Amare et al.

BMC Pediatrics (2018) 18:265

https://doi.org/10.1186/s12887-018-1196-6

RESEARCH ARTICLE Open Access

Illness recognition and appropriate care

seeking for newborn complications in rural
Oromia and Amhara regional states of
Ethiopia
Y. Amare1* , S. Paul2 and L. M. Sibley3

Abstract
Background: Ethiopia has made significant progress in reducing child mortality but newborn mortality has
stagnated at around 29 deaths per 1000 births. The Maternal Health in Ethiopia Partnership (MaNHEP) was a 3.5-
year implementation project aimed at developing a community-oriented model of maternal and newborn health in
rural Ethiopia and to position it for scale up. In 2014, we conducted a case study of the project focusing on
recognition of and timely biomedical care seeking for maternal and newborn complications. In this paper, we detail
the main findings from one component of the case study – the narrative interviews on newborn complications.
Methods: The study area, comprised of six districts in which MaNHEP had been implemented, was located in the
two most populous federal regions of Ethiopia, Oromia and Amhara. The final purposive sample consisted of 16
cases in which the newborn survived to 28 days of life, and 13 cases in which the newborn died within 28 days of
life, for a total sample size of 29 cases. Narrative interview were conducted with the main caregiver and several
witnesses to the event. Analysis of the data included thematic content analysis and the determination of care
seeking pathways and levels and timeliness of biomedical care seeking.
Results: Mothers and other witnesses do recognize certain symptoms of newborn illness which they often
mentioned in clusters. The majority considered the symptoms to be serious and in some case hopeless. Perceived
causes were mostly natural. Forty-one percent of care seekers sought timely biomedical care in the neonatal period.
Surprisingly, perceived severity did not necessarily trigger care seeking. Facilitators of biomedical care seeking
included accessibility of health facilities and counseling by health workers, whereas barriers included perceived
vulnerability of newborns, post-partum restrictions on movements, hopelessness, wait-and-see atttitudes, poor
communication and physical inaccessibility of health facilities.
Conclusions: Symptom recognition and care seeking patterns indicate the need to strengthen focused locally
relevant health messages which target mothers, fathers and other community members, to further enhance access
to health care and to improve referral and quality of care.
Keywords: Newborn complications, Symptom recognition, Care seeking, Illness narratives

* Correspondence: [email protected]
1
Consultancy for Social Development, P.O. Box – 70196, Addis Ababa,
Ethiopia

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Amare et al. BMC Pediatrics (2018) 18:265 Page 2 of 9

Background pertaining to illness recognition and care seeking for

Globally, 2.6 million newborns died in 2016. In Ethiopia, maternal complications. [5] In this paper, we detail the
as in much of the developing world, the death rate main findings on illness recognition and care seeking for
among children under 5 years of age has declined at a newborn complications and their implications for policy,
higher rate than among newborns which has remained programming and research.
around 29 deaths per 1000 live births in 2016. [1] Con-
sequently, 48% of deaths in children under 5 in Ethiopia Methods
occur in the neonatal period. [2] The most important Study site
causes of newborn death globally are pre-term birth As described in our recent publication focusing on ill-
complications (36%), intra-partum related events (24%), ness recognition and care seeking for maternal compli-
sepsis or meningitis (16%) and congenital abnormalities cations [5], the study was conducted in the two most
(11%). [2] Low levels of facility delivery, poor newborn populous federal regions of Ethiopia, Oromia and Am-
care practices and limited care seeking for complications hara (Fig. 1). [1] The districts were largely rural and in-
are underlying factors behind high rates of newborn cluded Degem, Kuyu and Warra Jarso in Oromia Region
morbidity and care seeking. and North Achefer, South Achefer and Mecha in Am-
The Maternal Health in Ethiopia Partnership (MaN- hara Region (estimated population 350,000). Each dis-
HEP) was a 3.5-year implementation project funded by trict has an urban center and around six health centers
the Bill & Melinda Gates Foundation to develop a each of which oversee five or six health posts. From each
community-oriented model of maternal and newborn district, one health center and two health posts were
health in rural Ethiopia and to position it for scale up. randomly selected. Cases of newborn complications oc-
[3] Emory University implemented MaNHEP, in collab- curring within the previous 6 months were identified
oration with John Snow Research and Training Inc., and sampled from the catchment areas of these facilities,
University Research Co. LLC, and Addis Ababa Univer- as described below. A case was defined as a mother, her
sity. In 2014, Emory conducted a case study of the pro- newborn and the witnesses to the newborn’s illness
ject focusing on recognition of and biomedical care event.
seeking for maternal and newborn complications. The
Ethiopia case study, was one of six country studies that Sampling and data collection
included India, Indonesia, Nigeria, Tanzania and Uganda. This section presents a summary of sampling and data
All case studies were framed by the Delay Model. [4] In collection procedures. For further details on sampling,
an earlier 2016 publication, we focused on findings the interview guide, reporting and maintainance of data

