RESEARCH ARTICLE Open Access

Neonatal care and community-leveltreatment seeking for possible severebacterial infection (PSBI) in Amhara,EthiopiaMeron D. Asfaha1* , Dawn L. Comeau1, Sydney A. Spangler1, Brandon L. Spratt1, Lamesgin Alamineh2,Abebe G. Gobezayehu3 and John N. Cranmer1

Abstract

Background: In Ethiopia, neonatal mortality accounts for approximately 54% of under-five deaths with the majorityof these deaths driven by infections. Possible Severe Bacterial Infection (PSBI) in neonates is a syndromic diagnosisthat non-clinical health care providers use to identify and treat newborns with signs of sepsis. In low- and middle–income countries, referral to a hospital may not be feasible due to transportation, distance or finances. Growingevidence suggests health extension workers (HEWs) can identify and manage PSBI at the community level whenreferral to a hospital is not possible. However, community-based PSBI care strategies have not been widely scaled-up. This study aims to understand general determinants of household-level care as well as household care seekingand decision-making strategies for neonatal PSBI symptoms.

Methods: We conducted eleven focus group discussions (FGDs) to explore illness recognition and care seekingintentions from four rural kebeles in Amhara, Ethiopia. FGDs were conducted among mothers, fathers andhouseholds with recruitment stratified among households that have had a newborn with at least one symptom ofPSBI (Symptomatic Group), and households that have had a newborn regardless of the child’s health status(Community Group). Data were thematically analyzed using MAXQDA software.

Results: Mothers were described as primary caretakers of the newborn and were often appreciated for makingdecisions for treatment, even when the father was not present. Type of care accessed was often dependent onconceptualization of the illness as simple or complex. When symptoms were not relieved with clinical care, ortreatments at facilities were perceived as ineffective, alternative methods were sought. Most participants identifiedthe health center as a reliable facility. While designed to be the first point of access for primary care, health postswere not mentioned as locations where families seek clinical treatment.

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© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you giveappropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate ifchanges were made. The images or other third party material in this article are included in the article's Creative Commonslicence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commonslicence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtainpermission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to thedata made available in this article, unless otherwise stated in a credit line to the data.

* Correspondence: asfaha.meron1@gmail.com1Emory University, Atlanta, GA, USAFull list of author information is available at the end of the article

Asfaha et al. BMC Health Services Research (2020) 20:264 https://doi.org/10.1186/s12913-020-05081-0

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Conclusions: This study describes socio-contextual drivers for PSBI treatment at the community level. Futureprogramming should consider the role community members have in planning interventions to increase demandfor neonatal care at primary facilities. Encouragement of health post utilization could further allow for heightenedaccessibility-acceptability of a simplified PSBI regimen.

Keywords: Ethiopia, Possible severe bacterial infection (PSBI), Sepsis, Neonatal mortality, Care seeking, Community-based care

BackgroundIn 2017, 15,000 children died per day contributing toabout 5.4 million under-five deaths globally [1]. Roughly54% of all under-five deaths are driven by deaths in theneonatal period [2]. Although notable progress has beenmade in reducing under-five mortality, neonatal mortal-ity rates have decreased at a much slower rate; from1990 to 2017, under-five deaths have undergone a 58%reduction compared to 49% of neonatal deaths [1]. Themajority of neonatal deaths (75%) are caused by prema-turity, intrapartum related events and neonatal sepsiswith sepsis alone contributing to an estimated one outof four neonatal deaths [3]. In Ethiopia, neonatal mortal-ity remains a public health concern; approximately 95,000 neonates died in Ethiopia in 2017 [1]. Additionally,the 2019 Ethiopian Mini Demographic Health Survey(EMDHS) reflects a neonatal mortality rate of 30 deathsper 1000 live births during the 5 years preceding the sur-vey [2]. Nationally, the burden of absolute and propor-tionate neonatal mortality remains elevated. In rural,agrarian regions the persistent mortality burden is largelydriven by limited availability and accessibility of clinicalservices due to geographic distance between householdsand facilities or financial costs of transportation [4–7]. Re-gionally, neonates in Amhara, Benishangul-Gumuz andTigray have a higher risk of mortality compared to theirpeers in Addis Ababa [8]. However, there remains limitedregion-specific data on the precise determinants of neo-natal death in Amhara.Within communities and primary care clinics, neonatal

infection is usually diagnosed based upon a set of signsand symptoms that lead the clinician to suspect sepsis.This syndromic diagnosis of sepsis is defined as PossibleSevere Bacterial Infection (PSBI). Clinical criteria ofPSBI are algorithmically determined per The Young In-fants Clinical Signs Study Group [9] and include fastbreathing (≥ 60 breaths per minute), severe chest-indrawing, fever (≥ 38 °C), hypothermia (< 35.5 °C), nomovement or movement upon stimulation only, poor orno feeding and convulsions [10]. First-line facility-basedtreatment for PSBI consists of a 7-day course of injectableantibiotics (either procaine penicillin plus gentamicin orampicillin plus gentamicin) [10]. However, accessingfacility-level care is not always feasible, possible or desirable,

