ARTICLE IN PRESS

Nama : Nurjannah Hana Maulida

Nim : 19631878

Kelas : S1 Keperawatan 4A

Hasil telaah jurnal Internasional

Nama Penulis Fariyal F Fikree, Tazeen S Ali, Jill M Durocher,
Mohammad Hossein Rahbar
Tahun Terbit 2005
Nama Jurnal Social Science & Medicine
Judul Artikel Newborn care practices in low socioeconomic
settlements of Karachi,Pakistan
Responden Wanita Postpartum
Kriteria Sampel Usia rata-rata dari 515 wanita dan pasangannya
masing-masing adalah 26,1 (75,6) dan 32,6
(711,6) tahun. Beberapa wanita (8,5%) lebih
muda dari usia 20 tahun; mayoritas berusia
antara 20-29 tahun.
Jumlah Sampel Jumlah sampel sebanyak 530 orang.
Tindakan yang Diberikan  Menunda menyusui pertama
 Memberi ASI Pra-laktasi
 memberikan ASI tambahan
 mandi saat sedang setelah melahirkan
 menggunakan pijat pijatan dengan
menggunakan minyak mustard.
 menerapkan substansi ke tali pusar
Hasil Penelitian Hasil penelitian dalam wawancara kuantitatif,
total 530 wanita postpartum memenuhi kriteria
penelitian kami dan setuju untuk berpartisipasi
dalam penelitian ini. Wawancara diselesaikan
pada 525 wanita (tingkat penolakan 1%). Wanita
yang melaporkan kembar (n = 10) dikeluarkan
dari penyelidikan karena kriteria inklusi kami
untuk penilaian bayi baru lahir adalah kelahiran
tunggal. Ukuran sampel akhir adalah 515
wanita.
Cakupan perawatan antenatal adalah umum;
sedikit lebih dari separuh wanita melahirkan di
rumah dengan dukun bersalin tradisional. Di
antara 387 wanita yang melaporkan setidaknya
satu kunjungan antenatal, sebagian besar
melaporkan menerima konseling menyusui oleh
penyedia layanan kesehatan mereka. Sebagian
besar wanita dilaporkan memberikan lakteal;
kolostrum atau susu hewan/formula sebagai
 pakan pertama. Bayi baru lahir segera
dimandikan setelah melahirkan karena vernix
dianggap 'kotor' , dan dirasa harus diangkat.
Untuk mendorong relaksasi otot dan
memperkuat tulang , pijat harian dilakukan
secara universal, minyak mustard menjadi
pelumas yang paling sering digunakan.
Praktik pemberian makan yang berisiko seperti
pemberian prelakteal atau makanan tambahan ,
atau menunda pemberian makan pertama
sering terjadi. Selama periode neonatal, ASI
adalah makanan yang disukai ; namun, madu ,
ghutti dan air juga diberikan untuk 'mengurangi
kolik' atau 'bertindak sebagai pencahar', yang
dianggap sebagai manfaat kesehatan yang
disebutkan oleh ibu dan dukun bayi. Etnis dan
penolong persalinan saat melahirkan
merupakan prediktor kuat bagi wanita yang
memberikan prelakteal (setelah disesuaikan
dengan pendidikan, status sosial ekonomi dan
fasilitas persalinan). Meskipun pemberian
kolostrum sebagai makanan pertama relatif
umum dalam pengaturan ini, dominasi praktik
perawatan bayi baru lahir tradisional yang
berisiko lainnya menekankan perlunya
mempromosikan program pendidikan
kesehatan untuk meningkatkan praktik
perawatan bayi baru lahir.

Apakah tindakan tersebut dapat diterapkan Dapat diterapkan di ponorogo . karena tindakan
diponorogo dan daerah sekitarnya . yang dilakukan tersebut sangat berguna bagi ibu
setelah melahirkan dan juga untuk bayi yg
dilahirkan.
 Social Science & Medicine 60 (2005) 911–921
www.elsevier.com/locate/socscimed

Newborn care practices in low socioeconomic settlements of

Karachi, Pakistan
Fariyal F. Fikreea,, Tazeen S. Alib, Jill M. Durocherc, Mohammad Hossein
Rahbard
a

International Programs Division, Population Council, One Dag Hammarskjold Plaza, New York, NY 10017, USA
b
School of Nursing/Department of Community Health Sciences, The Aga Khan University, Stadium Road, Karachi 74800, Pakistan
c

Population Council, One Dag Hammarskjold Plaza, New York, NY 10017, USA
d
Data Coordinating Center, College of Human Medicine, Michigan State University, Room 100, Conrad Hall East Lansing, MI
48824, USA

Available online 10 August 2004

Abstract

To explore traditional neonatal beliefs and care practices and to assess the predictors for giving
prelacteal feeds, a qualitative and quantitative study was conducted in low socioeconomic
settlements of Karachi, Pakistan. Five focus group discussions and 15 in-depth semi-structured
interviews were conducted in July and August 2000; structured questionnaires were administered to
525 recently delivered women through November.

Antenatal care coverage was common; a little over half of the women delivered at home with
traditional birth attendants. Among the 387 women who reported at least one antenatal visit, most
(78.6%) reported receiving counseling on breastfeeding by their healthcare provider. A significant
proportion of women (44.8%) reported giving lacteals; colostrum (41.7%) or animal/formula milk
(3.1%), as the first feed. Newborns were bathed immediately (82.1%) after delivery as the vernix was
considered ‘dirty looking’ (78.5%), and it was felt it should be removed. To foster muscle relaxation
(80.2%) and strengthen the bones (43.0%), daily massage was universally practiced, mustard oil
(75.9%) being the most frequently used lubricant.

