Newborn care practices: A case study of tribal women, Gujarat

Baiju Dinesh Shah, Laxmi Kant Dwivedi

Core Capability Group, Health and Public Services, Accenture Management Consulting, Mumbai, India;.
Department of Mathematical Demography & Statistics, International Institute for Population Sciences, Mumbai, India;.

DOI: 10.4236/health.2013.58A4005                

Abstract

Plateaued rate of decline in neonatal mortality rate is one of the major obstacles in achieving Millennium Development Goal 4 especially in developing countries. Even in India, nationwide interventions targeting safe mother and newborn care have not yielded the desired impact, indicating the necessity to combat neonatal mortality rate at population specific level. The objective of this study is to identify the newborn care practices and beliefs, analyze their harmful or beneficial characteristics, describe the deviations from the essential newborn care practices during hospital/home delivery, explain barriers to care seeking and identify areas of potential resistance for behavior change; and utilize study findings to tailor-make cost-effective essential newborn care package. The study uses qualitative data from in-depth interview of mothers who had experienced neonatal death and key-informant interviews with healthcare personnel and birth attendants. 33 cases were randomly selected from the registered neonatal deaths across Bharuch district of Gujarat, India. Key finding of this study is less prevalent practice of essential newborn care among all cases irrespective of place of delivery and the health-care personnel facilitating delivery. Habitual traditional/tribal newborn care methods challenge the practice of prescribed essential newborn care. Clustering of deaths in few households added significantly to the existing burden of neonatal deaths, attributed to superstition “Ratewa” by tribal. Study has concluded that the introduction and implementation of essential newborn care at hospital and community/ household level are the need of the hour. Quality home based neonatal care through cost effective interventions is deemed necessary where accessing institutional care is not possible in the immediate term. Community health workers can contribute to the eradication of harmful newborn care practices and the sustenance of essential practices through community education and behavior change communication.

Keywords

Home Delivery; Institutional Delivery; Newborn Care Practices; Essential Newborn Care; Cost-Effective Interventions; Home Based Newborn Care

1. INTRODUCTION

Globally, there has been a considerable decline in under-five and infant mortality during last four decades. However, neonatal mortality rates remain unchanged especially in developing countries [1,2]. It is estimated that each year around four million neonatal deaths occur almost exclusively in low income countries [3]. In these countries, progress towards achieving Millennium Development Goal 4—“Reducing under-5 mortality from the 1990 baseline by two-thirds” is being hampered by slow progress in reducing the number of neonatal deaths [4]. The neonatal period is only 1/60^th of the first five years of life, but contributes 38 percent of the estimated 10.5 million under-five deaths occurring every year all over the world [5].

In India, government, bilateral and multilateral agencies have made several efforts in the area of maternal and child health welfare. The introduction of government schemes like Janani Suraksha Yojana, Chiranjeevi Scheme, Propagation of Emergency Obstetric Care (EmOC), Implementation of Integrated Management of Childhood and Neonatal Illness, etc. has resulted in an increase in institutional delivery and decrease in infant and child mortality rates. But there is no significant difference in neonatal mortality rates, as evidenced by analysis of infant and child mortality rates over the past decade. Table 1 provides a comparison of neonatal, post-neonatal, infant, child and under five mortality rates from past three National Family Health Surveys (NFHS).

Even though the primary causes of neonatal deaths are estimated to be preterm birth (28 percent), severe infections (26 percent), birth asphyxia and injuries (23 percent), tetanus (seven percent), congenital anomalies (seven percent) and diarrhea (three percent), with Low Birth Weight contributing to large proportion of neonatal deaths [5]; studies show evidence about contribution of care practices immediately following delivery to newborn’s risk of morbidity and mortality [6]. Studies report that most newborns in low income countries like India die at home while they are cared by mothers, relatives, and traditional birth attendants [7].

In India, the practices of essential newborn care are not studied comprehensively and hence relatively less knowledge exists about the influence of practiced traditional newborn care practices on newborn survival. Studies on newborn care in some communities show that the knowledge and practice of basic newborn care for instance prevention of hypothermia, feeding of colostrum and exclusive breast-feeding are lacking; even awareness regarding care seeking on the identification of lifethreatening signs has been found to be very low [8]. Despite implementation of proven cost-effective solutions such as promoting antenatal tetanus toxoid immunization, skilled attendance during delivery, immediate and exclusive breast-feeding, and clean cord care; there has been relatively little change in neonatal mortality rate (NMR) [9].

The World Health Organization recommends improving essential newborn care practices at birth in order to reduce neonatal morbidity and mortality [10]. Effective promotion of essential newborn care at scale could significantly contribute to reducing the leading causes of newborn deaths in low income countries, especially those due to sepsis/pneumonia, preterm births and tetanus [6]. The essential practices include clean cord care, thermal care, initiating breast-feeding immediately or within an hour after birth, skilled assistance at birth for resuscitation, care-seeking and extra care for sick and underweight babies. Two Lancet series, on newborn health and maternal health propose key evidence-based interventions and packages which, if implemented to scale, could greatly contribute to saving maternal and newborn lives in low income countries. These interventions emphasize strengthening the continuum of maternal, newborn and child care during the antenatal, natal and postnatal phase [1,11].

