deliveries in relation to NMR in 2005 in the 13 districts (two smaller adjacent districts combined) of Quang Ninh province, Vietnam [72]. 27 however, the quality of care received is decisive. Many factors play a part, as illustrated by “health system factors” in the framework above. Equipment and facility status, attitudes, and knowledge among staff etc, are just some factors which matter. These factors could, on the other hand, be difficult to measure on an aggregated level, and instead the place of delivery can act as a proxy for the overall delivery situation. In the Vietnamese setting it is reasonable to assume that higher levels in a health care system will mean better conditions, and that resources are concentrated at certain locations. This should be considered together with such negative factors as overuse, which results in crowding, and that mothers might perhaps have to travel long distances in order to get to higher level facilities. Care-seeking at delivery The importance of continuum of care, from detection of pregnancy through childhood, has received in recent years an increasing amount of attention among researchers and health care planners [63]. The purpose of highlighting the continuum of care, defined as continuity and coordination in the care of mother and child, is to promote a holistic approach to pregnancy and child birth, since the health and well-being of mother and child are interrelated. In this thesis, however, the focus will be on specific parts of the continuum, i.e. delivery care facilitation and care-seeking at delivery, Nevertheless, it is important to bear in mind the broader picture. The three delays of seeking care One important aspect of safe motherhood and delivery is care-seeking. Moreover, the decision to seek appropriate care at the time of delivery, as well as the road to ensuring a safe delivery, is an important determinant of neonatal outcome. In a widely cited review article from 1994, Thaddeus and Maine present a conceptual framework of three delays in care-seeking [74]. They were mainly focusing on obstetric emergencies within a setting having a high home delivery rate, but their framework is applicable to most careseeking situations. The first delay potentially occurs during the time it takes from onset of a condition requiring medical attention until the decision to seek care is taken. This time, often referred to as “Patient’s delay” starts with the recognition of disease, but also involves socio-cultural factors influencing the decision. To lessen the first delay, and sometimes even to get to the decision to seek care, is a priority for improving maternal and newborn survival [75, 76]. To spread knowledge and educate families and health workers about the recognition of danger signs during the neonatal period has been suggested as one of the main interventions needed to reduce neonatal mortality [18], 28 emphasizing the urgency and importance of reducing the first delay in careseeking. The second delay is the time it takes from once the decision to seek care is made until a health facility is reached. This delay involves the time of transportation, which depends on mode of transportation, road quality and distance, but also the economical considerations and an ability to pay. The third delay is the time it takes from arrival at a health facility until appropriate and adequate care is commenced. This delay, often referred to as “Doctor’s delay” is strongly related to the quality and effectiveness of the care institution. The time of delay is not overcome until “adequate care” is given, meaning that transfers within the health care system prolong the delay unless it can be assured to take place after care has been initiated and without compromise to care quality. Thaddeus and Maine developed their conceptual framework for obstetric emergencies, but the same mechanisms are valid for preventive care-seeking for delivery, and Gabrysch and Campbell have expanded the framework to involve this aspect, as well (Figure 5) [77]. Gabrysch and Campbell acknowledge that the determinants of preventive care-seeking for delivery might not be the same as those in emergency situations, but the themes might be the same. Four themes to categorize determinants of care-seeking are presented: (1) socio-cultural factors, (2) perceptions, (3) economic accessibility and (4) physical accessibility. This framework is an application and illustration of the more general theory presented earlier (Figure 3) where the idea of structural and proximate determinants is applied in more detail to a specific event in relation to neonatal survival: care-seeking at delivery. Socio-cultural factors of care-seeking The socio-cultural factors relating to care-seeking presented by Gabrysch and Campbell can be found among both socioeconomic and proximate determinants in the framework described earlier (Figure 3). Ethnicity and religion, along with traditions, customs and beliefs influence the decisionmaking about how, when, and where to seek care [78-81]. In Vietnam, there is, for example, a widespread belief in traditional medicine, and in many instances these practices are tried before reaching the decision to seek care at a health facility. Education is another socio-cultural factor that has been shown to be an important factor related to the first delay of care-seeking [82-84]. Maternal education is associated