Risky feeding practices such as giving prelacteals (55.0%) or supplementary feeds (71.3%), or delaying
first feed (30.9%) were common. During the neonatal period, breast milk was the preferred feed
(98.6%); however, honey (28.7%), ghutti (27.8%) and water (11.8%) were also given in order to
‘reduce colic’ or ‘act as a laxative’, which were perceived health benefits mentioned by mothers and
traditional birth attendants. Ethnicity and birth attendant at delivery were strong predictors for
women who gave prelacteals (after adjusting for education, socioeconomic status and facility
delivery). Although administration of colostrum as the first feed was relatively common in this setting,
the predominance of other risky traditional newborn care practices stresses the need for promoting
health education programs on improving newborn care practices. r 2004 Elsevier Ltd. All rights
reserved.
Keywords: Beliefs; Colostrum; Pakistan; Practices; Prelacteals; Newborn care
Corresponding author. Tel.:+1-212-339-0605; fax: +1-212755-
6052.
E-mail addresses: ffikree@popcouncil.org (F.F. Fikree),
tazeen.ali@aku.edu (T.S. Ali), jdurocher@popcouncil.org
(J.M. Durocher), mohammad.rahbar@ht.msu.edu (M.H. Rahbar).
Introduction
The past two decades have witnessed a
sustained decline in infant mortality mainly due
0277-9536/$-see front matter r 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2004.06.034
to immunization,
oral re-hydration therapy, and other child-
related survival interventions. However, a
stagnation in the rate of decline has been
reported (United Nations Children’s Fund, 1999)
as a result of the static neonatal mortality rate
(Bhave, 1989). Ninety-eight percent of newborn
deaths occur in developing countries, where
most newborns die at home under the care of
mothers, relatives, and traditional birth
attendants (WHO, 1996). The major causes of
neonatal mortality are infections (tetanus,
sepsis, pneumonia and diarrhea), complications
from prematurity, birth asphyxia, and injuries
(WHO, 2001). Little is known about the extent
of neonatal morbidity in developing countries,
however most probably it is high.
Despite proven cost-effective solutions to
reduce neonatal mortality, such as promoting
tetanus toxoid immunization, skilled health care
at delivery, immediate and exclusive
breastfeeding, and clean cord care, there has
been relatively little change in neonatal
mortality. The implementation of an effective
program necessitates an understanding of
community and household traditional newborn
care practices to enable the development of a
program that promotes culturally sensitive and
acceptable change in practices.
Routine care of the newborn includes feeding,
bathing, massage and cord care practices. Many
communities in South Asia and Africa routinely
apply ghee1 or ash to the umbilical stump,
discard the colostrum, bathe the baby
immediately after birth, or apply oils to the skin
of the newborn (Bennett, Ma, Traverso, Agha, &
Boring, 1999; Obimbo, Musoke, & Were, 1999;
Oyo-Ita,
Meremikwu, Edet, & Akpan, 1999–2000; Osrin
et al., 2002; Kumar & Aggarwal, 1998; Nwankwo
& Brieger, 2002; Haider, Kaibir & Ashworth,
1999; Darmstadt & Saha, 2002). Although such
newborn care practices have been abided by for
hundreds of years, their extent and perceived
health benefits have not been extensively
studied in South Asia, specifically in Pakistan.
The aim of this paper is to describe newborn
care practices, to understand their perceived
health benefits, and to identify the predictors
for those women who give prelacteal feeds,
which is considered a risky practice, in low
socioeconomic settlements of Karachi, Pakistan.
1 Ghee is clarified butter.
Materials and methods each comprising a population of 10,000 to over
50,000 are generally Muslims, and are migrants
Combining qualitative and quantitative research
from India at the time of Partition in 1947
methods was reckoned to provide a more
(Mohajirs) or from upcountry (Sindhis, Punjabis
holistic picture of newborn care practices as
and Pathans). In these settlements, the houses
these practices have significant cultural
are usually made of bricks (pucca), and have
overtones. Five focus group discussions (FGDs)
electricity, community tap water connections
(8–10 participants per discussion group) and 15
and sewerage facilities (Fikree, Gray, Berendes,
in-depth interviews (IDIs) were conducted in
& Karim, 1994). Recruitment, which began in
July and August of 2000. Independent
mid-August, continued until the sample size was
discussion guidelines for FGDs and IDIs were
achieved. Women who satisfied the following
developed and pre-tested among women and
inclusion criteria—Muslim, live birth for index
traditional birth attendants2 (TBAs). Revisions
pregnancy outcome, and between 42 and 56
were made in the content of the guidelines and
days postpartum—were interviewed at their
in the conduct of the interviews after pre-
homes, upon receipt of verbal informed
testing. Questions that did not generate any
consent.
meaningful responses were removed and more
exploratory questions were added. A conscious Structured questionnaires were developed and
effort was made to probe into rationales for any translated into Urdu and then back-translated
traditional care practice. into English. Information on demographics,
antenatal care received, type of delivery
To elucidate variations in traditional neonatal
attendant and location of delivery, and newborn
care practices among women and TBAs, FGDs
care practices was elicited. Female interviewers
and IDIs comprised of (1) young and older
who had previous experience in conducting
mothers; (2) primiparous and multiparous
surveys, who lived in neighborhoods near the
mothers; and (3) trained and untrained TBAs.
study sites, and spoke at least one regional
Participants were identified from the
language (Punjabi, Sindhi, Pushto) in
quantitative research study sites. Interviews
were conducted in the local vernacular (Urdu), 2
Traditional Birth Attendant (TBA) or Dai: A person (usually a
upon receipt of verbal informed consent from
woman) who assists mothers at childbirth, and who initially
all participants. All interviews were audio-taped, acquires these skills of delivering babies by herself or by working
transcribed in Urdu, and back-translated into with other dais. A trained TBA is someone who has participated in
a formal training program, whereas an untrained TBA is someone
English.
who has not had any formal training.

