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Breastfeeding Practices and Health-seeking Behavior for Neonatal

Sickness in a Rural Community

Article  in  Journal of Tropical Pediatrics · January 2006

DOI: 10.1093/tropej/fmi035 · Source: PubMed

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Breastfeeding Practices and Health-seeking Behavior
for Neonatal Sickness in a Rural Community
by Monika Kaushal, Rajiv Aggarwal, Ashwani Singal, Hemant Shukla, Suresh K. Kapoor, and Vinod K. Paul
Department of Pediatrics and Community Medicine, All India Institute of Medical Sciences, New Delhi, India

Summary
The aim of the study was to evaluate the knowledge of mothers and grandmothers regarding
breastfeeding and health-seeking behavior for neonatal sickness in a rural community. A cross-sectional

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survey, using a triangulation of qualitative (focus group discussion) and quantitative (structured
questionnaire) methods was carried out. Although most of the grandmothers and mothers believed in
early feeding within 2 h of delivery, they often administered prelacteal feeds such as ghutti and honey.
Colostrum was considered beneficial. Most respondents believed that ghutti, water, or both should be
given along with breastmilk. Diluted buffalo milk was the preferred choice if supplementation was
required. It was thought that weaning should be introduced after 6 months of life. Mothers preferred
to give dalia and khichri as the initial weaning food compared to roti and dal water by grandmothers.
Both grandmothers and mothers felt that a baby who was playful and not crying excessively was usually
healthy. Most of the respondents described the normal pattern of breathing, feeding, urination, and
defecation adequately. Most of the grandmothers and mother’s felt that by touching forehead and limbs
of baby could reliably assess temperature. Refusal to feed was considered as a marker of a sickness by
most grandmothers and mothers. However, they also believed that health-seeking for poor feeding could
be delayed for 1 day. Respiratory distress was described by the presence of fast respiration, chest
retractions, or noisy breathing. Most respondents did not know how to assess cyanosis or seizures.
Jaundice was descried as yellowish discoloration of skin, eyes, and urine. Failure to pass urine for 4–6 h
bothered most of the respondents. The first response to illness was home remedies. The choice of
healthcare was unqualified village practitioners followed by government hospital. Knowledge regarding
desirable breastfeeding practices was inadequate and quite a few inappropriate beliefs were widely
prevalent. Although knowledge regarding sickness was present, health-seeking from qualified providers
was considerably delayed with most respondents preferring village practitioners to government
hospitals.

Introduction to risk of complications and delayed recognition of

India has made significant progress in reducing
infant mortality in the last three decades. The
infant mortality rate (IMR) in India has dropped
by almost 50 per cent from 140 in 1972 to 68 per 1000
live births in 2000.1 However, this decline has
been almost static for the last 10 years. One of the
reasons for static IMR has been the poor decline in
neonatal mortality rate (NMR). Further improve-
ment in infant survival is critically linked to improved
newborn survival.
Family practices and behavior play a fundamental
role in the care of newborn infants. Inappropriate
feeding and other practices predispose neonates
Correspondance: Dr Rajiv Aggarwal, Assistant Professor,
Department of Pediatrics, All India Institute of Medical
Sciences, Ansari Nagar, New Delhi 110029, India.
E-mail 5rajivreema@hotmail.com4.
illness, and delayed health seeking may lead to a
potentially preventable death. Hence it is of immense
value to understand community perceptions about
newborn health in order to devise behavioral change
communication strategies. With this objective we
conducted this observational study on knowledge
of newborn care and attitudes among mothers and
grandmothers in villages around Ballabhgarh in rural
Haryana.
Materials and Methods
Study setting
Seven villages around Ballabhgarh, a rural area in
Haryana, with a population of 40 000 were selected
for the study. Two primary health centers under the
rural outreach program of AIIMS provide health
services. In addition there are several unqualified

