Popul Res Policy Rev (2011) 30:517–536 DOI 10.1007/s11113-010-9199-5
Causes of Neonatal Deaths among Tribal Women in Gujarat, India Baiju Dinesh Shah • Laxmi Kant Dwivedi
Received: 23 May 2010 / Accepted: 10 December 2010 / Published online: 30 December 2010 Ó Springer Science+Business Media B.V. 2010
Abstract Mortality among neonates has long been largely neglected by research in all developing nations of world including India. This study aims to identify the primary and secondary causes of neonatal deaths among the tribes of Gujarat by retrospectively analyzing 106 neonatal deaths that occurred during the year 2008 and 2009. The socio-economic, biological and traditional newborn care practices impacting newborn survival were also studied. Case studies including in-depth interviews of 33 women who had experienced neonatal deaths in period of 2008 and 2009 have also been conducted. The results show that the main causes of neonatal deaths in the study area were birth asphyxia, prematurity, aspiration, infection and congenital anomalies, irrespective of place of delivery. Absence of trained and skilled personnel for newborn resuscitation was the main cause of perinatal birth asphyxia related deaths. Around 36% mothers had a history of infant deaths. Low birth weight is one of the important causes of neonatal deaths among mothers who had a history of child loss. Cyclicality of neonatal deaths continued among clustered families with social factors initiating the cycle. Qualified trained birth attendants practicing essential newborn care are necessary during home deliveries. Keywords Neonatal deaths Primary causes Clustering Traditional newborn care
B. D. Shah (&) L. K. Dwivedi School of Health Systems Studies, Tata Institute of Social Sciences, V N Purav Marg, Deonar, Mumbai 400 088, India e-mail:
[email protected] L. K. Dwivedi e-mail:
[email protected]
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Introduction Every year there are an estimated four million neonatal deaths occurring worldwide accounting for almost 40% of deaths of children less than 5 years (Lawn et al. 2005). Nearly 27 million babies are born in India each year; which accounts for 20% of global births. Of these, one million die before completing the first four weeks of life (Baqui et al. 2006). The primary causes of neonatal mortality are complications due to prematurity (21%), birth asphyxia and injury (23%), neonatal tetanus (7%), congenital anomalies (7%) and diarrhea (3%) with low birth weight contributing to a large proportion of deaths (Bryce et al., 2005). In Gujarat, the leading causes of neonatal mortality were found to be prematurity, birth asphyxia, neonatal infections and congenital anomalies (Yadav et al. 1998). Perinatal birth asphyxia is an important and common cause of preventable neonatal mortality in developing countries like India due to high prevalence of risk factors among mothers such as intrauterine growth retardation, lack of ante natal care and a higher incidence of preterm babies compared to developed countries (Deorari et al. 2000). The social and behavioral factors linked with child survival in developing countries include (1) individual-level variables (individual productivity, as measured by education and occupation; and traditions, norms, and attitudes); (2) household-level variables (income, wealth); and (3) community-level variables (ecological setting, political economy, health systems and community based newborn care) (Caldwell et al. 1983; Marsh et al. 2002). Socio-economic inequities in child survival exist from exposure, to the resistance to care seeking and to effective treatment resulting in poor children more likely to die than their better off die in childhood (Claeson 2004; Wagstaff et al. 2004). Marsh et al. (2002) developed a framework providing information about the special newborn care that needs to be imparted in all stages starting from antenatal care to post natal care stage. According to them facility based newborn care services are unlikely to be 100% available in the near term, especially in developing countries. Therefore they define ‘‘community’’ as a locus for provision of newborn care by identifying ante natal care, labor and delivery care, intra natal care and post partum care as optimal stages of practicing key behaviors and community practices which is termed as ‘‘special care’’. For example the presence of a skilled health care provider during delivery and clean delivery during the intra partum care stage, drying and warming, immediate and exclusive breastfeeding during immediate newborn care stage, maintenance of temperature, post partum visit, clean cord care, etc. during post partum stage will improve child survival. Infant mortality decreases with age, the early neonatal stage (first 7 days of life) being the time in which it is more elevated (Garcı´a-Marcos et al. 1998). Preterm birth and low birth weight (less than 2500 g) are found to be risk factors associated with perinatal and infant mortality (Wen et al. 2000 and Mohsin et al. 2003). Twins, triplets and higher order births have a greater risk of low birth weight, and neonatal morbidity and mortality (Mohsin et al. 2003) and male infants are known to be more likely to die in the first year of life (Wells 2000).
