3.3. Traditional Beliefs and Practices among Case Studies during Pregnancy and Newborn Care

Antenatal care: Perception was prevalent that sonography machine pressurizes fetus and leads to growth retardation or undetected congenital anomalies, “Sonography thi balak dabi jaaye, ane vadhe nahi”. Belief persists that if during first two pregnancies, complete antenatal care was done then it is not necessary to repeat it for the third pregnancy. In case of unmarried pregnancy no antenatal care check-up is done from the maternal house until the girl is accepted as a bride in paternal house. In most of the cases, it was found that pregnant women considered iron folic acid tablets or blood transfusion harmful for their fetus and therefore refused consumption even in cases of significantly low hemoglobin levels. Deliberate attempts of intake of iron folic acid tablets led to complaints of iron folic acid induced vomiting. A belief is prevalent among community that if there is amniotic discharge in the eighth month of pregnancy then it causes reduction in the size of fetus i.e. “Aath ma mahine paani padiyu, aetle balak sukai gayu”. Cases of eighth month delivery have no chances of survival of neonate therefore no treatment required i.e. “Aath ma mahine shuvavd thay to balak na bachvana koi asar nahoy aetle aeni dava karavi jarori nahoy”.

Mothers from this tribe believe that reduction in amount of food intake and also eating in small size plate during pregnancy leads to small size of baby’s head and small placenta which facilitates easy labor. Some food items were restricted during pregnancy such as papaya, brinjal, jaggery etc. because of their perceived potential to induce abortion (“garam pade toh kashvavad thai”). It is also perceived that intake of milk and curd in large amount causes deposition of white layer on the body of neonate “thandu pade toh balak na sharir par cough chipki jaaye”. Previous day’s cooked food does not provide nutrition to child during pregnancy “Vaasi khaiye toh khadhelu balak ne asar naa kare”. Pregnant women continue fasting (“Shankar-Parvati vrat”, “Aekvira vrat” and “Dashma vrat”) during pregnancy, even if it includes five days of fasting a week. These common perceptions about dietary habits among all case studies resulted in low body mass index among most of pregnant and delivered females. The dietary restrictions of mother increased in case of history of infant deaths especially on intake of non-vegetarian food, “maa ne rateva chey toh mansahar na levay”.

Intranatal care: Birth weight of the neonate should not be recorded under any circumstances as it will cast an evil eye on the neonate and negatively impact survival

and well being of child. Non-government organization based First Referral Unit was the last option for treatment of neonate and no further referral advice was followed even if the Non-government organization doctors had suggested referral.

Postnatal care: Mother should consume only roti and black gram during postnatal care, if she eats anything else it will lead to infection of umbilical cord of neonate, “Rotli ane mag khavanu biju khaiye to naidopake”. A common belief of “Chatti Puja” i.e. till seventh day of birth, neonate should neither be wrapped with clothes nor exposed to sunlight, “Chatthi puja sudhi balak ne kapda naa pehravay ane tadko naa dekhaday”. In some cases gender related neglect of care seeking was found because of increased expenditure for seeking specialized healthcare. Information related to immunization status could not be extracted as most of neonates had died within first week of life. Some Muslim families considered immunization as harmful to their neonate’s health and even elderly in the house considered it unnecessary.

4. DISCUSSION

High number of mothers preferring institutional births in the study area does not represent a positive trend because hospital delivery was preferred as no Dai were left in village (either they had migrated or died). It also indicates chances of shift of preference to home deliveries with availability of Dai. But instances among some mothers for preference of institutional delivery create an opportunity window to reciprocate shift. Decision of hospital delivery only after realization of possible delivery or neonatal complication is also one of the negative factors. Villages with predominant Muslim population recording zero institutional births require targeted behavior change interventions.

Case studies indicate that pregnant women and their relatives show no distinction between trained and untrained birth attendant and access decision was based on the availability and accessibility of the identified birth attendants. In villages with predominant Muslim community, a single woman was deemed responsible for conducting all home deliveries. Birth attendants (irrespective of training) were entirely responsible with partial assistance of relatives in conducting delivery in the study area. However, in some communities of Northern India, Trained birth attendants often do not get involved until after delivery, which is usually carried out by a family member, i.e. Trained birth attendants are at least certainly not in full charge [17]. It was also interesting to note that all the trained and untrained birth attendants were referred by a common name “Daayanben”—attempt is required to help mothers and relatives distinguish between trained and untrained birth attendants and realize the implication of delivery from both personnel. Many studies report that the term trained birth attendants is rarely used locally as there is no such clearly defined group, and it stems partly from use by government in their training programs [18].

