ABSTRACT
Introduction:
Neonatal sepsis is a major cause of morbidity leading to 2.7 million neonatal deaths annually worldwide. Around 26.14% of women in Tamil Nadu are illiterates, lacking personal, financial independence and empowerment that hinders the good home-based care of the newborn. Tribal population have their own cultural practices lacking scientific evidence like harmful practices. Hence this study was conducted to assess the home-based newborn care practices among tribal population.
Methods:
A community based cross-sectional study was conducted among 450 tribal mothers with children age < two months in Nilakottai, Nilgiris district, Tamil Nadu using multistage random sampling and validated semi-structured questionnaire. Statistical analysis was conducted using SPSS and Chi square test (P < 0.05 was statistically significant).
Results:
The safe new born care practice in the study was about 21.3% (CI: 21.3 ± 3.78). Age ranged from 20 to 32 years. About 35.8% of mothers had completed high school, joint families were 65.3%. Regarding harmful practices, 47.1% had applied kajal dye to eyes, 18.7% blew air in nose and 26.4% instilled oil in ears of newborn. Low level of awareness was observed on warmth, skin, umbilical care. Prelacteal feeding was 61%. Role of health personnel was observed for creating awareness among those who had practiced safe newborn care.
Conclusion:
Health education and behavior change communication is the need which can improve the new born care practices among mothers and family members among the tribal population.
Keywords: Awareness, cultural practices, harmful practices, neonates, tribal
Introduction
The birth of a baby brings joy and happiness to the couple and their families. The entire family gets prepared to receive the baby with love and affection, feeling proud of the baby to be their future generation. Babies between birth and first 28 days of life are called Neonates. The newborn period is characterized by transition from intrauterine to extra-uterine life, rapid growth, and development. They have unique health issues and problems due to structural and functional immaturity of various body organs depending upon gestational age and birth weight.[1] It can be rightly said that healthy and sturdy babies are likely to evolve as physically and mentally strong adults with enhanced quality of human resource development and thereby contribute to the development of the nation.[2]
Newborn period is the most vulnerable phase of life and neonatal deaths account for 70% of all infant deaths and 56% of all deaths of under-5-children. Neonatal sepsis is a major cause of morbidity worldwide and one of the three primary causes of 2.7 million deaths annually worldwide. About 95% of these deaths occur in developing countries.[3] Of 6.9 million cases of neonatal sepsis globally, South Asia accounts for 3.5 million cases annually. India with 1.2 billion population, claims a large proportion of the burden.[4] Although no population-based figures are available, the bulk of these sepsis-related neonatal deaths are taking place in rural India where >60% of the population live. Early onset sepsis most often appears within 72 hours of birth. Late onset sepsis occurs 72 h after birth; it is due to the organism thriving in the environment of home or hospital.[5] Neonatal mortality is a public health problem in India and needs to be addressed achieve the Millennium Development Goals-4 and Sustainable Development Goals-3.2.[6,7] World bank has estimated that the burden of disease contributed by perinatal courses in India accounts for 25% of the global Disability Adjusted Life Years (DALY’s) lost to the society. Among those who died before reaching 5 years of age, 75% died within their first year of birth and of those who died within their first year, a majority of the neonate lose their life even before completing the first month of life.[8]
The components of essential newborn care services include good quality antenatal care, safe delivery, and optimal care at birth, promotion of exclusive breastfeeding prevention and early treatment of hypothermia and infections.[9] Essential newborn care includes clean cord care, thermal care, initiating breastfeeding within the very first hour after birth, cleanliness, and prevention of infection in terms of health care. Home based new born care practice constitutes birth planning and birth preparedness, care for post-natal mother and newborn through a series of home visits, counsel the couple to choose an appropriate family planning method, early identification of postpartum complications and danger signs in newborn and refer appropriately to the higher centers.[9,10]
