Summary of findings
In relation to Delay 1, the study findings suggest that the mothers and witnesses did recognize certain illness symptoms in their newborn. On the one hand, a number of symptoms were reported in clusters and were associated with particular causes such as being born too soon (premature), a common cold or lack of hygiene, or a fallen uvula. On the other hand, frequently mentioned symptoms such as difficulty breastfeeding and fever, important danger signs from a biomedical perspective, were associated with a variety of causes. Although most mothers and witnesses considered the symptoms they observed to be serious, some considered them not serious or only gradually came to believe they were serious, which led to a wait-and-see approach. As mentioned previously, more caretakers who considered their newborns’ illnesses symptoms to be hopeless or not serious were among those whose newborns died.
Symptoms or causes perceived as serious, however, did not necessarily lead to care seeking, as evident in the 10 families who did not seek biomedical care or sought late care. It is especially concerning that symptoms such as difficulty breastfeeding, fever, difficulty breathing, weak or no crying, and a cold newborn body did not trigger care seeking in all cases. Although the newborn’s parents were the main decision makers, others such as their parents, a sister, sister-in-law, daughter or neighbor were often involved. Their considerations about whether to seek care are consistent with the Delay Model [
4] and include cultural norms such as perceived vulnerability and postpartum restrictions on the movement of mothers and newborns, advice from health workers, accessibility of services and perceived quality of care, as well as environmental conditions, economic and logistical issues.
In relation to Delay 2, in spite of the above considerations, 12 of 29 families sought timely bio-medical care, most often after an initial attempt at home-based care. Importantly, 38% of these families made the decision to seek care on the day that they recognized their newborn’s illness. And few families relied on local traditional healers and birth attendants as a first or second step of care (10% each), primarily for the traditional illness, fallen uvula. Timely biomedical care seeking was more common among younger mothers, mothers who had delivered in a health facility, babies who survived the neonatal period, and to some extent among families who perceived the illness episode to be serious.
Researchers examining illness recognition and care seeking typically conduct descriptive studies using mixed methods and situated in a variety of settings, often in South Asia and sub-Saharan Africa. Some of these studies found that newborn caretaker recognition of newborn illness symptoms to be poor [
9,
10] whereas other studies found that care takers did recognize such symptoms [
11,
12]. Findings from our study conform with the latter including symptom clusters associated with the common cold, the folk illness fallen uvula, and preterm babies and those with difficulty breathing, which are associated with different causes and outcomes. Previous studies have shown that perceived causes of newborn illness range from the supernatural to naturalistic which influence whether traditional or modern treatment is utilized [
12,
13,
14]. In this study, illness responses exhibited some association with specific types of mostly naturalistic causes. Conceptions and responses related to the fallen uvula illness in Amhara region resemble the local illnesses recognized in other countries which are seen to be best treated with traditional medicine [
10,
15]. Illness symptoms that are considered serious have been found to be associated with care seeking in some studies whereas this association was weaker in a study conducted in Ghana and also in our study [
10,
16].
Use of biomedical care ranging from 14 to 39% of illness episodes have been reported in various studies as compared to 40% in this study [
11,
17,
18]. One of these studies conducted in Nepal reported that half of those who sought medical care did so after the first 48 h from the onset of illness as compared to 38% who sought such care in the first day after symptoms were recognized in our study [
14]. The data we have presented on the characteristics of newborn care takers who seek such care are often not available in similar studies and contrast with the findings of one study on characteristics associated with care seeking for children under five [
19]. We have also found that newborn survival is associated with facility delivery, the assessment that illness symptoms are serious and with the use of biomedical care.
Previous research has also explicitly identified factors which delay or prevent care seeking for newborn illnesses. Barriers such as aspects of local understanding of illness including symptom recognition, causation and severity, associated use of traditional treatments, wait-and-see attitudes, hopelessnes, negative experiences at health facilities, and lack of physical and financial access have been discussed in various studies [
10,
14,
17,
20]. While finding that symptom recognition is not as much of a constraint on care seeking, this study has also identified all these barriers in addition to the role of postpartum restrictions on the movement and perceived vulnerability of women and newborns, reluctance to travel during the day time, limited clinic hours, and environmental factors. Furthermore, enablers such as the physical and financial accessibility of health posts and health counseling and education from health workers and acquaintances have been identified.