In the study area, untrained birth attendants or even in some instances the Trained birth attendants’s practice their own traditional way of intra-natal and neonatal care which many a times conflicted to those recommended by the essential newborn care package [19]. Instances were recorded that families have awareness that some neonatal deaths are attributed to the faulty practices of the birth attendants which signifies that the birth attendants can be both stigmatized and revered for their work [18].

A wide variety of newborn care practices have been documented in the study area. Traditional practices have the advantage of being affordable, culturally acceptable and relevant to the local environment and socio-cultural needs for enhanced usage by most of the population. However, practices like “chattipuja” which are intended for good neonatal health pose a potential harm to the newborn due to the related risky traditional methods.

Cord cutting and clamping practices have been identified as risk factors for neonatal infection [6,20,21]. A study in rural India reported that regular antenatal care and skilled attendance at delivery was significantly associated with clean cord care and early breast-feeding, but not with thermal care [22]. Some studies show low coverage of clean cord care practices among home deliveries in South Asia [23-25]. In the study area cord care was not practiced during delivery among home births; but in postnatal stage cord care was done with an antiseptic powder provided free of cost by the local Non-government organization. Maintaining good thermal care at birth is crucial for preventing hypothermia, hypoglycemia and neonatal infections. Regarding prevention of hypothermia, it was found that wrapping was not practiced among home births while skin-to-skin care was not practiced in all home births and few institutional births. Currently, skin-to-skin care is recommended for all neonates [26]. In addition, where it is recommended that babies should be bathed no earlier than 24 hours after birth, it was found that delayed bathing or non-bathing till seven days after birth was a common practice among home and institutional births. Both practices of nonwrapping as well as delayed bathing are result of a traditional belief of “chattipuja”.

Delayed breast-feeding especially up to three days was common and non-feeding of colostrum was recorded in all home births. This is a negative factor because if neonates are not breastfed within the first one hour of birth then it puts these neonates at an increased risk for death [27]. Pre-lacteal feeding was found universal i.e. prelacteal feeds were given for all home and institutional births. Many studies from India and other South Asian countries have indicated that women commonly wait for several days after birth to begin breast-feeding, avoid giving colostrum, or supplement breast-feeding with other food or liquids [28,29]. However findings from present study compare poorly with recent studies from Nepal, Pakistan and Bangladesh which shows early breast-feeding initiation rates of 91 percent, 73 percent and more than 90 percent respectively [25,30,31].

Practices related to airway cleaning and resuscitation might be the cause of respiratory disorders especially pneumonia among neonates [32] because in many home births household cloth, salt on Dai’s finger were used instead of mucus aspirator. Here mucus aspirator usage is emphasized because the local Non-government organization provides mucus aspirator free of cost along with training on its usage to all the community based health workers. Quantitative findings indicate that perinatal birth asphyxia was a commonest cause of perinatal mortality in this area [33].

Intra natal care and post natal care are crucial phases for survival of neonates. In the study area women have reported many reasons for not attending hospitals or primary healthcare centers for post natal care. These reasons are explained using the expanded “three delays model” [14,15], wherein the first delay is in making the decision to seek care, the second is in reaching the health facility, while the third is in receiving adequate care in the facility. Socio-cultural factors and perceived benefit from healthcare facility usage influence the decision to seek care. Economic and physical accessibility mainly influence whether the woman actually reaches the facility (and perceived accessibility also influences decision-making). Furthermore, this framework considers how clustered community attitudes create a more or less encouraging environment for family decision making. The location of residence influences most other factors. Figure 2 describes the barriers to seeking neonatal-care according to the three delays model as captured in the study area which include knowledge barriers; cultural, traditional beliefs and practices; financial constraints; issues related to 108 ambulance and other accessibility issues; peer influence of choice of care; service delivery gaps and some provider related factors as described in Table 5.

In this study a fourth delay is added because majority of critical newborn case families were advised secondary referral by the healthcare provider and still they had not accessed any other health facility.