Around 26.14% women in Tamil Nadu are illiterates, lacking personal, financial independence and empowerment hindering the good home-based care of the newborn.[11] The health outcomes of newborns are determined not just by their biological factors but also by the socio-cultural environment and how they are reared in the community.[12] The socio-cultural, economic and educational background differ from the urban and rural communities as they are not alike. Issues such as ignorance, illiteracy, strong adherence to beliefs, geographic locations, lack of accessibility and non-availability or utilization of health services, and their local traditional contribute to poor neonatal health outcomes. Studies report that most newborns in low-income countries like India die at home, while mothers, relatives, and traditional birth attendants care them.[13] It is indeed to explore the burden of this public health problem among the vulnerable sector viz tribal community in India, who are secluded geographically and culturally from the general population.[14]
As per 2011 census, in India, the tribal population is about 10.43 crores, constituting 8.6% of the total population. There is paucity of data regarding the newborn care practices among the tribes in Tamil Nadu, which habitats about 1% of the 10.43 crore in India.[15] As per NFHS-5, the likelihood of having received care from a doctor is lowest for tribal mothers, only 32.8% compared to 50.2% for general population. Only 32.4% had received advice of postnatal newborn care, only 17.7% births of tribal population is been conducted in health care facility compared to 51% births of other category hospital deliveries.[16] Despite implementation of proven cost-effective solutions such as promoting antenatal Tetanus toxoid immunization, skilled attendance during delivery, exclusive breast-feeding, providing warmth and clean umbilical cord care; there has been relatively little change in neonatal mortality rate (NMR) due to poor Home Based neonatal care practices.[17] Tribal population have their own cultural practices lacking scientific evidence like harmful practices. Hence, this study was conducted to assess the home-based newborn care practices and harmful practices in a tribal area in Nilgiris district in Tamil Nadu.
Subjects and Methods
A Community based cross sectional study was conducted among 450 tribal mothers, who have children less than 2 months of age residing in the Nilakottai area, of Nilgiri district from March 2024 to August 2024. Due to paucity of data on home based newborn care practices among tribal community, a pilot study was conducted in the study area, Nilakottai, involving 50 tribal mothers and it was found that 19% of them had been practicing safe home-based newborn care. With P = 19%. q = 81%. d = Relative precision of 20% and 10% for non-response rate, the sample size was calculated as 450.
In Tamil Nadu, the only district comprising of hilly and non-terrain region is Nilgiris district with highest tribal population. So multi-stage sampling method was used. Nilakottai area has 12 Primary Health Centers (PHC). Among the 12 PHCs, one was selected by lots method-Nilakottai. The Nilakottai Primary Health Center caters a tribal population of 9,844 with six Health Subcenters (HSC). Among the Health Subcenters, two Subcenters (Marakarai and Muthirakolli) was chosen at random from which, the line listing of tribal mothers was obtained from the birth register. The tribal mothers who satisfied the inclusion criteria were included and interviewed after permission from local public health authorities, tribal leaders Institutional Ethics Committee (Dt.03022022/IEC/SMC) using validated semi-structured questionnaire in regional language with female health assistant. Data was entered in SPSS version 16. Association between qualitative variables were done using Chi square tests and Fisher’s exact test. A P < 0.05 was considered to be significant. Based on literature review, scoring was done for antenatal care practices, newborn care practices, harmful practices, and awareness.[18] The score index was created from 21 items: seven for antenatal care practice, six for newborn care practices, three for harmful practices, and five for awareness of antenatal and postnatal care. Each item was scored accordingly to positive and negative behavior. The score index was calculated as the simple sum of the items. The score index was modified according to the local culture and validated with the help of expert and pilot study. Antenatal care practice was grouped into two groups, adequate and inadequate.
Results
The median age of the study participants was 25.6 with a maximum age of 32 years and a minimum age of 20 years. Among them, 153 (34%) were between 20 and 24 years, 271 (60%) were between 25 and 29 years and 26 (5.8%) were more than 30 years. Among the study participants 262 (58.2%) were married before the age of 21 and 188 (41.8%) were married after 21 years. The median age at marriage was 21.19 years varying between 28 years and 18 years. Among the 450 participants, 38 participants (8.4%) were illiterates, 50 participants (11.1%) had primary education, 103 participants (22.9%) had middle school education, 161 participants (35.8%) had completed high school, 80 participants (17.8%) were diploma holders, and 18 participants (4%) were graduates. Among the study participants 329 (73.1%) were unemployed and only 121 (26.9%) were employed.
