Household Knowledge and Practices of Newborn and Maternal Health in Haripur District, Pakistan
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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 Haripur district, Pakistan R Khadduri1, DR Marsh2, B Rasmussen3, A Bari3, R Nazir3 and GL Darmstadt4 1Independent Health Consultant, formerly of Save the Children-US, Islamabad, 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 (Khalabat township). 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,