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The survival and well-being of newborn is dependent on their mothers (Tinker and Ransom 2002). Newborn health is affected by the timing and frequency of pregnancy (Gwatkin et al. 2000). Complications during childbirth also have a significant impact on newborns as almost 30% of neonatal deaths are the result of injuries sustained during delivery (Kusiako et al. 2000). The nutritional status of girls and women, even long before pregnancy, affects fetal development and newborn health (Fourth Report on World Nutrition Situation 2000). Studies view malnutrition as a contributing factor to child mortality by increasing the risk of death, especially due to infections (Black et al. 2008; Claeson 2004). A mother with a higher number of prior losses is also considered to bear infants with higher risks of death, probably due to higher risk of malformation (Clark et al. 2002). The higher risk of malformation persists even after controlling for the socioeconomic, behavioral and biological factors (Das Gupta 1990; Miller et al. 1992; Zenger 1993). A family that experiences a child death is ‘‘scarred’’, by the causal process and the subsequent child in that family is predisposed to a higher death risk (Arulampalam and Bhalotra 2006). This phenomenon was named as ‘‘Clustering of Death’’ within families which had major implications to understanding the determinants of child survival (Das Gupta 1990). Essential newborn care (ENC) is a comprehensive strategy designed to improve the health of newborns through interventions before conception, during pregnancy, at and soon after birth, and during postnatal period (Narayanan et al. 2004). The World Health Organization (1996) guidelines for essential newborn care include clean delivery, keeping the newborn warm, early initiation of breastfeeding, exclusive breastfeeding, care of the eyes, care during illness, immunization and care of low birth-weight newborns. Maternal and newborn practices are generally acceptable to the community and health service providers, but often are not practiced due to health systems and community barriers (Waiswa et al. 2008). Baqui et al. (2007) found that in rural Uttar Pradesh, India, pregnant mothers had very poor knowledge regarding newborn care practices. Poor health seeking behavior is also found to be increasing the number of neonatal deaths, irrespective of whether the newborn is delivered at home or hospital (Mohan et al. 2008). Studies show that the community where the mother resides affects infant survival since it may influence attitudes and behavior. Some characteristics influence birth outcomes more directly, such as the availability of health services and environmental pollution, while there are other factors such as the practice of traditional birth practices that have an indirect influence on child survival (Mosley and Chen 1984). Most of the newborns in India die at home while being cared for by mothers, relatives and traditional birth attendants (Lawn et al. 2004). Studies on newborn care in Indian communities show that knowledge and practices of newborn care, for instance prevention of hypothermia, feeding of colostrum and exclusive breastfeeding, are lacking and even knowledge regarding identification of danger signs and care seeking behavior of the families has been found to be variable, and in general, poor (Bang et al. 2005a) which significantly impact newborn survival. In India, the risk factors for and causes of deaths have not been comprehensively studied. Strategies to improve child and maternal health require identification of risk factors for stillbirths and neonatal deaths. The aim of this paper is to find out the
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primary medical causes as well as secondary causes of neonatal deaths in south Gujarat and also investigate newborn care practices. The contribution of socioeconomic, demographic, clustering of deaths phenomenon and tribal based newborn care practices was also studied. The ultimate goal is to provide information that can guide the development of preventive strategies in identifying high-risk populations to reduce the incidence of neonatal deaths.
Materials and Methods Profile of study area The present study was conducted in a tribal block, Jhagadia of Bharuch district in Gujarat. Of this tribal population the ‘‘Bhil’’ tribe constituted 79% of population who are considered to be among the oldest settlers in the country (Gandotra and Patel 2001). They have their own typical mode of thinking, feeling and believing common beliefs and attitudes, sentiments and ideals (Shah 1964). Scheduled tribes are the lowest and traditionally poorest castes of the Hindu caste system. The termscheduled tribes refer to various aboriginal ethnic minorities who are concentrated in their traditional lands in different parts of India. As members of the scheduled tribes have distinctive social identities and face different forms of social and economic discrimination. Even within a particular tribal entity, differences in dialect, health practices, unique customs, values and traditions are apparent (Naik et al. 2005). Jhagadia is a block in Bharuch (Fig. 1) which records 331 neonatal deaths per 1000 live births (Sewa Rural report 2009). ‘‘Sewa Rural’’ Society for Education Welfare and Action (SEWA) has been working in Jhagadia block since 1980s and currently functioning as a First Referral Unit (FRU) under Public Private Partnership. The NGO works in the area of health development of the tribal people
Fig. 1 Location of Bharuch in Gujarat
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Neontal Mortality Rates in Jhagadia, per 1000 live births 50 45 40 35 30 25 20 15 10 5 0 2003-2004
2004-2005
2005-2006
2006-2007
2007-2008
2008-2009
Fig. 2 Neonatal mortality in Jhagadia
