Neonatal mortality is one of the major health problems in India. India has made remarkable progress in the reduction of child mortality in the last two decades. Still the United Nations (UN) estimates that about 2.35 million children died in India in 2005. It accounts for highest number of under five deaths in the world. Community practices regarding child birth and newborn care affect the survival of newborn the most. It is important to intervene in areas where community beliefs are affecting the survival of the baby.
Keywords: newborn care, antenatal care, community practices, infant mortality
Introduction
Health and survival of the newborn depends on the care given to them. Although care of newborn is very essential element in reducing child mortality, it often receives less than optimum attention. The world has committed to improve newborn’s health. Current global evaluations confirm that commitment of improving newborn health makes meaningful socio-economic contribution. Many other reasons related to newborn’s health why they have been neglected and why the huge mortality rates and neonatal deaths are unseen and undocumented.
Globally 5 million newborns die before they reach one month of age. Of which 3.2 million deaths occur during the first week of life. In 2015 approximately 45% of under five deaths occurred during their first month of life whereas deaths during the neonatal period accounts two-third of all deaths in the first year of life. The global burden of infant mortality rate has declined in past decades but the high neonatal mortality rates have remained relatively unchanged. In the past decade India shows a faster decline in Infant mortality rate i.e. 40 per 1000 live births (SRS 2013). Though India accounts highest burden of under % mortality rate in the world there has been a faster decline. Neonatal deaths account 56% of under five deaths in India. The primary causes of neonatal mortality in India are believed to be premature prematurity and low birth weight births, neonatal infections, complications of pregnancy, tetanus, congenital anomalies, pneumonia and diarrhea.
In any community, mothers and children constitute a priority group. In sheer numbers, they comprise approximately 70 % of the population of the * Assistant Professor, Department of Social Work, University of Lucknow (U.P.),
developing countries. In India, women of the child-bearing age (15 to 44 years) constitute 19 % and children less than 15 years of age about 40 % of the total population. Together they constitute nearly 59 % of the total population. By virtue of their numbers, mothers and children are the major consumers of health services, of whatever form. Mothers and children not only constitute a large group, but they are also the “vulnerable” or special-risk group. The risk is connected with growth, development and survival of infants and children.
India has launched the National Rural Health Mission with the objective to bring a dramatic improvement in health system and the health status of the people, especially who live in rural areas. The mission looks for universal access to equitable, affordable and quality health care services, which is accountable and responsive to the need of the people. The NRHM seeks to provide accessible, affordable and quality health care to the rural population, especially the vulnerable sections. It also seeks to reduce the Maternal Mortality Rate (MMR) in the country from 407 to 100 per 1,00,000 live births, Infant Mortality Rate (IMR) from 60 to 30 per 1000 live births and the Total Fertility Rate (TFR) from 3.0 to 2.1 within the 5 year period of the Mission. This study attempts to explore various community practices regarding newborn care in rural areas which are affecting the survival of newborns.
In India majority of the population resides in rural areas. Uttar Pradesh has maximum population among all states. The situation of maternal and child health was not very good in Uttar Pradesh. It is evident in last decades that Uttar Pradesh has improved maternal and child health as SRS 2012 shows reduction in infant mortality rate from 61/1000 live births in 2010 to 53/1000 live births in 2012.
Objectives
1. To study the knowledge and practices related to newborn care in rural areas of mall block of Lucknow district.
2. To identify critical community practices and barriers those influence the survival of newborns in rural areas.
Materials and Methods Study Population
The present study was carried out among mothers who gave birth to a live born within the last one year. There are eight rural blocks in Lucknow districts. The present study was carried out among women residing in rural areas of Lucknow district. The rural areas of Mall block of Lucknow district were selected for the study because Mall is the most distant (38 km) block from Lucknow district head quarter with lowest literacy rate, maximum number of schedule caste population (45.9%) and maximum worker in agriculture (83%).