particularly in rural low- and middle-income country con-texts. Further, obtaining financing for sick newborn caremay lead to catastrophic financial consequences [11]. Forinstance, low-income families in Enugu, Nigeria averagedcare expenditures totaling 157% of their monthly family in-come for neonatal care [12]; such large financial implica-tions are not uncommon in LMICs. In agrarian settings,peripheral health facilities such as health posts in Ethiopia[13], are more readily accessible to communities than hos-pitals. This is often due to limited transportation, lowhousehold financial resources, or varied sociocultural fac-tors that limit the accessibility or desirability of hospital-based care. When curative PSBI treatment at the hospital isnot possible, Health Extension Workers (HEWs) have theability to identify and treat PSBI symptoms using a simpli-fied antibiotic treatment plan [14]. Despite global guidanceon PSBI care outside of inpatient health facilities, PSBItreatment coverage at rural health posts and within com-munities remains low.Across Ethiopia, documented determinants to acces-

sing biomedical care for newborns at health centers orhospitals include distance to health facility, cost of trans-portation, and social care seeking norms [13]. At the pri-mary level, the decentralized Ethiopian Health Tiersystem includes a primary hospital, health centers andrural health posts [13]. Although HEWs may refer thoseseen during home visits or at health posts to higher fa-cilities for care, significant barriers limit communitymembers in accepting these referrals. Sociocultural fac-tors preventing care at health facilities include differ-ences in gender-based priorities and decision-makingdynamics at the household level which may delay seek-ing care for sick neonates [15–17]. Barriers impeding de-mand of care for newborn treatments include fear ofnewborn exposure to environmental factors (i.e. sun-light), newborn isolation from strangers until the new-born has been religiously blessed and ambiguousnewborn personhood [7, 14, 17]. However, only threeknown studies assess the determinants of care for sicknewborns in Amhara [6, 18, 19] with no known studiesassessing household care seeking for neonatal PSBI inthe region. Although findings are specific to the woredassampled in this study, recommendations may be trans-ferable by local and regional contexts. This study aims

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to understand household care seeking and decision-making strategies for neonatal PSBI symptoms. Due tolimited availability of data on drivers of newborn and in-fant care in Amhara, investigators also sought to identifygeneral determinants of care at the household level.

MethodsStudy settingTwo woredas (districts) within a 300-km radius of BahirDar (capital city of Amhara) were selected for inclusionin this study. Both woredas comprise a majority of ruralresidents and were selected based on data from the 2007Population and Housing Census of Ethiopia, StatisticalReport for the Amhara region. Indicators such as popu-lation size, number of households and type of settlement(urban versus rural) were considered during site selec-tion (Table 1). Number of households varied betweenworedas. Woreda A comprised 6405 households with767 households in Woreda B. Four rural kebeles werepurposively selected with the goal of representing vari-ous influencers for PSBI decision makers in ruralcommunities.

Study designQualitative research methods were employed to identifycare seeking determinants for neonatal possible severebacterial infection (PSBI) in rural Amhara. The method-ology for this study was informed by existing studiesanalyzing determinants of health-seeking behavior (suchas illness perception and characterization) in low- andmiddle-income contexts [20]. Data were collectedthrough focus group discussions (FGDs). The discussionguide was initially prepared in English and translatedinto Amharic. FGDs were led by one moderator and onenote taker, with observations documented by the princi-pal investigator to document setting, behavior and con-textual information for analysis. All discussions wereconducted in the Amharic language and interviews were

backtranslated into English. FGDs were stratifiedamongst mothers, fathers and household units. The pur-pose of collecting information from FGDs with mothers,fathers and household units was to understand householdresponsibilities and community-level decision making forneonates with signs of PSBI.Mothers in rural Ethiopia are typically primary care-

takers of the child, although approval from fathers isoften needed to follow-through on decisions requiring fi-nancial resources. Additionally, fathers are typicallyregarded as household decision-makers. For this reason,participant groups were separated by parental roles.Focus groups of household units, including all membersof the household concurrently, were included to under-stand responses that may be influenced by power dy-namics i.e. how maternal responses were given in thepresence of the father. Household units typically com-prised mothers, fathers and peripheral family memberssuch as grandmothers and siblings of the newborn.

RecruitmentPrior to accessing kebele sites, the research team (onemoderator, one notetaker and the investigator) met withhealth center directors, health center supervisors andhealth extension workers (HEWs) at their respective lo-cations to describe the study’s purpose. HEWs wereapproached and functioned as a recruiting mechanism,sampling participants from the catchment area of healthcenters. HEWs were asked to purposively identify house-holds with newborns from health center records, utiliz-ing the defined inclusion criteria, and targeted eight toten participants per kebele. Discussions with the selectedparticipants were scheduled over the phone or throughapproaching households by foot. Participants were se-lected if they had a newborn in the household within theprevious 2 years, were 18 years of age or older and hadnewborns with PSBI symptoms (symptomatic group,SG) or were residents of the target communities (com-munity group, CG). CG data was provided to comparecare methods and trajectories among participants thatwere not recruited based upon a pre-specified ailment orcondition.Participants identified in the SG were chosen if they

had a newborn in the household exhibiting one or morePSBI symptoms in the first 28 days of life, as docu-mented in health center records. PSBI symptoms weredefined per the 2015 WHO guidelines and included fastbreathing, chest in-drawing, fever, hypothermia, nomovement or movement only upon stimulation, poorfeeding or no feeding, and/or convulsions [10]. Commu-nity group (CG) participants were purposively selectedregardless of the newborn’s health status based on theirresidence in the target communities. HEWs selected par-ticipants that were accessible or approachable via foot or

