Illness recognition, decision-making, and care-seeking for maternal and newborn complications: a qualitative study in Sarlahi District, Nepal|
Lama, Tsering P.; Khatry, Subarna K.; Katz, Joanne; LeClerq, Steven C. & Mullany, Luke C.
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.
Maternal mortality; Neonatal mortality; Maternal complications; Newborn complications; Illness recognition; Care-seeking; Nepal