of this block and records a decline in child and infant mortality rates over the year during 2003–2009 but the perinatal, neonatal and post neonatal mortality rates have not declined on par with the child and infant mortality rates (Fig. 2). This indicates that the burden of neonatal deaths is still a burgeoning health issue in Jhagadia. Data Collection Procedure The complete list of 106 neonatal deaths has been collected from ‘‘Sewa Rural’’ registry about neonatal deaths that had occurred during the year 2008 and 2009 in Jhagadia block of Gujarat. There is a chance that ‘‘Sewa Rural’’ registry will not be able to capture all neonatal deaths which had occurred in the study area. However, while conducting the in-depth studies, it was observed that under-reporting was found to be more among those women who had a history of infant death. Further, most of the women (44.7%) from these groups have reported low birth weight as one of the important causes of neonatal deaths. Therefore, there is a possibility that reporting of low birth weight as a cause of neonatal death might be biased downward. Moreover it is assumed that reporting of cause of deaths was independent of the registration of neonatal deaths. The verbal autopsy method was adopted to know the cause of these 106 neonatal death using standard tools. For in-depth case studies, 33 households were randomly selected from the confirmed and registered neonatal deaths. Further, the consistency of reporting the cause of neonatal death and age (in days) at time of death etc. has been cross verified with the registry of Sewa rural. For the mismatched cases of neo-natal deaths, a researcher (from medical background) revisited the households to check the reliability of data. Around 2% of cases were found to be mismatched. The researcher was unable to identify the primary cause of death for one case. For selecting 33 households, the block was divided into different sectors with the area of the sector being the panchayats of that block. Further, random sampling was done from the registered number of neonatal deaths in each selected sector. The nine sectors selected for the study are Bhalod, Fichwada, Govali, Jhagadia, Kantipada, Umalla, Vali, Vasana and Velugam. For case studies, the sample was selected
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randomly from these sectors. This procedure was adapted to explore all possible primary and secondary causes of neonatal deaths in the block. The researcher obtained informed consent from all the participants before conducting the interview. Data Collection Tool Case studies were done through in-depth interviews of mothers who had experienced neonatal death. The questionnaire for in-depth interview consisted two parts. The first part has information related to socio-economic, maternal, birth and delivery related factors. The, second section has information of care adopted during the antenatal period, delivery, postnatal care stage; neonatal death history and traditional newborn care practices etc. through which the primary and secondary causes of death were identified. The study was conducted during the period May, 2009 to February, 2010. The questionnaire was adapted from the available guidelines of WHO verbal autopsy questionnaire for investigating neonatal deaths with added questions on socio-economic profile, maternal, pregnancy and childbirth factors. The instrument was further adapted to suit the local context and culture. The questionnaire started with close ended questions followed by open ended questions to elicit a narrative about a neonate’s death. The data collection was done by researcher herself. Case studies were done with mothers who had experienced neonatal deaths (who were the primary respondents of the study) but whenever possible effort was also made to interview an adult relative who had the closest contact with the child during the terminal illness, that person would be the secondary respondent of the case. During data collection, interviews were conducted in Gujarati using local vocabulary. All questionnaires and secondary data were reviewed by the research guide for accuracy, consistency and completeness and further validation of 18% of the registered neonatal deaths was done by the researcher through additional field visits. The data related to cause of death and age (in days) at time of death was compared with the original secondary data set to check for accurateness. After this, the data was entered and analyzed using SPSS software. Conceptualization of Causes of Neonatal Death Neonatal deaths were defined as live births that resulted in death before 28 days of neonatal life. The researcher had arrived at the socio-economic status using the variables used in Pareek scale for determining the SES status of households, a scale based on the social status and household construction material and assets. The researcher defined trained birth attendants as any attendant at delivery who was reported to be a qualified doctor, nurse, female health worker, ASHA or Trained ‘‘Dai’’. For assigning each cause of death, definitions were selected by reviewing the SEARCH-Gadchiroli study (Bang et al. 2005b) and the WHO three country verbal autopsy validation studies (Anker et al. 1995). A single cause of death was assigned by application of definitions as shown in the diagnostic algorithm of Fig. 6 given in Appendix. A variable was created for each factor and symptoms used in the causal
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definition and the algorithm applied the cause-of-death definition uniformly for each death. Other overlapping causes of death were explored through the narrated illness history which was cross tabulated as secondary causes of deaths.
Results Causes of Neonatal Deaths Table 1 shows that of a total 106 neonatal deaths approximately 62% were found to be males, whereas female neonates contributed to only 37%. There is no significant difference in proportion of neo-natal deaths between mothers who had given birth at hospital and mothers who had delivered at home. But, this indicates that tribal people of the block still preferred home deliveries over hospital deliveries. However, it may be noted that the share of neonatal deaths occurring in hospitals was relatively higher compared to deaths at home which might be attributed to better reporting of deaths from hospital. This could also suggest that newborn children are taken to hospital only when they are very critical or when there is an emergency. The association between place of delivery and place of death of all recorded neonatal deaths is shown in Table 2. It is interesting to note that 80% of home deliveries have resulted in death at home. However, there were 20% of neonatal deaths who were born at home and the place of death was a health facility. Further, around 27% of hospital delivered neonatal deaths had occurred at home.