Table 1 Characteristics of woreda sites

Zone Woreda andkebele

Number ofhouseholdsa

Populationsize

Rural Urban

WestGojam

Woreda A 6405 292,080 269,403

22,677

Site 1 1348 5764 – –

Site 2 7719 1832 – –

EastGojam

Woreda B 767 132,883 130,299

2584

Site 3 2332 10,183 – –

Site 4 1640 8082 – –

Source: Central Statistical Agency – Ethiopia. The 2007 Population and HousingCensus of Ethiopia: Statistical Report for Amhara Region. Addis Ababa,Ethiopia; 2012aHouseholds refer to housing units, per the Central Statistical Agency –Ethiopia definition

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vehicle for recruitment. The sampling frame includedten discussions per woreda (Table 2). Final recruitmentconsisted of 11 FGDs due to participant unavailability insome woredas.

Data collectionData were collected between July and August 2018. Themoderator and note-taker were both experienced inqualitative data collection. The moderator, fluent in Am-haric and English, was additionally trained as a clinicalnurse. FGDs typically lasted 45–75 min. Focus groupguides included questions on household decision-making, care-taking actions and responsibilities, illnesscausation and characterization, illness severity, decision-making power and methods or facilities for care (Add-itional files 1, 2 and 3). Although introduction questionsspecifically addressed the newborn period, some ques-tions were generalized to extend responses towardsinfancy.Discussions with mothers and fathers were conducted

at health post compounds. Focus groups with householdmembers (including the mother, father and peripheralfamily members such as brothers, sisters or grandparentsof the newborn) were conducted in participant house-holds. Demographic information was collected after dis-cussions to gather information on age, number of peopleresiding in the household, income, occupation, and edu-cation level. For mothers, information on the number oflive births and number of children was collected to de-termine child loss.Precision of qualitative instruments were improved

after reviewing preliminary data from the first two focusgroups. Using pre-testing and in-field revision, the re-search team identified opportunities to utilize additionalprobes to improve richness of data. The research teamadditionally decided to focus on recruiting SG partici-pants to ensure understanding of PSBI-related illnessrecognition, characterization and care seeking behaviors.As a result, after three CG focus groups, data collectionfocused on the SG to ensure saturation on the experi-ences of SG mothers, fathers and households (Fig. 1).

As a result of this recruitment strategy (Table 2), 14participants met CG recruitment criteria and 42 partici-pants met SG recruitment criteria (Fig. 1). Four FGDswith mothers (29 participants), four FGDs with fathers(13 participants) and three FGDs with households (9participants) were across the West and East Gojamzones. Of all FGDs, five were conducted in Woreda Aand six in Woreda B.All discussions were recorded utilizing audio re-

corders. After data collection ended, data were tran-scribed into English by one bilingual Amharic-Englishtranscriber with ample qualitative research and tran-scription experience. To assure quality of translation,three transcripts were re-transcribed by the same tran-scriber to affirm data quality. Discussions amongst thestudy team were continued throughout analysis to in-crease clarity when statements were made within thelocal context of communities.

AnalysisData were thematically analyzed utilizing MAXQDAsoftware (version 18.1.1, Berlin, GA, 2018). Thematicanalysis is an iterative analytical approach to identifyingconcepts (themes) in the transcriptions [21]. Analyticmemos were first created to contextualize emerging pat-terns and concepts. Memos largely addressed threequestions: 1) How do different family members play arole in newborn care and care decisions? 2) Where didparticipants go to seek treatment for the newborn? and3) How were these methods or facilities accessed? Acodebook was then developed inductively using conceptsthat emerged while reading transcripts.Three transcripts were independently coded by the

principal investigator and one research assistant experi-enced in qualitative research. During discussions of eachtranscript, agreement was sought to increase intercoderreliability. A final codebook was then created using inputfrom two investigators. Emerging themes were furtheridentified through iterative analytic memos, transcriptsummaries as well as analysis of key code intersections.Key codes were extrapolated then compared across sam-pling methods, sites and types of family members.Frameworks were created and revised throughout ana-lysis to conceptualize study findings. Coding, memosand interim analyses were then discussed across theteam—including the lead investigator, senior authors,faculty and data collectors.

EthicsDuring the consent process, participants were informedof the study’s purpose, procedure and implications. Ver-bal consent was obtained as most respondents did notread or write in Amharic. The Emory University Institu-tional Review Board (IRB) determined data were exempt

Table 2 Sampling strategy, per woreda

Target Group andCollection Method

Number byworedaa

TotalRecruitmentGoala

TotalRecruited

Mothers (FGD) 2 (5–8) 4 (10–16) 4 (29)

Fathers (FGD) 2 (5–8) 4 (10–16) 4 (13)

Household Members(FGDs)

2 (5–8) 4 (10–16) 3 (9)

Total 6 (15–24) 12 (30–48) 11 (51)

* Numbers are reported per the number of groups and range of participantsin each group

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from full human subjects research review (July 3, 2018).Activities were approved by the Amhara Public HealthInstitute (APHI) ethical review board (July 18, 2018).Letters of support were provided to West and EastGojam zonal health departments prior to data collection.