Fig. 1 Sample design

Amare et al. BMC Pediatrics (2018) 18:265 Page 3 of 9

quality, see our previous publication on recognition and analyses are available in an earlier publication on care
care seeking for maternal complications [5]. seeking for compications of pregnancy and child birth.
In the six districts, the study aimed to involve 30 cases: [7] We also conducted a multiple correspondence ana-
for each of the six districts, 3 mothers who perceived lysis (MCA) to detect underlying structures in the illness
that their newborn became ill during the first month of recognition data. MCA is an exploratory qualitative data
life and was alive at 28 days of life, 2 mothers whose analysis technique. Perceived symptoms and causes
newborn became ill and died within 28 days of life and (please refer below to the list of symptoms and causes)
several witnesses to each event . Representation of di- were treated as nominal variables with multiple levels,
verse views and availability of cases were considerations and the correlations among them were projected in a
in sampling. The inclusion criteria for these mothers 2-dimensional visual “map.” Proximity between different
were: female, age 18–49 years, gave birth in the previous levels of these variables and between groups of individ-
6 months, residence in the MaNHEP project area, per- uals associated with the levels in the map were examined
ceived her newborn became ill within the first month of for clusters or patterns of symptoms and causes in rela-
life and willing and able to participate. The final sample tion to outcomes. A clustering of symptoms and causes
consisted of 16 cases in which the newborn survived to suggests illness recognition on the part of respondents.
28 days of life, and 13 cases in which the newborn died Grouping individuals by an external outcome variable
within 28 days of life, for a total sample size of 29 cases allow one to examine whether clusters of symptoms and
(Fig. 1). causes are associated with differential outcomes-e.g. ba-
After obtaining verbal informed consent using stand- bies survived or did not survive the first 28 days of life.
ard disclosure procedures, the study team used illness MCA was performed using the statistical software R [8].
narrative interviews to collect data. The illness narrative
is a qualitative rendering of an illness event by those Ethical approval
who experienced the illness, along with those who were Before initiating the study, ethical review of and approval
witnesses to the event. [6] for the study was obtained from Emory University Insti-
The narrative interviews were conducted with a pri- tutional Review board and the Oromia and Amhara Re-
mary caregiver, usually the mother of the newborn, and gional State Health Bureaus.
several witnesses to the illness event, who varied in
number from one-to-three additional persons including Results
her husband, mother-in-law, mother, sibling or neighbor. Sample characteristics
Although the interviews prioritized the primary care- Of the 29 cases, a majority of mothers were between 19
giver who was usually the mother, other witnesses par- and 29 years of age (55%) and had never attended school
ticipated to a greater or lesser extent depending on (62%). A majority of mothers (62%) also had given birth
personality and their role in the management of the ill- in a health facility. Mothers from Oromia attended more
ness episode. Thus, it turned out that the main or only years of school than their Amhara counterparts (80%
respondent(s) in 13 of the 29 interviews was the mother; versus 43%). Of the cases, 13 cases involved newborns
the mother and her husband in seven interviews; the that had died. Of the newborns that had died, nearly all
mother and another person such as her mother-in-law died within the first week of life (11 died day 1–3, 1 died
or mother in five interviews; and persons other than the between 4 and 7 days, and 1 died between 7 and
mother in four interviews. 28 days). There were no notable differences in maternal
Shortly after the interviews were conducted, “ex- age or education between the the group of newborns
panded field notes” on them were developed from mem- who died and those who survived. On the other hand,
ory, field notes, and audiotape recordings. more babies born at home died than babies born in a
health facility (eight out of the nine babies versus five of
Analysis eighteen babies, respectively). The two babies who were
. Coding procedures are detailed in our previous publi- born on the way to a health facility both survived.
cation on illness recognition and care seeking for mater-
nal complication. [5] A codebook, based on the illness Delay 1
narrative guide content and containing code definitions Perceived symptoms and their severity
and inclusion and The analysis involved thematic con- Mothers and witnesses to the illness event mentioned a
tent analysis using NVivo 10 based on the Delay Model number of symptoms in their newborns. In order of fre-
[4]; re-coding of care-seeking pathways into: biomedical quency, many mothers mentioned inability to breastfeed
and non-biomedical or late biomedical categories; and (72%), followed by vomiting (41%), fever (38%), cough-
univariate analysis to identify respondent characteristics ing, sneezing and/or stuffy nose (38%), continuous cry-
and thematic code frequencies. Further details on these ing and weak or difficult breathing (31% each) and cold
Amare et al. BMC Pediatrics (2018) 18:265 Page 4 of 9

