Applying the Three Delays Model to Understand Care Pathway Barriers among Low-Birth-Weight Neonates in a Kenyan Referral Hospital

<jats:p>Abstract Background. Outcomes for low-birth-weight (LBW) neonates depend not only on biology but on the timeliness of the care pathway. The Three Delays Model—deciding to seek care (Delay 1), reaching the hospital (Delay 2), and receiving adequate care after arrival (Delay 3)—offers a validated lens for locating where that pathway fails. We applied the model to characterise care-pathway barriers affecting LBW neonates admitted to a Kenyan county referral hospital and to relate them to severe adverse outcomes. Methods. Facility-based mixed-methods cross-sectional study of 169 LBW neonate–mother pairs admitted to the newborn unit of Kericho County Referral Hospital, complemented by nine key-informant interviews with providers. Delay indicators were derived for each of the three delays, with denominators defined explicitly. Descriptive statistics summarised each indicator; associations with severe adverse outcome were tested with the chi-square or Fisher exact test (kept descriptive, not modelled). Provider interviews were analysed thematically and coded directly to the three delays; quantitative and qualitative findings were integrated in a delay-structured joint matrix. Results. A severe adverse outcome occurred in 136/169 neonates (80.5%). Pathway barriers clustered before arrival: decision-to-seek-care delay &gt;6 h in 13.6%, a transport-access problem in 32.5%, and residence &gt;10 km from a facility in 34.3%; nearly half (49.1%) were referred/outborn, and among referred neonates 26.5% arrived without a referral note. After arrival, care began within 30 minutes in 66.3%. Referral/outborn status was associated with higher odds of a severe outcome (crude OR 2.25, 95% CI 1.01–5.00; p = 0.043), as was essential drug/feed shortage (OR 2.26, 95% CI 1.04–4.90; p = 0.036). Paradoxically, decision delay, transport problems, and any pathway delay were each associated with a lower proportion of severe outcomes (all p &lt; 0.01); these inverse associations most plausibly reflect confounding by indication and reverse causation—the sickest neonates were prioritised for rapid transfer and care—and should not be read as protective effects of delay. Provider narratives, coded to the three delays, described caregiver danger-sign recognition gaps, transport and referral-coordination barriers (cold, poorly documented arrivals), and first-hour stabilisation, staffing, warm-chain, supply, and monitoring constraints. Conclusions. Barriers for the smallest neonates accumulate along the pre-hospital pathway, and referral status signals more than a transport category—it marks accumulated vulnerability from delayed decision-making, transport constraints, incomplete pre-referral stabilisation, and facility-response gaps. Reducing severe outcomes requires shortening specific, identifiable delays, especially strengthening referral coordination and the fragile first hour after arrival, rather than reproducing a full determinants model.</jats:p>