ß The Author [2005]. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org 366
doi: 10.1093/tropej/fmi035 Advance Access Published on 31 May 2005
M. KAUSHAL ET AL.
village practitioners and traditional birth attendants.
Mothers and grandmothers whose infants were less
than 1 year old were the respondents.
Methodology
Whenever community behavior is to be seen the
methodology used is qualitative followed by quanti-
tative. We chose focus group discussions (FGDs)
and structured questionnaire for collecting infor-
mation for qualitative and quantitative surveys,
respectively.
Five FGDs were conducted in different villages.
For FGDs, 12 grandmothers in Dyalpur and nine
each in Shahpurkala and Sotai villages were taken.
Two FGDs with mothers were conducted in
Dyalpur and Bokhrala villages. One coordinator
conducted the cross-sectional survey with the FGD.
One reporter sat at the back to note the response
given by each. A tape recorder was also kept in the
centre after seeking permission from the group in
order to ensure accurate recording of all responses
from the respondents. After an initial introduction
about the objectives of the meeting, trigger questions
were floated in the group. The responses were
recorded on the tape recorder as well as noted
down verbatim by the reporter.
Common issues relating to breastfeeding and
health-seeking behavior were identified and a struc-
tured questionnaire was formulated which was first
subjected to pre-testing. Two villages were chosen.
A convenient sample size of 30 was chosen. In each
village, using stratified sampling, 30 houses were
chosen. The same person visited all the houses. The
mothers and the grandmothers were interviewed
separately. The answers given were noted down
verbatim.
Results
Feeding practices: FGDs
Three rounds of FGD with grandmothers and two
rounds of FGD with mothers were conducted in
five different villages of Ballabhgarh (Table 1). All
respondents were living in joint families. Almost all
respondents believed in giving pre-lacteal feeds in
the form of honey, ghutti, sugar, and tea. Although
the majority believed in early feeding within an
hour, almost all of them preferred to give pre-lacteal
feeds prior to breastfeeding. According to some
grandmothers, breastfeeding was started according
to the time of birth of the baby. If the baby was born
in the morning, breastfeeding was started in the
evening after seeing the stars, and if the baby was
born in the night, feeding was started within a
few hours or early morning. Very few grandmothers
were of the view that breastfeeding should be
started early.
Journal of Tropical Pediatrics Vol. 51, No. 6
Almost all believed in giving colostrum, although
a few grandmothers were against it, because they
thought that it was old and stored milk, and hence
not good for the baby. Almost everyone believed
in using daily supplements like ghutti, water, or
honey along with breastmilk. Very few mothers
expressed knowledge about exclusive breastfeeding;
however, they were concerned that they may not be
able to practice due to the contrary opinion of the
grandmothers.
Most of the grandmothers and mothers believed in
predominant breastfeeding up to 4–6 months of age.
Some grandmothers believed in continuing exclusive
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breastfeeding up to 1–2 years. Only a few grand-
mothers and mothers were in favor of using top-up
milk in the first 4–6 months of life and felt that it
was necessary only if mothers were away working in
the fields or the baby cried excessively. The most
common top milk used was diluted buffalo milk with
dilutions varying from 2 : 1 to 4 : 1.
Complementary feeds were inadequate and
included pieces of roti, dal ka pani, and biscuits.
Age at which complementary feeds were introduced
varied from 4 months to 4 years, with grandmothers
preferring to start weaning foods later. The majority
of mothers had a proper knowledge of weaning, but
felt that they could not adopt these practices due to
the views of the grandmothers. Almost all grand-
mothers felt that babies were ready to partake
of home food by 3–4 years of age, while mothers
felt they were ready by 1–2 years. Grandmothers
correlated the correct age to start complementary
feeds with various milestones including the child
asking for the roti and food, the child starting to
walk, and/or eruption of teeth.
Feeding practices: structured questionnaire
According to data obtained from the structured
questionnaires (Table 2), 68 per cent of mothers and
88 per cent of grandmothers would start feeds within
2 h of birth. However, the majority of respondents
(65 per cent mothers and 85 per cent grandmothers)
felt that the first feed should be ghutti and not
breastmilk. A few (20 per cent) mothers believed in
delaying breastfeeding until 6 h after delivery, com-
pared with 62 per cent of grandmothers. Colostrum
should be given according to 79 per cent mothers
and 82 per cent grandmothers.
Exclusive breastfeeding (without ghutti) was con-
sidered as a feeding option in only 7 per cent of
grandmothers and mothers. Most respondents felt
that ghutti should be given along with breastmilk in
the first 4 months of life (48 per cent mothers and
59 per cent grandmothers). Predominant breastfeed-
ing should be continued up to 4–6 months according
to 31 per cent of mothers and 22 per cent of grand-
mothers. An overwhelming 48 per cent of mothers
and 77 per cent grandmothers preferred to continue
367
 M. KAUSHAL ET AL.