body (24%). Symptoms mentioned by between 10 and body was as cold as iron. So I did not think they
20% of mothers included swollen uvula, weak or no cry- would start breastfeeding.” (Grandmother, Oromia).
ing, weakness and diarrhea. Lastly, symptoms mentioned
by less than 10% of mothers included inability to pass Some mothers and witnesses also reported changing
urine or stool, change in stool color and weight loss, as perceptions of severity as symptoms presented. In three
well as hiccups, frothing from the mouth, bleeding from out of the 29 cases, they thought that the symptoms
the nose and mouth, moaning, rash, swollen umbilical were not serious or that the baby would get better. Four
cord, and swelling on the back of the head and neck. families believed that the symptoms were not serious,
Symptoms were often mentioned in clusters. For ex- but then serious when these symptoms persisted or
ample, eight Amhara mothers and witnesses among the other symptoms appeared.
total of 29 mothers noticed that the baby was unable to
breastfeed, vomited and/or had a fever, high temperature As one mother poignantly described, “I did not think
on the back of the neck, in addition to a red swollen that the baby was going to die. It was in the evening
uvula. Three mothers and witnesses observed that their around nine that she was born and started to have
baby had a cough, congested nose or difficult breathing difficulty breathing and sucking the breast. I was
in conjunction with inability to breastfeed, fever or thinking that she may start sucking the breast next
vomiting. Others mentioned continuous crying, inability morning but she did not and her breathing problem
to breastfeed, vomiting and diarrhea, along with fever persisted. Then she became weaker and weaker the
and increasing weakness. following evening...” (Mother, Oromia).