Table 1 Percent distribution of neonatal deaths by sex of child, place of delivery and place of death Variables
Percent
Number
Sex of child Male
62.3
66
Female
37.7
40
Home
45.3
48
Private hospital
13.2
14
Government hospital
14.2
15
NGO-FRU
25.5
27
On the way
1.9
2
Home
47.2
50
Private hospital
12.3
13
Government hospital
12.3
13
NGO-FRU
23.6
25
Place of delivery
Place of death
On the way Total
4.7
5
100.0
106
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Table 2 Place of delivery classified by place of death of neonatal deaths Place of delivery
Place of death
Total
Home
Hospital
Home
80.0
20.0
Hospital
26.8
73.2
Total
55
51
50 56 106
Percentage of Neonatal Death
Note: p \ 0.05 80 70 60 50 40 30 20 10 0 0 - 3 days
4 - 7 days
8 - 28 days
Time of Neonatal Death
Fig. 3 Time pattern of neonatal death
Figure 3 indicates that nearly 67% of the neonatal deaths occurred within 72 h after birth and around 80% of the deaths had taken place in the first week of neonatal life. Figure 4 shows the distribution of respiratory disorders, prematurity, infection, congenital anomaly, massive aspiration and deliberate neglect which were the identified primary causes of neonatal deaths in Jhagadia. Among respiratory diseases of neonates, 82% neonates had died of birth asphyxia as shown in Table 3. The percent of neonatal deaths due to infection is less compared to newborn dying due to infection in India. Notably, most of the deaths had occurred due to septicemia which is preventable. Massive aspiration of milk and food (83%) was still a cause of neonatal death for newborn child of Jhagadia block. Congenital anomalies caused 11% of the total newborn deaths. The feeding problem, gastroenteritis, head injury, hypothermia of newborn and umbilical hemorrhage were identified as other primary causes of neonatal deaths. Table 4 shows the common cause of neonatal deaths during home deliveries. The birth asphyxia followed by infection and massive aspiration of food and milk that are preventable, are causes of neonatal deaths during home deliveries. The most common cause of neonatal death in the health facilities was prematurity followed by respiratory disorders. The evidence suggests that in Jhagadia the maximum number of neonatal deaths occurred due to birth asphyxia and 75% of them were home delivered (Table not shown). A majority of neonatal deaths delivered at home and even in private hospitals had occurred due to aspiration of food and milk. The distribution of place where neonatal deaths have taken place and the primary cause of death are shown in Table 5. Among the deaths taking place at home, 30%
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Percentage of Neonatal Death
40 35 30 25 20 15 10 5 0 Respiratory Prematurity Infection Disorders and Low Birth weight
Congenital Massive Deliberate Anamoly aspiration Neglect
Others
Causes of Neonatal Death Fig. 4 Distributions of primary causes of neonatal death
Table 3 Distribution of primary cause of neonatal deaths Variables
Percent
Number
Respiratory diseases Birth asphyxia
81.6
31
Pneumonia
5.3
2
RDS/SIDS
13.2
5
100.0
38
Septicemia
71.4
10
Fever
28.6
4
Total
100.0
14
Total Infectious diseases
Aspiration Meconium aspiration
16.7
2
Milk & Food
83.3
10
100.0
12
Total
Table 4 Primary cause of neonatal death classified by place of delivery Place of delivery
Primary cause of death
Total
Respiratory disorders
Prematurity/ Low birth weight
Infection Congenital anomaly
Massive Deliberate aspiration neglect
Others
Home
44.9
12.2
12.2
6.1
12.2
2.0
10.2
49
Hospital 30.4
25.0
12.5
16.1
10.7
–
5.4
56
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Table 5 Primary cause of death classified by place of death Place of death
Primary cause of death Respiratory disorders
Prematurity/Low birth weight
Infection Congenital anomaly
Massive aspiration
Others Total
Home
29.9
18.8
15.2
9.6
15.2
11.5
54
Hospital
45.1
19.6
9.8
13.7
7.8
3.9
51
Total
39
20
13
12
12
8
105
Table 6 Primary cause of death classified by time of neonatal deaths Age Primary cause of death (in days) Respiratory Prematurity/ Infection Congenital disorders Low birth anomaly weight
Total Massive Deliberate aspiration neglect
0–3
50.0
21.2
4.5
7.6
7.6
4–7
23.5
17.6
11.8
23.5
11.8
9.1
13.6
36.4
13.6
22.7
–
4.5
20
13
12
12
1
8
8 – 28 Total
39
1.5
Others
–
7.6
66
11.8
17 22 105
Note: p \ 0.05 Table 7 Percent distribution of neonatal deaths by family-history of infant death Family-history of infant death
Percent
Frequency
No
64.2
Yes
35.8
68 38
Total
100.0
106
of deaths occurred due to respiratory disorders of which the major share was of perinatal birth asphyxia. However, of total hospital based deaths, nearly 45% of deaths occurred because of respiratory disorders; whereas the contribution of prematurity/low birth weight was found around 20%. Comparing percentage of neonatal deaths due to respiratory disorders from Table 4 and 5, it can be concluded that for respiratory disorders, referral to hospitals had increased. Table 6 indicates that 0–3 days neonatal deaths had occurred mostly due to respiratory disorders, prematurity and low birth weight. The period of 4–7 days showed an equal distribution of all identified causes of neonatal deaths and in the period 8–28 days of newborn life septicemia was the leading cause of neonatal death. Table 7 indicates that of the total 106 neonatal deaths 36% had occurred to mothers who had earlier experienced an infant death. During data collection, it was found that the tribal people as well as health personnel of the Jhagadia block were aware of the existing pattern and prevalence of the neonatal deaths. This phenomenon of clustering of death in families is known as ‘‘Ratewa’’ among tribes.
