RECOGNITION AND CARE SEEKING BEHAVIOR FOR NEWBORN AND MATERNAL COMPLICATIONS AND FACILITY READINESS TO PROVIDE QUALITY ANTENATAL, INTRAPARTUM AND POSTPARTUM CARE IN RURAL NEPAL

Background Globally between 1990 and 2015, maternal and newborn mortality have decreased 44% and 46% respectively. Achievement of the Sustainable Development Goal targets, however, will require accelerated progress to ending preventable maternal and newborn deaths. This requires a renewed focus on maternal and newborn care at the facility level and by trained health workers. In settings such as rural Nepal where the majority of the births still occur at home, there are still knowledge gaps on reasons for low usage of maternal and newborn care at health facilities despite safe motherhood programs and community based newborn care services. Objective This dissertation aims to describe the facility readiness in providing quality maternal and newborn care services, to assess how women and caretakers identify maternal/newborn complications, and to characterize the decision making process and patterns of care seeking. We also explored if place of birth was associated with the type of postnatal care sought for severely ill newborns. Methods Primary data on facility readiness and health worker knowledge to provide maternal and newborn care was collected through a health facility audit and health worker interviews at 23 birthing centers and one district hospital in Sarlahi district. A qualitative study included 32 illness event narratives (6 maternal/newborn deaths each and 10 maternal/newborn illnesses each) collected through small group interviews and in-depth interviews on illness recognition, decision-making process and the care-seeking steps along with timeline of events from illness recognition to illness resolution or death. Bivariate and multivariate multinomial logistic regression was used to analyze the association between place of birth and type of postnatal care sought among a subset of severely ill newborns from a population based sample of newborns. Results Readiness of facilities to provide basic emergency obstetric and newborn care services was poor among the primary health care center level birthing centers. Infection prevention was lacking in quarter of health facilities and shortage of essential medicines was a major barrier to facility readiness. Only half of the health workers had received the government-mandated additional training in skilled birth attendance and the private sector staff scored significantly lower on knowledge of essential maternal health issues. Delay in perceiving the severity of illness, and initial care-seeking from informal health providers (traditional healers for mostly maternal cases; village doctors for both) delayed prompt care-seeking at health facility. Some barriers to seeking care at a health facility included transport problems, lack of money, illness onset at night, low perceived severity and distance to facility. Informal care and no care was sought for 44% and 20% of severely ill newborns. Caregivers of severely ill newborns born in a health facility were twice as likely to seek formal care as opposed to no care compared to non-facility born newborns [adjusted relative risk ratio (RRR): 2.00; 95% CI: 1.30-3.06]. Conclusion These findings have important implications for safe motherhood programs, newborn care programs and quality of care improvements in health facilities. We suggest addressing the gaps in facility readiness through routine monitoring and supervision, improving supply chains, creating an enabling environment for health workers, and extending refresher trainings to all health workers. Our findings show the need to utilize informal care providers as links to the formal providers by training them in danger sign identification and referrals to health facility. We also suggest improving counseling on recognition of danger signs and prompt care seeking through community level interventions so as to reach a wider audience. The supply and demand for delivery at health facilities needs to increase and postnatal home-visits of home births by female community health volunteers could increase care seeking from formal providers