Why women die after reaching the hospital : a qualitative critical incident analysis of the ‘third delay’ in postconflict northern Uganda

After reaching the health facility, a pregnant woman goes through a complex pathway that leads to delays in receiving emergency obstetrics and newborn care (EmONC). Five reasons were identified: shortage of medicines and supplies, lack of blood and functionality of operating theatres, gaps in staff coverage, gaps in staff skills, and delays in the interfacility referral system. Shortage of medicines and supplies was central in most of the pathways. Improvement of skills, better management of meagre human resources, and availability of essential medical supplies in health facilities may help increase emergency readiness