A survey was then conducted in five low

addition to Urdu were recruited and trained in
socioeconomic settlements of Karachi, Pakistan,
an intensive field-training program. The
between August and November 2000 to
interviewers were closely supervised to
investigate newborn care practices among
maintain quality control of data; completed
recently delivered mothers. The low
questionnaires were field-edited.
socioeconomic settlements identified had
operational maternal health surveillance Sample size
systems in which community health workers
This study was part of a larger research project
from each of the field sites facilitated the
conducted to estimate the proportion of
identification of potential subjects. The
mothers reporting risky newborn care practices
residents of these long established settlements,
and identifying factors associated with such
practices during the postpartum period. Our
target sample size of 525 was calculated in
order to estimate these parameters within a 4%
bound on the error estimation at 95%
confidence level. In addition, this sample size of
525 was considered sufficient to detect odds
ratios of 2 or higher with a power of at least
80% at a 5% level of significance.
Measurement of outcomes
The assessment of traditional newborn care
practices was based on neonatal feeding and
care practices. Giving prelacteal feeds, delaying
first feed, providing supplementary feeds,
bathing immediately after delivery, using
mustard oil as the lubricant for massage,
instilling nasal/ear drops, and applying
substances to umbilical cord were defined as
risky newborn care practices (‘yes’ category).
Prelacteals
‘Non-consumers’ (non-risky practice) were
women who reported giving breast milk,
formula milk or animal milk; ‘consumers’ (risky
practice) were women who gave their babies
prelacteals such as honey, water, or tea as the
first feed.
Delayed first feed
Irrespective of the content of the feed, women
were asked about the time that the first feed
was given after birth. If the first feed was given
within one hour after birth, the first feed was
not considered delayed (‘no’ category); if not, it
was considered delayed (‘yes’ category).
Supplementary feeds
Women who reported only giving breast milk
and not any other substances were categorized
as not giving supplementary feeds (‘no’
category); whereas those women who gave all
other substances including formula or animal
milk as part of the neonatal diet were
considered as giving supplementary feeds (‘yes’
category).
Bathe immediately after delivery
Women who bathed the baby immediately after
delivery were considered as having a risky
newborn care practice (‘yes’ category); those
women who reported that the neonate was
bathed after waiting an half hour or longer were
included in the ‘no’ category.
Massage with mustard oil
Women who reported that the neonate was
routinely massaged with mustard oil were
included in the ‘yes’ category; whereas women
who reported massaging their baby routinely
but used a substance other than mustard oil or
did not massage were included in the ‘no’
category.
Instillation of nasal/ear drops
Instilling drops into the ear or nose of neonates
was categorized as risky practice (‘yes’
category). Women who did not instill drops into
the ear or nose of the neonate were categorized
in the ‘no’ category.
Cord care
The application of traditional substances such as
mustard oil, coconut oil, or surma3 to the
umbilical cord was categorized under risky
practice (‘yes’ category); non-risky practice (‘no’
category) was if no substance was applied to
the umbilical stump or if an antiseptic/
antibiotic (ointment, liquid or powder) was
applied.
Measurement of independent variables
Household wealth
A composite index was computed for
socioeconomic status (SES) based on ownership
of 12 household assets (such as an iron, sewing
machine and refrigerator). The classification of
lower, middle, and higher SES was based on the
number of assets for each household. The cut-
off values were approximately one standard
deviation around the mean number of
household assets reported. Owning up to two
items was categorized as lower SES; three to
eight items categorized as middle SES; and nine
or more items as higher SES.
Parity
Women were classified as primiparous (the
newborn being their first live birth), multiparous
(2–4 live births), and grand-multiparous (5 or
more live births).
Statistical analysis
Standard descriptive analysis was performed.
Prevalence estimates were calculated to reflect
the relative frequency of risky traditional
neonatal feeding and care practices.
Associations between the traditional neonatal
care practices (risky vs. benign/beneficial) and
socio-demographic and maternal care coverage
were
3 spouses was 26.1 (75.6) and 32.6 (711.6) years,
Surma is a powdered antimony—used as a cosmetic that is
applied to the lower eyelid, similar to modern eyeliner.
performed using w2 tests; a p-value of o0.05
was considered significant. When the
assumptions of the w2 test were not met we
used the Fisher’s Exact test.
Analyses (bivariate and multivariable logistic
regression) were limited to the traditional
prelacteal feeding practices. The bivariate
associations between socioeconomic,
demographic, and maternal care coverage
variables with consumers and non-consumers of
prelacteals were investigated; odds ratios and
95% confidence intervals were calculated
(Schlesselman, 1982). In order to control for
potential confounding and investigating
potential interactions, multiple logistic
regression models were run to assess the effect
of each factor in the presence of other variables
in the model. The criteria for including variables
in the multiple logistic regression analyses was a
p-value of o0.1 upon bivariate associations
(Hosmer & Lemeshow, 1989). All analyses were
completed using the Statistical Package for the
Social Sciences (SPSS Statistical Software, 1999).
Results
Participants
In the quantitative interviews, a total of 530
postpartum women met our study criteria and
agreed to participate in the study. Interviews
were completed on 525 women (1% refusal
rate). Women who reported twins (n=10) were
excluded from the investigation as our inclusion
criteria for the newborn assessment was
singleton birth. The final sample size was 515
women.
Characteristics of the participants
The mean age of the 515 women and their
respectively. Few women (8.5%) were younger
than age 20; the majority was between the ages
of 20–29 years. The ethnic mix included the
major ethnic groups of Pakistan—Mohajir,
Sindhi, Punjabi, and Pathan. Only 38.3% of
women reported any formal schooling, and
formal female employment was rare. Only 6.8%
of women reported working to earn an income.
General living conditions were moderately
good; most owned their own homes (64.1%)
and almost all homes were built of solid
construction material; piped water and
sewerage disposal was nearly universal (Table
1).
Maternal care coverage
Antenatal care coverage was common; less than
a quarter of recent mothers did not seek any
antenatal care for their most recent pregnancy
and a substantial number reported more than
five visits. First time mothers (86.8%) were Parity 2
Primipara (1 live birth) 0
more prone to seek antenatal .
106 6
Table 1
Multipara (2–4 live births) 257 4
Descriptive analyses of socio-demographic and obstetric care 9
variables among 515 mothers of neonates (low socioeconomic .
settlements, Karachi, Pakistan, 2000) 9
Grandmultipara (X5 live births) 152 2
Demographic and obstetric variables n % 9
.
Age (years) 8 5
o20 . 2
44 5 4
20–29 309 6 Antenatal visits .
0 None 128 8
. 1–4b 281 5
0 4
X30 162 3 .
1 6
. X5 106 2
5 0
Formal education 3 .
Yes 8 6
. Facility delivery 5
197 3 Yes 0
No 318 6 .
1 257 0
. No 258 5
7 0
Socio-economic status 1 .
Lower 6 0
. Birth attendant 5
87 9 TBA 3
Middle 364 7 .
0 273 0
. Paramedics 63 1
7 2
Higher 64 1 .
2 2
. Doctor 179 3
4 4
2 .
8 8
Ethnicity . 7
Mohajir 146 3 8
Sindhia 115 2 Breastfeeding counselingc .
2 Yes 304 6
. No 83 2
3 1
Pathan 177 3 .
4 4
. a n=115 (99 Sindhi and 16 Balochi).
4
b
Punjabi 77 1
n=281; including 133 women who went whenever provider
5
called or when perceived a problem.
.
0 c
 n=387; excluding 128 women who never went for an antenatal 26, no formal education, Pathan, parity
visit.
three)
Traditional substances such as ghutti and honey
care compared to multiparous (75.1%) or grand-
were given for various perceived health
multiparous (67.1%) mothers. Among the 387
benefits, such as reducing colic or as a laxative,
women who reported at least one antenatal
which was mentioned by mothers and
visit, most (78.6%) reported receiving
advocated by TBAs.
counseling on breastfeeding by their healthcare
provider. Facility-based deliveries, generally in Ghutti helped to clean the stomach, released
hospitals, were relatively common (50%), the pain, and allowed stool to be passed.
however TBAs (53%) remained the most (age 30, educated, Pathan, parity five)
common birth attendant (Table 1). Ghutti clears all of the waste from the baby’s
stomach and clears the stomach. If this waste
Feeding practices and beliefs
stays in the baby’s stomach, it can be harmful
A significant proportion of women (44.8%) for the baby. (age 48, Punjabi TBA, no formal
reported giving lacteals, such as colostrum education)
(41.7%) or animal/ formula milk (3.1%), as the Giving prelacteals or delaying breastfeeding for
first feed. Other first feeds given included a up to 3 days was perceived as beneficial:
range of traditional substances such as honey
(24.7%) or ghutti4 (17.0%). The proportion of My mother-in-law said that the first milk is
women who subsequently gave breast milk dirty because it has been stagnant for nine
increased significantly (73.2%); breast milk was months. So, I let this milk come out, and I
the preferred feed (98.6%) during the neonatal gave my baby buffalo milk with a bit of water
period. An appreciable number of neonates mixed in it for three days. (age 23, no formal
(13.8%) were breastfed within the first half education, Pathan, parity one)
hour; nearly 30% of neonates were breastfed However, with larger numbers of women
within the first hour. On the other hand, nearly seeking antenatal care and delivering in facilities
8% of neonates were breastfed after waiting within these
two or more days after birth. Supplementary
feeds were common (71.3%); honey (28.7%),
Table 2
ghutti (27.8%) and water (11.8%) were most
frequently reported (Table 2). Descriptive analyses of newborn care practices among 515
mothers of neonates (low socioeconomic settlements, Karachi,
Information from our qualitative research sheds Pakistan, 2000)
light on traditional feeding practices and health
beliefs. For example, one mother explained the Newborn care practices n %
perceived health benefits of giving her neonate Type of first feeda 215 41.7
water with sugar and salt:
Colostrum 16 3.1
yfor the baby to urinate frequently. By
Animal/formula milk 127 24.7
urinating, the heat inside the baby’s body is
Honey 87 17.0
released and then the baby feels hungry. This
is necessary for the newborn’s health. (age Ghutti 26 5.1