ResultsParticipant characteristicsFifty-one participants took part in FGDs (Table 3).Thirty-seven respondents had symptomatic newborns(SG) while 14 were community members (CG). Ruralkebeles were selected in both woredas; 21 respondentscame from Woreda A and 30 respondents came fromWoreda B. There were 29 respondents in focus groupswith mothers, 13 in focus groups with fathers and nineparticipants in household focus groups.All participants identified as being of Christian Ortho-

dox faith and were of Amhara ethnicity. The median re-spondent age was 28 years and median household sizewas 4. Participants primarily reported working in agri-culture or as merchants (66.7%) with a median annualhousehold income of 14,400 birr (approximately 495USD). There were substantive variations in obstetric his-tory with 31.3% of all mothers experiencing a child lossand mothers having a range of 1 to 8 live births.

Key themesThemes from the data included family decision-makingmethods for newborn care. We summarizedcommunity-level experiences related to newborn care,relationship-based roles within the household, illnessidentification strategies and preferred treatment ap-proaches based on illness type. Consequently, five key

themes emerged from these data: maternal responsibilityfor the newborn; maternal decision-making; environ-mental, hygiene and nutrition practices as drivers of ill-ness; illness conceptualization based on complexity; andcare seeking trajectory.

Maternal responsibility for the newbornMothers generally reported having primary responsibilityfor providing general care to newborns. While partici-pants from FGDs regarded both parents as instrumentalfor newborn and infant care, mothers were consistentlyidentified as the primary caretakers across respondentgroups—particularly in the first 2 weeks of life. Mostparticipants indicated the mother’s key role is to breast-feed and/or provide breastmilk. Some participants indi-cated maternal breastfeeding was one of the few actionshouseholds could take to protect the newborn’s healthduring the first 2 weeks of life. Additionally, respondentsindicated mothers were responsible for maintaining thechild’s hygiene using practices such as washing the new-born’s clothes and cleaning the newborn’s body withbaths. During the infant period, participants additionallymention protecting the child from being exposed todirty objects or environments such as from contami-nated water or placement of miscellaneous items intothe mouth. Other maternal caretaking roles during thenewborn period include preparation of the newborn’ssleeping space (preparing the “mat”), relaxing or playingwith the child and protection from harm or diseases. Spe-cific actions that were taken to protect the newborn in-cluded avoiding sunlight, safeguarding the newborn fromcold weather and utilizing mosquito nets while sleeping.

Fig. 1 Recruitment outcome

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Maternal responsibility for the newborn was often de-scribed with regards to the provision of nutritional nour-ishment and dietary care. This is described in a dialoguebetween fathers:

F3: From my knowledge the mother should eat differ-ent types of balanced foods such as energy-givingfoods. Up until 6 months the infant should feed fromthe mother’s breastmilk only.I: What about others? As a father what do you do tomake your child healthy?F1: There is nothing more than this. It is the same ashe explained. Before, we gave [food] for the infant tomake his body grow faster but it became harmful sowe don’t give other foods up until 6 months of age.Because of this until the child grows bigger we don’tdo anything but the mother performs most of thecare. The infant doesn’t take the other foods we feedto the mother.(Fathers, PSBI, Woreda A)

Participants mention the importance of adhering to adiet of breastmilk up until 6 months of age in order tomaintain the child’s health. In assuring these dietaryneeds were met, participants remarked that there is “noth-ing more than the mother” as mothers are regarded asessential for newborn care provision. However, fathers

and peripheral family members such as siblings andgrandparents of the newborn indirectly cared for thechild.Paternal actions for newborn care primarily included

securing materials such as soap and food for the child.Additional paternal actions included transporting thenewborn to health facilities, namely the health center,for care during times of illness or to receive vaccinations.For instance, several fathers mentioned they assuredmedications were given to the child as prescribed byhealth workers, although information on the types ofmedications taken were not discussed. Actions takencomprised preparation of food and coffee for the motherwhile she was away at the health center or washing thechild’s clothing for the parents.After the newborn period, respondents identified vari-

ous nutritional practices. For instance, participants inFGDs with mothers and FGDs with fathers self-identified that when the infant becomes 6 months ofage, the child’s diet is expanded to include complemen-tary foods. Food items provided after 6 months of ageinclude cow milk, bread, eggs and roasted barley flour(besso). One participant described giving raw butter(kibeh) to the newborn, however this was only men-tioned when referencing a traditional dietary practicethat is now considered harmful and does not widelyoccur in the community. Prior to 6 months, participants

Table 3 Demographic Characteristics of All Participants (SG and CG)

% (N) Median (Range)

Number of Family Members 4 (3–10)

Age (years) 28 (18–54)

Last Year of Formal Schooling No Formal Education 49% (25)

Primary Education 37% (19)

Secondary Education 12% (6)

Degree or higher (bachelors and/or post-graduate) 2% (1)

Occupation Merchant/Petty trade 43% (22)

Agriculture 43% (21)

Skilled Labor 14% (7)

Unskilled Labor 14% (7)

Housewife 25% (13)

Other: Student 3.9% (2)

Professional/Technical/Managerial 2% (1)

Ethnicity Amhara 100% (51)

Religion Christian (Orthodox) 100% (51)

Annual Household Income 14,400 birr (495 USD)

Number of Live Births 2 (1–8)

Number of Living Children 2 (1–8)

TOTAL (N = 51)

(a) Number of family members, Age (years), Annual Household Income, Number of Live Births and Number of Living Children reported in median and rangevalues. Occupation responses were not mutually exclusive, some participants reported having more than one occupation. (b) Median (Range) is an absolute range

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repeatedly mentioned the necessity of breastmilk as aprotective mechanism for newborn and infant health.