“He refused to suck my breast and when he did suck Comparison of assessments of illness severity within
on it, he vomited soon afterwards. He cried a lot and cases of newborns who died versus cases of newborns
he was sweating and had high fever. There was a who survived showed that, among the former,cases
sound inside his stomach when he was which were deemed to be hopeless were more frequent
crying.”(Mother, Oromia). (4 of 13 cases versus 0 of 16 cases, respectively), cases
which were deemed to be initially or ultimately not ser-
Of the 13 babies who died, several mothers and wit- ious were more frequent (5 of 13 cases versus 2 of 16
nesses reported that their baby cried continuously after cases, respectively), whereas cases which were judged to
birth, was unable to breastfeed, lost weight and had a be serious were less frequent (4 of 13 cases versus 14 of
fever. Another mother noticed that her baby felt very 16 cases, respectively).
cold and was silent until she died, whereas a father and
his mother observed that their twin babies were cough- Perceived causes
ing and had a congestion, difficulty breathing and were Mothers and witnesses mentioned a number of causes
cold. Finally, one mother and the two grandmothers re- for the observed symptoms. In order of frequency these
alized that their twin babies were born too soon, observ- included fallen uvula – a condition involving a red and
ing that they were very small and thin, weak and/or swollen uvula and resulting in inability to breastfeed and
making moaning sounds. fever (28%, Amhara only), prolonged labor and common
Seventeen of the twenty-nine mothers and witnesses cold (17% each), pregnancy workload and poor hygiene
believed that their newborn’s illness symptoms were ser- as well as supernatural causes such as God, evil eye or
ious; whereas in four cases, they thought the symptoms evil spirits (10% each). Causes mentioned in less than
indicated the babies’ condition was hopeless. One 10% of cases included maternal conditions such as
woman, whose newborn experienced two separate illness bleeding, abdominal cramping, HIV, poor diet or malnu-
episodes, perceived the initial illness to be serious, but trition, eating bad food, physical sprain and maternal
the second illness episode as not serious. cough, as well as exposure to environmental and meta-
physical elements resulting in a local illness known as
“Yes, I was worried that the baby had fever and spent mitch and the use of a scented soap for bathing, evil
the whole night crying. I was worried that he may die. spirits or pre-term birth resulting in an illness known as
A baby cries and stops but my baby cried tilla. Causes also included newborn conditions such as
continuously. He also did not breastfeed and had being in a bad position (e.g., breech), being malnour-
vomiting and diarrhea.” (Mother, Amhara). ished (e.g., due to twins), being born too soon, having
the umbilical cord around the neck as well as improper
“When they [twins] came out from the womb, they cord tying. The causes mentioned by mothers and care-
were born with many problems. Even if the elder one givers in 90% of cases might be considered as “physical”
was crying, they were coughing since birth and their or “biological.”
Amare et al. BMC Pediatrics (2018) 18:265 Page 5 of 9

Symptoms were sometimes thought to have multiple Illness recognition

causes. For example, prolonged labor was associated with The MCA bi-plot map (Fig. 2) of the top 11 contributing
maternal twins or a baby that was in a bad position. In variable levels for symptoms and causes reported by
turn, prolonged labor was seen by some as a cause for in- mothers and witnesses in each case shows that two MCA
ability to breast feed, continuous crying, difficult breathing dimensions explained almost 40% (dimension 1 and 2 ex-
or a cold body. A baby born too soon was associated with plains ~ 24 and 14%) of the variance in the data respect-
supernatural forces. Among some Amhara respondents, ively. The cases are color-coded by two outcome groups: 1
symptoms such as an inability to breastfeed, vomiting and = died within first 28 days, 2 = survived more than 28 days.
fever were attributed to a swollen uvula which was, in One can see in the upper left quadrant of the map that
turn, thought to be a result of natural processes, a heavy symptoms of cough and congestion are correlated with
workload during pregnancy, bodily sprain or exposure to causes common cold and poor hygiene, and that most of
cold. Among Oromo respondents, these symptoms were these newborns were among those that survived more than
thought to be caused by exposure to mitch, inadequate 28 days. Similarly, in the lower left quadrant one can see
diet or poor hygiene. A cough, difficulty breathing and that symptoms of red swollen uvula and fever are associ-
fever were often attributed to a common cold which was, ated the condition of fallen uvula, a folk category reported
in turn, thought to be a result of exposure to cold weather, in Amhara only. In the lower right quadrant, symptoms of
a bad smell or lack of hygiene. As one father described, “weak or no cry,” “difficulty breathing,” “cold body,” and
the cause “born too soon” were clustered together, and
“I have found out that he had difficulty breathing, fever, most of the newborns in this quadrant died within the first
coughing and vomiting. I thought the problem was a 28 days. The cases falling into the two outcome categories
common cold due to the cold weather and the smell (marked by green and brown triangles) appear separated
from the cattle we share our house with.” (Father, and associated with different kinds of symptoms and
Oromia). causes, and the 95% confidence ellipses drawn around the