Water 17 3.3
Kahwab 26 5.1 Time of first bathf

Othersc Immediately 416 82.1

Time of first breastfeed p30min 24 4.7

p15min 25 4.9 p1h 9 1.8

16–30min 46 8.9 41h 8 1.6

31–60min 81 15.7 424h 50 9.8

g
1.1–6h 226 43.9 Massage Oils

7–23h 66 12.8 Baby oil 32 7.0

1 day 30 5.8 Mustard oil 349 75.9

2–3 days 36 7.0 Coconut oil 38 8.3

4–5 days 5 1.0 Olive oil 31 6.7

d
Type of supplementary feed Ghee 12 2.6

Formula milk/animal milk 77 21.0 Othersh 3 0.6

Honey 148 40.3 Cord carei

Ghutti 143 39.0 Talcum powder 9 2.0

Kahwa 42 11.4 Cicatrin powder 99 21.9

Water 61 16.6 Ointment 89 19.7

Rose water 24 6.5 Spirit 26 5.8

Gripe water 17 4.6 Antiseptic (Dettol) 8 1.8

Tea/herbal water 19 5.2 Mustard oil/with onion/with salt 232 51.3

Otherse 36 9.8 Coconut oil 7 1.5

4 Ghutti is a herbal paste.

Ghee 31 6.9

Table 2 (continued) .
5
Newborn care practices n % Whenever stump is dry 4 0
.
4
9
.
Don’t know 2 0
Surma 21 6
.
Othersj 20 4
4
.
a n=514; missing information for one woman.
4
1 b