Table 1
Focus Group Discussion (FGD): knowledge of the mothers and grand mothers regarding feeding practices

Feeding practice Mothers (n ¼ 22) Grandmothers (n ¼ 30)

Staying in a joint family? 22 30

When should the first feed be given after birth? 1–2 h: 20 1 h: 29
2–6 h: 2 when cries: 1
What should the first feed be?
Mothers’ milk 5 6
Prelacteal 17 (13 honey, 4 others) 24 (16 honey, 3 ghuti, 4 others)
When should breastfeed be given?
1–2 h 5 6

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2–6 h 11 3
46 h 6
If born in the morning, then feed in evening after – 18
the stars shine; if born in the evening, then feed
within 2 hours or after 4 am
When cries after being given ghutti – 3
Should colostrums be given?
Yes 20 22
No 2 8
What should be given in the first 4 months?
Only BF 3 1
BF þ ghutti 2 –
BFþ ghutti þ water 15 29
BF þ water 2
What should be the duration of exclusive breast feeding?
52 months 7 3
4–6 months 12 14
6–12 months 2 6
412 months 1 4
Depends on the mothers’ milk output 3
When should top milk be given?
52 months 5 2
2–4 months 2 2
4–6 months 9 2
46 months 6 24
Which milk can be used as top-up milk?
Cows diluted 2 2
Cows undiluted 2 2
Buffalo diluted 18 24
Buffalo undiluted
When should top-up milk be given?
Decrease milk 4 6
Mother working 1 24
Mother-in-law says 17
How should top-up milk be given?
Katori spoon 16 28
Bottle 6 2
What food should be started as weaning food? 10: dalia þ khichri 11: biscuit, roti
2: dal water 5: dal water, roti
4: dal and rice water 9: khichri, dalia, rice, roti
6: whatever is cooked 5: whatever is cooked
in the house in the house

(continued )

368 Journal of Tropical Pediatrics Vol. 51, No. 6

M. KAUSHAL ET AL.
Table 1
Continued
Feeding practice
When should weaning be started?
54 months
4–6 months
6–10 months
10–12 months
412 months
By what age can the baby eat most foodstuffs
cooked in the house
51 year
1–3 years
44 years
predominant breastfeeding without introducing
complementary feeding beyond 6 months of age.
Only 34 per cent of mothers and 25 per cent of
grandmothers considered it appropriate to introduce
complementary feeding by 4–6 months of age. Dalia
and khichdi were the choices for complementary
foods among 41 per cent of mothers and 34 per cent
of grandmothers. However, most of the respondents
(59 per cent mothers and 66 per cent grandmothers)
expressed that they were not absolutely sure when
to start weaning and what semi-solids to wean with.
Health-seeking behavior: FGD
Most felt that a healthy baby feeds well, plays, and
sleeps after a feed (Table 3). A sick baby, according
to them, cries excessively and is inconsolable on
picking-up and on being fed. Almost all believed that
passing urine is very important. Homemade remedies
for anuria included giving lemon water or soda
water, pouring warm water on the abdomen, or
keeping a wet cloth on the abdomen.
Most of the respondents felt that failure to pass
stools for 3–5 days was acceptable before seeking
medical attention. Homemade remedies for this prob-
lem included pudina, onion water, and soap enema.
Regarding loose stools, most respondents felt that
even four to five loose stools were significant as they
could result in significant loss of body water and
cause dehydration and death. Home treatment
included sugar–salt solution (a glass of water, a
pinch of salt and a spoon of sugar with lemon,
kali ghutti).
Most respondents were aware of jaundice and
described it as staining of eyes, urine, and clothes.
Most felt that fever could be diagnosed by feeling the
forehead and the hands. A few described fever as the
presence of a hot forehead with cold hands. A few
thought that it was significant only if it was
associated with poor feeding, lethargy, and rapid
breathing. Signs such as respiratory distress and
Journal of Tropical Pediatrics Vol. 51, No. 6
Mothers (n ¼ 22) Grandmothers (n ¼ 30)
3 3
10 8
4 6
2 7
3 6
14 13
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8 15
2
vomiting were well described by most respondents.
Grandmothers described difficult signs like cyanosis
and seizures better than the mothers.
On being asked about health-care seeking, most
felt that it was appropriate to first try home-based
remedies and then seek medical attention. If medical
attention was required, they preferred to take the
child first to the unqualified village practitioners
and then to government hospitals. Reasons for not
taking a sick baby to the government hospital
included distant location, long queues, and impolite
and callous behavior of the staff.
Health seeking behavior: structured questionnaire
Most respondents (79 per cent mothers and 85 per
cent grandmothers) felt that a healthy baby could
be recognized by playful behavior and not crying
excessively (Table 4). Most respondents described
a normal pattern of feeding, urination, and defeca-
tion well. Regarding body temperature, 90 per cent
of grandmothers and mothers felt that touching
the forehead and limbs of the baby could assess it.
Normal breathing was recognized as a baby
being comfortable by 65 per cent of mothers and
grandmothers. The baby should sleep after every
feed according to 50 per cent of mothers and
grandmothers.
Refusal to accept feed for 5–10 h was a marker
of a sick baby according to 41 per cent of mothers
and 28 per cent of grandmothers. However,
healthcare-seeking for poor feeding could be delayed
up to 1 day according to 57 per cent of mothers
and 13 per cent of grandmothers. Most of the respon-
dents expressed their ability to diagnose respiratory
distress in a baby and described it varyingly as the
presence of fast breathing tachypnea, chest retrac-
tion, or noisy breathing. The majority of the
respondents (69 per cent mothers and 42 per cent
grandmothers) answered that they did not know
how to assess cyanosis. Most respondents described
369
 M. KAUSHAL ET AL.