Maternal decision-makingMothers were often identified as the primary decision-makers for newborn healthcare. This included seekingcare for sick infants at health facilities or using informal,non-biomedical methods. Mothers reported they typic-ally decided how and where the newborn received carefor illness. However, this contrasts with what fathers re-ported. Fathers reported that both parental figures aregenerally responsible for making healthcare decisions.These respondents mention that actions taken for treat-ment are only made after discussions amongst both par-ents regarding the child’s state of health. In some cases,fathers also mentioned that the mothers are primarydecision-makers for care, although this was reported lessfrequently than in focus groups with mothers. However,when mothers are unable to make care decisions due totheir own ailments or not being present at the time ofchild illness, fathers indicate that their role was to do sothemselves.Beyond the primary caretaking role of mothers, fathers

explicitly appreciated mothers taking initiative in thechoices made on how to care for infants that were sickwere commended. One father remarks:

F: We simply accept her decision. For example, whenshe makes decisions about family situations, maybefor health conditions, we accept and help her to beeffective in her decisions.(Household, CG, Woreda B)

Most members of the household, in fact, valued mater-nal decision-making. Types of care decisions that wereappreciated were both preventative and curative in na-ture. These included securing vaccinations for the new-born or active follow-through on visiting formal orinformal care services, particularly when the father wasnot present due to working “in the town” or in theirfarms. Fathers generally expressed agreeance to maternaldecisions, at times explicitly expressing appreciation (asseen above). Some household members explained thatthis appreciation was due to the amount of time fathersusually spent outside of the house. As such, fathers werenot always present when newborn illnesses were recog-nized and next steps for care were deliberated.

Environmental, hygiene and nutrition practices as drivers ofillnessParticipants across groups and locations reported new-born illnesses were primarily caused by gaps in hygienepractices or unmet maternal nutritional needs. Twohygiene-drivers of newborn illness were identified. One

included an unclean home environment while the otherconsidered exposure of the newborn to polluted waterwhich could introduce bacteria and cause illness. Mater-nal nutrition drivers included improper dietary habitssuch as high consumption of alcohol or having an imbal-anced diet, such as ingestion of diverse foods that maynot be agreeable to the mother. Improper foods alsocomprised those that would not contribute to themother’s vitality and were not “energy-giving.”One mother lists causes of newborn illnesses and

states:

M: [It occurs] when we feed them contaminatedfoods, when we do not keep the children clean, ex-posing the newborn baby with cold air and when wedo not put them to sleep properly.(Mothers, PSBI, Woreda B)

External environmental and spiritual causes of illnesswere less commonly identified. Exposure to cold weatherand wind were generally identified as factors contribut-ing to illness. Further, specific sleeping habits, such assleeping without a mosquito net or without properlypreparing the sleeping mat, was identified as a cause. Fi-nally, evil eye could also cause infant illness although re-spondents indicated protective measures such as visits totraditional healers and herbal remedies could avert theeffects of evil eye for infants.Most participants reported that severe consequences

could result if a family fails to access the health centerwhen an infant is ill. Without biomedical care at healthcenters or hospitals, participants expressed that some in-fants could die or suffer further illness progression.However, in the case of severe adverse outcomes such asdeath, participants saw this as a spiritually-driven out-come. In some cases, participants referred to seriousconsequences as fate or “God’s will.” For example, onemother who recently lost a daughter comments on herchild’s outcome:

I: Maybe if your child got better medical treatmentdo you believe she may have been cured?M3: No, I do not think so. It was fatal. She couldn’treach the next referral. God didn’t allow her to growup and be mine.(Mothers, PSBI, Woreda A)

Although maternal responsibility in nurturing the childwas emphasized, blame for illness or death was not placedon any household member. Instead, unsuitable outcomeswere either reported as being caused by environmental andsocial factors (nutrition, hygiene and evil eye) or lack of pre-ventative care. Limited treatment services at the health cen-ter were mentioned as contributors of illness exacerbation.

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For example, one father noted the lack of supplies (medica-tion) at the health center that are suitable for various typesof illnesses. Another father stated that going to the healthcenter could “waste time,” particularly when the child issick and needs immediate attention. However, the afore-mentioned factors that may potentially intensify illness pro-gression were not frequently mentioned.

