Table A4.

Studies adding a fourth delay (N = 4).

					Factors determining the delays
No	Author (ref) Year of publication Study aim	Country	Type of study Sample population	Method of data collection Key informants	1st Delay	2nd Delay	3rd Delay	Definition of 4th delay
1	Combs Thorsen et al., 2012 To identify the socio-cultural and facility-based factors that contributed to maternal death	Malawi Lilongwe, 2 urban hospitals	Qualitative study 32 Maternal deaths	Case notes reviews (VA) and in-depth interviews Healthcare staff, family members, neighbour’s, traditional birth attendants	Illness factor (no recognition of danger signs and severity of illness by woman and husband) Perceived accessibility (remoteness) Tradition (preference for home delivery/TBA instead of institutional care)	Distance Lack of motorised vehicles in rural settings Lack of means of transport (at night)	Poorly staffed facility (lack of staff, lack of competences and communication skills) Poorly equipped facility (medicine and blood) Inadequate management (incorrect diagnosis, inadequate clinical work, lack of monitoring, attentiveness)	The patients conceal the HIV status and religion to the provider thus delaying treatment
2	MacDonald et al., 2018 To explore determinants of maternal mortality from the perspectives of women of near-miss maternal experiences and community members and their solutions to reduce maternal mortality in the community	Haiti Rural communities close to the mountains	Qualitative study (Participatory Action Research) 5 near-miss women	Semi-structured interviews Focus group discussions Women, men community leaders and traditional birth attendants	Illness factor (lack of awareness, denial of danger signs, waiting too long to seek care) Socio-legal issues (hiding pregnancy to partner for fear of financial worries) Women’s status (reduced ability to make informed choices, decision-making by partner) Economic status Perceived accessibility (cost of care and transportation) Tradition (local medicine before formal care) Negligence from the woman/ignorance of young women	Distance (time) Cost for transport	Poorly staffed facility (lack of competences) Disrespectful care (feeling unwelcomed, humiliated by HCW, lack of respect toward accompanying TBA)	Delays from community accountability for maternal death due to Lack of a system to support transports Trusting traditional practice endangering women (pressure) and use precious resources
3	Wallace et al., 2018 To gain insights into what influences people’s decision to seek care antenatally and during labour and birth.	Timor-Leste 4 municipalities: rural, peri-urban and urban settings	Qualitative study 17 women with various reproductive history	Semi-structured interviews (17) and focus group discussion (9) Women and men/partners	Women’s status (husband’s decision of place of birth and reliance on mother’s in law and TBA to resolve issues at home) Economic status Perceived quality of care (facility birth perceived good but not allowing to perform cultural blessing, fear of not having privacy and family support) Short labour Limited birth preparedness ANC provide confidence of healthy pregnancy not requiring institutional birth	Distance Lack of means of transport Cost for transport Poor road conditions Lack of ambulance/late arrival	Disrespectful care: staff ignoring cultural practices and perceptions	Delay from perceptions of respectful quality care Misgivings about staff Perceptions of hospital environment and policiesIndividual plans of the womanMinimal exploration of birth preparedness
4	Påfs et al., 2016 To explore care-seeking and experiences of maternity care among women who suffered a near-miss event in the early or late stage of pregnancy, and to identify potential barriers and health system limitations to maternal survival	Rwanda Kigali, 3 hospitals, urban setting	Qualitative study 47 women	Naturalistic inquiry using open ended questions Women	Illness factor (fail to recognise the need for care) Socio-legal issues (keep pregnancy secret if outside marriage, fear of stigmatisation) Economic status (no support from partner, lack of national insurance) Perceived accessibility (unaffordability of health services) Perceived quality care (fear of being mistreated if coming too early) Belief (late disclosure of pregnancy because of fear of witchcraft) Tradition (traditional medicine because of delayed payments)	Problems in referrals (lack of transports and constrains communication between facilities)	Poorly staffed facilities (lack of staff) Poorly equipped facilities Inadequate management (incorrect diagnosis and treatment, wrong referral, cost not covered by insurance, receiving hospital unprepared for to handle an emergency) Disrespectful care: Poor patient-provider interaction and communication Fourth delay Disrespectful care (distrust in health staff) Self- treatment	Third Delays split in 2 parts: Third delay: Delay in receiving care Fourth Delay: Delay from perception of respectful quality care Splitting the identification of factors affecting the delays by distinguish between formal care seeking and informal care seeking