Table 2
Structured questionnaire: knowledge of mothers and the grand mothers regarding feeding practices

Feeding practices Description Mother Grandmother

n ¼ 29 (%) n ¼ 27 (%)

When should the first feed be given after birth? 52 h 22 (68) 24 (88)
2–6 h 7 (24) 3 (11)
46 h
What should be the first feed? Breastfeed 10 (34) 2 (13.5)
Honey 19 (65) 23 (85)
Others 2 (13.5)
When should breastfeed be given? 52 h 15 (51) 2 (7.4)

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2–6 h 8 (27) 8 (29)
46 h 6 (20) 17 (62)
Should colostrum be given? Yes 23 (79.3) 24 (82.8)
No 6 (20.7) 3 (10.3)
What should be given in the first 4 months? Only BF 2 (6.8) 2 (7.4)
BF þ ghutti 14 (48) 16 (59.2)
BF þ ghutti þ water 10 (34) 5 (18.5)
BF þ water 2 (6.8) 3 (11)
Others 1 (3.4) 1 (3.7)
What should be the duration of exclusive breast feeding? 54 months 6 (20.6) 2 (7.4)
4–6 months 9 (31) 6 (22)
6–12 months 9 (31) 16 (59)
412 months 5 (17.2) 5 (18.5)
When should top-up milk be given? Decrease milk 24 (82.8) 1 (3.4)
Mother working 3 (10.3) 25 (86.2)
Mother-in-law says 2 (6.9) 1 (3.4)
Which milk can be used as top-up milk? Cows diluted 8 (27.6) 1 (3.4)
Cows undiluted 3 (10.3) 3 (10.3)
Buffalo diluted 15 (51.7) 20 (74)
Buffalo undiluted 0 2 (7.4)
When should top-up milk be started? 52 months 4 (13.7) 0
2–4 months 4 (13.7) 1 (3.7)
4–6 months 8 (27.6) 6 (22.2)
46 months 13 (44.8) 20 (74)
How should top-up milk be given? Katori spoon 20 (68.9) 25 (86.2)
Bottle 9 (31) 2 (7.4)
When should weaning be started? 54 months 3 (10.3) 0
4–6 months 10 (34.4) 7 (25.9)
6–10 months 7 (24) 7 (25.9)
10–12 months 4 (13.7) 9 (33.3)
12 months 5 (17.2) 6 (22.2)
What food should be started as weaning food? Dalia þ khichri 12 (41) 10 (34.5)
Dal ka pani 9 (31) 5 (17.2)
Dal þ rice ka pani 6 (20) 10 (34.5)
Dal ka pani þ roti 2 (6.9) 2 (6.9)