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70 60 50
31
History of Infant Death Low Birth Weight
8
Other Secondary Cause of Death
40 30 20
28
10
11
9 3 5
6 5
0 0-3 days
4-7 days
8-28 days
Time of Neonatal Death Fig. 5 Influence of history of infant deaths with time pattern of neonatal death
Perceptions about the causes of ‘‘Ratewa’’ were that it develops among pregnant females on whom someone casts an evil eye or after the evil eye is cast the pregnant female does not take efforts to visit specialized male persons who casts off the evil eye ‘‘Ratewa’’, ‘‘jo garbhavastha ma maa jharava naa jaye toh Ratewa thay’’. If the pregnant female does not follow ‘‘vrata’’ i.e. fast during pregnancy for avoiding ‘‘Ratewa’’ then she develops the disease. Signs of ‘‘Ratewa’’ as identified by the tribal people were that during pregnancy the mother develops yellow coloured boil on her umbilicus, after birth the neonate does not cry or there is delay in onset of crying or initially cries and later stops, or experiences difficulty in breathing and has cyanosed lips and extremities, either at birth the skin is ulcerated or neonate develops skin infection during the postneonatal period. Common perceptions regarding accessing healthcare if diagnosed as ‘‘Ratewa’’ were that there are no chances of survival of neonate once ‘‘Ratewa’’ is diagnosed or there is no felt need to access healthcare further even if advised by the doctor or even no felt need to continue treatment at the place of delivery. The only treatment of mother is by traditional healers who prescribe some herbs or insert some medicine in the uterus. A pertinent belief was that mothers with a history of infant deaths are suffering from ‘‘kokhe Ratewa’’ i.e. ‘‘Ratewa’’ in her genes which is not curable. Association of Prevalence of History of Infant Deaths with Other Variables Figure 5 shows that as compared to all time frames, 31% of index child neonatal deaths had occurred between 0 and 3 days of neonatal life. Table 8 shows that there is a strong association between history of infant death and primary cause of neonatal death. Low birth weight/prematurity were one of the important causes of neonatal deaths among those mothers who had a history of child loss. However, for those mothers who have never experienced any child loss during earlier pregnancies, respiratory disorders was the prominent reasons for neonatal death.
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Table 8 Family—history of infant death classified by primary cause of death Family— Primary cause of death history of Infant death Respiratory Prematurity/ Infection Congenital disorders low birth anomaly weight
Massive Deliberate aspiration neglect
No
44.8
4.5
16.4
14.9
13.4
Yes
23.7
44.7
5.3
5.3
7.9
Total
39
20
13
12
Total
12
1.5
Others
4.5
67
–
13.2
38
1
8
105
Note: p \ 0.05
Discussion An attempt has been made in this study to understand the primary and secondary causes of neonatal deaths and new born care practices. The case studies provide a complete causal analysis of neonatal deaths. The argument that female newborn are biologically stronger than male newborns (Park 2000; Waldron 1987) and also that male babies are more likely to suffer from congenital abnormalities associated with X chromosome-linked genetic defects (Waldron 1998) justifies the finding that male newborn deaths are recorded in a higher proportion than female newborn deaths. There are eight functional primary health centres (of which three primary health centres are functional for 24 h) and two community health centres (CHCs) and one functional FRU for a population of 1, 32,000 which means that health facilities are well within the reach of people, but still pregnant women prefer home deliveries. The neonatal deaths that were delivered in health facilities and also died in the health facility with the susceptible period of newborn being the first 7 days of newborn life, indicates possibility of existence of both provider and beneficiary influence in mitigating newborn survival. It has been observed that referred patients from any health facility used to avoid further medical access. It can be hypothesized that social, economic and environmental factors were affecting the patient’s decision of not accessing another health facility. Since among the recorded neonatal deaths, maximum had been hospital delivered this raises a question about the quality of newborn care imparted by the existing healthcare facilities and also the trained health personnel in these settings when most of the health personnel in the various health facilities have received Integrated Management of Neonatal and Childhood Illness (IMNCI) training. Perinatal birth asphyxia was the commonest cause of perinatal mortality. Gujarat was among the first states to implement the newborn resuscitation programs in all its districts since year 2004, but the study area records higher number of neonatal deaths due to birth asphyxia. Most of these neonatal deaths occurred at home justifies the fact that the newborn care support imparted during child birth is not efficient. The result also provides evidence that the trained birth attendants or untrained birth attendants did not have proper training about newborn resuscitation. For example, there was a practice of using a pinch of salt/cotton swab/rough cloth for purpose of newborn resuscitation. Public health facilities like CHC did not even
