Illness recognition, decision-making, and care-seeking for maternal and newborn complications: a qualitative study in Sarlahi District, Nepal

Abstract

Background: Identification of maternal and newborn illness and the decision-making and subsequent care-seeking patterns are poorly understood in Nepal. We aimed to characterize the process and factors influencing recognition of complications, the decision-making process, and care-seeking behavior among families and communities who experienced a maternal complication, death, neonatal illness, or death in a rural setting of Nepal.

Methods: Thirty-two event narratives (six maternal/newborn deaths each and 10 maternal/newborn illnesses each) were collected using in-depth interviews and small group interviews. We purposively sampled across specific illness and complication definitions, using data collected prospectively from a cohort of women and newborns followed from pregnancy through the first 28 days postpartum. The event narratives were coded and analyzed for common themes corresponding to three main domains of illness recognition, decision-making, and care-seeking; detailed event timelines were created for each.

Results: While signs were typically recognized early, delays in perceiving the severity of illness compromised prompt care-seeking in both maternal and newborn cases. Further, care was often sought initially from informal health providers such as traditional birth attendants, traditional healers, and village doctors. Key decision-makers were usually female family members; husbands played limited roles in decisions related to care-seeking, with broader family involvement in decision-making for newborns. Barriers to seeking care at any type of health facility included transport problems, lack of money, night-time illness events, low perceived severity, and distance to facility. Facility care was often sought only after referral or following treatment failure from an informal provider and private facilities were sought for newborn care. Respondents characterized government facility-based care as low quality and reported staff rudeness and drug type and/or supply stock shortages.

Conclusion: Delaying the decision to seek skilled care was common in both newborn and maternal cases. Among maternal cases, delays in receiving appropriate care when at a facility were also seen. Improved recognition of danger signs and increased demand for skilled care, motivated through community level interventions and health worker mobilization, needs to be encouraged. Engaging informal providers through training in improved danger sign identification and prompt referral, especially for newborn illnesses, is recommended.

Trial registration: ClinicalTrials.gov NCT01177111.

Keywords: Care-seeking; Illness recognition; Maternal complications; Maternal mortality; Neonatal mortality; Nepal; Newborn complications.

Conflict of interest statement

Ethics approval and consent to participate

Written informed consent was obtained from all the respondents. Ethical approval was obtained from The Johns Hopkins Bloomberg School of Public Health Institutional Review Board (Baltimore, USA) and the Nepal Health Research Council, Ministry of Health and Population (Kathmandu, Nepal). This study was nested within a large cluster-randomized community-based trial of the impact of topical applications of sunflower seed oil (compared to mustard oil) to newborn babies on neonatal mortality and morbidity in rural Sarlahi District, Nepal (Trial registration number NCT01177111).

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

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Figures

Fig. 1

Maternal death cases. a Care-seeking steps and b care-seeking timing and locations. ‡Village doctor is an informal “doctor” who provides allopathic medicine with little or no training and conducts home visits or runs a pharmacy where care is also provided. **Birthing center is attached to a government primary care facility (health post or primary health care center), staffed by nurse and/or auxiliary nurse midwives that provides free ANC and 24/7 labor/delivery and immediate postpartum care †MD-5 was at a private hospital during onset of symptoms; MD-6, a TBA was present at home to help with the home birth, and a local doctor had been called to give injection to induce labor but had left before the delivery of baby and symptoms recognized

Fig. 2

Maternal complication cases. a Care-seeking steps and b care-seeking timing and location. †MC-4, MC-5, MC-8, and MC-10 were already at a health facility during onset of symptoms; MC-9, a village doctor was present at home to check on the newborn baby before onset of symptoms

Fig. 3

Newborn death cases. a Care-seeking steps and b care-seeking timing and location

Fig. 4

Newborn complication cases. a Care-seeking steps and b care-seeking timing and location. †Illness not resolved yet; still on continuous care from same local doctor every week. Not resolved even after 24 weeks since the onset of signs (NC-2). ‡Illness not resolved yet; still on continuous care from same local doctor every 11th day. Some signs not resolved yet even after 15 weeks since onset of signs (NC-4)