jaundice as yellowish discoloration of the eyes and/or
urine. Respondents would seek care for vomiting
more than 2–3 times and the inability to pass stools
for 2–4 days. Regarding loose stools, most of the
respondents linked it to frequency rather than to
consistency of the stools. Only 10 per cent of mothers
and 21 per cent of grandmothers could describe
abnormal movements and were aware of its implica-
tion. Inconsolable crying was thought to be the most
important parameter for a sick baby. Inconsolability
was described as crying that was unresponsive to
being fed or being picked up. Home remedies were
the first response for treatment. The first option
for healthcare providers was village practitioners
(27 per cent) followed by government hospitals
(6 per cent). The next option in case of non-response
was private practitioners (27 per cent), traditional
healers (24 per cent), and government hospitals

370 Journal of Tropical Pediatrics Vol. 51, No. 6

M. KAUSHAL ET AL.

Table 3
Focus Group Discussion: health-seeking behavior of grandmother

Variables Description Mothers (n ¼ 22) Grand mothers (n ¼ 30)

How to assess that baby is not sick Playing þ not crying 5 22

Playing þ feeding well 17 6
Poor feeding 3–4 h 12 2
5–10 h 8 10
1 day 2 10
41 day 0 8
Poor activity Not playing 18 20
Other than normal 4 10

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Not passing urine worries them 54 h 8 14
4–8 h 11 9
48 h 3 5
Not known 0 2
Not passing stools worries them 1–2 days 4 10
2–5 days 8 19
45 days 10 1
How many loose stools worry them 55 18 19
5–10 4 5
410 0 4
Not known 2
Abdominal distension þ Tight 1 4
þ Vomit 5 7
þ Other symptoms 6 8
Not known 10 11
No. of vomiting that worries them 2–3 10 5
4–6 10 14
6–10 2 11
How to assess jaundice Eyes and hand yellow 8 18
þ Clothes yellow 4 4
þ Urine yellow 10 8
þ Stools white 1
How to assess fever Head & hand hot 9 18
þ Refusal to feed 4 5
þ Lethargic 1 1
þ Rapid breathing 2 4
Head hot, hands cold 0 2
Warm breath 2 0
Increased pulse & hot 4 0
Respiratory distress Retractions 10 10
Rate 2 4
Restless þ cries 5 4
Rate þ retractions 5 12
Cyanosis Not known 16 10
Blue color lips 4 6
Glow lost 2 14
Inconsolable cry Not known 2 1
On feeding 10 15
On picking 10 14
Treatment from where First home than private 12 1
Private (pvt) 12 10
Government (govt) 8 9
First home than pvt than govt 2 10

(continued )

Journal of Tropical Pediatrics Vol. 51, No. 6 371

 M. KAUSHAL ET AL.

Table 3
Continued

Variables Description Mothers (n ¼ 22) Grand mothers (n ¼ 30)

Home treatments For jaundice: morning sunlight,
tube light, no yellow clothes
Fever: cold sponging, nimulid and
paracetamol, plenty of water
Loose stools: ORS, sugar salt
solution
For jaundice: beads, chandrawali
waterbathing, morning sunlight,
traditional healer
Fever: cold food, lemon water, cold
sponging, cold food
Loose stools: glass of water pinch
of salt and one spoon of sugar kali
ghuti lemon water

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Not passed urine: plenty of water
to drink, water on the private parts
and abdomen, hing application
Vomting: no suggestion
If not passed stools: suhaga, salt
water, churan, soap enema
Not passed urine: hot water on
abdomen, keep wet cloth on
abdomen, give soda water to drink,
hing on umbilicus, hot water on
abdomen
Vomiting: onion, pudina, honey
If not passed stool: pudina, soap
enema rat stool þ hing þ soap mix
and put on umbilicus

