membranes were intact at the time of the operation, making such
a diagnosis unlikely. Three cases of cesarean delivery were due to huge
hydrocephalus, which went undetected during the first stage of labor.
Rupture of the uterus occurred in 18 cases (9.0%); 8 occurred in
hospital and 2 occurred in dispensaries or health centers. Although
health workers often state that women with uterine rupture present
late, 10 of 18 cases (55.6%) occurred after admission to a health facility.
In 1 case, it remained unclear whether rupture had occurred at home
or in a dispensary. Only 3 women had a uterine scar from a previous
cesarean delivery.
Partograms were graded into categories of absent (1.5%), non-
satisfactory (10.5%), and satisfactory (88.0%). Doctors were called for
consultation in 80 cases (40%), and the average time for arrival was
1 hour (range, 0.5–4.0 hours). After daytime working hours, doctors
were called from home when abnormalities were noted on the parto-
gram or when specific emergencies were detected (e.g. severe pre-
eclampsia, eclampsia, prolonged labor, previous cesarean delivery, or
antepartum hemorrhage). In the case of cesarean deliveries, the
average time between decision and operation was 1 hour (range,
0.25–2.5 hours).
Occassionally, women with high-risk pregnancies were cared for
by low-cadre staff. This resulted in disastrous situations, especially
breech deliveries where auxiliary nurses failed to deliver the after-
coming head (n = 14). Half of the neonatal deaths were due to birth
asphyxia, and infections accounted for nearly 20%. Hypothermia was
documented in 10% of the neonatal deaths, while cerebral hemorrhage
and hypoglycemia were each recorded in 4% of cases. In the remaining
12% of neonatal deaths, the cause of death could not be determined.
Most of these early neonatal deaths occurred at night.
3.4. More than 1 delay
Several women experienced more than 1 type of delay: 83% had just
1 kind of delay, 10% had 2 kinds of delay, and 3% experienced all 3 types.
Table 4
Third delaysa among intrapartum fetal and early neonatal deaths in which birth weight
was ≥ 2000 g (n = 200).
Third delays No. (%) (n = 145)
Delay in dispensary and/or health center
Delay in first stage of labor in hospital
Delay in second stage of labor in hospital
Uterine rupture in a health facility
Clinical mismanagement
Unskilled breech delivery
Elective cesarean delivery 1 month too early
Cesarean delivery for prolonged or obstructed
labor, intact membrane
Cesarean performed when vacuum preferable
Cesarean for hydrocephalus
Cesarean for dead fetus
Undetected twins
Mismanagement of (pre-)eclampsia
Non-standard treatment of neonatal infection
Total (women, not conditions)b 145/200 (72.5)
a
Thaddeus and Maine [23].
b
Total number of conditions is greater than 145 because different conditions
sometimes occurred in the same woman.
87
4. Discussion
To our knowledge, the present study is the first in which the 3-delays
model has been applied to perinatal mortality. Health workers tend to
refer to first and second delays rather than to delays that occur after
women enter a health facility (third delay). In this audit, however, the
majority of substandard care occurred within the health facilities: third
delays occurred in 72.5% of perinatal deaths, compared with second and
first delays happening in 21.5% and 19.0% of perinatal deaths,
respectively.
By allocating perinatal deaths to etiologic categories with direct
clinical implications, one may identify problem areas in care provision
[12–15]. We found that 19% of pregnancies in our study were un-
planned, confirming findings from Pakistan [8]. Family planning is an
important part of the further reduction of perinatal mortality rates.
First and second delays are important because many births still
occur at home and referral practices still cause problems—as observed
in this study, where 81 of 226 delays (35.8%) occurred at home owing
not only to poor transport and long distance, but also lack of trust in the
health system [25,26]. These delays had important bearings on peri-
natal outcome. A significant proportion of the pregnant women did
attend peripheral health facilities, where some spent a considerable
amount of time before health workers decided to refer them to the
regional hospital. This may indicate problems ranging from the degree
of the peripheral health workers' knowledge to a lack of transport from
these areas. Indeed, 61% of uterine ruptures occurred in women who
had been admitted to health facilities before rupture occurred. There is
a general feeling in the community that pregnant women will go to
hospital only when labor is well established or when they perceive
complications. Furthermore, it is sometimes the relatives rather than
the pregnant woman herself who decide that she should go to hospital
[27]. Improving institutional care could have a positive impact on the
decision at home to seek care, thereby reducing first delays.