Among the 450 study participants, majority 294 (65.3%) belonged to joint families, followed by nuclear families 91 (20.2%), and three generation families 65 (14.5%). Among the study participants, the number of members in their families ranged from three to nine members. The mean number of family members in the family of the study participants was 5.56. The per capita income was calculated from the total family income mentioned by the participants and socio-economic classification was classified based on Modified BG Prasad scale for September 2017. From the Table 1 it has been observed that no households belonged to upper class, 20.7% of the households belonged to upper-middle class, 30.8% of the households belonged to middle class, nearly half (42.7%) of the households belonged lower-middle class, and 5.8% of the households belonged to lower class.
Table 1.
Socio demographic details of the study population (n=450)
| Determinant | Frequency | Percentage |
|---|---|---|
| Age | ||
| 20-24 | 153 | 34 |
| 25-29 | 271 | 60 |
| >30 | 26 | 6 |
| Age at marriage | ||
| <21 years | 262 | 58.2 |
| >21 years | 188 | 41.8 |
| Educational status | ||
| Illiterate | 38 | 8.4 |
| Primary | 50 | 11.1 |
| Middle | 103 | 22.9 |
| High | 161 | 35.8 |
| Post high school/diploma | 80 | 17.8 |
| Graduate/post graduate | 18 | 4 |
| Occupational status | ||
| Unemployed | 329 | 73.1 |
| Employed | 121 | 26.9 |
| Type of family | ||
| Joint | 294 | 65.3 |
| Nuclear | 91 | 20.2 |
| Three generation | 65 | 14.5 |
| Socio economic status | ||
| Upper | - | - |
| Upper-Middle | 93 | 20.7 |
| Middle | 139 | 30.8 |
| Lower-middle | 192 | 42.7 |
| Lower | 26 | 5.8 |
The study participants were divided into two groups based on the awareness of antenatal care practices and new born care, breast feeding and immunization practices of the new born. They were assigned a score of 1-5. A score of 3-5 was taken as good awareness and <3 was taken as Poor awareness. Among the study participants, 42.20% (190) had poor awareness and 57.80% (260) had good awareness on antenatal and new born care practices.
Safe newborn care practices were grouped into two groups, good and bad, considering the variables like feeding practice, thermal care practice, bathing the baby, applying substance to the umbilical cord at birth, eye care of the baby and hand washing. The maximum score was 28. The score of 20-25 was taken as good practices and less than 20 was taken as poor practices. Figure 1 shows that, 78.7% (354) practiced poor newborn care and 21.3% (96) practiced safe newborn care.
Figure 1.
Home based new born care practices
Among the 217 newborn who were given prelacteal feeds, 112 (51.1%) were given honey and, 105 (48.9%) were given sugar water. When asked for the reason for giving prelacteal feeds, 92 (41.8%) were given prelacteal feeds as local belief, 65 (30.2%) were given prelacteal feeds as tradition, and 60 (28%) were given prelacteal feeds as custom.
Among the study participants 46 (10.2%) did not give colostrum to the baby. Among the babies denied of colostrum, 78.30% (36) were not given considering it was not good for the baby, 13% (6) were not given as traditional habit and, 8.7% (4) were not given as a custom. Among the study participants, 155 (34.4%) initiated breast feeding within 1 hour, 242 (53.8%) initiated breast feeding between 1 and 4 hours, and 53 (11.8%) initiated breast feeding after 4 hours of delivery [Table 2].
Table 2.
