Illness recognition and care seeking for maternal complications of pregnancy and birth in rural Amhara and Oromia Regional States of Ethiopia

Background: Ethiopia has made steady progress in improving maternal health over the decade, yet mortality remains high. The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) was a 3.5-year project aimed at developing a community-oriented model to improve maternal and newborn survival in rural Ethiopia. Two years after the project ended, we carried out a case study to explore illness recognition and care seeking for complications of pregnancy and childbirth in the project area. This paper describes the results of one component: illness narratives. Methods: Sampling involved random selection of 12 health facilities from 6 MaNHEP project districts in Amhara and > Oromia regions, and purposive selection of cases from the facility catchment areas. The purposive sample included 17 cases of perceived excessive bleeding, 5 cases of maternal death from any cause, and witnesses to the illness events. Two-person teams facilitated the narrative interviews. Analysis included thematic content analysis of symptoms, causes, decision makers and decision-making, factors facilitating and impeding care seeking, and delineation of care-seeking steps. Results: Most surviving mothers (and witnesses) perceived the symptoms and seriousness of excessive bleeding; a majority (53%) sought timely biomedical care. Three of five families of mothers who died from causes unrelated to bleeding failed to initially perceive symptoms as serious, yet all sought timely appropriate care once they did so. Many of these families took multiple steps to obtain care, leading to delays.. Health worker counseling and proximity to health services facilitated, while certain cultural norms, economic, geographic, and environmental constraints impeded care seeking. Surprisingly, poor quality of care at health facilities was not a barrier. Conclusion: Mothers and family caregivers are able to recognize and seek timely biomedical care for abnormal bleeding, and for less obvious symptoms of illness. These achievements can be reinforced through continued and focused health education and counseling, reduction of known barriers to care seeking, and improvements in the capacity of the health system to respond to maternal complications with high quality basic and comprehensive emergency obstetric care.