Journal of Medical Sciences and Health

Introduction

India is a diverse country of 1.2 billion plus population with different religions, tribes, culture and races. According to 2011 Census approximately 635 tribal groups and subgroups including 73 primitive tribes are living in India which represents about 8.6% of total population. In the state of Assam 12.4% of the population belongs to scheduled tribes located in both plain and hills areas of the state. 1 Different health indicators are historically poor among tribal populations than the general population. High prevalence of various genetic diseases has been seen among tribal populations.2, 3 Infants and young children are the most vulnerable age group among the tribal population. Infant and child mortality is very high among tribals in different parts of India.4, 5 Prevalence of LBW babies is found to be higher among the tribals than the general population. ⁶ Health seeking behaviour of mothers plays an important part in the well-being of low birth weight babies (LBW). But there are very few studies among tribal mothers of North Eastern states of India including Assam regarding their care seeking behaviours for the LBW children. Since infant mortality is a major public health problem in the state of Assam and care seeking behaviours of mothers influence the outcomes, therefore this study was attempted among mothers from tribal community in Assam to assess the prevailing care seeking behaviours for their LBW babies during the first year of life.

Methodology

The study was a community based cross-sectional study conducted in Boko Bongaon Developmental Block area of Kamrup district of Assam. The study area is situated around 85 Km west of Guwahati city. For our study out of the 110 villages of the block we purposively selected 30 villages where more than 80% population were tribal. Predominant tribe was the Boro tribe, while Garo and Karbi tribes were also residing in our study area. We surveyed those villages and identified tribal mothers who had delivered a LBW in the last six months. Total 112 eligible mothers were identified who had delivered LBW babies in the last six months. After taking informed consent, they were interviewed using pretested predesigned semi structured interview schedules. Birth weight of the baby was found out from either MCP cards present with mothers, Sub Centre Registers and discharge certificates. Inclusion criteria: A mother who had delivered a LBW baby in the preceding six months of the study was included in our study provided she belonged to the tribal community as well as gave informed consent to be part of our study and was a permanent resident of the village. Exclusion criteria: Babies delivered at home were excluded from the study as birth weight was not available, also mothers not giving consent, giving incomplete information were excluded from our study. Study period: January 2014 to August 2016. Data collected through personal interviews were compiled, tabulated and entered into Microsoft Excel software. Statistical analysis was done using SPSS software version 18. Ethical clearance for our study was obtained from the Institutional Ethics Committee of Gauhati Medical College.

Variables under study: Socio-demographic characteristics of mothers, feeding and care practices for LBW babies, knowledge on special care to LBW babies, health seeking behaviours of mothers of LBW babies.

Results

In our study total 112 tribal women were interviewed who delivered a LBW baby in the preceding six months from the date of interview. Total 116 LBW babies were delivered by these tribal women as 4 women had delivered twins. Out of those 116 LBW babies 3 (2.7%) had died within the six months of birth. Among the 112 mothers 87 (77.7%) had delivered at government hospitals while 25 (22.3%) had delivered in private hospitals. Total 76 (67.8%) cases were term pregnancies while 36 (32.2%) were either preterm or post-dated pregnancies. Most women (98%) had registered in the local health centre during the antenatal period but only 63% had consumed full 100 IFA tablet courses and 78% had two doses of Tetanus Toxoid immunization during pregnancy. 13% of women had reported some morbidity during pregnancy which needed hospitalization or visit to health facilities.

On analysis of socio demographic factors of the mothers (Table 1) we found that most of the women were in the age group of 20 to 29 years while 22.3% were teenage mothers and 29.5% were more than 30 years of age. Most mothers (60%) belonged to Hindu religion and from joint families (63.4%). Most of them belong to lower middle (60%) socioeconomic categories with cultivation being the main occupation among the families. Education qualification of most mothers was up to middle school with only 10% mothers studied beyond class 10 or more, while the study noted that most mothers of LBW babies had 2 children (50.9%). In our study we found that 87.5% mothers could recognize LBW condition of their babies but 12.5% mothers were not aware of the condition of their babies. We found in our study that among the 112 mothers, 37.5% mothers thought nutritional deficiency during pregnancy as the reason for LBW babies while 27.6% mothers believed that the cause of LBW was religious. When we enquired the mothers about special care to their LBW babies, most (92%) were exclusively breastfed for six months, 86% were initiated to complementary at correct age though only 4.5% mothers gave formula feed to their babies. Most mothers were aware of proper nutrition during the postnatal period (57%) and were taking adequate nutrition. Massage of oil was followed by 67% mothers which they believe was good for the health of the baby. Religious rituals were also performed on 38% babies for the betterment of the health though none of those rituals were harmful for the babies though were not necessary. Delayed bathing of the LBW babies was practiced by 60% mothers and 30.3% mothers practiced KMC. (Table 3)

On enquiring the mothers regarding knowledge of Kangaroo Mother Care (KMC) we found that only 20% had correct knowledge about KMC, majority 42.8% had no knowledge about it. Most important source of information for delayed bathing and KMC was local health workers ASHA and ANM. Immunization status of the children were enquired and 82% children were found to be getting immunization according to the schedule but 28% children had inadequate immunization.