Safe new born care practices
| Variables | Number of participants (n=450) | Percentage | |
|---|---|---|---|
| Prelacteal feeds | Yes | 217 | 48.2 |
| No | 233 | 51.8 | |
| Total | 450 | 100 | |
| Colostrum given | Yes | 404 | 89.8 |
| No | 46 | 10.2 | |
| Total | 450 | 100 | |
| Initiation of breast feeding | <1 h | 155 | 34.4 |
| 1-4 h | 242 | 53.8 | |
| 4-24 h | 53 | 11.8 | |
| Total | 450 | 100 | |
| Care of the cord | Natural herb | 153 | 34.0 |
| Cow dung | 2 | 0.4 | |
| Others | 1 | 0.2 | |
| Nil | 294 | 65.3 | |
| Total | 450 | 100 | |
| Care of the eyes | Clean cloth | 176 | 39.1 |
| Nil | 56 | 12.4 | |
| Others | 218 | 48.5 | |
| Total | 450 | 100 | |
| Hand washing | Yes | 290 | 64 |
| No | 160 | 36 | |
Mothers who married at an earlier age had less awareness on antenatal and newborn care practices, than mothers married at a later age. The awareness was poor among the illiterates. Woman married at a later age had a statistically significant association with adequate antenatal care (P = 0.006). Mothers in joint families had higher prevalence of poor antenatal care than the other types of families. As the age of the mother’s increase, safe newborn care practices decrease. Poor practices were common among joint families. The association between the type of family and newborn care practices was found to be statistically significant. The safe newborn care practice in the study was found to be 21.3% (CI: 21.3 ± 3.78).
Mothers who practiced good antenatal care practices also practice good postnatal care practices. As the birth order of the newborn increases, the safe newborn care practices decreased. Mothers who delivered in public health facilities followed good newborn care practices than the mothers, who delivered in private health care facilities. This association was found to be statistically significant (P = 0.003). Mothers who practiced safe newborn practices immunized their babies for age. There was a significant association between mode of delivery and safe newborn care practices (P = 0.024). Normal delivery had more of good newborn care practices than caesarean delivery [Table 3].
Table 3.
Association of awareness and newborn care practices with Socio demographic details
| Socio demographic variable | Awareness | Total | Chi square test | P | ||
|---|---|---|---|---|---|---|
|
| ||||||
| Poor | Good | |||||
| Age at marriage | <21 years | 117 (44.7%) | 145 (55.3%) | 262 (100%) | 1.523 | 0.246 |
| >21 years | 73 (38.8%) | 115 (61.2%) | 188 (100%) | |||
| Total | 190 (42.2%) | 260 (57.8%)) | 450 (100%) | |||
| Educational status of the mother | Illiterate | 22 (57.9%) | 16 (42.1%) | 38 (100%) | 9.135 | 0.103 |
| 1st-5th Std | 21 (42.0%) | 29 (58.0%) | 50 (100%) | |||
| 6th-10th Std | 39 (37.9%) | 64 (62.1%) | 103 (100%) | |||
| 11th and 12th | 75 (46.6%) | 86 (53.4%) | 161 (100%) | |||
| Diploma | 28 (35.0%) | 52 (65.0%) | 80 (100%) | |||
| Graduate/Post Graduate | 5 (27.8%) | 13 (72.2%) | 18 (100%) | |||
| Total | 190 (42.2%) | 260 (57.8%) | 450 (100%) | |||
| Type of family | Joint | 218 (74.1%) | 76 (25.9%) | 294 (100%) | 5.792 | 0.056 |
| Nuclear | 72 (79.1%) | 19 (20.9%) | 91 (100%) | |||
| Three generation | 57 (87.7%) | 8 (12.3%) | 65 (100%) | |||
| Total | 347 (77.1%) | 103 (77.1%) | 450 (100%) | |||
| Age of the mother | 20-24 years | 39 (25.5%) | 114 (74.5%) | 153 (100%) | 2.633 | 0.279 |
| 25-29 years | 53 (19.6%) | 218 (80.4%) | 271 (100%) | |||
| >30 years | 4 (15.4%) | 22 (84.6%) | 26 (100%) | |||
| Total | 96 (21.3%) | 354 (78.7%) | 450 (100%) | |||
| Type of family | Joint | 51 (17.3%) | 243 (82.7%) | 294 (100%) | 8.276 | 0.015* |
| Nuclear | 25 (27.5%) | 66 (72.5%) | 91 (100%) | |||
| Three generation | 20 (30.8%) | 45 (69.2%) | 65 (100%) | |||
| Total | 96 (21.3%) | 354 (78.7%) | 450 (100%) | |||
| Sex of the Baby | Male | 56 (24.5%) | 173 (75.5%) | 229 | 1.675 | 0.228 |
| Female | 40 (18.1%) | 181 (81.9%) | 221 | |||
| Total | 96 (21.3%) | 354 (78.7%) | 450 | |||
| Mode of delivery | Normal | 76 (29.8%) | 179 (70.2%) | 255 | 0.018 | 0.024* |
| Caesarean | 20 (10.3%) | 175 (89.7%) | 195 | |||
| Total | 96 (21.3%) | 354 (78.7%) | 450 | |||
| Birth order | 1 | 71 (66.4%) | 36 (33.6%) | 2.147 | 0.346 | |
