The Six Delays Model: expanding the three delays model with evidence from Madagascar for maternal referrals in LMICs

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.