Background
In 2008, approximately 8.8 million children under 5 years of age died worldwide. Most of these deaths occurred in developing countries, but little is known about poor mothers' care-seeking behaviors for their children.

We examined poor mothers' care-seeking behaviors in response to childhood illness, and identified factors affecting their choices. We also assessed mothers' perception of the medical services and their confidence in the health care available for their children.

Methods
We carried out a community-based cross-sectional study with structured questionnaires. Participants were 756 mothers and their young children (0-23 months) in Nandaime municipality, Granada province, Nicaragua. We took the children's anthropometric measurements and we assessed the mothers according to their income. We divided them into 3 global absolute poverty categories (income: <1 USD/day, 1-2 USD/day, >2 USD/day), and 4 quintile.

Results
When a child showed symptoms of illness, most mothers (>75%) selected public health facilities as their first choice. More than half (>58%) were satisfied with the medical services, but the poorest mothers expressed more dissatisfaction (p = 0.003), when we divided the participants into 4 quintiles groups according to their income. In the poorest group, the main reasons for dissatisfaction were cost (46.6%), and distance to the facilities (25.8%). Almost half (41.3%) of mothers lacked confidence in the health care offered to their child, while most of the wealthiest mothers (75.7%) did have confidence in it (p = 0.001). The poorest mothers showed greater interest in health education than the wealthiest (86.2% vs. 77.8%) (p = 0.015). We found that poor mothers (=2 USD/day) changed their second choice for care in a positive direction. Factors affecting the change in second choice were the child having symptoms of respiratory disease (AOR, 2.51; 95% CI, 1.28-4.90, p = 0.007), visiting health post as the first choice (AOR, 2.11; 95% CI, 1.26-3.53, p = 0.005), and experiencing a child death in the past (AOR, 2.05; 95% CI, 1.15-3.68, p = 0.016). Child stunting, mother's level of education, and past participation in health education programs did not affect.

Conclusions
Determination of the severity of a childhood disease is a difficult task for mothers. The national rural health system was functioning, yet the services were often limited. We should consider the feasibility of providing a more effective primary care system for the poor.

To encourage mothers' care-seeking behaviors in poor settings, the referral system and the social safety net need to be strengthened. Poor mothers need further education about the danger signs of childhood illness.