Fig. 2 Multiple correspondence analysis of perceived symptoms, causes and outcomes

Amare et al. BMC Pediatrics (2018) 18:265 Page 6 of 9

mean point of the two groups of individuals do not overlap, Delay 2

indicating that the group means were significantly different. Care seeking pathways
There is heterogeneity in symptoms and causes among the Mothers and families took different pathways to ac-
cases in which the newborns survived. cess care for their newborns. Of the 16 newborns
who survived the illness event, twelve families (75%)
sought biomedical care (Table 1). Two newborns
Decision-makers and time to make a decision to seek care first received care at a health center. Seven new-
Decision-makers included parents of the newborn as borns were first treated at home or by a local healer
well as other close members of the family such as their and secondly received care at a hospital, health cen-
parents, a sister, sister-in-law, daughter or neighbor. Al- ter, health post or by an HEW who was called-in to
though the decision to seek biomedical care was often the home. One of these newborns was subsequently
made in consultation with others, the final treated at home and at a health center as third and
decision-makers were often the parents (8 out of 29 fourth steps of care. Three newborns received two
cases) or the mother herself (8 cases). Fathers were less treatments at home or by a local healer who was
often the sole decision maker (4 cases). As one woman called-in before being taken to a health center. One
commented: of them was also subsequently treated by a local
healer who was called-in as a first step of care. Of
The baby spent the night crying a lot. It got even the four surviving newborns who did not receive
worse at night. I then decided that I would take the biomedical care (25%), two received treatment at
baby to the health center. Neighbors were home and two were treated by a local healer who
complaining that I should not go to the health center was called-in. One of the former was also subse-
before the baby was baptized. They said that an evil quently treated by a local healer.
spirit would attack me. I ignored them and took the Of the 13 newborns who died, ten families (77%) did
baby to the health center. (Amhara mother). not seek biomedical care and were treated or cared for
only at home (Table 2). Of the remaining three new-
Of the 16 cases in which biomedical care was pursued, borns, two received treatment at a health center and one
the time from illness recognition to the decision to seek at a hospital.
care varied, from less than 12 h (six cases), 12–24 h (five For analytical purposes, we chose to define care seek-
cases), 25–72 h (two cases) togreater than 72 h (three ing at a health facility as a first or second step in re-
cases, on days 5, 7 and 28). sponse to newborn illness symptoms as ‘timely

Table 1 Biomedical and non-biomedicalcare-seeking steps taken by families of 16 surviving newborns

First Step Second Step Third Step Fourth Step
Biomedical care
Health Center
(n = 2)
Home Hospital/Health Center/Post Home Health Center
(n = 5) (n = 5) (n = 1) (n = 1)
Home Home Health Center
(n = 1) (n = 1) (n = 1)
Home Home Call-in Health Center Home Call-in
(n = 2) (n = 2) (n = 1) (n = 1)
Home Call-in Hospital Health Center
(n = 1) (n = 1) (n = 1)
Home Call-in Home Health Center
(n = 1) (n = 1) (n = 1)

Non-Biomedical care
Home Home Call-in
(n = 2) (n = 1)
Home Call-in
(n = 2)
Amare et al. BMC Pediatrics (2018) 18:265 Page 7 of 9