7 Kahwa is green tea.

Frequency of applicationk . c
Once a day 77 0 Others include herbal paste, caster oil, honey with warm
2–3 times per day 331 7 water, spices, tea, others. d n=367, excludes those woman who
3 exclusively breastfed.
. Multiple responses—do not add to 100%.
2 e
More than 3 times per day 38 8
 Others include cottage cheese, caster oil, herbal paste, spices,
biscuits, halwa, others.
f n=507; excludes 8 women who responded ‘don’t
know’.
g n=460; excludes those women who did not massage
daily.
Multiple responses—do not add to 100%.
h Others, not specified.
i n=452; excludes those woman who did not apply
substance.
Multiple responses—do not add to 100%.
j
Others include tumeric powder, gentian violet, others. k n=452;
excludes those women who did not apply substance.
low socioeconomic settlements, bolstered by
mass media campaigns, there is a noticeable
shift in traditional newborn care practices. For
example, a 25-year-old uneducated Pathan
woman stated that:
The doctors told me that the mother should
breastfeed after the delivery. Also, the
television commercials say the same. It is
very nutritious for the baby and makes the
baby healthy.
A 48-year-old illiterate Punjabi TBA voiced
similar sentiments:
Now they say on the television that one
should give breast milk to the baby. So, we
tell the women that doctors have told us that
the child should receive the mother’s milk
first of all.
Information from the survey substantiated the
information from the qualitative interviews.
Mothers/ mothers-in-law (24.3%), elders
(27.8%) and TBAs (7.0%) advised recent
mothers to give prelacteals to the baby. The
main reasons reported for giving prelacteals to
the baby were to ‘clean the baby’s stomach’
(19.4%) and to ‘soothe the baby’ (17.7%). On
the other hand, advice to refrain from giving
prelacteals was given by doctors (24.1%), TBAs
(5.8%) and other paramedical personnel (5.7%).
Only 5.6% of recent mothers reported that they
were advised to refrain from giving prelacteals
by their family, friends, and/or neighbors. In
general, giving supplemental feeds to the baby
was the norm, since it is believed that
supplementary feeds ‘cleaned out the baby’s
stomach’ (31.5%) and that ‘breast milk was not
enough’ (13.6%).
Caring for the neonate—beliefs and practices
Traditional neonatal care practices include
bathing, massage, cord care and instillation of
oil drops into the ear or nose. Mothers generally
reported that their newborns were bathed
immediately (82.1%) or within a half hour of
delivery (4.7%). Mothers (74.2%) generally
reported that the vernix should be removed as
it was ‘dirty looking’ (78.5%) or ‘harmful to the
baby’ (8.1%). Women who perceived the vernix
as risky for the baby described it as ‘infected
with germs’, ‘infected with germs from mother’,
and ‘having maternal intestinal content’.
Daily massage was commonly practiced (89.3%);
mustard oil (75.9%) was the most frequently
used lubricant. Other lubricants applied
included olive oil (6.7%), ghee (2.6%), and baby
oil (7.0%) (Table 2). Massage of the neonate is
perceived to be beneficial for the baby since it is
believed to foster muscle relaxation and
strengthening of the bones:
The newborn cannot move his/her own
body, so it needs assistance in strengthening
his/her bones. (age 45, educated, Mohajir,
parity four)
Massaging the baby makes the bones strong
and the child will learn to sit and walk at the
proper time. (age 23, educated, Pathan,
parity three)
The majority of women (80.2%) perceived
muscle relaxation as the principal benefit of
routine body massage, although some also
considered bone strengthening (43.0%) and
sitting (11.3%) or walking sooner (6.1%) as
additional benefits. However, a 29-year-old
educated Pathan mother described that
massage was avoided with ‘weak babies’:
Weak babies have soft bones and massage
will cause the baby’s bones to break. A baby
is considered weak if it is born before its due
date and is small in size. (age 29, educated,
Pathan, parity 5)
Although a string (46.8% unsterilized; 16.6%
sterilized) was most frequently used to tie the
cord, cord clamps (36.5%) were also reported.
Once the umbilical cord is cut, cleanliness is
important to avoid infection and to facilitate the
drying and healing of the umbilical stump. Most
women (87.8%) reported the application of a
range of substances to the umbilical stump for
faster healing (97.6%). Antibiotic ointments
(19.7%) or Cicatrins5 powder (21.9%) were
commonly used; few mothers reported using
antiseptics (Dettols6) (1.8%). Traditional
substances were also applied; over half of the
mothers applied mustard oil (51.3%), whereas
only few reported using coconut oil (1.5%),
ghee (6.9%), surma3 (4.6%), or tumeric paste
(0.8%). Substances were applied to the
umbilical stump two or three times a day
(73.2%); more frequent applications (8.4%)
were also reported (Table 2).
Our qualitative data suggest that not only are
multiple substances used for dressing the cord
but also that the perceived health benefits vary
by type of substance used.
We clean it (umbilical stump) with water and
antiseptic solution and cotton. After the cord
sheds, we put surma on it. We did this for 40
days. This helps fill the hole of the umbilical
stump. The dai advised us to use antiseptic
solution that helps to prevent germs. I also
put coconut oil on it, using my hand. (age 35,
educated, Pathan, parity seven) Some
women will put ash from the stove on the
cord that dries the cord quickly. (age 48, no
formal education, Punjabi, TBA)
When the cord wilted on the 3rd day, there
was a wound on it. We mixed salt and
mustard oil and put it on the cord using
cotton. This helped to treat the wound and
the cord dried out more quickly. We also
used antibiotic powder. (age 14, no formal
education, Sindhi, parity one)
Instillation of oil routinely into the ears (27.2%)
or nose (11.3%) was less frequently practiced.
Although instillation of oil-based drops into ears
and nose was not as common as other
traditional care practices, elders and TBAs
advocated this practice for its perceived health
benefits. For example, instilling nasal oil drops
with a cotton wick soaked in mustard oil was
practiced:
yif the newborn is sick or if his/her nose is
dry and the newborn cannot sleep. (age 19,
educated, Pathan, parity one)
Risky neonatal care practices
Risky feeding practices, prelacteals (55.0%),
delaying first feed (30.9%), and supplementary
feeds (71.3%), were common. Prelacteal feeds
were not as common as anticipated. Other risky
practices such as routine massage using
mustard oil (75.9%) or the application of various
traditional substances to the umbilical stump
(57.3%) were common newborn care rituals.
Among those women who reported massaging
their neonate, Pathans (27.4%) and Mohajirs
(22.0%) most often
Table 3
Descriptive frequency of traditional newborn care practices
among 515 mothers (low socioeconomic settlements, Karachi,
Pakistan, 2000)
Traditional newborn care practices Yes % (n)
Give prelacteals as first feeda 55.0 (283)
Delay first feed 30.9 (159)
Give supplementary feeds 71.3 (367)
Bathe immediately after birthb 82.1 (416)
Massage with mustard oil 67.8 (349)
Instill nasal/ear drops 28.2 (145)
Apply traditional substances to cord 57.3 (295)
a n=514; missing information for one woman.
b n=507; excludes 8 women who replied
‘don’t know’.
routinely massaged the neonate with mustard
oil as compared to Punjabis. Association
between ethnicity and routine massage or
ethnicity and cord care (risky vs.
benign/beneficial) depicted statistically
significant differences7 (Table 3).
Demographic and socioeconomic characteristics
such as maternal education, age, and
socioeconomic status were not significantly
associated with consumer status for prelacteals.
However, ethnicity was significantly associated
with consumer status. Although the strength of
the association (odds ratios) varied, Punjabis
5
Cicatrin powder is a combination of bacitracin and neomycin
6 Dettol is a chloroxylenol derivative.
Table 4
Percentage distribution of socio-demographic and maternal care coverage characteristics, unadjusted and adjusted odds ratio (OR) and 95%
confidence intervals (CI) among consumers (283) and non-consumers (231) of prelacteals (low socioeconomic settlements, Karachi,
Pakistan, 2000)
Characteristics Consumers % (n)
(OR 2.58; 95% CI 1.36–4.92) and Mohajirs (OR
2.15; 95% CI 1.27–3.66) were more likely to
report this care practice as compared to the
No %
‘‘other’’ ethnic group. On the other hand,
(n)
45.0 maternal health characteristics, such as parity,
(231) delivery location, and category of birth
69.1 attendants were strongly associated with
(356)
28.7 consumer status. Neonates that were delivered
(148) at home (OR 1.63; 95% CI 1.13–2.35), by TBAs
17.9
(OR 2.11; 95% CI 1.41–3.15) were significantly
(91)
32.2 more likely to be prelacteal consumers
(166) compared to neonates delivered at a facility or
71.8
by doctors (Table 4).
(370)
42.7
(220)
The adjusted odds ratios based on the final
multivariate logistic regression model is shown
in Table 4. An appreciable increase in the
strength of the association (odds ratio) is noted
for ethnicity; parity and birth attendant retained
their statistical significance with minimal change
in the odds ratio; facility delivery lost its
statistical significance. However, the data for
the final logistic regression model presented in
Table 4 are adjusted for the potential
confounding effects of maternal education,
socioeconomic status, antenatal visits, and
facility delivery. It is interesting to note that if
we present the model without adjusting for
these potential confounders the magnitude of
the effect size for ethnicity decreases
appreciably but the effect size for
7
Data available upon request.
Non-Consumers % (n) Crude OR (95% CI) Adjusted OR (95% CI)
Age (years)
[Ref]o20 8.5 (24) 8.7 (20)
20–29 62.5 (177) 57.1 (132) 1.12 (0.57–2.20)

