FAKTOR PENYEBAB KETERLAMBATAN RUJUKAN MATERNAL - SYSTEMATIC REVIEW CAUSATIVE FACTOR OF DELAY IN MATERNAL REFERRAL SYSTEMATIC REVIEW

family status in society (4 articles), community status (3 articles), and cultural influences (7 articles) studies are acquired. Conclusions: The previous delay will affect the next delay and the problem of delay in seeking health care is in decision-making which mostly found in upper-middle countries, the causes of cultural factors which also causing the delay in referrals, followed by the socioeconomic influence that most widely discussed are maternal education and women's empowerment, the problem which is also most commonly found in upper-middle-income countries.


INTRODUCTION
In 2017, every day around the world, there are approximately 810 women died from pregnancy and childbirth-related causes. In 2015, around 85,000 women in the Asia-Pacific region died by the same cause. Essentially, 90 percent of these deaths could be prevented through adequate antenatal, obstetric and perinatal care -which provided by highly trained midwives and traditional birth attendants. Increasing access to emergency care, by decreasing the three main types of delay in service delivery, has the potential to reduce deaths in every setting, system, and population. (Calvello et al., 2015) In Afghanistan, Bangladesh, Cambodia, India, Indonesia, Laos, Myanmar, Nepal, Pakistan, Papua New Guinea, the Philippines and Timor-Leste, conflicts, poverty, weak infrastructure and health systems causes tackling the problem to be more challenging.
Monitoring and reporting is a bigger challenge, meaning the actual death toll could be higher. Nonetheless, Bangladesh, Indonesia, Laos and Timor-Leste are on track to meet the target. In a study in India, delay due to first delay, 65% of the cases took 2-7 days to detect complications leading to subsequent death. From the 65% of the first delay cases, only 64% decided to seek treatment and only 28% of those who decided to seek treatment, had decided to seek treatment to a health facility. (Khan & Pradhan, 2013)

MATERIALS AND METHODS
This research is a systematic review method with the following inclusion criteria: Literature in English and Indonesian, using articles from the last 10 years, journals with full text, and journals with open access. In research with non-research studies, review articles are not included in this study. The study was conducted in a middle-income country. Literature were searched using Boolean Operator using specific keywords on searching the literature which are, "Three delay" OR "Three Phases of delay" AND "Delay in deciding to seek care" AND "EmOC" OR "Emergency Obstetric Care" OR 3 "Obstetric Emergencies" OR "Emergency Mother". As for Indonesian literatures, the keywords used were "Tiga Terlambat" AND "Pengambilan Keputusan" AND "Gawat Darurat Obstetri" OR "Gawat Darurat Kebidanan" OR "Gawat Darurat Obstetrik". The literatures obtained as the search results using ScienceDirect, Scopus, SageJournals, and Google Scholar databases. The literature search process was reported in the PRISMA flowchart. Furthermore, data preparation was carried out by filtering and grouping articles using Mendeley Desktop. Additionally, important information was transferred from the literatures into a format according to the specified theme using Evernote.v.6.25.1. The final result is 9 full-text articles which then assessed using Mixed Method Appraisal Tools (MMAT)

RESULTS
There are 6323 studies based on keyword search results. Researchers conducted screening and obtained 9 articles that matched the inclusion and exclusion criteria to be included in this systematic review. The following are the results of the PRISMA diagram in the literature search.

Literature Quality Assessment
The literature quality assessment was carried out using the Mixed Method Appraisal Tools (MMAT) for the assessment phase of the systematic mixed study review, which include qualitative, quantitative, and mixed methods studies. The assessment used 5 indicators by the research design and the outcome is carried out by discussing with the team. (Hong et al., 2018) (3) and key community and family members (approximately 15) V: how gender relations have been institutionalized in the Wixárika community, and the historical situation from the perspective of gender coloniality to visualize the impact of colonial and post-colonial governance and institutions on previously more egalitarian gender relations. I: interview transcripts and field observations. Late in making decisions to seek health care due to the influence of women's empowerment, mother's education, mother's income, welfare, and unsupportive environmental factors.  Indonesian Midwifery and Health Sciences Journal, 2022, 6 (1), 1-14 9