| 2 | 165 (63.2%) | 96 (36.8%) | ||||
| >3 | 59 (72%) | 23 (28%) | ||||
| Total | 295 (65.6%) | 155 (34.4%) | 450 | |||
*Represents Statistically Significant association
Discussion
The age of the participants ranged from 20 to 32 years with more belonging to 25-29 years age. Majority of participants were married <21 years of age (58.2%). Median age of first marriage was 21.0 that was like that in Tamil Nadu is 21.1 (NFHS-4).[16] Only two thirds of the participants (35.8%) had completed high school, as against 98.4% of Tamil Nadu (NFHS-4), and almost three-fourths (73.1%) were unemployed.[16] More than two thirds (65.3%) belonged to joint families. Socioeconomic status was classified based on modified B.G. Prasad’s classification 2017. Nearly half (42.7%) belonged to lower-middle class and then lower class. As age of the mother increased, safe newborn care practices decreased. Also, joint families had higher prevalence of poor newborn care practices. This could be probably due to the influence of the family members, especially the senior female members in the family toward the practice of various traditional beliefs that were prevalent among the tribal population. Similar findings were found in report by Inayati, D.A. et al.[19] on infant feeding practices in Nias island in Indonesia. It was noticed that 53% babies were exclusively breast fed, as against the prevalence of exclusive breast feeding practice of 44.8%, according to the NFHS-4 data on Tamil Nadu.[16] Also 48.2% of the mothers had practiced prelacteal feeds, and it was found more in joint families, similar to study by Sathish K. Wadde[20] in Aurangabad, where there was a significant association between type of family and feeding practices.[20]
About 10.2% of the study participants did not give colostrum to their babies and 78.30% considered it was not good for the baby. Similar findings and beliefs were found in the studies done in Philippines, Nepal, Burma, Egypt, and hilly areas in Himachal Pradesh.[21,22,23,24,25] In the study, 34.4% of mothers, initiated breast feeding within 1 hour of delivery, as against the 56.9% of the tribal mothers initiating breast feeding within the first hour of delivery (NFHS-4, Tamil Nadu).[16] In a study by Suzanne in Tanzania, it was noted that 20% of the mothers initiated breast feeding within the first hour of delivery. The difference in our study, could be due to the awareness given by the health worker.[26]
About 65.3% of the mothers did not apply any substance to the umbilicus at birth and 34% applied natural herbs. Similar findings were found in a study in Sittilingi tribal area in Dharmapuri district of Tamil Nadu where habit of applying vasambu (herbal substance) to the umbilical cord was practiced extensively.[27] It was found that mothers who were above thirty years followed more harmful newborn practices than mothers in the lesser age groups. This association was found to be statistically significant (P < 0.04). This was seen in a study by Mohini H et al.,[28] which showed that age of the mother had significant relationship with newborn care practice. It was also found that unemployed mothers followed more harmful newborn care practices than employed mothers.
Conclusion
The safe newborn care practice in the study was 21.3%. Mothers who practiced good antenatal care practices also practice good postnatal care practices. Among the study participants, 48.2% mothers gave prelacteal feeds to their babies, 84.3% followed providing thermal care to baby, and 65.35% of the mothers did not apply any substance to the umbilicus at birth. Health education and behavior change communication is the need, which can improve the new born care practices. Family members need awareness and health education regarding safe newborn care practices, even in the antenatal period.
List of abbreviations
List of abbreviations
| Abbreviation | Definition |
|---|---|
| DALY | Disability Adjusted Life Years |
| NMR | Neonatal Mortality Rate |
| PHC | Primary Health Centre |
| HSC | Health SubCentre |
| SPSS | Statistical Package for the Social Sciences |
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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