with all sorts of health care behavior, and the mechanisms for this have multiple explanations. One argument is that higher education leads not only to more knowledge, but also to the ability to adopt to and process new information [54]. This results in a higher receptivity of 29 Figure 5. Delay phases and factors affecting use of delivery care and maternal mortality (adapted from Thaddeus and Maine) [77]. health messages and increased understanding of preventive care. Educated women also have a higher status in the household, on average, and thereby a greater decision-making potential, better communication within the family, and higher economic independence [85, 86]. Among the proximate determinants, we find maternal age, martial status, family structure, level of female emancipation etc. Women of older age might have more decision-making power in the household, be more confident and experienced, which might lead to a better pattern of health care utilization [78, 87]. Martial status is not as strongly associated with health care use during pregnancy or at delivery as maternal age, but a few studies have shown an association [88, 89]. Preventive care seeking Before delivery Phase I: Deciding to seek preventive care for delivery Phase II: Identifying and reaching health facility Receiving normal delivery care at health facility Development of COMPLICATIONS Quality of preventive care Quality of emergency care Physicial Accessibility Economic Accessibility Sociocultural factors Perceived benefit/need Emergency care seeking Phase III: Receiving adequate and appropriate treatment for complication Home delivery Phase I: Deciding to seek care for complication Phase II: Identifying and reaching health facility Preventing maternal and neonatal death Development of COMPLICATIONS Perception 30 There are, of course, many other factors attributed to socio-economy and culture not mentioned here, but the main idea is to consider the possible influence of these factors and to acknowledge the complexity of the decision-making process that is necessary to overcome the first delay of care-seeking. Perceptions When making the decision to seek care, whether in an emergency situation or when planning for delivery, the perceptions of advantages and possible outcomes of sought care play an important role. The first dimension relates to the woman’s perception for the need to seek care, which is closely linked to knowledge about the severity of certain conditions or the benefits of preventive care. Ideas and perceptions of the quality of care that will be provided if there is a decision to seek care, based on rumors or previous experiences, greatly influence the first delay [74]. In the same way, perceptions about travel time and the hazards of transportation are influencing the choices. The perceptions and expectations about the delivery care can also be influenced by antenatal care (ANC), with more prenatal visits, which thereby increase the likelihood of a health facility delivery [82]. All are illustrated by dotted arrows in the figure (Figure 5). Quality of delivery care is not only a question about staff’s knowledge and experience, but also depends on staff attitudes. There are many examples in the literature of women reporting dissatisfaction with rude and arrogant health staff [80, 90, 91]. This could also be a source of discrimination against ethnic minorities and other marginalized groups, thus functioning as a cause of inequity in health. Economical accessibility Many studies deal with user fees in health care – and delivery care is no exception [92, 93]. But the costs for delivery are not limited to admission fees and transportation costs. Informal payments must be taken into the calculation, as well. The impact of costs on care-seeking is, however, disputed. Thaddeus and Maine point out that the perceived quality of care overrides the barrier of high costs as a decisive factor [74]. Lower costs for delivery do however play an important role [94, 95], even if there is evidence that reducing the costs for delivery care is not of major importance to change care-seeking behavior [96]. Physical accessibility Physical accessibility is directly affecting the second delay, but the perceptions of how to get to the health facility also plays an important role in 31 the decision to seek care [77]. Geographical factors such as distance and living area are suggested to influence the choice of delivery place [77] and to be determinants of neonatal mortality [52]. Geographical distance has, for example, been demonstrated to influence health care-seeking and utilization, with less usage of health services the longer the distance to a health facility. This phenomena, often called the distance-decay effect [97], has been described for various situations and patient categories [98-101]. The distance-decay effect has also been presented for the utilization of delivery and maternal health care [102-105]. Distance is, however, a complicated concept, and is not easily measured due to the complexity of reality. Many factors, like elevation, road quality, seasonal flooding and temporary road blocks must be taken into consideration if the true distance should be measured. Simpler measurements, like Euclidian (straight-line) distances or two dimensional road distances, are therefore often used as proxies for the thought true distance. But even if the true distance in meters