Sampling and Sample Size
Multi stage sampling was applied for selection of respondents. The present study was conducted among 120 women of six villages of mall block namely Saspan, Thari, Saleh Nagar Auntgarhi Madwana and Mall on the basis of highest population. 20 respondents from each village were selected for the study on the basis of purposive sampling.
Period of Study
The study was carried out from June 2014 to November 2014 which included the development of study tools, collection of data, analysis, tabulation of findings, and interpretation of results.
Analysis and Interpretation of Data
The data were tabulated on Microsoft excel sheet and analyzed in percentage. Results
i) Profile of Respondents Socio-demographic Scenario
A total 120 mothers (who have given birth to a child in last one year) were interviewed. The data show that there were 74.2% Hindus and 25.8% Muslims families. Among Hindu families there were 67.5% respondents belonged to schedule caste followed by 15.8% OBC and 16.7 % from general caste. The majority of respondents (72.5%) were belonged to joint families. Majority of respondents (65%) were illiterate, where as 31.7% mothers were educated upto primary level only 3.3% mothers had education level upto secondary or higher level. More than one third population belonged to lower class, 31.7% respondents were belong to below poverty line followed by 11.7% form lower middle class and only 8.3% population were from middle class.
Majority respondents 67.5 % said that the pregnancy was registered with the ANMs, some 22.1 % registered with ASHAs and few 10.4 % registered with AWWs.
Ante-natal Care Received by Respondents for the Pregnancy
The data represented that 64.2 % pregnant women registered their pregnancy and rest 35.8 % pregnant women had not registered their pregnancy with any health personnel. This was further classified with the receiving of registration card for the registration of pregnancy. Majority 87.0 % women received cards of their pregnancies and 13% has not received the card. Majority of (62.3%) registration of respondent’s was done in second trimester of pregnancy followed by 28.6 % registration in 1st trimester and 5.2 % were registered in third trimester. Very few 3.9 % respondents were not registered in any trimester of pregnancy.
To summarize the antenatal care received for the pregnancy by respondents, 64.2 % pregnant women registered their pregnancy out of which 87.0 % women received registration cards. Majority 67.5 % said that the pregnancy was registered with the ANMs but the maximum registration of pregnancy was done in second trimester of pregnancy with 62.3 %.
The findings clearly show that there is a delay in the registration process because it takes the woman three or four months to confirm her pregnancy. This is because women hesitate and feel shy to talk about their pregnancy, or they are unable to identify their pregnancy. Sometimes the family members want to hide the news of pregnancy as they believe that if people know about it chance of contracting the evil eye is more “nazar lag jayega”.
Visits by Service Providers and Place of ANC
Majority of the respondents i.e. 58.4 % respondents said that they visited the medical centre twice during pregnancy. On the other hand 31.2% respondents said that service providers had visited their homes thrice. It can be concluded that a good number of house visits are being done to support the care of pregnant women. 36.4% respondents received ANC at village level followed by 15.6% and 16.9% respondents received ANC at public health facility and other places. 22.1 % respondents received ANC at their own home and 5.2% respondents reported to the private facility for receiving the ANC checkups.
ii) Community Practices during Pregnancy
In this study, the information is collected on the events and practices followed by the women for their last child. It is but natural that their reporting of knowledge would be influenced by practices followed in their community. This phenomenon is very clearly evident in a close relationship between the knowledge and practices of healthy pregnancy norms.
Practices on Services during Pregnancy
The Tetanus Toxoid (TT) immunization status is quite good in the district. Data shows that 91.2% respondents received the TT and further 69.2% has received the IFA and 73.3% respondents has received the supplementary nutrition. So, it can be summarized that the services and of immunization availability status is quite good in district.
Intake of Supplementary Nutrition and Food Intake during Pregnancy
Majority of the respondents i.e. 53.3 % respondents had not taken the supplementary nutrition provided by Anganwadi centers. Only 39.2 % has taken the supplementary nutrition. So, intake of supplementary nutrition is quite low. There is a need to emphasize on the awareness is required for benefits of supplementary nutrition during pregnancy. About 48.3% respondents had taken more food during pregnancy followed by 6.7% who said that they have
also taken extra meal for some times but 34.2% respondents have not taken any extra food during pregnancy period.