(27 per cent). Reasons for government hospitals
being the last choice included the need to stand in
long queues and the need to know someone in the
hospital to get the best treatment.
Discussion
This study was conducted to document the various
feeding practices and neonatal healthcare-seeking
behavior in the rural villages around Ballabhgarh.
Both qualitative and quantitative methods were
employed in order to have the benefit of triangula-
tion and hence an improvement of the results.
It appears from the study that despite having
known about the benefits of breastfeeding for such
a long time, we have not been able to disseminate
this knowledge effectively in our rural population.
Although most of the mothers and grandmothers
expressed their willingness to breastfeed, there were
many inappropriate practices especially with regard
to initiation and prelacteal feeds. Although some
mothers were in favor of initiation of breastfeeds,
they indicated their inability to do so because of
contradictory opinions of their mothers-in-law.
Although some feeds were started early for most
neonates, they were in the form of prelacteal feeds
like ghutti and honey, which continued throughout
the first 4–6 months along with breastfeeding. Most
of the respondents believed in giving colostrum to the
babies.
Most of the respondents felt it necessary to add
top-up milk only after 4–6 months of breastfeeding.
Earlier introduction of top-up milk was considered
necessary for working mothers and for a baby that
cried excessively. Top-up milk was usually diluted
buffalo milk as it is readily available.
Gururaj, et al.2 found that various types of
prelacteal feeds either in isolation or in combination
were used in rural area near Banglore. Sugar, water,
and castor oil were the main prelacteal feeds used.
Colostrum was administered in a very small number
of infants. Hossain, et al.3 found that 60 per cent
infants in Egypt were fed sugar water, tea or both
as prelacteal feeds. In his study, infants receiving
prelacteal feeds were significantly less likely to be
exclusively breastfed. In contrast, in a study con-
ducted by Mahgoub, et al.4 in Botswana, 95 per cent
of mothers had started breastfeeding immediately
after delivery. From an African study it was found
that cultural factors and taboos have a powerful
influence on feeding practices and eating patterns.
Young mothers often find it impossible to ignore
their ill-informed elders or peer group.5 It was seen
in Aligarh that 99 per cent of the infants received
a prelacteal feed, especially ghutti (94 per cent),
within 6 h of delivery. Ninety-nine per cent were
breastfed. Breastfeeding began between 6 and 72 h
of birth. Almost all mothers believed ghutti cleanses
the intestines and that colostrum is harmful. They
discarded the colostrum and most of the infants
received diluted top-up milk. Half of the mothers did
not give their infants semi-solid foods until after
9 months, and about one-quarter did not give any
semi-solid or solid food until 1 year. The findings
revealed that inadequate knowledge about proper
weaning, not lack of food, is the limiting factor in
infant nutrition.6 Bhat, et al.7 found that mothers
whose infants were well nourished had a higher

372 Journal of Tropical Pediatrics Vol. 51, No. 6

M. KAUSHAL ET AL.

Table 4
Structured questionnaires: health-seeking behavior of the grandmothers and mothers

Variables Description Mother 29 (%) Grandmother 27(%)

Healthy Playing þ not crying 23 (79.3) 24 (85.7)

Playing þ feeding well 4 (13.8) 3 (10.7)
Normal 2 (6.9)
Feeding normally Not known 1 (36)
2–3 hourly 15 (51.7) 30 (71.4)
4–6 hourly 14 (48.3) 6 (21.4)
Active Playful 27 (93.1) 26 (92.9)
Normal 2 (6.9) 2 (3.6)