A. Overview of the Distribution of Research Areas
The distribution of the area where it is obtained from 3 continents. Four literatures discuss research on the Asian continent, namely Indonesia and India (Jeffery & Jeffery, 2010;Nataria et al., 2020;Octaviani et al., 2019;Rizkianti et al., 2020). Four studies from African continent, namely South Africa, Ghana, Tanzania, and Zambia (Annoon et al., 2020;Kaiser et al., 2019;Maro et al., 2016;Sibiya et al., 2018). And one study in North America, namely Mexico (Gamlin, 2020).
Countries were grouped based on economic conditions and the type of region which are countries with middle to lower incomes. Two of the literatures discuss researches on rural areas, namely India and Zambia (Jeffery & Jeffery, 2010;Kaiser et al., 2019), one of the literature discusses research in an urban area, namely Ghana (Annoon et al., 2020) , and one literature discusses research in both rural and urban areas, which is Tanzania (Maro et al., 2016). In countries with upper middle income, there are two literatures researched in rural areas, namely Mexico and South Africa (Gamlin, 2020;Sibiya et al., 2018) and three literatures studied in rural and urban areas, namely Indonesia (Nataria et al., 2020;Octaviani et al., 2019;Rizkianti et al., 2020).

B. Delay in Relation to Using Three Delay Models
The causes of delays in making decisions to seek care in countries with lowerto-middle income are family-level decisions (Maro et al., 2016), lack of family resources, husbands not knowing the right role, not having prepared delivery equipment for fear of being given a bad stigma by health workers (Kaiser et al., 2019), and widespread and longterm distrust of health facility services (Jeffery & Jeffery, 2010). In countries with middle-to higher income, the cause is a lack of understanding of alarming signs (Nataria et al., 2020), mothers fully submit all decisions to their husbands (Gamlin, 2020), delaying the Some demographic, reproductive, socioeconomic, household, and geographical characteristics. I: Household Questionnaire, Women's Questionnaire, and Men's Questionnaire A: Descriptive statistics, frequency with percentage, Chisquare test, and logistic regression with STATA SE version 15.1 and the appropriate IDHS weights and were taken into account for the IDHS survey design. administration of government health insurance but also not preparing maternity funds (Octaviani et al., 2019), bad experiences with the attitude of health workers (Sibiya et al., 2018).
Meanwhile mothers who can make decisions at various levels, tend to choose to give birth in health facilities and be assisted by experts. (Rizkianti et al., 2020) The causes of delays to get the healthcare are mostly the result of previous referral problems (Maro et al., 2016), transportation (Gamlin, 2020), geography, activestandby villages have not started (Octaviani et al., 2019), transparency of health service information (operating hours, patient capacity, patient rights), and finances (Sibiya et al., 2018). In this case, things that affecting the travel time such as transportation and communication can be made easier using application innovation. (Nataria et al., 2020) The causes of delays in receiving the healthcare are lack of drug preparations, lack of equipment, lack of skills of health workers, lack of human resources for health workers (Maro et al., 2016), blood services are not ready 24 hours and preparations are not always available, operating rooms and ICU are not always ready (Maro et al., 2016;Nataria et al., 2020), the lack of responses from the hospital in receiving patient complaints, the attitude of health workers, the condition of the referred patient is in an unstable state (Octaviani et al., 2019), inadequate infrastructure, no record card of maternity cases are provided from the hospital, and previous reference. (Sibiya et al., 2018) C. Socioeconomic Factors

