Integrated Determinants of Maternal Healthcare Decisions: A Cross-Sectional Analysis of Predisposing, Enabling, and Illness-Level Factors in Bo District, Sierra Leone.

Background

Maternal and child outcomes in Sierra Leone continue to reflect rural-urban inequities in access to care and timely healthcare-seeking. Understanding how predisposing, enabling, and illness-level determinants interact across settings is essential for explaining these disparities.

Objectives

To examine how predisposing, enabling, and illness-level factors influence maternal and child healthcare-seeking decisions in Bo District, and to quantify rural-urban differences in these determinants.

Methods

We conducted a facility-based cross-sectional study among 500 women attending antenatal, postnatal, or child health services at an urban tertiary hospital and a rural maternity facility. Descriptive statistics summarized participant characteristics. Rural-urban differences were assessed using Pearson's chi-square tests, odds ratios with 95% confidence intervals, Mann-Whitney U tests for ordinal outcomes, and Cramér's V to estimate effect sizes. Findings: Predisposing influences on maternal healthcare-seeking were ubiquitous (97.4%), with knowledge and health awareness most frequently reported. Predisposing influences didn't differ by residence; however, cultural factors were significantly prominent among rural women (p = 0.004; Cramér's V = 0.14). Enabling factors showed the strongest rural-urban differentiation, with small-to-moderate effect sizes. Urban respondents more often reported health insurance coverage, financial stability, proximity to facilities, and transportation availability, whereas rural respondents more frequently reported traditional social, language, and communication support, perceived infrastructure adequacy, preventive service availability, and community engagement. Pregnancy-/childbirth-related complications were common (68.2%) and didn't differ by residence; however, the perceived influence of illness on care-seeking differed significantly between settings (p < 0.001; Cramér's V ≈ 0.21). For childcare-seeking, knowledge and awareness were foundational across settings, while financial protection and prior healthcare experience exerted greater influence among urban caregivers.

Conclusions

Rural-urban differences in maternal and child healthcare-seeking in Bo District appear driven less by awareness or illness occurrence and more by context-specific enabling conditions and differences in how illness is interpreted and acted upon.