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have a functional newborn care corner because of which newborns suffering from birth asphyxia were referred to the FRU. In such cases delay in diagnosis and delay in accessing FRU led to development of complications of birth asphyxia. With the availability of newborn care facilities to tackle the burden of neonatal birth asphyxia, the NGO based FRU does a remarkable job in averting deaths, but the number of neonatal deaths due to complications of birth asphyxia is still high in the FRU. The neonatal deaths due to preterm delivery occurring in the institution delivered neonates throws light on the hospital based facilities not being able to provide the type of treatment necessary to increase the chances of survival of preterm delivered neonates. This is an area which requires intervention to reduce the overall burden of neonatal deaths in Jhagadia. Provider and health services related factors like unavailability of doctor and unavailability of required newborn care instruments also act as added factors for causing neonatal deaths. In this study, most of the women had not received healthcare support during intra natal care and post natal care period despite the presence of ASHA (Accredited Social Health Activist) and community health workers in the same village which has a maximum influence to cause a negative health outcome of the newborn. The present healthcare interventions need to focus on provision of health care support during the intra natal and post natal care period to reduce the burden of neonatal deaths in the rural parts of India. Time pattern of neonatal death due to septicemia denotes that these neonates might have developed infection in the place of delivery rather than at home. Aspiration was among the causes of neonatal deaths recorded mostly among those that had been delivered at home which show that women who are going for home delivery are unaware of importance of the practice of burping. Contrary is the case with the NGO based FRU which records the highest number of institutional deliveries in the block but still has a very minute share of deaths due to aspiration of milk and food credited to the maternal and newborn counseling centre for recently delivered mothers in the FRU. Congenital anomalies were diagnosed irrespective of the place of delivery, and even after diagnosis further access for surgical treatment to district hospital where surgical facilities were available was not evidenced as reported by the health functionaries of the FRU and the CHC. This non-accessing of health facility was a major cause of death rather than a newborn being born with a congenital anomaly. Time pattern for a particular cause of death which is exhibited in neonates has a significant association with the treatment modality provided as most of the neonates had died of birth asphyxia and prematurity in the earlier days of newborn life. Early identification of danger signs in newborn by the healthcare provider was found lacking in most of the cases, which adds to reducing the chances of newborn survival. Studies in the 1980s in India showed that babies born in joint and large size families and in families with crowded homes had greater risks of mortality during the neonatal period (Vajpayee and Govila 1987). In the present study neonatal deaths had mostly occurred in nuclear families where both mother and father were unskilled/semi-skilled workers in farms. Women used to work in the farms during pregnancy and even immediately within 2–3 days of childbirth and because it is a nuclear family, there is no one else present at home to impart
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newborn care. This type of interplay between type of family and work culture coupled with lower educational status (Pena et al. 2000) of household affecting postnatal newborn care can be termed as ‘‘unavoidable social neglect’’. Lower economic status coupled with ignorance, illiteracy and unawareness act as contributing factors for occurrence of deaths. This study reveals that irrespective of the birth order, women who had given birth in the age group of 15–19 years recorded more neonatal deaths compared to other age groups. The study of Bhalotra show clear evidence of frailty, fecundity, and causal effects of birth spacing on neonatal mortality (Bhalotra and Soest 2008). Studies show higher risk of neonatal mortality among adolescent women in rural settings partially associated with differences in socioeconomic factors in younger versus older women and mediated primarily through preterm delivery, LBW or interaction of these variables (Sharma et al. 2008). Clustering of deaths in a few households added significantly to the existing burden of neonatal deaths in Jhagadia. The study of Arulampalam and Bhalotra (2006) indicates that the probability of survival of the 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 a social phenomenon and some feel that non-visible factors such as genetics (Williams et al. 2008) or close cousin marriages (Hussain 2002) indirectly have an impact on the child survival. In case studies, many tribal women had pointed the existence of this phenomenon among their tribe, which commonly is referred as ‘‘Ratewa’’. It was interesting to note that even the healthcare providers were aware of this terminology used by the tribe. An attempt was made to assess contributing factors in relation to clustering of deaths. 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. Contributing factors for recurrence of infant deaths identified through observation were (1) No system of marriages is established among tribe (2) Premarriage sexual mixing common among unmarried youths and girls (3) Commonality of extra marital relationships among the population and practice of consanguineous marriages. (4) Social neglect of the newborns illustrated by the fact that despite existence of newborn child in house, family members are busy doing their occupational work during daytime and enjoying night time. The biological factors of low birth weight and premature newborn in those particular families where the mothers are undernourished cannot be negated as a contributing factor for clustering of neonatal deaths (Agarwal et al. 2002). Among these clustered neonatal deaths, most of the deaths had occurred within the time frame of 0–3 days, irrespective of place of delivery. Hence, the necessary treatment modality should be made available for treating low birth weight and prematurity among these neonatal deaths. In developing countries, where 96% of the global burden of neonatal deaths occurs, neonatal care is practically non-existent as evidenced in India, wherein maximum neonates are home delivered there is a pertinent need for a package dealing in home based neonatal care (Bang et al. 1999). This study showed that the practice of practicing essential newborn care was given much importance neither in home delivered nor in hospital delivered newborn deaths. Simple practices which