The majority of perinatal deaths that occurred in the regional hospital
were associated with third delays. This has been observed in both low-
income [17,28,29] and high-income countries, where substandard care
has been recognized as a major cause of perinatal death [21].
In the present study, 132 deaths (66%) were intrapartum, and the
birth weight was ≥2500 g in 161 cases (80.5%), implying that all of
these deaths occurred in viable fetuses. This high incidence of normal
birth weight intrapartum fetal deaths was similar to findings in Sudan,
Kenya, 6 West African countries, and Bangladesh and points to a lack
of adequate obstetric care during labor [18,29–32]. When we com-
pared perinatal mortality in our study with data from elsewhere, we
concluded that there was an excess of intrapartum and neonatal
deaths of infants weighing greater than 2000 g [33].
In this hospital-based study, the majority of early neonatal deaths
occurred at night. This was at least partly because of a shortage of
qualified night staff; on average, only 1 midwife was present and many
21 (14.5) deliveries were assisted by nurse attendants. In addition, neonatal
19 (13.1) hypothermia is more likely to occur at night, especially for preterm and
23 (15.9)
low birth weight infants. Emphasis should be on monitoring through
10 (6.9)
regular intermittent auscultation of fetal heart sounds, especially in the
late first and second stages of labor. Appropriate action should be taken
14 (9.7) as soon as abnormalities are detected.
1 (0.7) Observation of the partogram and history taking also revealed that
13 (9.0)
prolonged labor both outside and inside the hospital was associated with
23 (15.9) a substantial number of intrapartum and neonatal deaths. Misinterpreta-
3 (2.1) tion of clinical signs and mismanagement were also significant contri-
19 (13.1) butory factors to intrapartum deaths; this has also been reported in
5 (3.4)
audits performed in other areas of the continent [34,35].
4 (2.8)
5 (3.4) Audits have been accepted as a systematic critical analysis of medical
care. The review of circumstances of adverse health outcomes, especially
in cases of maternal and perinatal death, has received increasing
attention as a means of improving the quality of care [22]. Benefits have
been observed not only in high-income countries, but also increasingly
88 G. Mbaruku et al. / International Journal of Gynecology and Obstetrics 106 (2009) 85–88
in low-income countries [35–37]. Audit exercises are not easy to
undertake, however, because they require strong commitment and staff
time. When audits are performed only by specialists based in urban
settings, the contextual factors that contribute to local practices,
including underlying reasons for poor performance, may be overlooked
[11,13].
In many instances, cesarean delivery is mentioned as a major
intervention to reduce perinatal mortality. In our study, cesarean
delivery had been performed in 33% of cases of perinatal death; this
seems to be a very poor outcome for an intervention meant to prevent
maternal and perinatal mortality. Three maternal deaths occurred: 1
after uterine rupture and 2 after cesarean delivery for obstructed labor
with intrauterine fetal death and full dilatation of the cervix. The lives
of these latter 2 women might have been saved if birth had been
achieved by the vaginal route. When the fetus is already dead in utero,
the best mode of delivery is by the vaginal route because the dangers
of abdominal delivery are much more profound [38].
The large number of perinatal deaths in our study also indicates
the lack of equipment such as Doppler for fetal auscultation, oxygen,
and naso-gastric tubes in the hospital studied. Most studies indicate,
however, that basic affordable methods do exist that could save
substantial numbers of infants who, instead, are stillborn or die during
the first days of life. When these technologies are applied with proper
evaluation and monitoring, they could save millions of lives in a cost-
effective manner [39].
Our inability to analyze perinatal mortality occurring outside
health facilities is a limitation of the present study. Home birth is often
the preferred way of giving birth, although improved hospital care
may influence women's decisions to seek early care in institutions
instead of waiting too long and jeopardizing the outcome.
5. Conclusion
Perinatal mortality can be elucidated in low-resource settings similar
to the one investigated through the systematic analysis of perinatal
deaths using the simple 3-delays methodology. It is, however, unrealistic
to expect reductions in mortality rate at the same pace in all countries
because much depends on the economy, individual professional devo-
tion, political will, and deliberate efforts to combat the problems in a
defined setting. This methodology appears to be generally useful for
analyzing not only maternal but also perinatal deaths.
Acknowledgments
This research was funded by Danida (Denmark) and Sida (Sweden).
The project was developed by GM for a PhD dissertation.
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