Journal of Perinatology (2008) 28, 182–187 r 2008 Nature Publishing Group All rights reserved. 0743-8346/08 $30 www.nature.com/jp ORIGINAL ARTICLE Household knowledge and practices of newborn and maternal health in ,

R Khadduri1, DR Marsh2, B Rasmussen3, A Bari3, R Nazir3 and GL Darmstadt4 1Independent Health Consultant, formerly of Save the Children-US, , Pakistan; 2Saving Newborn Lives Initiative, Save the Children-US, Washington, DC, USA; 3Formerly of Save the Children-US, Islamabad, Pakistan and 4Department of International Health, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD, USA

Introduction Objective: To learn about household maternal and newborn health Pakistan has very poor neonatal health indicators, with newborn knowledge and practices to aid the design of newborn programming within mortality estimated at 54 out of 1000 live births in Save the Children’s Haripur Program. 2006Faccounting for more than two-thirds (69%) of infant Study Design: In April, we conducted 43 semi-structured interviews mortality (78 out of 1000 live births), and well over half (57%) (SSIs) and 34 focus group discussions among men, women of of all deaths to children under the age of 5 years (94 out of reproductive age and health service providers; in September, we added 21 1000 live births).1 Nearly 300 000 newborns die every year in SSIs among new mothers, new fathers and dais. Two investigators Pakistan, the third highest number in the world, after India analyzed the findings according to themes within six care types: and China.2 antenatal, delivery, immediate newborn, routine postpartum, special Antenatal care (ANC) attendance is low (61% of mothers have maternal and special newborn. one or more visits) as is tetanus toxoid immunization coverage Result: Findings indicated poor maternal diet and antenatal care- (58% of pregnant women receive at least two tetanus toxoid seeking. Home delivery with an untrained dai was the norm. Respondents immunizations). Two-thirds (66%) of births take place at home knew about benefits of clean delivery, but rarely put knowledge into (44% in urban areas versus 75% in rural areas); much less than practice. Knowledge and practices for maintaining the newborn’s warmth half (39%) of all births are attended by a skilled provider; and only were good. Delayed initiation of breastfeeding, avoidance of colostrum 22% of mothers receive postpartum care from a health professional 1 and prelacteal feeding were almost universal. Unhygienic cord care, within 24 h of delivery. Little more than half of all newborns including an unclean cut and application of ghee on the cord-stump, was (55%) are exclusively breastfed for the first month of life, a the norm. After delivery, mothers often maintained low fluid intake but proportion that drops to 37% of babies being exclusively breastfed 1 otherwise reported healthy nutritional practices. Knowledge of some for the first 6 months of life. More than 60% of neonatal deaths danger signs in newborns was common, but timely action upon occur in the first week of life, predominantly at home, without care 3 recognition was not. from the formal health sector. Yet, apart from breastfeeding practices, little has been reported Conclusion: Although the findings illustrate some beneficial practices, on household newborn care practices and care-seeking behavior for many reported practices are harmful to the newborn. These findings, Pakistani newborns. Save the Children Federation USA (SC) consistent with the sparse existing data in Pakistan, inform program commenced the Haripur District Reproductive Health (RH) interventions for household-level behavioral change. Program in August 1999, and conducted research on newborn Journal of Perinatology (2008) 28, 182–187; doi:10.1038/sj.jp.7211903; health-care beliefs and practices to inform programming and published online 6 December 2007 highlight areas for further research. Keywords: newborn health; antenatal care; delivery; breastfeeding; danger signs; traditional practices Methods Save the Children Federation conducted two studies on maternal Correspondence: R Khadduri, Independent Health Consultant, H 31A, Street 56, F-7/4, and newborn practices in Haripur district in the North-West Islamabad 44000, Pakistan. Frontier Province. The first, in April 2000, was a Participatory E-mail: [email protected] Received 13 April 2007; revised 10 October 2007; accepted 12 October 2007; published online 6 Rapid Appraisal designed to better understand and document RH December 2007 knowledge and practices. The study instruments were pre-tested on Household newborn practices R Khadduri et al 183 a random sample of five mothers, five fathers and five dais months regardless of outcome, and dais who attended at least one (untrained birth attendants), and adapted to reflect the correct live birth in the past 6 months. Three local researchers were language (a mixture of Urdu and the local language, Hindko) and trained to use a semi-structured topic guide with probes for each appropriate length of the instrument, and confirmation was sought question. As above, researchers obtained verbal informed consent to ensure that the questions were understood by the respondents. from all informants, and only male researchers worked with male Investigators trained 24 local researchers, both men and women, respondents and female researchers with female respondents. for 5 days to conduct this research. Investigators were trained on Analysis was