X30 29.0 (82) 34.2 (79) 0.86 (0.42–1.78)

Formal education
Yes 38.2 (108) 38.5 (89) 0.98 (0.68–1.43) 0.82 (0.51–1.30)
[Ref] No 61.8 (175) 61.5 (142)

Socioeconomic status
Lower 15.9 (45) 18.2 (42) 0.95 (0.47–1.90) 1.08 (0.50–2.37)
Middle 72.1 (204) 68.8 (159) 1.13 (0.64–1.99) 1.03 (0.57–1.87)
[Ref] Higher 12.0 (34) 13.0 (30)

Ethnicity
Mohajir 31.1 (88) 24.7 (57) 2.15 (1.27–3.66) 4.04 (2.15–7.59)
[Ref] Sindhia 17.0 (48) 29.0 (67)

Pathan 34.3 (97) 34.6 (80) 1.69 (1.02–2.80) 2.22 (1.29–3.83)

Punjabi 17.6 (50) 11.7 (27) 2.58 (1.36–4.92) 4.09 (2.07–8.09)
Parity
Primipara 18.0 (51) 23.8 (55) 0.92 (0.54–1.55) 1.00 (0.58–1.73)
Multipara 55.1 (156) 43.7 (101) 1.52 (1.00–2.33) 1.57 (1.02–2.44)
[Ref] Grandmultipara 26.9 (76) 32.5 (75)

Antenatal visits
None 26.5 (75) 22.9 (53) 1.06 (0.61–1.85) 0.85 (0.47–1.54)
1–4b 52.3 (148) 57.6 (133) 0.83 (0.52–1.34) 0.79 (0.49–1.28)
[Ref]X5 21.2 (60) 19.5 (45)

Facility delivery
[Ref] Yes 44.5 (126) 56.7 (131)
No 55.5 (157) 43.3 (100) 1.63 (1.13–2.35) 1.20 (0.68–2.12)
Birth attendant
TBA 59.0 (167) 45.4 (105) 2.11 (1.41–3.15) 2.61 (1.39–4.88)
Paramedics 13.8 (39) 10.4 (24) 2.15 (1.15–4.05) 2.60 (1.37–4.91)
[Ref] Doctor 27.2 (77) 44.2 (102)

a
Sindhi includes Balochis (Consumer 6; Non-consumer 10).

b
1 to 4 antenatal visits includes women who went for ANC ‘whenever provider called’ or ‘had a problem’ (Consumer 63; Non-
consumer 70).

parity and birth attendant depicts a minimal decrease. We did not find any statistically significant
interactions between the variables in our final model.

Discussion

This study has demonstrated that prelacteals and supplementary feeding practices are still common,
although early breastfeeding initiation is better than expected and colostrum is less frequently
discarded. On the other hand, clinically acceptable newborn care practices for cord care, bathing, and
massage are uncommon; therefore, newborns remain at high risk of sepsis and hypothermia in these
low socioeconomic urban settlements.

A number of important methodological constraints should be considered when interpreting the results
of this study. It is important to highlight that newborn care practices were self-reported by women and
may be subject to various forms of recall and response bias. We attempted to decrease recall bias by
interviewing mothers within a two week timeframe immediately after the completion of the postpartum
period. Furthermore, this paper is part of a larger study that investigates a wide range of traditional
newborn care practices. An indepth analysis of prelacteals, rather than other risky newborn care
practices (delayed breastfeeding, supplemental feeds, bathing immediately after birth among others),
was conducted to assess factors associated with risky feeding practice of prelacteals to illustrate the
grasp that ingrained traditional customs/beliefs have on newborn care practices, after adjusting for
education. An additional methodological constraint is that this research focused on five low
socioeconomic settlements with a maternal health surveillance system; therefore, the study findings
may not be generalizable to women living in other low socioeconomic settlements of Karachi or
elsewhere in Pakistan.