Table 2 Biomedical and non-biomedicalcare-seeking steps care. Facilitators included physical and financial accessi-
taken by families of 13 newborns who died bility of HEWs or health posts, as well as health educa-
First Step Second Step Third Step Fourth Step tion and advice from HEWs, health workers or
Biomedical care neighbors. Factors that either delayed or prevented care
Health Center seeking included postpartum restrictions on women’s
movement, perceived physical or spiritual vulnerability
(n = 2)
and weakness of post-natal women and newborns, hope-
Hospital
lessness, the hope that the baby will get better, fear of
(n = 1) travelling during the day time which may expose one to
Non-Biomedical care mitch, the evil eye or curious neighbors, or fears of poor
Home treatment at the health facility. Other delaying factors
(n = 10) were clinic hours, rain or night time hours, poor com-
munications, distance, lack of transportation and finan-
cial constraints, e.g., one family that had to wait several
weeks to receive a loan from their funeral association to
biomedical care seeking’. According to our definition, 12 cover medical costs.
of 29 families (41%) sought timely biomedical care in the
neonatal period. Discussion
Timely biomedical care seeking was more frequent Summary of findings
in the case of newborns who survived (8 of 16) com- In relation to Delay 1, the study findings suggest that the
pared to newborns who died (4 of 13). It was also mothers and witnesses did recognize certain illness
associated with some characteristics of families. symptoms in their newborn. On the one hand, a number
Timely biomedical care seeking was more frequent of symptoms were reported in clusters and were associ-
among younger mothers aged 19 to 29 years of age ated with particular causes such as being born too soon
versus mothers older than 29 years of age (8 of 17 (premature), a common cold or lack of hygiene, or a
versus 3 of 10, respectively), mothers who delivered fallen uvula. On the other hand, frequently mentioned
in a health facility as opposed to in a home or on symptoms such as difficulty breastfeeding and fever, im-
the way to a health facility (10 of 18 versus 2 of 11, portant danger signs from a biomedical perspective,
repectively), and, to a lesser extent, those who per- were associated with a variety of causes. Although most
ceived the illness episode to be serious as compared mothers and witnesses considered the symptoms they
to those who perceived it to be initially or ultimately observed to be serious, some considered them not ser-
not serious or hopeless (8 of 12 versus 10 of 17, ious or only gradually came to believe they were serious,
respectively). which led to a wait-and-see approach. As mentioned
Symptoms and causes that appeared to have triggered previously, more caretakers who considered their new-
biomedical care seeking were coughing, sneezing or borns’ illnesses symptoms to be hopeless or not serious
stuffy nose associated with the common cold and poor were among those whose newborns died.
maternal hygiene; and prolonged labor associated with Symptoms or causes perceived as serious, however, did
maternal cramping and bleeding. Other symptoms in- not necessarily lead to care seeking, as evident in the 10
cluded continuous crying, vomiting, malnutrition and families who did not seek biomedical care or sought late
improper cord tying. Symptoms that were as likely to care. It is especially concerning that symptoms such as dif-
trigger care seeking as not were difficulty breastfeeding ficulty breastfeeding, fever, difficulty breathing, weak or no
and fever, both associated with a number of causes. Fi- crying, and a cold newborn body did not trigger care seek-
nally, symptoms and causes that were not associated ing in all cases. Although the newborn’s parents were the
with biomedical care seeking included swollen red uvula main decision makers, others such as their parents, a sis-
associated with the folk illness fallen uvula; and difficulty ter, sister-in-law, daughter or neighbor were often in-
breathing, weak or no crying, and cold body associated volved. Their considerations about whether to seek care
with being born too soon or to supernatural causes. Few are consistent with the Delay Model [4] and include cul-
families relied on local traditional healers and birth at- tural norms such as perceived vulnerability and postpar-
tendants as a first or second step of care (6 of 29), in al- tum restrictions on the movement of mothers and
most all cases for a fallen uvula. newborns, advice from health workers, accessibility of ser-
vices and perceived quality of care, as well as environmen-
Facilitators, delayers and barriers to care seeking tal conditions, economic and logistical issues.
Respondents reported a number of factors that facili- In relation to Delay 2, in spite of the above consider-
tated, delayed or prevented their use of health facility ations, 12 of 29 families sought timely bio-medical care,
Amare et al. BMC Pediatrics (2018) 18:265 Page 8 of 9