conducted manually, using general themes to classify general social science methodology and then specifically on the the information. One investigator conducted the analysis, and then Participatory Rapid Appraisal instruments. Intensive supervision of had a feedback session with other investigators and the researchers researchers in the field and at the time of data compilation ensured to discuss the findings. quality of data used for final analysis. Data were presented in six care clusters, based on the SC The Participatory Rapid Appraisal took place in two conceptual framework for maternal and newborn care: ANC, predominantly rural areas of Haripur (Rehana and Khanpur) and delivery care, immediate newborn care, routine postpartum care one semi-urban area (). It consisted of 43 semi- for mother and newborn, maternal special care and newborn structured interviews (SSIs) and 34 focus group discussions (FGDs) special care. Investigators examined data from female and male involving matrix ranking and mapping. Informants were men, respondents separately, and some of the differences in reporting of women of reproductive age and health service providers, chosen behaviors and knowledge are given below. In general, however, through ‘snowball’ sampling (see below) for both the FGDs and the investigators considered the body of research as a whole because SSIs. Researchers obtained verbal informed consent from all it was known that decision-making does not take place by informants. Only female researchers worked with female each gender in isolationFmothers, fathers, mothers-in-law informants and male researchers with male informants, and dais are all involved in making decisions regarding pregnancy following standard cultural etiquette in rural Pakistan, for both and birth. FGDs and SSIs. There were three researchers in each FGD, one leading the discussion using the instrument, one taking notes and the third Results negotiating with the crowd and focusing on logistics. All three Antenatal care researchers had the instrument with them and would refer back to Check-up. A pregnant woman usually seeks ANC from a health it to ensure that all topics were covered in appropriate detail. For facility or health worker only if she is feeling unwell and, even the SSIs, there were two researchers, one who was the primary then, not always. Otherwise, she may see the dai for advice, researcher and the other the primary note-taker. Again, both pregnancy confirmation and/or massage. Reasons for not seeking followed the instrument and prompted the other to cover all the formal care are as follows: no need without a complication; topics and probe for appropriate detail. The FGDs informed norms, shyness to admit pregnancy to family members; fear of ultrasound while the SSIs informed variation and provided further detail. The examinations and radiographs conducted by male staff; required Participatory Rapid Appraisal assessed people’s RH knowledge, ANC- time or money; and expected poor quality of care. Formal ANC, seeking, delivery practices and breastfeeding counseling. Two usually at a governmental facility, included iron supplements, investigators conducted the analysis independently, categorizing the tetanus toxoid injection, blood pressure, weight determination and findings into general themes, sharing interpretations, seeking physical examination. Very few recalled receiving advice regarding consensus and, when necessary, re-consulting the data to reach a diet, delivery planning, danger signs or postpartum family common interpretation. planning. The second study was conducted in September 2000 in rural Khanpur, primarily among ethnic Gujar and Ghakkar people. The Nutrition. Although respondents generally associate a large baby aim of this investigation was to obtain more detailed information with good health, a small baby is frequently encouraged for easy regarding newborn’s health. Researchers conducted 21 SSIs, 7 with delivery. Some women restrict their antenatal diet to avoid difficult new mothers, 7 with new fathers, and 7 with active dais (untrained labor, some cannot afford the cost of eating more during traditional birth attendants). All 21 respondents were from different pregnancy and others eat less because of nausea. Some eat desi households, and the dais had not participated in the births of the ghee (clarified butter) to ‘soften their insides’ to ease delivery. interviewed women or the wives of the interviewed men. Respondents were chosen through snowball sampling, using key Delivery care informants to identify people who fit the selection criteria, and Birth attendant. Most deliveries take place at home due to these, in turn, identified additional subjects. The selection criteria difficult access to health facilities, poor care at governmental were as follows: mothers and fathers of children born in the past 6 facilities, modesty and belief that travel during advanced pregnancy