Despite living in squatter settlements of Karachi, many women reported facility-based deliveries with
doctors or paramedics. Furthermore, most women had attended at least one antenatal check-up. In
contrast to the high level of home deliveries (83%) reported for a middle class community in Dhaka,
Bangladesh (Haider et al., 1999), the high utilization of health facilities for birthing in low socioeconomic
settlements in Karachi is an encouraging manifestation of the maternal health services outreach in urban
Pakistan.

What is even more encouraging is that health care providers imparted breastfeeding counseling (78.6%)
at antenatal visits, an appreciable proportion of women (41.7%) gave colostrum to neonate, and nearly a
third of women breastfed within the first hour. Studies conducted in similar Pakistani settings report that
the level of administration of colostrum varies between 3% (Karachi) and 18% (urban Punjab) (Akram,
Agboatwalla, & Shamshad, 1997; Kar, Morisky, & Chaudry, 1991). In other South Asian countries, studies
report lower levels for giving colostrum and initiating breastfeeding after birth (Haider et al., 1999;
Singhania, Kabra, & Bansal, 1990; Kumar, Nath, & Reddaiah, 1989). On the other hand, supplemental
feeds remained common (71.3%). Despite gains in appropriate breastfeeding practices in urban Pakistan,
giving prelacteals, delaying breastfeeding, and providing supplemental feeds continue to be a significant
public health concern for policy makers, program managers, obstetricians, and pediatricians.
To advocate a change in practices, not only must traditional and neonatal feeding practices be identified,
but also the underlying rationales such as perceived health benefits must be explored to enable a holistic
understanding and sensitivity to such culturally rooted rituals. Information from our qualitative findings,
substantiated by the quantitative data, shed light on the perceived benefits of such rituals. For example,
the perceived benefit for giving the neonate water was to allay fears of dehydration. It was also believed
to indirectly facilitate the neonate’s health, since it was perceived that when the newborn urinated
‘‘ythe heat inside the baby’s body is released and then the baby feels hungry’’. Giving ghutti to the
neonate to act as a laxative or to reduce colic is another example of the perceived benefits of certain
feeding practices. Consequently, recognition of women’s traditional knowledge, which is based on
humoral and health belief rationales, must be considered before developing health education strategies
for exclusive breastfeeding. The results from this study have also demonstrated that ethnicity and the
type of birth attendant at delivery were strong predictors for those women who gave prelacteals (after
adjusting for education, socioeconomic status and facility delivery). Therefore, the target audience for
health education messages should not only include family members and elders, but also TBAs and
paramedics.

Neonatal hypothermia is an important contributing factor to neonatal mortality (Mann, 1955; Mann &
Elliott, 1957) and morbidity (Dagan & Gorodischer, 1984; El-Radhi, Jawad, Mansor, Ibrahim, & Kamil,
1983) and is therefore a focus for essential newborn care (WHO, 1993). For instance, bathing the
neonate immediately or within a half hour of delivery has negative effects on thermal control, especially
among low birth weight babies (Raman, Rehka, & Chandrasekhara, 1996). More than three-quarters of
women in our study reported bathing their newborns immediately or within half an hour of delivery,
similar to studies conducted in other developing countries (Osrin et al., 2002; Kumar & Aggarwal, 1998).
We should be aware that this practice might have religious connotations especially among Muslims. In
traditional Muslim society, a male family elder usually recites azaan2 in the newborn’s ear soon after
delivery. The interplay between vernix conceptualized as ‘‘dirty looking’’ and bathing as ‘‘ritually
cleansing’’ must be recognized as a potential hurdle in advocating delaying bathing as a behavior change
strategy for preventing neonatal hypothermia.

Umbilical sepsis and associated neonatal septicemia can be prevented by keeping the cord clean, which
is one of the essential elements of newborn care practices. However, unsafe umbilical care practices
persist, especially in developing countries where most deliveries continue to be conducted at home by
untrained birth attendants. Although some women reported applying antibiotic ointment (19.7%) or
powder (21.9%), traditional substances such as mustard oil, ghee, surma, were commonly applied, which
is similarly reported in other South Asian countries (Osrin et al., 2002; Bennett et al., 1997). Previous
studies have demonstrated the relationship between neonatal tetanus and application of ghee to the
umbilical cord (Bennett et al., 1999; Bennett et al., 1995) and that the use of topical antimicrobials
reduces this risk (Bennett et al., 1997). However, given the sociocultural rationales, curtailment of
applying traditional substances to hasten drying and healing of the umbilical cord may prove difficult to
implement. Nevertheless, health education messages must be encouraged to reduce the use of
traditional substances and advocate the increased use of topical antimicrobials instead.

Another routine newborn care practice that is reported in South Asia (Darmstadt & Saha 2002;
Fernandez, Patkar, Chawla, Taskar, & Prabhu, 1987), including in this study, is the application of oils to
the skin of newborns. Recent evidence has demonstrated the potential neonatal health benefits of
2 Azaan refers to a call to prayer.
topical application using specific oils, improving skin barrier function (Darmstadt & Dinulos, 2000).
However, not all oils are universally beneficial. Some topical products such as mustard oil or olive oil may
have detrimental effects on the epidermal structure and barrier function, which increases the risk of
neonatal septicemia especially in low birth weight and premature babies (Darmstadt et al., 2002). The
dilemma arising from the near universal use of mustard oil might be allayed by further qualitative
research on its perceived benefits.

Little is known about routine newborn care practices in homes that might have an adverse impact on
neonatal mortality and morbidity. This study provides an important insight into these care practices and
will assist in the development of culturally appropriate health education interventions. Essential
newborn care interventions for breastfeeding, cord care, and oil massage are warranted to reduce
neonatal mortality and morbidity. Effective health education messages must emanate from within the
cultural context, where traditional knowledge concerning perceived health benefits are generated and
transmitted, in order to promote appropriate change in practices, which is the public health challenge
for improving newborn health care. Birth attendants, TBAs and relatives should, therefore, be
appropriately trained in best practices for newborn care especially in the first days of life. Efforts to
facilitate the development of a comprehensive maternal and neonatal health policy and programmatic
strategies that serve poor urban and rural women in Pakistan and other developing countries must
contemplate on the synergies between medical anthropology and the biomedical fields of obstetrics and
neonatology.