Illness conceptualization based on complexityApproaches to identifying child illness were similar amonghousehold respondents (mothers, fathers, family mem-bers) and between households across regions. Families pri-marily identified symptoms of concern such as fever (highbody temperature), abnormal breathing, lack of feeding orno feeding. Families also mentioned non-PSBI symptomsincluding abnormal or frequent crying, vomiting and diar-rhea. Participants often attributed the onset of symptomsor illness to the lack of precautionary hygienic measures,such as keeping the child away from dirty environmentsor bathing regularly; lack of regular feeding patterns; andpoor weather leading to cold temperatures and wind.Illness conceptualization thus led to various methods

of care according to the treatment that was deemed ap-propriate for the particular illness. Some participants de-scribed their child’s ailments as either “simple” or“complex.” These descriptions were based on the per-ceived severity of the illness and in some cases subse-quently defined how families made decisions fortreatment, due to how the illness was characterized.“Simple” cases were referred to when symptoms, or theonset of symptoms, were easily understood whereas“complex” cases were indicated when symptoms, or theironset, could not be explained. Simple and complex casesboth included crying, behavioral changes (i.e. irritability)and physiological (i.e. temperature) changes. However,complex symptoms regarded as indicative of serious dis-ease were abnormal breathing and lack of response, asmentioned by one father. What differentiated simple orcomplex characterization was how rapidly symptoms de-veloped as well as how symptoms were understood. Incomplex cases, participants sometimes remarked thatthe disease was or might have been too severe for bio-medical treatment. For simple, “common” or “ordinary”cases, participants mention seeking care at health cen-ters. One father comments:

“When the disease is simple we take the child to thehealth center but when it is complicated we will takethe child to the church for holy water treatment.”(Fathers, PSBI, Woreda A)

These characterizations of illness informed decisionsfor where families sought care. Similar to this response,

another father comments on the alternative methodsused to treat “emergency” cases where the the illness in-volved a drastic or sudden onset of symptoms that couldnot be justified. He remarks:

I: Do you use traditional medicine to treat childsickness?F: Yes, we do.I: What kinds of medicine do you use?F: When there are sudden diseases that the healthworkers cannot understand, at that time we usetraditional medicines. The children suddenly cry orbecome silent and their temperatures drop, at thattime we use traditional medicine in emergency casesto help sick infants.(Fathers, PSBI, Woreda A)

Through this dialogue, the onset of signs and symp-toms that were least understood consisted of the childbeing quiet, the child suddenly crying or a sudden de-crease in temperature.. Although non-biomedical (trad-itional) medications were considered in these cases,participants did not often refer to them as their firstchoice for care. Further, receiving holy water at theOrthodox Church was viewed primarily as a preventativestrategy to ward against future illness.

Care seeking trajectoryAll participants mentioned healthcare facilities as a pri-mary method for treating sick newborns. Specifically,health centers were referred to as the fundamentalsource of curative care for childhood illnesses. Healthposts were not reported by any participants as a locationto seek care for sick newborns. However, participants re-ported visiting health posts to receive preventative care,such as newborn vaccinations, when needed. When no-ticing that the newborn was sick, only one participantstated that they did not access the health center whenthe newborn was sick.If families first sought biomedical treatment for sick in-

fants that was deemed ineffective, most families thensought alternative care. These options included either holywater (kurban) or traditional medications. Holy water wasreceived at churches as a strategy to avoid ailments forchildren and parents. Medicinal herbal treatments wereobtained through traditional healers and used to preventor cure evil eye. In addition, traditional therapies andhealers were the primary resource for treating complex ill-nesses or used when the illness cause was not well under-stood. This care seeking pathway is described by onefather during a CG focus group in Woreda B:

F: Most of the time the community goes to the healthcenter when the child becomes sick. After the health

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center, if not cured, we go to other places to treat oursick child. First we use medical treatment and thenholy water treatment...if they’re not cured we usetraditional medicine... if they’re not cured we comeback to the health center and get medical treatmentbut we complain about why they don’t refer us tothe hospital because there we have medical insur-ance. After that, the community makes their ownchoices. Either they go for holy water treatment orthey use traditional medicine.(Fathers, CG, Woreda B)

The health center was the facility that participantsmost often went to when recognizing that the child wasill. Multiple participants mentioned that due to theirhealth insurance coverage, there was no reason not tovisit health centers. During a household discussion, onefather comments:

“At this time everyone goes to the health center. Wepay one time a year for health treatment so, we go tothe health center when there are any problems. Atthis time there is health insurance and we pay oncea year, when there are any little problems we rush tothe health center but before this program we hadshortage of money. Due to this we used traditionalmedicines to cure our sicknesses but now we visit thehealth center. For those that have no money the gov-ernment covers all medical costs. In our town thereare more than 40 people that the government coversall expenses for medical treatment.”(Household, SG, Woreda B)

Although insurance status was mentioned on severaloccasions, only a few participants commented on theirown universal healthcare status (whether they were cov-ered with an insurance plan or not).

When illnesses were unresolved, alternative methodssuch as home treatments and the hospital were subse-quently sought (Fig. 2). Failure to visit biomedical facil-ities for care was at times due to observedineffectiveness of medical treatments. In one CG focusgroup, fathers mentioned forgoing a HEW’s advice toavoid the removal of tonsils in their sick children. Thiswas due to repeated occurrences of child deaths fromtonsillitis within the community. Upon noticing thesechild deaths and recurring infections in their ownchildren, they opted to either visit the traditional doc-tor or self-perform removal of tonsils. However, for-going medical advice was not common and neveroccurred without first visiting a biomedical facility.Participants repeatedly recommended the health cen-ter for treatment when recognizing symptoms indicat-ing illness in the newborn.

