Maternal and Newborn Care Practices Among the Urban Poor in Indore, India - Gaps, Reasons and Potential Program Options
131 Pages Posted: 16 Aug 2016
Date Written: August 2007
One of 14 newborns die among urban poor of Madhya Pradesh (M.P.) in India. Neonatal survival is influenced by care received before, during and after delivery, which in turn is influenced by the mother’s beliefs, perceptions of her immediate family. Antenatal, intra-partum and postnatal practices associated with better newborn survival are known. To promote these practices in wider program settings, an understanding of current practices and factors influencing them would help identify barriers and context responsive program options for improving these evidence-based practices.
Findings: A. Antenatal care: Practices and reasons: 95.5% mothers established contact with health provider during pregnancy either for antenatal advice or antenatal care (routine checkup or sickness care). Of those who established contact, 84.0% approached a health provider in first trimester, 6.7% in second trimester and 4.8% in third trimester. Health providers approached for antenatal care/advice included: a) ANMs during health camps in slums (45.4%), b) doctors in government hospitals (39.7%), c) doctors in private charitable institutions (28.2%) and d) private doctors residing nearby (16%).
2 tetanus toxoid shots: 82.0% of mothers received 2 TT shots during pregnancy. This was possible due to UHRC's program efforts in ensuring that ANMs conducts monthly outreach in these slums. Barriers to complete TT immunization included- i) pregnant women away from slum at time of outreach due to being at work or gone to native village for delivery in 7th month of pregnancy; ii) Infrequent visits by ANM in few slums and iii) reluctance to take TT shots, due to scare of injections.
Consuming 100 Iron Folic Acid (IFA) tablets during pregnancy: IFA tablets were provided through NGOs working in slums in UHRC's program so supply was adequate. 86.2% mothers received IFA tablets. Of mothers who received IFA tablets only 11.5% consumed IFA tablets for 3 months during pregnancy. Reasons cited by mothers who consumed some IFA tablets but insufficient number during pregnancy were – i) belief that the tablet is "hot" and hence may lead to miscarriage; ii) diarrhoea/nausea after eating tablet; iii) IFA tablet perceived foul smelling, iv) forgetting to consume tablet due to house work.
B. Preparedness for delivery and obstetric complications: Practices and Reasons: (a) Identifying a trained birth attendant for delivery and obstetric complications: Nearly 70% mothers mentioned that while pregnant they had identified a birth attendant to seek help for delivery and related obstetric complications. Birth attendants identified included - trained sTBA of the slum and doctors in government/charitable hospitals. Possibly, health education through trained slum or cluster level health volunteers (LCBOs/BCBOs) contributed to these preparedness practices. Lack of perceived need, economic constraints or traditional practices emerged as barriers to this practice.
b)Identifying a health facility for delivery and obstetric complications: While pregnant, 64% mothers identified a health facility they would contact in event of an obstetric complication. Barriers to this practice were: not facing any complication in pregnancy, poverty related constraints, taking for granted that delivery would be conducted at home.
c)Savings: 76.9% families saved money for delivery related costs and prepare for any complications that could arise. In slums where SHGs were active, only 41% of mothers were aware of an SHG being present in their slum and 15.8% mothers were members of such a group. A large proportion of mothers were not members of SHGs owing to : i) uncertain livelihood related fear of not being able to save each month, ii)family members' disapproval due to irregular income or lack of faith in SHG after hearing negative experiences from members of SHGs of other programs. d) Making transport arrangements: Arrangements for transportation to prepare for an obstetric emergency were made only in 29.5% of families, as in the slums visited, tricycle ‘Rickshaws’ were available close by and private doctors resided in the vicinity.
e) Identifying danger signs indicating a complication and seeking prompt referral: Of 312 mothers interviewed, 65 were not aware of any maternal complications during pregnancy. Most others mentioned excessive bleeding prior to labour pains, breathlessness with blurring of vision and severe abdominal pain suggestive of referral. Economic constraints, apathy on part of the family members to escort the pregnant lady to a referral facility at night, advice of the sTBA that pain is natural emerged as barriers for seeking timely emergency obstetric care.
C. Hypothermia assessed by Human Touch: Field supervisors of slum-based health volunteers measured body temperature of 152 newborns by HT and ADT, observed suckling and weighed newborns. Hypothermia prevalence (axillary temperature <36.5oC) was 30.9%. Hypothermia assessed by HT was in agreement, with hypothermia assessed by ADT (<36.5°C), in 107 out of 152 observations. Taking ADT as gold standard, sensitivity and specificity of HT method to correctly identify hypothermic (true positive) and non-hypothermic babies (true negative) was 74.5% and 68.5% respectively.
D. Program Options: There is a need to act at slum and at facility level to improve newborn care in underserved slums. a)Three counselling contacts through health workers during antenatal period and even one counselling contact by trained health volunteer (Urban ASHA of NUHM) contact during neonatal period showed potential to improve timely initiation of breastfeeding and exclusive breastfeeding during neonatal period, b) Timely, persuasive and well-supervised antenatal and postnatal home and group counselling, c) sTBA linkage with affordable private and public health facilities can promote institutional deliveries. d) At facility level, capacity building and supervision of health and paramedical staff in following recommended guidelines and sensitively communicating with the poor will help the latter overcome fears of availing services at government health facilities. e) For low-birth weight (or small) newborns, i) trained slum-based volunteers (Urban ASHA in NUHM) be trained to identify low birth weight (<2.5 kgs) and emphasize need for extra care; ii) Babies born in 7th/8th month of pregnancy; iii) baby lying listless with poor suckle looking very weak/small/thin and cold to touch. needs extra warmth and care. iv)Wrapping such babies in woolens (shawl, layers of soft cloth) from head to toe, holding in close proximity with the mother, with both mothers and baby clothed (Practice of kangaroo mother care (skin-to-skin) contact and keeping the room temperature through a smoke free heating method is conducive for the newborn.
Keywords: urban slums, neonatal care, maternal care, low-birth weight, care of sick newborn, hypothermia
JEL Classification: H75, I00, I10, I12, I18, I19, I30, I31, I38, I39, J13, J18, L30, L31, R20, R23
Suggested Citation: Suggested Citation