Acknowledgments

The authors wish to thank Ms Anne Tinker for her valuable comments on an earlier version of this paper.

They gratefully acknowledge the funding support of the John D. and Catherine T. MacArthur Foundation
and the Robert H. Ebert Program for Critical Issues in Reproductive Health.

References

Akram, D. S., Agboatwalla, M., & Shamshad, S. (1997). Effect of promotion of exclusive breastfeeding. Journal of Pakistan Medical Association,
47(2), 46–48.
Bennett, J., Azhar, N., Rahim, F., Kamil, S., Traverso, H., & Killgore, G., et al. (1995). Further observations on ghee as a risk factor for neonatal
tetanus. International Journal of Epidemiology, 24, 643–647.
Bennett, J., Ma, C., Traverso, H., Agha, B. S., & Boring, J. (1999). Neonatal tetanus associated with topical umbilical ghee: covert role of cow
dung. International Epidemiological Association, 28, 1172–1175.
Bennett, J., Macia, J., Traverso, H., Agha, B. S., Malooly, C., & Boring, J. (1997). Protective effects of topical antimicrobials against neonatal
tetanus. International Journal of Epidemiology, 26, 897–903.
Bhave, S. (1989). Trends in perinatal and neonatal mortality and morbidity in India. Indian Pediatrics, 26, 1094–1099.

Dagan, R., & Gorodischer, R. (1984). Infections in hypothermic infants younger than 3 months old. American Journal of Disease in Childhood,
138, 483–485.
Darmstadt, G. L., & Dinulos, J. G. (2000). Neonatal skin care. Pediatric Clinics of North America, 47, 757–782.

Darmstadt, G. L., & Saha, S. K. (2002). Traditional practice of oil massage of neonates in Bangladesh. Journal of Health & Population Nutrition,
20(2), 184–188.
Darmstadt, G. L., Mao-Qiang, M., Chi, E., Saha, S. K., Ziboh, V. A., & Black, R. E., et al. (2002). Impact of topical oils on the skin barrier: possible
implications for neonatal health in developing countries. Acta Pediatrics, 91, 546–954.
El-Radhi, A. S., Jawad, M. H., Mansor, N., Ibrahim, M., & Kamil, H. (1983). Infection in neonatal hypothermia. Archives of Disease in Childhood ,
58, 143–145.
Fernandez, A., Patkar, S., Chawla, C., Taskar, T., & Prabhu, S. V. (1987). Oil application in preterm babies, a source of warmth and nutrition.
Indian Pediatrics, 24, 1111–1117.
Fikree, F. F., Gray, R. H., Berendes, H. W., & Karim, M. S. (1994). A nested case–control study of maternal mortality from Karachi, Pakistan.
International Journal of Gynecology and Obstetrics, 47, 247–255.
Haider, R., Kabir, I., & Ashworth, A. (1999). Are breastfeeding promotion messages influencing mothers in Bangladesh? Results from an urban
survey in Dhaka, Bangladesh. Journal of Tropical Pediatrics, 45, 315–318.
Hosmer, D. W., & Lemeshow, S. (1989). Applied logistic regression. New York: Wiley.
Kar, S., Morisky, D., & Chaudry, S. (1991). Knowledge, attitude and practices of respondents regarding child care in Pakistan. Islamabad,
Pakistan: UNICEF.
Kumar, S., Nath, L. M., & Reddaiah, V. P. (1989).
Breastfeeding practices in a resettlement colony and their implications for promotional activities. Indian Pediatrics, 56, 239–242.
Kumar, R., & Aggarwal, A. K. (1998). Body temperatures of home delivered newborns in North India. Tropical Doctor, 28, 134–136.
Mann, T. P. (1995). Hypothermia in the newborn: a new syndrome? Lancet, ii, 613–614.
Mann, T. P., & Elliott, R. I. K. (1957). Neonatal cold injury due to accidental exposure to cold. Lancet, I, 229–234.
Nwankwo, B. O., & Brieger, R. (2002). Exclusive breastfeeding is undermined by use of other liquids in rural southwestern Nigeria. Journal of
Tropical Pediatrics , 48, 109–112.
Obimbo, E., Musoke, R. N., & Were, F. (1999). Knowledge, attitudes and practices of mothers and knowledge of health workers regarding care of
the newborn umbilical cord. East African Medical Journal, 76(8), 425–429.
Osrin, D., Tumbahangphe, K. M., Shrestha, D., Mesko, N., Shrestha, B. P., & Manandhar, M. K., et al. (2002). Cross sectional community based
study of care of newborn infants in Nepal. British Medical Journal, 325(7372), 1063–1067.
Oyo-Ita, A. E., Meremikwu, M. M., Edet, E. E., & Akpan, E. A. (1999–2000n). Neonatal tetanus in south eastern Nigeria: a qualitative study of the
pattern and influence of local perception. International Quarterly of Community Health Education, 19(3), 241–248.

Raman, V., Rehka, S., & Chandrasekhara, M. K. (1996). Effect of bathing on temperature of normal neonates. Indian
Pediatrics, 33, 340.
Schlesselman, J. J. (1982). Case control studies: design, conduct and analysis. New York: Oxford University Press.

Singhania, R. U., Kabra, S. K., & Bansal, A. (1990). Infant feeding practices in educated mothers from upper socio economic status. Indian
Pediatrics, 27, 591–593.
SPSS statistical software. (1999). SPSS Base 11.5 for Windows. Chicago, IL: SPSS, Inc.

United Nations Children’s Fund. (1999). Trends in childhood mortality in the developing world 1960–1996. New York: UNICEF.
World Health Organization (WHO). (1993). Thermal control of the newborn: a practical guide. Geneva: Maternal Health and Safe Motherhood
Program; Division of Family Health,

WHO.

World Health Organization (WHO). (1996). Perinatal mortality: a listing of available information. FRH/MSM. 96.7. Geneva: WHO.

World Health Organization (WHO). (2001) estimates. Based on data collected around 1999.