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Pink Not known 10 (34.5) 10 (35.7)
Glow 16 (55.2) 16 (57.10)
Normal 3 (10.3) 1 (3.6)
Temperature Not known 1 (3.6) 1 (3.6)
Touch and see 26 (92.9) 26 (92.9)
Normal activity 1 (3.6)
Urine Not known 2 (7.4) 1 (3.6)
4–5/day 16 (55.2) 6 (21.4)
5–10/day 6 (20.7) 12 (42.9)
410/day 5 (17.2) 8 (28.6)
Stool 1–5/day 17 (58.6) 12 (42.9)
5–10/day 2 (6.9) 3 (10.7)
1 in few days 9 (31) 11 (39.3)
Variable 1 (3.4) 1 (3.6)
Breathing Not known 8 (27.6) 5 (17.9)
Comfortable 19 (65.5) 19 (67.90)
Looks normal 2 (6.9) 2 (7.1)
Feeds well 1 (3.6)
Sleep Not known 5 (17.2) 5 (17.9)
2–6 h 7 (24.1) 8 (28.6)
After every feed 17 (58.6) 14 (50)
Poor feeding 3–4 h 11 (37.9) 1 (3.6)
5–10 h 12 (41.4) 8 (28.6)
1 day 4 (13.8) 16 (571)
Other than routine 2 (6.9) 2 (7.1)
Poor activity Not known 1 (3.4) 1 (3.6)
Not playing 26 (89.7) 26 (92.9)
Other than normal 2 (6.9)
Respiratory distress Not known 2 (6.9) 0
Retractions 5 (17.2) 9 (32.1)
Rate 5 (17.2) 4 (14.3)
Restless þ cries 6 (20.7) 3 (10.7)
Rate þ retractions 7 (24.1) 8 (28.6)
Noisy breathing 4 (13.8) 3 (10.7)
Cyanosis Not known 20 (69) 12 (42.9)
Blue color of lips 4 (13.8) 10 (35.7)
Glow lost 5 (17.2) 5 (17.9)
Yellow/jaundice Not known 12 (41.4) 3 (11.1)
Eye yellow 12 (41.4) 11 (40.7)
Nail þ urine þ eye yellow 4 (13.8) 11 (40.7)
Above þ clothes yellow 1 (3.4) 1 (3.7)
Abdominal distention Not known 21 (72.4) 5 (53.6)
Tight 2 (6.9) 8 (28.6)
Vomit 2 (6.9) 3 (10.7)
þ Other symptoms 4 (13.8) 1 (3.6)

(continued )

Journal of Tropical Pediatrics Vol. 51, No. 6 373

 M. KAUSHAL ET AL.

Table 4
Continued

Variables Description Mother 29 (%) Grandmother 27(%)

Vomiting Not known 1 (3.4) 0

2–3 21 (72.4) 17 (60.7)
4–6 6 (20.7) 10 (35.7)
6–10 1 (3.4) 0
Not passed urine 2–4 h 7 (24.1) 3 (10.7)
4–6 h 5 (17.2) 5 (17.9)
6–12 h 6 (20.7) 8 (28.6)
1 day 11 (37.9) 11 (39.3)

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Not passed stool 1 day 6 (20.7) 2 (7.1)
2–4 days 18 (62.1) 16 (57.1)
5–8 days 5 (17.2) 6 (21.4)
48 days 3 (10.7)
Loose stools Not known 1 (3)
4–5 13 (44.8) 8 (28.6)
5–10 10 (34.5) 5 (17.9)
10–15 5 (17.2) 14 (50)
Abnormal movements Not known 26 (89.7) 21 (75)
Limb movements persistent 2 (6.90) 6 (21.4)
Froth 1 (3.4)
Inconsolable cry Not known 4 (13.8) 1 (3.6)
On feeding 11 (37.9) 12 (42.9)
On picking up 7 (24.1) 8 (28.6)
On feeding and on picking up 7 (24.1) 6 (21.4)
First treatment to be sought Hospital 2 (6)
Private doctor 11 (37)
Traditional healer –
Home remedy 16 (55)
Second treatment to be sought Hospital 8 (27)
Private doctor 8 (27)
Traditional healer 7 (24)
Home remedy 6 (20)
Third treatment to be sought Hospital 17 (58.6)
Private doctor 7 (24.1)
Traditional healer 5 (17.2)
Home remedy

level of breastfeeding knowledge than those whose
infants were moderate to severely malnourished.
In Sewagram, it was seen that illiterate women and
mothers with a primary school education, multi-
paras, and those living in joint families were most
likely to defer weaning until after 6 months.8
Knowledge regarding age of complementary feed-
ing (CF) and CF foods was inappropriate in this
population. Some respondents felt that this could be
delayed and predominant breastfeeding continued
until 1–2 years of life. This could be one of the
factors responsible for malnutrition and iron defi-
ciency anemia in infants more than 6 months old.
Although mothers expressed the opinion of early
semi-solid feeds, this was negated by grandmothers
who felt that CF should be commenced when the
infant starts walking or asking for food.
There were some major differences in knowledge
relating to feeding practices between mothers and
grandmothers. During FGDs mothers reiterated that
although their knowledge was different, they usually
followed practices as advised by grandmothers.
As far as CF is concerned, most of the studies have
reported practices varying with the prevailing cul-
tural practices of a particular area. Data from
National family health survey (NFHS-2)9 revealed
that breastfeeding is delayed for the vast majority
of children and most mothers squeeze out the first
breastmilk. Instead of exclusive breastfeeding, almost
half of the children under 4 months old are given
water or other supplements along with breastmilk.
The introduction of solid food is delayed. The good
thing in our study was that these malpractices,
although present, were much less compared with