DiscussionStrategies for community-based, HEW-delivered carehave been proven effective and feasible in settings wherereferral to a hospital is not possible. However, treatmentdemand at community-level health facilities remainslow. The aims of this study are to describe householdneonatal care and decision-making strategies for neo-natal PSBI symptoms. Although there are several exist-ing studies on treatment seeking for newborns withillnesses in low- and middle-income countries (LMICs)[6, 22–24], this study may be the first to assess the de-terminants of securing treatment within the communityfor newborns with PSBI. This qualitative study outlinesfive key themes for neonatal care and management for PSBIsymptoms: maternal responsibility of the newborn; mater-nal decision-making; environmental, hygiene and nutritionpractices as drivers of illness; illness conceptualizationbased on complexity; and care seeking trajectory. Findingsgenerated from this study will be synthesized into an

Fig. 2 Care trajectory

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implementation science portfolio for a decentralized andsimplified antibiotic regimen strategy.Understanding the roles different household members

have in providing neonatal care is critical to informingtargeted public health programming. Across focusgroups, mothers were repeatedly acknowledged as sig-nificant for maintaining or improving newborn health, afinding consistent with another study in the region [6].This was often due to the nutrient demands (breastfeed-ing) and time required of mothers during the newbornperiod. This finding suggests that mothers have manyopportunities to detect newborn illness. As such, publichealth programming such as HEW and HDA home visitsmay largely focus their efforts on mothers to influencedemands for care at outpatient facilities. Health cam-paigns that involve community members in targetedhealth messaging may promote newborn care seeking asa strategy to increase the demand for services at thehealth post and to create a sense of the individual’s au-tonomy in care acquisition [25].Although most family members in our study were en-

couraging of the mothers’ autonomy to make care deci-sions, fathers often mentioned reminding the mother ofnewborn care duties such as providing medication regi-mens for the child on time. Another study conductedacross Nigeria, Tanzania and Ethiopia finds fathers actas authoritative figures of whom agreeance is needed tofollow through with accessing treatment methods, eventhough these figures may not often directly involvethemselves in newborn care [26]. As timing of care is anessential component of ameliorating health conditionsand preventing neonatal death [17, 27], increasing pater-nal awareness of neonatal danger signs through accept-able campaign messaging may facilitate transition fromillness recognition to facility access.Across contexts, recognition of neonatal danger signs

are often proposed as a determinant of the types of caremethods sought as well as care timeliness [6, 23, 28].Symptoms that indicated illness among parental figuresmost often included fever, lack of breastfeeding and ex-cessive or abnormal crying. All of these symptoms havebeen identified in a similar study on newborn care seek-ing practices in Central and Southern Ethiopia [29]. Sev-eral participants identified newborn illnesses as either“simple” or “complex.” Some who specifically character-ized the newborn’s illness as complex described theirnewborn’s illness as being too severe for successful clin-ical care due to perceived ineffectiveness of biomedicaltreatment. Delays in newborn care seeking have alsobeen reported when the condition of the child was per-ceived to be hopeless or too severe [7]. Unique to thisstudy is that some families characterizing newborn ill-ness as “simple” mentioned visiting the health center be-cause there was no reason not to. Health insurance was

often commented as justification for liberally visitinghealth centers if the child became ill (“there is no reasonnot to visit the health center”). Since 2010, Ethiopia hasimplemented and scaled up community-based and socialhealth insurance in rural areas [30, 31]. This may explainwhy families in this study rarely mentioned finances as abarrier to accessing the health center.Participants frequently and strongly indicated sick

newborns should be cared for at health centers. Logis-tical barriers such as distance to facilities and time wererarely mentioned as obstacles in assuring biomedicaltreatment. However, many studies conducted in LMICsrecognize geographic accessibility as a significant im-pediment to achieving care, particularly in rural settings[32–34]. This contrast may have been because study par-ticipants were recruited from the catchment area of localhealth centers and thus, participants may not have beenlikely to reside in hyper-rural areas far from health facil-ities. Most constraints on accessing care for sick new-borns were thus related to how illnesses wereconceptualized. This is a key finding in support of multi-sectoral partnerships for improved healthcare provisionsand scale-up of the health insurance scheme in Ethiopia.Further, there are discrepancies between pre-servicerural HEW education and the day-to day reality of ruralHEW tasks [35]. To improve recognition of neonataldanger signs amongst community members, pre-serviceHEW education for rural HEWs could emphasize theimportance of universal healthcare seeking regardless ofillness conceptualization as “simple” or “complex” to fur-ther strengthen the link between household illness rec-ognition and biomedical care acquisition.Interestingly, the health post was not mentioned at all

as a viable care facility for sick newborns. This may bean artifact of the HEW-based purposive sampling fromhealth center records since participants were selectedfrom the catchment area of health centers due to theiraccessibility during HEW recruitment. Health postsfunctioned as one solitary room within the health cen-ters visited. Mother and father focus group discussionsoccurred in health posts nested within the local healthcenter. Therefore, some participants may not have dif-ferentiated between services offered at health posts andhealth centers because of their shared locations.Studies should aim to increase understanding of poor

care seeking behaviors at health posts. Implementationstrategies can enhance proven approaches in low- andmiddle-income country contexts. To do so, action shouldbe taken to incorporate community mobilization, expandcommunity health worker strategies (HEWs and HDAs)and enhance community-based interventions of whichcommunity members are involved in the developmentand implementation of programming efforts, to amplifyacceptability of care seeking learned approaches [36].

