Comment on “Healthcare-Seeking Behaviour for Obstetric Complications in Ethiopia: A Multilevel Mixed-Effect Analysis”

Abstract

This commentary addresses methodological and interpretive limitations in Geremew et al.’s study on healthcare-seeking behaviour for obstetric complications in Ethiopia, emphasizing the need for clinically validated definitions, analytical exploration of variable interactions, inclusion of all obstetric events, and facility-level cross-validation to strengthen the policy relevance and accuracy of the findings.

Dear Editor,

We read with great interest the study by Geremew et al, ¹ which offers valuable national estimates on healthcare-seeking behaviour (HSB) for obstetric complications across the pregnancy continuum in Ethiopia. The use of the Performance Monitoring for Action longitudinal survey and multilevel modelling provides robust stratification of individual and contextual factors. However, several key concerns merit further reflection before integrating these findings into maternal health policy frameworks.

First, the study’s operational definition of “obstetric complications” is based entirely on self-reported symptoms without clinical validation, yet it includes subjective indicators such as “severe headache” and “lower abdominal pain,” which have low specificity for life-threatening conditions.^2,3 This broad inclusion likely inflates the denominator for complication cases, leading to an underestimated HSB rate that may not reflect the actual burden of medically significant events.

Second, while the study applies Andersen’s behavioural model, the categorization of variables into predisposing, enabling, and need-based factors is not analytically leveraged to generate interaction insights. For instance, the strong effect of antenatal care (ANC) on HSB could be moderated by community wealth or media access, ⁴ but interaction terms were absent from the regression models. This limits our understanding of how community-level interventions interact with individual behaviours.

Third, the exclusion of termination-related complications from the analyses of childbirth and postpartum HSB introduces selection bias, particularly in Ethiopia, where unsafe abortion is a leading contributor to maternal morbidity. ⁵ Although justified methodologically, this exclusion distorts the postpartum complication profile and weakens the generalizability of the findings to all obstetric events.

Additionally, the authors reported intraclass correlation coefficients (ICCs) as high as 63% for childbirth complications in HSB, suggesting strong clustering by enumeration area. However, the implications of this high variance at the community level have not yet been adequately discussed. This clustering may indicate deeply entrenched local norms or supply side disparities; however, the study does not contextualize these findings using qualitative or service delivery data.

Lastly, the reliance on recall up to nine weeks postpartum and the absence of cross-validation with facility-level data raise concerns about misclassification and social desirability bias. While the authors cite efforts to minimize these effects, the absence of sensitivity analyses to account for misreporting weakens the robustness of the outcome interpretation.

In summary, although this study contributes important national data, the findings should be interpreted cautiously. Refining complication definitions, exploring variable interactions, and integrating facility validation would enhance the utility of this evidence for programmatic planning and maternal health strategies.