Access to care during labor and delivery and safety to maternal health

Objective: to analyze the time of access to care during labor and delivery and the safety of maternal health. Method: cross-sectional analytical study, carried out in five maternity hospitals, four of which are of habitual and intermediate risk and one of high risk. For data collection, data from the maternal medical record and interviews with the puerperal woman were used. In the data analysis, the Chi-square test (p≤0.05) was performed to search for possible associations between the independent variables - model three delays and dependents [Adverse maternal outcomes], [Knowledge about labor/delivery] and [Service satisfaction]. Results: statistical significance was observed between the adverse maternal outcome and the delay in looking for a health service (p = 0.005) and the delay in transport to the maternity hospital (p = 0.050), while the outcome knowledge about labor/delivery showed statistical association with delay in looking for a health service (p = 0.048). There was no statistically significant difference between the three delays model and satisfaction with the care. Conclusion: the women’s knowledge about labor and delivery and the time of access to obstetric care negatively interferes with the maternal outcome at delivery, which directly impacts maternal health safety.

In this study, the unit of analysis was not the delay, but the "access time" to health care, based on the reports of the mothers, based on the three phases proposed by the authors. The term access was used for the act of receiving assistance in the childbirth care by obstetric services in a timely manner, because these weaknesses impair care and can contribute to the occurrence of adverse maternal outcomes, as previously described. It is noteworthy that the beginning of the measurement of time was considered the beginning of the symptoms of labor.
To minimize the data collection bias and guarantee the quality of the information, a collection script was created as a standard operating procedure adopted by all collectors. Double data collection was also performed, one for data from medical records and another for interviews with the puerperal woman. Subsequently, This study is an excerpt from the metacentric research project funded by the National Council for Scientific and Technological Development (CNPq).

Results
As for the socioeconomic and demographic characteristics that the majority of puerperal women were aged between 20 and 34 years old (70.2%), more than 12 years of study (46.0%), unpaid occupation (58.5%), family income two to three minimum wages (54.7%) and had a partner (86.6%). Regarding the previous clinical-obstetric history, it was found that 67.9%of women had no pathological clinical-obstetric history, and 52.8% were primiparous.   In this study, the outcome of women's knowledge about labor and delivery was also investigated, and it was found that 57.2% (n = 269) of the puerperal women were aware of the care and guidelines of that period. The outcome of satisfaction in care was also analyzed, and it was identified that 89.5% (n=421) of the puerperal women were satisfied with the care received during hospitalization for childbirth.  delivery. Knowledge about labor and delivery was found in 60.1% of women who took less than three hours from the onset of symptoms to seek health care (Table 4).

Discussion
The three delays model was created to explain cases of obstetric emergencies that contribute to the occurrence of fatal maternal outcomes, but other situations of less serious maternal outcomes can also evolve unfavorably, leading to an urgency and \/or obstetric emergency that represent risks to maternal health therefore, they should also be investigated, as they are more prevalent in the current obstetric care scenario (5) . A study carried out in another region of the country also highlighted that inadequate access to care in childbirth care can increase maternal risks, due to possible obstetric complications that can be avoided by timely care, leading to severe complications when unavailable (16) .

The factors that influence this model in relation to
A situation that deserves to be highlighted in the access to obstetric care is the referral, in a timely manner, to services that offer adequate health care, availability and access to resources, the latter in relation to long distance to maternity, lack of accessible transport, delay in accessing a reference service for childbirth and indirect costs related to birth places (17) .
Similar to these data, a study showed that obstacles to obstetric care were represented by the lack of adequate delivery places, insufficient transport and inadequate supply of health care providers, which resulted in adverse maternal outcomes in developing countries (7) .
The difficulties in the demand and in the supply that hinder the use of health services referring to childbirth are considered primary barriers, characterized by women's fear of being neglected or mistreated by professionals, long distance, poverty, lack of support from their husband, staff-related health system deficiency, inadequate training and inefficient referral systems (18) .
Another study carried out in an underdeveloped country pointed out that the long waiting time for care, poor quality of care, lack of privacy in obstetric services and the difficulty in the availability of adequate pains. According to these women, the husband's late decision to seek care and health professionals was responsible for the delay. For the second delay, he found that the delay in access was due to distance and traffic. The third delay was experienced by the high demand of patients in an obstetric emergency.
Furthermore, the lack of knowledge and precarious socioeconomic factors were also identified as causing these delays (10) .
In this study, women who took more time to make the decision to seek health care and more transport time to maternity had a negative association regarding the occurrence of adverse maternal outcome, which is, they developed a greater number of AMOs.
These findings are in line with an international study, in which women who arrived at the hospital within four hours of the decision to seek care had a greater chance of a favorable outcome than those who arrived within eight hours (11) .
It is known that women's decisions to seek assistance during labor and birth are influenced by their lack of preparation for birth, family context, personal beliefs and perceptions, limitations of intra-structure, geographical location and inappropriate attitudes of professionals, which favor delay in reaching obstetric care (12) .
In this sense, another research developed outside Brazil found that there is a disarticulation between the health team and women regarding the Specifically in relation to the first delay, when obstetric emergencies arise during labor and delivery, the importance of recognizing danger signs and seeking care quickly is essential for responding in a timely manner and improving maternal and neonatal outcomes (7) . Furthermore, knowledge about the current clinical condition and the woman's guidance on the need for care are essential for the decision to seek a health service or call for care in a timely manner (14) .
Another data found in this study was the longer time spent transporting to the maternity hospital and the occurrence of AMOs. Similar findings were found in a study in southeastern Brazil, which analyzed the fatal maternal outcome and accessibility to health services, identifying that the distance between home and hospital is an important risk factor for the fatal outcome in the studied population (15) .
transport were considered the main barriers in the health system for equitable access and use of services by the population studied (19) .