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did not require much of infrastructure facilities like practice of burping and kangaroo mother care through maternal counseling were not followed by the health personnel. Health planner’s stress on the need of increasing institutional deliveries for reduction in neonatal deaths but no stress is given to the fact that even after or during an institutional delivery non-practice of essential newborn care will lead to negative health outcome of the neonate. Insufficient staff, drugs, equipment and supplies for deliveries and managing newborn problems in public health facilities, no proper sterilization, poor utilization of nearest health facility, mother’s unawareness of danger signs before, during and after delivery and in newborn care add to the burden. Case studies reflected that often the intent of practicing these traditional healthcare practices was healthy, but the consequences were unbeneficial, inconsequential, or even harmful. The practices were influenced by elderly in the household primarily mother- in-law who advices the pregnant women what to eat, drink, which health facilities to avail, which type of modern allopathic tests and medicines are harmful for the neonate, decision maker whether to go for home or hospital delivery and advices practice of newborn care practices like ‘‘gadthuti’’ (sugar diluted water) feeding immediately after birth, avoid colostrum feeding as it is a cause of indigestion and abdominal distension, etc. Reliance on untrained birth attendants for delivery is still a common perception among Muslim households. Many practices had their roots in the traditional systems of medicine especially Ayurveda known as ‘‘jahdimudi ni dava’’. For example, one of the trained birth attendants prepared Ayurvedic medicines for wellbeing of newborn or for treatment of mothers having history of neonatal deaths. The nutrition component of women during pregnancy and lactation is affected persistently because of the traditional beliefs of fasting, non intake of IFA tablets, mother eating in small ‘‘thali’’(plate) during antenatal and postnatal period etc. acting as a risk factor for both maternal and neonatal mortality through birth of low birth weight babies. Not all traditional newborn care practices were harmful like breastfeeding as a norm practiced in a majority of villages and top feed resorted only in cases with feeding problems. Massaging the baby using oil or ghee is also beneficial for the newborn. Wrapping the baby in several layers of clothing and exposing to sun after massage and bath is also practiced which helps prevent hypothermia but is practiced only after 6 days of birth which is harmful. Dripping colostrum in the eyes of newborn to prevent conjunctivitis was also a beneficial practice.
Conclusion The efforts of NGO based FRU and its community outreach programs are commendable in reducing the neonatal deaths in Jhagadia over a period of time, especially due to infection and aspiration which are leading causes of neonatal deaths in other rural parts of India. Among the neonatal deaths, women still preferred delivery at home compared to hospital based delivery. The hospital delivered neonatal deaths were found maximum in the FRU which is the first option of referral for most of the families. The reason might be the high burden of
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institutional deliveries in the hospital; limited newborn care facilities available in the neonatal intensive-care unit (NICU), non-availability of specialist in neonatology and non-existent treatment seeking behavior at higher centers for further tertiary care even when neonatal complications were identified at the place of delivery and advised for referral. Total reliance was observed among the families of the neonatal deaths on the health personnel at the place of delivery level to provide treatment and increase the chance of survival of neonate. Most of the neonatal deaths had occurred in the first 2 days of neonatal life and maximum in the first week of neonatal life. Primary causes of neonatal deaths identified were birth asphyxia, infection and congenital anomalies which are preventable outcomes. Neonatal deaths due to birth asphyxia were recorded the highest even though the health professionals had received both IMNCI and newborn resuscitation program training. Septicemia and aspiration were recorded especially due to non-practice of essential newborn care practices. Referral pattern was weak for neonates identified as suffering from congenital anomalies. Among neonatal deaths delivered at home and government hospital, birth asphyxia was the most common cause of death and among neonatal deaths delivered at private hospitals, prematurity was the main cause of death. Most of the neonatal deaths due to birth asphyxia and prematurity were in the first 3 days of neonatal life. Case studies indicated weak practice of post-natal care at home due to mother’s occupation and nuclear families which together lead to unavoidable social neglect. It was