most often after an initial attempt at home-based care. understanding of illness including symptom recogni-
Importantly, 38% of these families made the decision to tion, causation and severity, associated use of trad-
seek care on the day that they recognized their new- itional treatments, wait-and-see attitudes, hopelessnes,
born’s illness. And few families relied on local traditional negative experiences at health facilities, and lack of
healers and birth attendants as a first or second step of physical and financial access have been discussed in
care (10% each), primarily for the traditional illness, various studies [10, 14, 17, 20]. While finding that
fallen uvula. Timely biomedical care seeking was more symptom recognition is not as much of a constraint
common among younger mothers, mothers who had de- on care seeking, this study has also identified all these
livered in a health facility, babies who survived the neo- barriers in addition to the role of postpartum restric-
natal period, and to some extent among families who tions on the movement and perceived vulnerability of
perceived the illness episode to be serious. women and newborns, reluctance to travel during the
Researchers examining illness recognition and care day time, limited clinic hours, and environmental fac-
seeking typically conduct descriptive studies using mixed tors. Furthermore, enablers such as the physical and
methods and situated in a variety of settings, often in financial accessibility of health posts and health coun-
South Asia and sub-Saharan Africa. Some of these stud- seling and education from health workers and ac-
ies found that newborn caretaker recognition of new- quaintances have been identified.
born illness symptoms to be poor [9, 10] whereas other
studies found that care takers did recognize such symp-
toms [11, 12]. Findings from our study conform with the Strengths and challenges
latter including symptom clusters associated with the The illness narrative method generated data on the ac-
common cold, the folk illness fallen uvula, and preterm tual experience and diverse perspectives of witnesses to
babies and those with difficulty breathing, which are as- the event. The illness event timeline and neutral probes
sociated with different causes and outcomes. Previous used in the narrative interview stimulate recall and in-
studies have shown that perceived causes of newborn ill- crease validity of the data. The replicability of the narra-
ness range from the supernatural to naturalistic which tive interviews is unknown.
influence whether traditional or modern treatment is
utilized [12, 13, 14]. In this study, illness responses ex-
hibited some association with specific types of mostly Conclusions
naturalistic causes. Conceptions and responses related to The findings of this study show that mothers and other wit-
the fallen uvula illness in Amhara region resemble the nesses generally recognize certain newborn illness symp-
local illnesses recognized in other countries which are toms and their seriousness. Several of them did initially or
seen to be best treated with traditional medicine [10, ultimately consider symptoms to be not serious or hopeless.
15]. Illness symptoms that are considered serious have Recognition of the seriousness of symptoms does not al-
been found to be associated with care seeking in some ways lead to timely biomedical care seeking, although in
studies whereas this association was weaker in a study our setting care seeking appears to occur more frequently
conducted in Ghana and also in our study [10, 16]. among younger mothers, as well as those who gave birth in
Use of biomedical care ranging from 14 to 39% of ill- a health facility. The findings thus indicate an urgent need
ness episodes have been reported in various studies as to focus health education and behavior change efforts on
compared to 40% in this study [11, 17, 18]. One of these the seriousness as well as treatability of illness symptoms
studies conducted in Nepal reported that half of those and identified local cultural factors that impede care seek-
who sought medical care did so after the first 48 h from ing such as traditional postpartum restrictions on women’s
the onset of illness as compared to 38% who sought such movement and associated beliefs about the vulnerability of
care in the first day after symptoms were recognized in mothers and newborns to harmful metaphysical elements if
our study [14]. The data we have presented on the char- taken outside of the home, hopelessness and, in the case of
acteristics of newborn care takers who seek such care Amhara region, the folk illness, fallen uvula. Families must
are often not available in similar studies and contrast come to understand timely biomedical care will improve
with the findings of one study on characteristics associ- the chances of their newborns’ survival. Continued efforts
ated with care seeking for children under five [19]. We to reduce known environmental, logistic and economic bar-
have also found that newborn survival is associated with riers to care seeking are also needed.
facility delivery, the assessment that illness symptoms
are serious and with the use of biomedical care. Abbreviations
Previous research has also explicitly identified fac- FMoH: Federal Ministry of Health; HDA: Health Development Army;
HEW: Health Extension Worker; MaNHEP: Maternal and Newborn Health in
tors which delay or prevent care seeking for newborn Ethiopia Partnership; RHB: Regional Health Bureau; URC: University Research
illnesses. Barriers such as aspects of local Company, LLC; USAID: United States Agency for International Development
Amare et al. BMC Pediatrics (2018) 18:265 Page 9 of 9