We enquired from mothers and the local health workers about the morbidity and mortality status of the LBW babies included in our study. We found that out of 116 LBW babies 3 babies had died before reaching their sixth birthday. Pneumonia was the cause of death in all three cases as noted from the hospital documents. Among the remaining 113 children total 85 children had any morbidities documented during their first six months of life. Many children had multiple morbidities during the study period. On analysing the health seeking behaviours of mothers during these morbidity episodes we found that 75.4% mothers of LBW babies approached health care facilities for treatment and advice. Government health facilities were the preferred choice for most mothers (88.4%). Most mothers (70.2%) also approached local ASHA and ANMs for health advice and assistance. Self-medication practices were seen among 15.2% of the children. We also found in our study that 85% mothers took major decisions regarding the health of their LBW babies with consultation of their husbands and parents while 15% mothers depended on their husbands to take any major decision regarding the health of LBW children.

In our study we divide the health seeking behaviours of mothers of LBW babies into two categories; appropriate health seeking behaviour and inappropriate health seeking behaviour. The study found that appropriate health seeking behaviour was demonstrated by 64 (75.3%) mothers while in the rest of the mothers 21 (24.7%) health seeking behaviour for their LBW babies was found to be inadequate. The study also analysed the effect of certain determinants on the health seeking behaviours of mothers and found that adequate exposure of mothers to mass media was significantly associated with appropriate health seeking behaviours. While education of mothers, socioeconomic status, gender of children, numbers of children in the family, were some important determinants influencing health seeking behaviours though these determinants were not found to be statistically associated with appropriate health seeking behaviours of the mothers of LBW children.(Table 4)

Discussion

Health seeking behaviour of mothers is one of the key components which influences the proper growth and development of their children. LBW babies need additional care during their first few years of life so that they can achieve the optimum growth potentials. Our study conducted among mothers of LBW babies in the rural tribal community of Kamrup District Assam obtained some important findings regarding health seeking behaviours.

Our study found that 87.5% of mothers could recognize LBW condition. Preterm labour and nutritional deficiency were the main reasons for LBW babies according to most of our study subjects while some mothers also believed that the LBW baby was born due to religious causes. Study by Shakya KL et al also found that most mothers accurately identified the low birth weight condition of their babies.7

Most of the mothers (84.8%) understood the need for special care to their LBW babies in our study. Exclusive breastfeeding, good nutrition to mother and baby, Kangaroo Mother Care, delayed bathing were some of the special care components provided by mothers as mentioned by our study population. Such practices were found to be beneficial for growth and development of the infants. ⁸ Oil massage to the baby was one practice followed by most tribal mothers in our study. Past studies had reported health benefits of oil massage on LBW infants. ⁹

Kangaroo mother care (KMC) is one important home based intervention to provide much benefit to LBW babies. In our study 30% mothers were found to be practising KMC. Though only 20% were doing it with correct knowledge. Similarly Shah BD et al in their study among tribal mothers also found low prevalence of KMC due to lack of knowledge and counselling. ¹⁰

Delayed bathing was another live saving intervention for LBW infants, in our study 60.7% mothers practiced delayed bathing of their children after birth because of counselling by doctors, ANM and ASHA.

In our study more than 50% of the LBW infants were found to be suffering from any morbidity during the entire study period, on analysing the health seeking behaviours of those LBW infants we found that 75% mothers visited the health facility during the illness episodes. Government health facilities were the preferred choice for most women. Accessibility and economic factors influenced the choice of facility for most. Rural tribal population is still having inadequate health infrastructure and govt health facilities were the mainstay of curative care.

Grass root level health workers like ASHAs were the main source of health information among the tribal mothers in our study. Also 15% parents practiced self-medication for their children. Mainly the economic reasons influenced these behaviours. Previous studies also found widespread self-medication practices among rural parents due to economic reasons. ¹¹

The study found that appropriate health seeking behaviour was demonstrated by 75% mothers and mass media exposure was significantly associated with appropriate health seeking behaviours of mothers. Ghosh N et al also found positive health outcomes among children due to adequate mass media exposure of rural mothers.12 Similar findings were reported by Karki M et al in a study conducted in rural areas of Bangalore India. 13 Our study observed that 25% of mothers' health-seeking behaviour for their LBW babies was inadequate. Though no significant association was found, low education level and poor socio-economic conditions influenced the lack of health seeking practices of the mothers. Previous study conducted among rural mothers of Assam reported similar results. ¹⁴

Limitation of our study: In this study we could include only limited variables, sample size was small, only one district was included because of resource constraint (no funding was available). The investigation findings are very much pertinent to the problem and should elicit interest for broader research on the problem of LBW among rural tribal communities.

Conclusion

The study obtained some significant findings regarding health seeking behaviours among mothers of LBW babies in rural tribal population. Our study found high awareness among mothers regarding LBW condition but correct knowledge and practice of KMC was found to be very less. Most mothers were found to be approaching health facilities and taking help of community level workers during morbidity episodes of their LBW babies, though some mothers failed to get any outside help and some practiced self medication. The study also revealed the important role of mass media in spreading health information. These findings are definitely going to help in understanding the infant health problems and will be a catalyst in doing larger research projects among the tribal population of North East India for the betterment of maternal and child health.