Place of Delivery
Majority (66.7%) of the deliveries were conducted at PHC/ CHC level due to accessibility of the institution followed by 32.5 % deliveries conducted at home. Very few (1.6%) deliveries were conducted at private facilities. So, due to accessibility and reach to PHC/ CHC and sub centers majority of deliveries were conducted at government facility level.31.7% of women have given birth to their children at home. It reflects a serious gap in the outcomes of the efforts made to promote institutional deliveries. The data reflect that more institutional deliveries were held in the government health institutions than the private health facilities. All the institutional deliveries were conducted at hospitals and were assisted by doctors/nurses. Most of the home deliveries i.e. 55.3 % were assisted by family members (relatives and friends) and traditional health providers.
The data shows that 65.0 deliveries were conducted with clean washed hands. Majority of respondents (81.5%) said that a new blade was used for the cutting the cord of neonatal. This reflects the high level of awareness regarding the use of new blade.
60.5% women used the clean place for home delivery. On the other hand 32.5% women have not used the clean place for delivery at home. So, the use of clean place at house level is quite low, this directly affects the neonatal health and deaths due to infections.
This study also shows that 52.6% respondents did not use a clean thread for tying the cord of baby born at home. Only 44.8% respondents used the clean thread for tying the cord of baby. Only 55.2% respondents arranged the clean cloth for wrapping and wiping the baby. 42.1% respondents did not use clean cloth for wiping and wapping the neonate.
iii) Knowledge about Neonatal Healthy Behaviors
Data clearly show that the knowledge about healthy behaviors in women is moderate and most of the respondents were not having the complete knowledge of neonatal healthy behaviors. It was seen that 81.6% of respondents were having knowledge regarding breast feeding followed by 43.3% were having knowledge about colostrums feeding and benefits of that. The other important and easily adopted behaviors like delay in bathing, drying and wrapping, safety of cord were seen among respondents in 45.0%, 48.3% and 57.5% cases respectively. So, the knowledge about the neonatal healthy behaviors was found to be moderate in respondents. So, the situation shows that there is a need of intervention.
Knowledge about Benefits of Colostrums Feeding
Colostrums provide immunity to the child against several preventable diseases and is considered as one of the crucial new born care practices. In many
Indian societies, cultural practices forbid women against feeding colostrums to the child. Efforts are being taken to educate women on its relevance for the children through mass media and other sources. 48.3 % of the respondents have knowledge that after giving the colostrums to baby will be strong and his/her immunity developed. 50.8% of the respondents have reported no constipation in the baby after feeding the colostrums.
Knowledge about Starting Breastfeeding
35.8 % of the respondents said that after discussing with religious leaders and family members they decided when the first milk should be given to the neonate. This was found a major area of concern even after lots of programmes by government and non government organizations, the community is rigid to beliefs and traditions. 32.5% of the respondents replied that breast feeding should start after one hour followed by 55.8% of respondents having fair knowledge that breastfeeding should started immediately after the child birth. So, the knowledge about the starting breastfeeding to the neonatal just after birth was found to be low in the respondents. This was found to be a major area of concern that after lots of programmes by government and non government organizations, the community is rigid to their beliefs and traditions.
Knowledge about Exclusive Breastfeeding
In Indian context, breast feeding of child is almost universal. However, on duration of exclusive breast feeding, opinions and practices vary. There was a mixed knowledge about exclusive breastfeeding. 35.8% said milk should be given for 2-3 months followed by 36.7% of the respondents having knowledge of complete duration of exclusive breastfeeding to baby. Very few 12.5% and 15%s respondents had given mixed responses of one month and 3 to 4 months. So, the knowledge about exclusive breastfeeding in study area was mixed and only 35.8% of the respondents had knowledge of complete duration of exclusive breastfeeding to baby.