The Status of Women in Families and Society
Socioeconomic factors based on the status of women towards family and society includes mothers with low education (Annoon et al., 2020;Maro et al., 2016;Octaviani et al., 2019), the practice of early marriages and pregnancies so that they leave school at a young age and husband's perception that learning is not for women (Gamlin, 2020). A mother's education that is high compared to the low has a higher probability of utilizing the ANC adequately and making decisions (Rizkianti et al., 2020).
Socioeconomic factors based on Income and Employment, working mothers are less likely to use a trained traditional birth attendant during delivery (Rizkianti et al., 2020), and for those who are not working, families supported by the government funds, but it is too difficult to be qualified for those whom have many children. (Gamlin, 2020) Socioeconomic factors based on women's empowerment in low-to-middle income countries are the mother's decision to depend on her husband (Jeffery & Jeffery, 2010) Amalia et al. : Causative Factor of Delay… Indonesian Midwifery and Health Sciences Journal, 2022, 6 (1), 1-14 11 the reason why is that husbands need mothers at home to cook, take care of children, and have sexual intimacy. In addition, they do not want male nurses to take care of their wives, have low knowledges of maternal health, afraid of being tested for HIV, and have not prepared for delivery equipment (Kaiser et al., 2019). Factors for women's empowerment in upper-middle income countries including health decisions centered on the husband, but the husband is not present when giving education on danger signs during ANC for reasons of work (Octaviani et al., 2019), the wife is dependent on her husband because of financial problems (Nataria et al., 2020), forced marriage, domestic violence triggered by pregnancy at a young age, husbands don't care about their wives when they are pregnant or giving birth, and being a single mother for many children (Gamlin, 2020). Couples counseling, special education for couples, and home visits are considered to increase community knowledge and change perceptions about partner involvement (Annoon et al., 2020)

Family Status in Society
Socioeconomic factors based on family status in the community are the average low level of family education (Octaviani et al., 2019) resulting in a lack of understanding of health informations (Nataria et al., 2020), Poverty (husband's occupation, land ownership, husband's income) is also described as the main problem in decision-making process (Jeffery & Jeffery, 2010). Wealth status affects the choice of giving birth in health facilities, the services of a trained traditional birth attendant, and the intensity of performing ANC (Rizkianti et al., 2020).

Community Status
Socioeconomic factors based on community status are the active-standby villages are not running properly, the resources of midwives who are always changing causing less intimacy with the community, resulting in decreased community motivation for ANC (Octaviani et al., 2019), an inadequate environment also reduces the motivation for partner involvement for ANC (Annoon et al., 2020;Octaviani et al., 2019) but there is no significant difference in the use of ANC between cities & villages (Rizkianti et al., 2020).

D. Cultural Factors
Norms, culture, and community influences can affecting the decisions (Kaiser et al., 2019;Sibiya et al., 2018). Cultural factors that cause delays are the religious leader's prohibition of a health procedure that changes public perceptions widely, the belief that mothers are slowly becoming not afraid of death if they continue to give birth to children and refuse to be given treatment including medical treatment, a belief that a child is harmful for their mother because the child, seeing the experiences of other pregnant women who have given birth successfully despite ignoring the warnings from health facilities, the belief that recommendations from private doctors are more profitable for certain institutions rather than medical aspects (Jeffery & Jeffery, 2010), Women who will have their pregnancy checked just when it is clearly shows so, this fear is based on belief in magic (Sibiya et al., 2018), trusting traditional healers because it's more affordable and considered to be more amicable than the health workers (Octaviani et al., 2019), the system in society that favors men (Gamlin, 2020), spouse's age, marital status, partner's disapproval of having to do housework and the assumption that they feel controlled by their partner, and partner's feeling of being excluded from everything that happens in health facilities (Annoon et al., 2020).

CONCLUSIONS AND RECOMMENDATIONS
A systematic review study on the distant determinants of late referral in obstetric cases found nine literatures that met the inclusion and exclusion criteria. Previous delays will affect subsequent delays. Using the Three Delay Models Framework, the problem of delays in seeking adequate health care is in decision-making process which most commonly found the upper-middle-class countries, the cause of cultural factors which dominates the cause of delay in referrals followed by socioeconomic influences that most widely discussed are maternal education and women's empowerment, the problem which is also most commonly found in upper-middle-income countries.
The literature study carried out still has limitations, such as the amount of literature reviewed, the uneven distribution of the area, the unbalanced type of area and the country's economic status, the dissimilarity of research methods from selected articles, and the researchers' ability of critical appraisal that greatly affects the understanding and interpretation of the analysis which can lead to errors in drawing conclusions.
It is important to maintain trust, which is the most commonly found factor, starting from increasing patient's satisfactions, carefully considering the health workers who will be delegated in the community, regularly educating families, training more traditional birth attendants to ease the need for human resources for health workers,