Journal of Perinatology Household newborn practices R Khadduri et al 184 may endanger the baby. The dai, the preferred birth attendant could not provide reasons. Most mothers delay breastfeeding from because she is experienced and locally accessible, usually cuts the 2 h to 3 days during which an elderly pious person gives the baby cord, assures the baby’s breathing, washes the newborn and ghutti, often sucked from his/her finger. This traditional provides extensive postpartum maternal support. concoction of honey and sometimes saliva ‘cleans the stomach,’ strengthens the baby and transfers the ghutti-provider’s qualities to Clean delivery. Mothers, fathers and dais know that germs the baby. Animal milk, water, desi ghee and tea with herbs are cause disease and that cleanliness is important. Dais claim to wash sometimes fed to the newborn during the first 3 days. their hands with soap before attending a delivery, but all mothers and fathers asserted that their dai (not the same dais whom we Postpartum care interviewed) did not wash their hands. Routine. The mother and her female in-laws care for the baby. Women deliver while lying on a charpai (rope bed), lying on Some fathers take the male baby to the doctor or to the barber for the ground or squatting with a brick beneath each foot. The dai circumcision or head shaving. Mother’s milk is commonly usually places unwashed plastic (table mat, appliance or furniture supplemented with water, desi ghee and tea with herbs during the wrapping) and a washed bed sheet beneath the mother to prevent first 4 months of life, or with animal milk if the mother’s milk is surface soiling, not to protect the mother or the baby. not considered sufficient. Supplementation with porridge and banana occurs after 4 to 5 months. Most women breastfeed for 2 Cord care/temperature control. The importance of a clean cord years, consistent with Islamic teaching, or until they are pregnant cut is not common knowledge. Few families provide the dai a new again. The mother and other females continue to apply ghee to the blade; most provide a used blade, knife or scissors. Dais claim to cord stump for several days. Family members continue to wrap the wash these, but the mothers and fathers asserted that their dais did newborn depending on the weather, and avoid placing the newborn not. under a fan, to prevent cold or pneumonia. In winter, wood, coal The dai generally asks the mother’s permission before cutting or gas fires keep the room warm. The dai visits the mother for the cord lest she be ‘blamed for how the child grows up.’ An elderly 10 to 30 days postpartum to clean the delivery area, massage the woman of the family uses an uncleaned chicken feather from the woman to relieve delivery pain, massage her breasts for milk flow, ground or freshly plucked to apply desi ghee, sometimes as a paste give emotional support, wash clothes, cook and sometimes help with fried onions or mustard oil, to the cord stump. Most keep the with other household chores if necessary. room warm, turning fans off, even in summer. Special customs. According to Islamic custom, babies have their Immediate newborn care heads shaved about 7 days after birth, and male babies are Drying and warming. Most dais leave babies unattended, circumcised. The barber normally performs both procedures, but sometimes on the floor or ground, until the placenta has been some fathers take the baby to a hospital for circumcision. Barbers delivered. Then they wash them with warm water and soap 1 to 2 h rarely use a new blade to shave the baby’s head. Sweet dishes such after delivery. Rarely, the dai only wipes the baby with a damp as halwa help celebrate these customs. cloth. A few dais give the baby an oil massage to relieve dry skin Babies are usually named after consultation with many family after the bath. The dai then loosely wraps the newborn with an old members, 5 to 15 days after birth. Although gender discrimination cloth. was denied, male babies seemed to be named sooner than females, An elderly male family member, but not the father, recites the perhaps because ‘the birth of the son is an occasion of happiness’ azan, the Muslim call for prayers, into the ear of the washed, and ‘everyone is keen to propose a name for a boy.’ Few families ceremonially cleansed baby. The azan is supposed to be the first officially register their baby’s birth. words heard by the newborn. After the azan, the baby is usually given to the mother-in-law, and ultimately back to the mother several hours after birth. Maternal activity and nutrition. While being aware that ‘the grave keeps its mouth open for a mother for 40 days after delivery’ Breastfeeding. Most respondents say that mother’s milk provides (that is, the cultural 40-day confinement or chilla), most women resistance against illness of the newborn, the main sources of resume their chores about 7 days postpartum. Many beliefs information being television, radio and lady health workers. Most surround the chilla, such as, if a new mother hears the voice of women breastfeed their babies, but initiation within 1 h of birth, another breastfeeding mother, her milk will dry up, or if she hears feeding colostrum and exclusive breastfeeding for four or more the voice of a mother whose child has recently died, her own child months are not common. Some respondents think that colostrum will be in danger. Mothers are given special food (containing milk, can kill the baby because it is dense, dirty, old milk stored in the almonds, chicken soup or halwa) during the postnatal period to breast for 9 months. A few know that colostrum is important, but restore their strength, not to improve lactation. Indeed, many