Literature suggests that the challenge for reducing neonatal deaths in any developing country requires solutions through research to inform program innovation and action oriented policies designed to improve newborn health and increase their probability of survival [12]. Implementation of an effective program for the promotion of childbirth and newborn care practices requires understanding of the community and household traditional newborn care practices. Such information will enable the development of programs which promote culturally sensitive and acceptable change in practices. Information about reasons for delivering at home, preference of traditional birth attendant for delivery and newborn care practices is lacking from rural tribal areas of India, which is necessary for healthcare planners to design health services. The objective of this study is to describe the deviations from the essential newborn practices followed during hospital and home delivery. Study also explores the tribal specific home based newborn care practices during the antenatal, intranatal and postnatal care period and assesses its impact on the morbidities of neonate and hence the neonatal health outcomes. It also identifies the socio-demographic, antenatal and delivery care factors associated with these practices; along with understanding of care seeking behavior of mother and family members. This study by analyzing the newborn care practices in the rural tribal study area of “Gujarat” has made an attempt

Table 1. Percentage of early childhood mortality rates for the five-year period preceding the surveys, NFHS-1992-1993, NFHS- 1998-1999 and NFHS-2005-2006.

to recommend the desired interventions necessary for improving the newborn survival which are cost effective and which can be practiced by healthcare personnel irrespective of place of delivery.

2. MATERIALS AND METHODS

The present study was conducted in a block of Bhauch district of Gujarat wherein the population constituted 79 percent of “Bhil” tribe population, who are considered to be among the oldest settlers in the country. They have their own typical mode of thinking, feeling and common beliefs and attitudes, sentiments and ideals. As members of the scheduled tribes, they have distinctive social identities and face different forms of social and economic discrimination. Hence within this population and tribal entity, differences in dialect, health practices, unique customs, values and traditions are apparent. This study was undertaken during period from May, 2009 to November 2009.

For case studies the block was divided into different sectors (sector being the panchayats of that block) to explore all possible newborn care practices and other contributing factors for neonatal deaths in the district. Of total 106 neonatal deaths randomly selected from the list available from Non-Government Organization sampling frame (i.e. registered neonatal deaths in years 2008 and 2009), 33 deaths had been selected randomly for case studies considering the sectors (the distribution of the sampling frame and sample of neonatal deaths is shown in Figure 1).

The data for case studies was collected using different interview techniques, with in-depth interview of mothers who had experienced neonatal death (primary respondent), and whenever possible even of an adult relative who had the closest contact with the child during terminal illness (secondary respondent). Key-informant interviews were conducted with four healthcare personnel (two medical doctors and two community health

Figure 1. Distribution of causes of neonatal deaths (sampling frame and sample).

workers and four birth attendants (out of which two were trained birth attendants and other two were untrained birth attendants).

The data collection tool or questionnaire for in-depth interview consists of two parts. First part has information related to socio-economic, maternal, birth and delivery related factors. The second section has information of essential newborn practices followed during delivery, neonatal death history and traditional newborn care practices. The questionnaire was adapted from the available guidelines of World Health Organization verbal autopsy questionnaire for investigating neonatal deaths with added questions on socio-economic profile, maternal, pregnancy and child-birth factors. The instrument was further adapted to local context and culture. The questionnaire started with close ended questions followed by open ended questions to elicit a narrative about neonate’s death. The researcher obtained an informed consent from all the participants before conducting the interview. The data collection was done by researcher herself (from medical background). During data collection, interviews were conducted in Gujarati using local vocabulary.

Analysis of the in-depth interviews and Key Informant interviews was done using latent thematic content analysis. Transcripts were first read several times to get an overall picture and then meaningful units were coded, condensed and categorized into broad themes [13]. Analysis is presented in three sections which include analysis of current practice of various components of essential newborn care and traditional newborn care practices during the antenatal, natal and postnatal phase. Barriers to care seeking were characterized according to the three delay model which includes delay in deciding to seek care, delay in reaching the health facility, and delay in receiving care once at the health facility [14,15].

3. FINDINGS

3.1. Practice of Essential Newborn Care Practices

Essential newborn practices that were not followed in the hospital and home births among the neonatal deaths are listed in Table 2.

3.1.1. Institutional Delivery

Of the 33 cases, hospital births accounted for 66 percent. The incidence of home delivered neonatal deaths was high among Muslim families because of prevalent belief that hospital for deliveries should be accessed only in the absence of traditional birth attendant alias “Dai” or in instances of postpartum complications. Even among women who had accessed health facility for delivery, the reasons for preference of Institutional delivery were: all the Dai’s in our village have either died or migrated, no Dai is left in the village and hence we had no option other than institutional delivery. It was quite surprising to find that the mothers usually did prefer institutional delivery, but the decision was subdued by family members.

3.1.2. Skilled Attendance for Delivery

Table 3 shows attendance at birth among institutional and home deliveries. Home deliveries show uniform distribution in attendance at birth by trained and untrained birth attendants.

Conflicts of Interest

The authors declare no conflicts of interest.

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