The mean age of the patients was 27.4 years ± 6.9 years, with extremes of 17 and 40 years; the age group 18 - 23 represented 30.6%. The patients were uneducated (40.8%), housewives (51.1%), and resided in rural areas (65.3%) (Table 1).

The deceased patients had made fewer than 4 prenatal contacts (53.1%). The associated pathologies were arterial hypertension (43.7%), viral hepatitis B (25.0%), and sickle cell disease (18.7%) (Table 2).

Table 1. Distribution of patients according to socio-demographic characteristics.

Table 2. Distribution of patients according to obstetric history and associated pathologies.

The patients were referred/evacuated (89.8%). The ambulance was used in 32.7% of cases (Table 3).

Table 3. Distribution of women according to mode of admission and means of transportation.

The average distance traveled was 45.2 kilometers. The patients were admitted to CHU Kara on average 24.8 hours after their referral.

The general condition was altered in 75.5% of cases, and 46.9% of patients had a poor level of consciousness (Table 4).

Table 4. Distribution of patients according to general condition and state of consciousness.

The death occurred in the postpartum period (55.1%) (Figure 1).

Figure 1. Distribution of patients according to the time of death.

Direct causes predominate among maternal deaths, representing 53.1% of cases. Arterial hypertension with its complications (46.2%) and hemorrhagic causes (30.8%) are predominant (Table 5).

Table 5. Distribution of women according to the cause of death.

The first delay was identified in 71.4% of cases (Table 6).

Table 6. Distribution of patients according to the type of delay.

The main factor identified for the first delay was the absence or insufficient antenatal care visits in 53.1% of cases (Table 7).

Table 7. Distribution of patients according to the determinants of delay.

The mean age of the patients was 27.4 ± 6.9 years, with a predominance in the 18 - 23 age group, representing 30.6% of cases. Thus, it involved a relatively young population. Several authors have reported similar results in the sub-region. For instance, Padonou et al. in Benin and Alkassoum et al. in Niger reported mean ages of 29.6 and 26 years, respectively [5][6]. The extremes of reproductive age, particularly young age, are recognized as risk factors for maternal mortality [6][7][8]. More than half of the women were educated, but they were housewives in 51.1% of cases. Timsal in Pakistan reported a similar proportion (54.8%) of educated women [9]. In contrast, Diassama et al. in Mali reported a very high proportion of uneducated women (98.8%), also predominantly housewives [10]. The non-negligible education rate observed in our study could be explained by the various policies and actions implemented by the Togolese government in favor of literacy and girls’ education, considered an essential lever for improving maternal health. However, despite this relatively satisfactory level of education, the economic and social empowerment of women remains limited, as evidenced by the high proportion of housewives (51.1%).

In our study, the most frequent delay was the first delay. The women experienced the first delay in 71.4% of cases. This rate is very high compared to the 37% and 6.3% reported respectively by Diassama et al. in Mali and Mohammed et al. in Egypt [10][11]. This result highlights the importance of the delay in deciding to seek care, considered one of the main determinants of maternal mortality in low-resource countries. This delay typically occurs between the onset of the first signs of complications and the decision to consult an appropriate health facility. Several factors could explain this high frequency of the first delay in our context. On one hand, the low economic and decision-making empowerment of women observed in our study could limit their ability to seek care quickly, as nearly half of the women were housewives without income. In many families, the decision to seek care still depends on the spouse or family environment, thereby delaying access to health facilities [12][13]. On the other hand, the low level of knowledge about danger signs, as highlighted by Duysburgh et al., can lead to an underestimation of symptom severity [14]. This argument is supported by the high rate of primigravidas (36.7%) recorded in our study. All these factors lead to late consultation, often more than 24 hours after the onset of symptoms, and frequently in a state of poor general condition in 75,5% of cases. The high proportion of the first delay observed in our study thus underscores the need to strengthen community-based interventions focused on health education for women and families, particularly on the early recognition of obstetric danger signs. Involving spouses and community leaders, developing financing mechanisms for obstetric emergencies, and improving women’s empowerment could significantly reduce this delay and, consequently, maternal morbidity and mortality.

The second delay and especially the third delay also represented significant proportions (34.7% and 61.2%). While the first delay was the most prevalent in our study, this was not the case in the studies by David et al. and Mohammed et al., who reported the third delay as the most important in 69.7% and 34.8% of cases, respectively [11][15]. Muriithi et al. also reported a predominance of the third delay [16]. Our rate of the third delay is likely underestimated, as the third delay was analyzed at the referral site, which is CHU-Kara. If the analysis of the third delay had focused on the first referral center, the rate would have been higher, since 44 women, or 89.8%, were referred or evacuated. This high proportion of referrals indirectly highlights the inadequacies of the peripheral health system, particularly in terms of capacity to manage obstetric emergencies, availability of qualified staff, and adequate technical platforms—key determinants of this delay. This difference prompts reflection on expanding the classic three-delays model to include the six delays: delay in seeking initial care, delay in reaching initial care, delay in initial management, delay in seeking referral care, delay in reaching referral care, and delay in management at the referral level [17].

This was a monocentric study conducted exclusively at Kara University Teaching Hospital, which limits the generalizability of the findings. In addition, the identification of delays based on medical records may introduce classification bias.