predominant among families of lower economic strata and poor environmental condition. Maternal factors like age at marriage and age at delivery and other demographic factors such as birth order and birth spacing showed a strong association with the incidence of neonatal deaths. Women have strong traditional beliefs of harmful effect of use of allopathic medicines during pregnancy. Healthcare support from health workers was available during the time of ante natal care; but was not available during intra natal and post natal care. For intra natal care in home delivered neonates, mostly the birth attendants were called, irrespective of whether they were trained or not. The practice of unsafe essential newborn care was recorded for both untrained and trained birth attendants. Clustering of neonatal deaths was a common phenomenon, existent in the name of ‘‘Ratewa’’ among the tribal mothers who had experienced infant deaths. Neonatal deaths among these clustered families had occurred within 3 days of birth and prematurity or low birth weight were the commonest cause of deaths among these clustered families. No treatment seeking behavior was observed by mothers among the clustered families. These mothers were neglected in the family with incidence of just one incidence of neonatal death acting as a triggering factor. Traditional pattern of consanguineous marriages and social neglect might be attributed for incidence of clustered deaths. Practice of essential newborn care was not observed among neonatal deaths, either home or hospital delivered. Among neonatal deaths delivered at home, this non-practice of essential newborn practice was more common. Importance of home based newborn care was not found essential in the study area rather there was a belief that hospital delivery means safe newborn care. Case studies provide evidence of practice of both harmful and non-harmful traditional birth practices. The harmful traditional newborn care practices were mainly linked with dietary
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practices of mothers; beliefs regarding accessing the health facilities and utilization of health services during ante natal care period. During intra natal care, total reliance on the birth practices adopted by the birth attendants was observed among the neonatal deaths that were home delivered. The decision making for referral of a particular illness was also in hands of birth attendants. Post natal care related to breast feeding practices, dietary intakes of mother, performing ‘‘chatti puja’’ were contrary to the medically approved newborn practices.
Policy Implications The study concluded that main preventable causes of neonatal deaths in the study area were birth asphyxia, prematurity, aspiration and congenital anomalies, irrespective of the place of delivery of neonate. Presence of trained and skilled personnel for newborn resuscitation is essential at every health facility to save neonates from perinatal birth asphyxia. More emphasis on post natal care of both mother and newborn are essential after newborn discharged from hospital which cannot be possible without community level healthcare support. Cyclicality of neonatal deaths continues among clustered families, these are families where health interventions need to be targeted with little importance given to social factors initiating the cycle. More emphasis is necessary to be given to the practice of essential newborn care practices even at home deliveries rather than just promotion of institutional deliveries for imparting the same when the existing health facilities are still not able to sustain the load of institutional deliveries. Qualified trained birth attendants practicing essential newborn care practice is essential during home deliveries. Health programs targeting survival of newborn should add a component of intervention addressing the removal of traditional newborn care practices rather than total emphasis on the biological factors of neonatal deaths. Programs to improve neonatal survival in such rural settings will need to invest both in strengthening primary health services provided during labor and delivery through training and monitoring, and in community promotion of special newborn care. Acknowledgments The authors are indebted to Dr. Lata Desai and Dr. Pankaj Shah, Managing Trustees of SEWA Rural, Jhagadia, Gujarat for their valuable help and guidance. We are also grateful to Dr. Dhiren Modi and Dr. Shobha Shah for guidance in planning the study and the SEWA Rural team who extended the infrastructural facilities very generously. We are especially grateful to Prof. S. Parasuraman, Director, Tata Institute of Social Sciences (TISS), Mumbai and Prof. C.A.K. Yesudian, Dean, School of Health Systems Studies, TISS, Mumbai for constant support and encouragement. Authors are also grateful to the anonymous referees for their constructive comments on the earlier version of this paper. Authors are also thankful to Dr. Manoj Alagarajan, IIPS, Mumbai and Dr. Lakhan Singh, TISS, Mumbai for their comments on the paper.
Appendix See Fig. 6.
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Congenital Abnormality – physical malformation or gross malformation present right from birth
n = 12
Low Birth Weight/Premature Birth – baby very small or smaller than usual at birth indicated by maturity in gestational weeks or weight at time of birth
n = 20
Sepsis/Infection – at least two of the following signs: stopped suckling, fever or cold to touch, unresponsive or unconscious or lethargic, bulging fontanelle or convulsions or vomiting or skin bumps containing pus or blisters or single large area of pus with swelling
n = 13
Respiratory disorders – which include Birth Asphyxia, Pneumonia, Respiratory distress syndrome and Sudden Infant Death Syndrome. Birth Asphyxia – age at death
