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Abstract Background Indonesia’s progress on reducing maternal and newborn mortality rates has slowed in recent years, predominantly in rural areas. To reduce maternal and newborn mortality, access to quality and skilled care, particularly at the facility level, is crucial. Yet, accessing such care is often delayed when maternal and newborn complications arise. Using the “Three Delays” model originated by Thaddeus and Maine (1994), investigation into reasons for delaying the decision to seek care, delaying arrival at a health facility, and delaying the receiving of adequate care, may help in establishing more focused interventions to improve maternal and newborn health in this region. Methods This qualitative study focused on identifying, analyzing, and describing illness recognition and care-seeking patterns related to maternal and newborn complications in the Jayawijaya district of Papua province, Indonesia. Group interviews were conducted with families and other caregivers from within 15 villages of Jayawijaya who had either experienced a maternal or newborn illness or maternal or newborn death. Results For maternal cases, excessive bleeding after delivery was recognized as a danger sign, and the process to decide to seek care was relatively quick. The decision-making process was mostly dominated by the husband. Most care was started at home by birth attendants, but the majority sought care outside of the home within the public health system. For newborn cases, most of the caregivers could not easily recognize newborn danger signs. Parents acted as the main decision-makers for seeking care. Decisions to seek care from a facility, such as the clinic or hospital, were only made when healthcare workers could not handle the case within the home. All newborn deaths were associated with delays in seeking care due to caretaker limitations in danger sign identification, whereas all maternal deaths were associated with delays in receiving appropriate care at facility level. Conclusions For maternal health, emphasis needs to be placed on supply side solutions, and for newborn health, emphasis needs to be placed on demand and supply side solutions, probably including community-based interventions. Contextualized information for the design of programs aimed to affect maternal and newborn health is a prerequisite.

World Vision implemented the community-based Maternal and Child Health Transformation (MaCHT) Project from September 2010 to September 2014 in fragile-state South Sudan. To document and measure health-related activities executed by an international nongovernmentalo rganisation to sustainably strengthen the capacity of the health system in delivering essential health services to pregnant women and children under two years of age, including new-borns and infants. A range of mixed methods, including in-depth interviews, focus group discussions, observation, and uncontrolled cross-sectional before-and-after surveys using Henderson’s method were carried out. The unit of analysis was mothers of children under two years of age, and community health workers (CHWs). An estimated 39 000 children under age two were attended to by CHWs. Coverage of essential maternal and childhealth care (MCH) increased in all single interventions, ranging from a minimum of 5% points to a maximum of 49% points during the implementation period. The capacity of the health system to deliver essential MCH services improved by building the supply and performance of the health workforce through task-shifting and in-service training. Likewise, operational linkages between community structures and local health services were strengthened. In conclusion, this program supported health system strengthening, mainly in the areas of service delivery, health workforce, and medical products, vaccines, and technologies. The project also informed policy at district and national levels and repositioned the maternal, neonatal, and child health (MNCH) agenda to further scale up these activities. An evaluation of a four year USAID-funded child survival project implemented by an international non-governmental organisation (NGO) in fragile-state context showed progress and challenges in health system strengthening for maternal health practices and community case management of diarrhoea, pneumonia, and malaria in children under five.