374 Journal of Tropical Pediatrics Vol. 51, No. 6

M. KAUSHAL ET AL.
data from all over the country as obtained by
NFHS-2. A recent survey has shown that promotion
of exclusive breastfeeding until 6 months of age in
a developing country through existing primary
healthcare services is feasible, reduces the risk of
diarrhoea, and does not lead to growth faltering.10
The second component of the study addressed
the issue of healthcare-seeking behavior for
neonatal sickness in the community. Most of the
mothers and grandmothers were well versed in
recognizing a healthy neonate and provided
acceptable limits for patterns of feeding, sleeping,
urination, and defecation. They were also adept in
picking up danger signs such as poor activity,
poor feeding, hypothermia, and respiratory distress.
Most expressed an inability in picking up difficult
signs like cyanosis and seizures. Grandmothers
had many homemade remedies for common
ailments, some of which could be harmful. A study
in Sudan showed that grandmothers play a signifi-
cant role in health education and child care within
families in the Sudan.11
In a recent study it was seen that seeking care
was less common (57 per cent) for those who died
before the first week of life and was delayed (25 per
cent) after that period.12 They found major lacunae
in care-seeking behavior and care provided to
sick infants. The majority of deaths occurred in
infants aged less than 4 months who were malnour-
ished. Hence the main problem, which seems to be
prevalent, is delay in recognition, assessment, and
action at all levels and this needs to be rectified.
In Pakistan the factors responsible for increased
infant mortality were mothers changing healers
too frequently and using traditional healers.13
Birth order, complications during pregnancy,
and/or delivery and death of a sibling were found
to be significantly associated with reported neonatal
14
morbidity in a study in Bangladesh.
Despite knowing the signs of neonatal illness,
health-seeking was usually delayed. Most households
preferred to use homemade remedies and when
these failed, they approached the nearby private
practitioners. This practice could be due to the
easy availability of the doctor next door or due
to distant and unfriendly service in government
hospitals. Ahmed, et al.14 found that different
providers were contacted, the commonest being
homeopaths (38 per cent) and village doctors
(37 per cent). Seventeen per cent were taken to
trained providers, and only 5 per cent to government
health facilities. In Bengal, a persistence of gender
disparities in health-seeking was found.15
Information gathered from this survey suggests
that the private practitioners are the first contact
with the medical facility and it becomes paramount
to assess their knowledge with respect to neonatal
care. Investing in government hospitals may not be
effective in reducing neonatal mortality as these
Journal of Tropical Pediatrics Vol. 51, No. 6
facilities are usually the last option and by the time
help is sought from hospitals, it is probably too
late. There is an urgent need to make government
healthcare facilities more patient-friendly so that
proper medical care is sought more quickly.
Conclusions
Although knowledge regarding breastfeeding was
present in the community, feeding malpractices in
the form of delayed initiation of breastfeeding, sup-
plementing breastmilk with ghutti/water, and delayed
weaning was widespread in the community. Although
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mothers seemed better informed regarding acceptable
feeding practices, grandmothers dictated practices
in the household. Grandmothers unanimously did
not believe in early weaning with semi-solid foods.
Health-seeking behavior was quite variable.
Although most respondents were adept in recogniz-
ing early markers of neonatal illness, there was an
inappropriate delay in getting medical help for the
sick neonate. Home remedies were always the first
option followed by treatments from private practi-
tioners. Government health facilities were usually
the last choice.
There is an urgent need for behavior change
strategies to improve feeding practices. There is an
urgent need to conduct a survey of village practi-
tioners for their ability to diagnose and treat neonatal
ailments. Village practitioners need to be involved
in newborn care programmes since they are early
providers of neonatal care. A definite cause of
concern is the apparent faith in the government
healthcare facility. There is a need to make govern-
ment healthcare facilities more community friendly.
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