A matter of concern is the clustering of deaths in few households which added significantly to the existing burden of neonatal deaths in the study area. Among these clustered neonatal deaths, most of the deaths had occurred within the time frame of 0 - 3 days after birth. Low birth weight/prematurity was the major cause of death irrespective of place of delivery pointing towards need of availability of necessary treatment modality. Study indicates that the probability of survival of index child highly depends upon the survival status of the preceding child. Some researchers are of the opinion that death clustering is purely a biological and social phenomenon, while some indicate influence of non-visible factors such as genetics [34] or close cousin marriages for child survival. Among case studies, many tribal women had pointed existence of clustering of deaths among their tribe, which is commonly referred as “Ratewa”. Little variation was observed among these clustered families according to the social and economic variables because they belonged to the similar social hierarchy and occupation. The biological factors of Low birth weight and premature delivery in these families with undernourished mothers cannot be negated as a contributing factor for clustering of neonatal deaths [35]. Figure 3 highlights in a consolidated manner the direct causes, indirect causes (household/community level) and causes at society level for the cyclicality of neonatal deaths among these scarred families of the community, according to the observations and recordings of the case studies.

5. CONCLUSIONS

Ensuring universal access to skilled care is the accepted strategy to make childbirth and the early postnatal period safe for mother and newborn. While additional skilled attendants are being trained and deployed, health systems strengthened, and demand for appropriate care increased; a simultaneous strategy supporting community-based providers can help save lives in near future,

especially in poor, low resource and high mortality settings. Community based health workers have a major role to play in the eradication of harmful newborn care practices and the sustenance of good practices and also prove to be a link between families and health system.

Emphasis for provision of essential newborn care at both health facility level as well as community/household level is required. Essential newborn care should start during pregnancy with Tetanus toxoid immunization, proper nutrition including iron/folate supplements,

and treatment of maternal infections, such as malaria and sexually transmitted infections which have a strong influence on newborns’ health and survival. Two priority interventions during labor and delivery are reducing the risk of infection to mothers and newborns and resuscitating newborns with breathing problems. Definite actions are required to increase the survival chances of newborn during post natal care phase. It can be achieved by emphasizing practice of immediate and exclusive breast-feeding, keeping the newborn warm and cleaning umbilical cord under supervision of a trained health-care provider. In addition to counseling on the practice of essential newborn care practices, effective medical management of low birth weight newborn and prematurity cases with timely diagnosis and immediate treatment follow-up is cardinal.

Figure 4 shows the areas of essential newborn care interventions for the study area. Only the identification of essential newborn care package is not sufficient, the need of the hour is implementation and sustenance of practice of essential newborn care package at the hospital as well as the community or house-hold level. This requires a two pronged strategy:

1) Focusing on quality of care in areas with a higher proportion of institutional births;

2) Develop cost effective interventions to provide quality home based neonatal care where accessing institutional care is not possible in the immediate near term.

These strategies need to be customized for the study area depending on the infrastructure, availability of resources and newborn health care need assessment. In low resource settings these strategies can be implemented in a phased manner.

Eradication of harmful newborn care practices and sustenance of good practices are not possible in immediate term without behavior change communication and regular counseling of mothers and relatives to impart knowledge of practice of essential post natal care. Teaching aids for mothers and relatives and frequent home visits by community health workers serve as an effective

method of counseling. The strategies for behavior change communication and counseling can be deployed in a phased manner to have a sustained impact. Continued information, education and communication initiatives will help maintain belief of positive impact of the introduced essential newborn care interventions.

Introduction of targeted interventions is required to reduce cyclicality of neonatal deaths among the unfortunate scarred families by controlling the socio-economic variables, referral management and case management at household level especially for Low birth weight babies.

6. POLICY IMPLICATIONS

Only introduction or implementation of above stated newborn care interventions is not sufficient to improve newborn health and survival in the immediate as well as long term. Policy level commitment is required to integrate such type of interventions in existing healthcare programs considering the share of neonatal deaths among Under 5 mortality. An implementation plan should be developed based on analysis of maternal and newborn health status, existing services, and newborn care practices; with agreement on objectives and priorities among relevant stakeholders. Interventions to improve newborn health should be integrated with the existing maternal and child healthcare programs. Research into attitudes and dynamics of decision-making at family and community levels will contribute to improved newborn care practices and appropriate use of services. Even after efficient deployment of interventions continuous monitoring and evaluation will help developing and sustaining effective interventions.

REFERENCES