Journal of Perinatology Household newborn practices R Khadduri et al 185 women drink less water in the early postnatal period because water those involved in the birth process, and to document finer details of ‘bloats the stomach.’ the process. Some quantitative studies have been conducted in Pakistan, but Newborn special care mostly all have concentrated on neonatal tetanus. A matched Birth asphyxia. Many recognize that a newborn is breathing if it case–control study conducted in Karachi showed that the cries, or if its nostrils or chest move. If the newborn does not cry, subsequent application of substances like mustard oil, ghee or dais look for cord pulsations to confirm life. Most dais clean the surma (black cosmetic powder) on the umbilical cord, delivery newborn’s mouth and nose with a finger or cloth to initiate carried out in the home and an illiterate mother were risk factors breathing. If the baby does not cry, the dai may hold the newborn for neonatal tetanus.7 Contamination of samples of ghee that were upside down and pat it on the back. One dai mentioned blowing repeatedly heated and handled by the mothers was reported in a air into the baby’s lungs if the baby did not cry, but a father said study from the North-West Frontier Province of Pakistan.8 Ghee was this would transmit germs and should not be done. A common applied to the umbilical stump several times a day for the first few emergency procedure is for dais to heat the placenta or the days of life. umbilical cord, while still attached, in a metal pan over the fire for A study on diet and nutrition of pregnant women in Karachi 15 to 30 min. ‘When the heated placenta starts crackling, the baby found that women preferred milk and fresh fruit during starts crying and breathing.’ pregnancy.9 Milk was considered to enhance fetal bone development, lactation and good skin, and settle the stomach. Danger signs. Most mothers and fathers name at least two Many women avoided ‘hot foods’ (foods believed to generate heat perceived danger signs in newborns, especially jaundice and blue when ingested), as they considered the womb to already be a spots. Blue spots occur with sarishna (an as yet undefined source of heat production. Women of lower socio-economic status condition) and ‘nobody has survived after falling victim to this did not trust their judgement about beneficial foods and could not deadly disease.’ Other danger signs are inability to suck, crying too afford the foods they desired. In this group, meat was eaten less much, pain in the chest, diarrhea, pus oozing out of the cord or than twice a week and calories came primarily from flatbread, low weight. Dais know at least four danger signs without cereals and cooking oil. prompting, including the above plus convulsions. Respondents Research conducted in India and Nepal has shown similar generally do not know the causes for these signs. Respondents give results. A prospective study on pregnant women in rural India more importance to pneumonia and oozing cord when they occur showed very poor utilization of primary health services. The results after the immediate newborn period. Most know that a very small showed that transportation, traveling long distance by foot and low baby may be weak and unhealthy, but there is little clarity about levels of female literacy were barriers to the use of antenatal assessing size. Dais confuse pounds with kilograms, and according services.10 A community-based newborn study conducted in Nepal to dais and mothers, ideal birth weight is 2 kg or 5 lb. concluded that less than 50% of women receive any ANC and over 90% of births occur at home, of which approximately 85% are Response to danger signs. Upon recognition of danger signs, attended to by untrained birth attendants.11 Three-fourths of all caregivers first provide home remedies, such as heating the baby’s deliveries in India take place at home with less than 40% being cloth for sarishna or massaging the baby’s chest with mustard oil attended to by a trained provider.12 for pneumonia or hypothermia. Prayer and acceptance of Allah’s According to Bang et al.,13 women in rural Gadchiroli, India, will are common responses. Traditional care (that is, amulets to underfed themselves during pregnancy to avoid having a large ward off the evil eye) is also sought from a pir, a type of religious baby and ensure an easy delivery. Mothers do not leave the delivery leader. Failing home remedies or traditional care, families opt for room until baj kadhane (a ceremony performed on the seventh formal medical care at a nearby public facility or by a private day after birth), and limit their intake of food and fluids to avoid doctor. using the latrine. In Nepal, only 55% of women recalled that the birth attendant had washed his/her hands before delivery. The umbilical cord was Discussion cut with a razor blade in 56% of births and a household sickle was Further gains in child survival require attention to newborn health used in approximately one-third of the births. The umbilical stump since mortality rate is so high in the first month of life.4 Indeed, a was left undressed 73% of the time. Time taken to wrap the baby detailed situation analysis of newborn health5 and objectives for was prolonged and almost all babies were bathed within 6 h of newborn programming and research5,6 in Pakistan have been birth. It was observed that 45% of those participating in the study developed. This study, however, is one of very few qualitative reports had discarded colostrum.11 of household newborn care practices in Pakistan. Qualitative Results from a study carried out in Haryana, India, showed that research is desperately needed to understand the perspectives of only 5 to 8% of women exclusively breastfed their babies between