Acknowledgements Received: 25 July 2016 Accepted: 27 June 2018

The authors would like to thank Allisyn Moran, Supria Madhavan, and Neal
Brandes of USAID, and Danielle Charlet and Jim Sherry of URC for their
vision, technical and financial support to the six country case study teams, References
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Authors’ contributions
the context of the IMCI strategy in rural Ghana. Tropical Med Int Health. 2003;8:
YA contributed to the development and standardization of the illness
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narrative guide and procedures, training of interviewers, oversight of data
11. Awasthi S, Verma T, Agarwal M. Danger signs of neonatal illnesses:
collection and data quality, the analysis, interpretation and write-up of the
perceptions of caregivers and health workers in northern India. Bull World
data. SP contributed to the multiple correspondence analysis, its interpret-
Health Organ. 2006;84:819–26.
ation and write-up. LS contributed to the overall six-country study design
12. Engmann C, Adongo P, Akawire Aborigo R, Gupta M, Logonia G, Affah G,
and common protocol, its adaptation to the Ethiopia context, the develop-
Waiswa P, Hodgson A, Moyer CA. Infant illness spanning the antenatal to
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approve of the final manuscript.
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and southern Ethiopia and implications for community-based
Ethics approval and consent to participate
programming. Ethiop J Health Dev. 2012;27(1):3–7.
This study was reviewed by and exempted from oversight by the Emory
14. Mesko N, Osrin D, Tamang S, Shrestha BP, Manandhar DS, Manandhar M,
University Institutional Review Board and by the Amhara and Oromia
Standing H, Costello AM. Care for perinatal illness in rural Nepal: a descriptive
Regional Health Bureau Ethical Review Committees. Informed verbal consent
study with cross-sectional and qualitative components. BMC Int Health Hum
was obtained from all participants according to standard disclosure
Rights. 2003;3(1):3.
procedures. The verbal consent procedure was approved by the Institutional
15. Awasthi S, Srivastava NM, Pant S. Symptom-specific care-seeking behavior
Review Board and the Health Bureau Ethical Review Committees.
for sick neonates among urban poor in Lucknow, northern India. J Perinatol.
2008;28:S69–75.
Consent for publication 16. Amarasiri de Silva MW, Wijekoon A, Hornik R, Martines J. Care seeking in Sri
Not applicable. Lanka: one possible explanation for low childhood mortality. Soc Sci Med.
2001;53(10):1363–72.
Competing interests 17. Bazzano AN, Kirkwood BR, Tawiah-Agyemang C, Owusu-Agyei S, Adongo
The authors declare that they have no competing interests. PB. Beyond symptom recognition: care-seeking for ill newborns in rural
Ghana. Tropical Med Int Health. 2008;13(1):123–8.
18. Chowdhury H, Thompson S, Ali M, Alam N, Yunus M, Streatfield P. Care
Publisher’s Note seeking for fatal illness episodes in neonates: a population-based study in
Springer Nature remains neutral with regard to jurisdictional claims in rural Bangladesh. BMC Pediatr. 2011;11:88.
published maps and institutional affiliations. 19. Sutrisna B, Kresno S, Utomo B, Sutrisna B, Reingold A, Harrison G. Care-
seeking for fatal illnesses in young children in Indramayu, West Java,
Author details Indonesia. The Lancet. 1993;342(8874):787–9.
1
Consultancy for Social Development, P.O. Box – 70196, Addis Ababa, 20. Mohan P, Iyengar SD, Agarwal K, Martines JC, Sen K. Care-seeking practices
Ethiopia. 2Nell Hodgson Woodruff School of Nursing, Emory University, 1520 in rural Rajasthan: barriers and facilitating factors. J Perinatol. 2008;28(S2):
Clifton Road NE, 30322 Atlanta, Georgia. 3Nell Hodgson Woodruff School of S31–7.
Nursing and Rollins School of Public Health, Emory University, 1520 Clifton
Road NE, 30322 Atlanta, Georgia.