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LimitationsAlthough this study aimed to sample households withsymptomatic newborns (SG) and community members(CG), this sampling frame did not yield divergent re-sponses to care seeking strategies for sick newborns be-tween CG and SG households. Since many childhoodillnesses share symptoms (fever, diarrhea, poor feeding),the similarity in findings across CG and SG groups mayrepresent commonly shared approaches to childhood ill-ness at the community level. Additionally, to obtain anadequate sample for analysis, we included any house-holds that had a sick newborn in the previous 2 years.This extended timeframe may contribute to recall biasand diminish respondents’ specificity about PSBI-specificcare seeking behaviors. Future studies may compare re-sponses from families with sepsis-confirmed newbornsversus community members to gain an additional under-standing of PSBI/sepsis-specific care in this setting orlimit the sample to respondents whose newborns weremore recently ill—perhaps in the previous one to 2months.

ConclusionsThis study contributes to knowledge on household-levelnewborn care and drivers of newborn treatment seekingin rural Amhara, Ethiopia. It suggests care seeking strat-egies and trajectories in this context may be widelyshared at the community level. Consequently, strategiesto engage community members in defining and creatingdecentralized approaches to PSBI care are indicated tomaximize their relevance, accessibility and desirability.In the Ethiopian health system context, engaging periph-eral health workers (HEWs) and volunteers (HDAs) maybe a salient strategy for creating a decentralized modelof care, particularly in understanding “simple” and “com-plex” symptoms as identified by community membersand various subsequent care pathways. Community-based interventions, of which community members areinvolved in the development and implementation of pro-gramming efforts, may serve to strengthen the identifica-tion of these symptoms while amplifying acceptability oflearned and normative care seeking behaviors regardlessof simple or complex illness identification [36]. Encour-aging home visits using HDA volunteers may be onepowerful strategy for bringing PSBI care and treatmentcloser to the households—particularly in contexts wheregeographic or contextual barriers limit the uptake oflife-saving PSBI care at referral facilities or hospitals.However, in instances where community members donot view or acknowledge the health post as a sufficientfacility to care for newborns, emphasis on reinforcingthe health post and health centers in HEW training mayprove helpful.

Supplementary informationSupplementary information accompanies this paper at https://doi.org/10.1186/s12913-020-05081-0.

Additional file 1. Focus group guide for recently-birthed women.

Additional file 2. Focus group guide for fathers.

Additional file 3. Focus group guide for households.

AbbreviationsFGD: Focus Group Discussion; HEW: Health Extension Worker; HDA: HealthDevelopment Army Volunteer; PSBI: Possible Severe Bacterial Infection

AcknowledgementsWe thank the Emory-Ethiopia staff and research team (moderator, notetakerand transcriber) of this qualitative study. Specifically, we’d like to thankTadesse Biru in assisting with the transcription of interview guides and Mulu-sew Belew in helping to guide ethical review. Additional thanks goes toBethlehem Besrat for coding interviews and participating in discussions tosupport intercoder reliability.

Authors’ contributionsMDA, JNC, BLS and AG were primarily responsible for conceptualizing anddesigning this study. Qualitative data collection methods were informed byDLC, SAS and LA. MDA conducted the literature review and supervised datacollection and analysis. JNC, DLC and SAS guided and revised review of theliterature and data analysis proceedings. MDA, JNC, DLC and SAS supportedthe interpretation of results with all authors contributing towards manuscriptreview and editing. Further, all authors contributed towards manuscriptpreparations and approved the manuscript for submission.

FundingFunding for this study was provided by the Center for Excellence in Maternaland Child Health, Education, Science and Practice and the Emory GlobalField Experience. Additional funding was obtained from the FacultyDevelopment Award through Dr. John Cranmer (co-author).

Availability of data and materialsThe datasets generated and analyzed during the current study are notpublicly available to protect confidentiality of participants in thecommunities studied. However, these data are available from thecorresponding author upon reasonable request.

Ethics approval and consent to participateEthical approval was obtained from the Amhara Public Health Institute andthe Emory University Institutional Review Board. Oral informed consent wasprovided by all participants of the study. Oral consent was approved by bothethics committees, given the literacy and education level of thecommunities in the study. Consent was tracked on a notepad by the note-taker prior to initiating focus group discussions.

Consent for publicationNot applicable.

Competing interestsThe authors declare that they have no competing interests.

Author details1Emory University, Atlanta, GA, USA. 2Emory University – Ethiopia, Bahir Dar,Amhara, Ethiopia. 3Emory University – Ethiopia, Addis Ababa, Ethiopia.

Received: 12 August 2019 Accepted: 9 March 2020

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