Identifying behavioral, demographic, and clinical risk factors for delayed access to emergency obstetrical care in preeclamptic women in Port au Prince, Haiti
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OBJECTIVES: We conducted a mixed methods study of delayed access to emergency obstetrical care among preeclamptic and non-preeclamptic women in Port au Prince, Haiti, grounded in the Three Delays model of Thaddeus and Maine. The primary objectives were to identify factors affecting delays in accessing care and clinical consequences of delays. METHODS: 524 surveys were administered to women admitted to the Médecins Sans Frontières (MSF) obstetric emergency hospital. Survey questions addressed demographic, clinical, and behavioral risk factors; first (at home), second (transport) and third (health facility) delays; and clinical outcomes for women and infants. Bivariate statistics were used to assess relationships between preeclampsia status and delay, and between risk factors and delay. Twenty-six survey participants with lengthy delays (> 6 hours) were chosen for interviews, which elicited details about delays women experienced. Data were analyzed using a grounded theory approach. RESULTS: We found long delays to accessing care for preeclamptic women (median 5.0 hours, IQR 10.5, vs. 4.0 hours, IQR 5.0, for non-preeclamptic women, p<0.01), primarily due to delays at home before leaving for the hospital (median 2.6 hours, IQR 10.6). No demographic, clinical, or behavioral factors were related to access to care. Women's health prior to pregnancy was not associated with delays, with the exception of preeclamptic women who had previously seen a doctor, who had significantly longer delays than women who had not previously seen a doctor (22.8 hours versus 11.2 hours, p=0.02). Long delays for both preeclamptic and non-preeclamptic women were not associated with poorer clinical outcomes. Although the MSF hospital is free of charge, financial barriers at other hospitals limited access to emergency obstetric care for many women, who commonly experienced non-evidence-based care, including inappropriate education from antenatal care providers when diagnosed with hypertension or preeclampsia. CONCLUSIONS: Pregnant women with preeclampsia in Port au Prince reported significant delays in accessing emergency obstetric care. Many delays stemmed from poor quality antenatal care services, which fail to screen, treat, or educate women appropriately. Improvements should be made in education and supervision for antenatal care providers, and in accessibility of emergency services at public hospitals in Port au Prince.