Journal of Perinatology Household newborn practices R Khadduri et al 186 the age of 4 and 6 months, and 75% of newborns were given and postpartum maternal care seems reasonable. (ii) Knowledge– prelacteal feeds of honey, tea and diluted milk.14 Babies are often practice gaps exist (that is, for clean delivery and colostrum), not breastfed during the first 3 days and are often given sweetened suggesting that interventions allowing practice or dialogue around water.13 They are not made to wear clothes until after the baj new behaviors might bridge the gap. (iii) Multiple community and kadhane ceremony is performed, and are not adequately wrapped family members superintend newborn care; thus, behavior change either. Common explanations for sickness are the ‘evil eye’ or strategies must be multitargeted. ‘witch craft.’ Thus, families believe that doctors and nurses cannot effectively treat the newborn.13 Some of the practices reported in this study benefit the mother Acknowledgments and the newborn, including the occasional use of the ANC package, We acknowledge the work of the researchers Amama Ambreen, Irum Fatima and knowledge of the value of clean delivery, dais’ emotional and Mohammed Shafique in collecting the data; Naureen Raheel for translating the physical support to mothers, newborn warming, special postpartum research findings into English; Munawar Sultana for back-translating a selection food for mothers, breastfeeding for 2 years and knowledge of some of the manuscripts for checking; and Zohra Patel for editorial assistance. We are danger signs in newborns. Conversely, some findings likely also grateful to the other members of the Haripur District RH Program, jeopardize the newborn and the mother, including use of ANC only particularly the Administration Department, for their support during the study. for a problem; suboptimal maternal nutrition motivated in part by This research has been made possible by funding for the Saving Newborn Lives the desire for a smaller baby and an easier delivery; home delivery Initiative of the SC through a grant from the Bill & Melinda Gates Foundation with delayed care-seeking for danger signs; untrained dais and from the Royal Netherlands Embassy for the Haripur District RH Program. conducting unclean deliveries (unclean hands, cord cut, dressing and surface); washing babies soon after birth, risking hypothermia and removal of protective vernix; delayed contact between mother References and baby, risking hypothermia, suboptimal bonding and 1 Pakistan Demographic and Health Survey 2006–07, Preliminary Report. National postpartum hemorrhage; prelacteal feeding of ghutti; delayed Institute of Population Studies: Islamabad, Pakistan and MEASURE DHS, Macro initiation of and lack of exclusive breastfeeding; postpartum International: Maryland, USA. maternal water restriction; and head shaving and circumcision 2 Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: when? where? why? Lancet with unclean blades. Respondents reported several danger signs, 2005; 365(9474): 1845, Neonatal Survival March. 3 Macro International. Pakistan Demographic and Health Survey 1991. but not hypothermia, decreased crying, chest indrawing or fast- 4 Save the Children USA. Saving Newborns Lives Initiative. State of the World’s breathing, abdominal distension or vomiting. Moreover, Newborns. Save the Children USA: Washington, DC, 2001. respondents’ understanding of the volunteered terms, plus 5 Save the Children USA. Saving Newborn Lives Initiative. State of the World’s sarishna, needs verification. Definitive care-seeking behavior is Newborns: Pakistan. Save the Children: Islamabad, 2001. often delayed for home-based and traditional remedies. 6 Bhutta ZA. Newborn care in Pakistan: priorities for research and intervention. Reports of household newborn care in Pakistan are scarce, Proceedings from 10th National Pediatric Conference, vol. 23. Pakistan Pediatric Association Federal Branch 2001. mostly addressing maternal diet, breastfeeding, infant feeding and 7 Raza SA, Akhtar S, Avan BI, Hamza H, Rahbar MH. A matched case control application of ghee and other agents on the umbilical stump. We study of risk factors for neonatal tetanus in Karachi, Pakistan. J Postgrad Med 2004; found one study reporting cord-cutting and newborn washing 50: 247–251. practices in Sindh;15 one reporting ‘eating down’ in pregnancy to 8 Bennett J, Macia J, Traverso H, Agha SD, Malooly C, Boring J. Protective effects of avoid a large baby;16 and two documenting similar reasons for topical antimicrobials against neonatal tetanus. Int J Epidemiol 1997; 26: 897–903. 17,18 9 Zobairi SE, Freitas ML, Wasti SA. Diet and nutrition: a knowledge, attitude, and preferring home delivery, that is, access, quality and modesty. practice study of pregnant women in Karachi. Aust NZ J Obstet Gynaecol 1998; 38(2): The most comparable study was SC’s positive deviance inquiry of 188–193. newborn care in Bagra Union Council in Haripur district in 10 Bhardwaj N, Hasan SB. High perinatal and neonatal mortality in rural India. J R Soc January 2001.19 This study described community norms and Health 1993; 113(2): 60–63. identified specific exemplary practices that might motivate 11 Osrin D, Tumbahangphe KM, Shrestha D, Mesko N, Shrestha D, Manandhar MK et al. community behavior change. Many community norms in Bagra Cross sectional, community-based study of care of newborn infants in Nepal. 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