Knowledge about Neonate Bathing
The knowledge level of respondents was found very low regarding the neonatal bathing. The study showed that women were not having knowledge of the correct timing and day of baby bathing. 56.7 % of respondents said that neonate should bathe either within one hour after birth or after the first day. Half of the respondents said that baby should be washed with warm water. Very few, 15.8% followed by 6.7% women said bathing should be done on 3rd -5th day and 6th day respectively. In the Muslim community they practice a religious ritual (ajan phukna) which is only done when the child is clean and since they believe that the dirty baby as “Napak” (unclean, polluted), they bathe the baby immediately after birth. This reflects the limited knowledge sources and resulted high mortality of neonates.
So, the knowledge about bathing to the neonate in the community was found very low and women were not having correct information about neonate bathing. This is a point of intervention that can be addressed through awareness generation among the community members.
Knowledge about Cord Safety
The majority of respondents i.e 64.2% of the respondents were not having correct knowledge about cord safety. Few (27.5%) of the respondents had good knowledge about cord safety. 8.3% of the respondents were unaware about the safety of the cord. So, picture clearly shows that women are not aware about cord safety and causes for infections in cord. That also proves the hypothesis of the researcher that the people have desired behaviors about infant care.
iv) Community Practices with Neonates after Delivery Neonate Wiped with Clean Cloth
Data showed represent that women were not arranging clean cloth for any emergency and wiping the neonatal. So, there should be proper counseling and awareness generation on arranging clean cloth for neonate wiping. As data shows that two-thirds (73.3 %) of the neonates were not wiped with clean cloth resulting in infections in neonates. Very few 26.7 % of the respondents had arranged clean cloth for wiping the neonate.
Neonate Kept with Mother for Warmth
The present study also explored the practices of neonate being kept with mother for warmth. 60.9 % of respondents are keeping their neonates with them for warmth. On the other hand approximately half of the respondents are not having neonates with them after delivery. The practices in villages are when “Naun” or “Dhobin” will come and neonate will be cleaned then after neonate will go the mother. So, the practices related to keeping the neonate with the mother for warmth is low.
Substances Applied on Cord
Majority of (46.7%) of respondents applied Ghee/ Turmeric and mustered oil on the cord for early dry followed by ash, medicine and other substances which were found 3.3, 5.0 and 9.2 respectively. On the other hand 35.8 % of respondents had nothing applied on the cord.
As per public health guidelines there is no need of any substances applied on the cord as this will dry and will leave after 3-5 days of delivery. But at the community level people believe that if substances are applied on the cord it will dry soon. These substances cause the infections on the cord and due to which the neonates dies.
They believe that “Jis jis bacche ke naal mein infection ho jat hai, Supari (betel nut) ghis ke laga diya jata hai.” (Whenever there is a case of infection in the umbilical cord we apply betel nut powder on it).
The first milk which is called “Colostrum” is the most suitable food for the baby during this period because it contains a high concentration of protein and other nutrient the body needs; it is also rich in anti-infective factors which protect the baby against respiratory infections and diarrhoeal diseases. Supplementary feeds are not necessary. The regular milk comes on the third to sixth day after birth. The baby should be allowed to breast- feed whenever it wants. Feeding the baby on demand helps the baby to gain weight. It is very important to advice mother to avoid feeding bottles and other pre-lacteals like honey, cow milk, goat milk and ghutti. In this section, researcher tried to understand the practices related to the breastfeeding in community.
First Thing Given to Neonate
65.0% of the respondents had given their own milk to neonate. Rest 35.0% of respondents has given some other things to the neonatal.
Time of Colostrums Feeding Started
Majority (51.7%) of respondents said that the first milk was given after discussion with Pandit/ family members, followed by 21.7% of respondents said that they started feeding their child after one hour. Only 15.8% of the respondents started breastfeeding their child immediately after birth. So, the initiation of breastfeeding in the study areas was found to be low.
Reasons for not Giving the Mother’s First Milk