Introduction

The perinatal period is a very significant phase for every mother. It is a vital parameter of quality of care during the antenatal, intra-natal, post-natal phase, and the quality of health care services available to the mother. Across the world, many mothers and children are dying during postnatal phase due to various reasons. Factors responsible for infant mortality are prematurity, low birth weight, neonatal infections/sepsis, pneumonia, birth asphyxia, diarrhea, congenital malformation, perinatal causes, sudden infant death syndrome, malnutrition, and birth trauma.1,2 Maternal deaths occur due to post-partum hemorrhage, complications of labor, and puerperium.3 Additionally, various socio-cultural practices that are followed by families that increase the mother’s and child’s risk of death in India.4–6

No matter how equipped health care facilities are, the level of benefaction that makes the difference for the better health of women and children.7 The infant mortality rate (IMR) is considered an essential indicator of community health. A higher IMR can be attributed to poor hygiene, unfavourable environmental factors, economic status, the health of the environment, and healthcare.8 In the recently published report in Uttarakhand, maternal mortality reported an 89/100000 live birth rate between 2015-17 against the national average of 122.9

Even after broad strategies and approaches to improve maternal health, there is still a prolonged decline in maternal mortality and morbidity in developing countries like India.10 Socio-economic conditions and cultural practices are considered key predictors of women’s health and well-being. Seeking and acceptance of health care facilities are greatly influenced by the socio-economic status and cultural beliefs of people and families.7 The most common identified delays contributing to maternal deaths in Uttarakhand were an inappropriate quality of care at the health care facility (55.1%), lack of care-seeking approach (18.1%), difficulty in reaching the health care facility (15.3%).11

Likewise, deliveries in an institution or safe hands are influenced by various factors such as educational status of women, social group, place of habitat, access to health care services, economic status, exposure to mass media, and parity of women.12 In Uttarakhand, due to geographical conditions, people find it difficult to reach health care facilities for antenatal services; similarly, many deaths (>80%) are not registered.13

Despite several efforts made to overcome the issues of delayed maternal care, underlying causes responsible for maternal death need to be explored further. The present study aimed to explore socio-economic and cultural factors influencing maternal and infant health and mortality in selected areas of Uttarakhand. It also extended to find out the contributing factors for maternal and infant mortality according to local health care providers.

Methods

Design and setting

A Mixed-method study was conducted in rural and urban areas of Rishikesh Taluk from 1 Jan 2020 to 5 February 2020.

Study Participants

In the present study, twenty-five families who had delivery within a year were selected by purposive sampling technique, where mother and child were live or died (due to any reason). For in-depth interviews, mothers were interviewed; where the mother died, but child is alive, or mother and child both died, the immediate caregiver (mother/mother-in-law) was included.

Data collection tools

A sociodemographic profile data sheet was prepared to obtain baseline information from the participants; it included information about the informants and the mothers including obstetrical history. p

Tools for quantitative data

Socio-economic status (SES), a modified Kuppuswamy scale, was used to measure SES in urban and rural areas. This scale consists of a composite score, which includes education, occupation of the Head of Family, and income per month of the family. This scale classifies the study populations into five SES, viz socio-economic class I (Upper: 26-29), class II (Upper middle: 16-25), Class III (Lower middle: 11-15), class IV (Upper Lower: -10), and class V (Lower: 01-04).14

A structured survey schedule was developed to identify practices during the pregnancy, delivery and post-natal period and the common contributing factors for maternal and infant mortality.

The developed questionnaires were validated by nine experts. Language validation was obtained by a Hindi language expert. Pre-testing of tools was done for feasibility and language difficulties.

Modified WHO’s verbal autopsy scale was used to explore the causes of maternal and infant mortality.15 It included a detailed exploration of the events occurred and care taken during pregnancy, delivery and post-natal period, including care of the infant. Through the sequential questions, the causes which led the mother and / or infant to death were explored.

Tools for qualitative data

An in-depth interview schedule was developed to explore socio-cultural practices during pregnancy, delivery, and post-natal period. Open-ended questions were focused to explore practices & beliefs during antenatal period, delivery process, post-natal period, and care of infant.

Data collection

Detailed information regarding families where a mother had delivered a child within a year, and families were approached along with accredited social health activists (ASHA) (to minimise the stranger ambiguity), and written informed consent was taken before data collection. Individual families were surveyed by face-to-face conversation, and an interview was scheduled based on the participants’ convenient time at their home, and all the data was collected by the researcher.

Quantitative data was collected using demographic data sheet, socio-economic scale, and survey schedule on practices during pregnancy, delivery, and post-natal period on a one-to-one basis. Further, immediate caregivers of the deceased mother or infant were asked about the sequential steps which led to the death of the mother or baby.

Qualitative Data: Interviews were conducted in a separate room of study participants’ residence. An ASHA of the rural/urban area was present during the interview so that study participants and family members feel comfortable. Each interview lasted for 40-50 minutes of duration. Women and/or first-line informants were interviewed about their most recent experience of childbirth process and socio-economic status, including practices during pregnancy, delivery and post-natal period. The families who had either mother and/or infant mortality were additionally asked to narrate the causes of mortality. Literature has reported that a direct, face-to-face approach enhances discussion and helps in better understanding of questions.15

The researcher conducted all interviews in Hindi and recorded them on a digital audio-recording device. The recordings were transcribed, and then given to the language expert for converting into English and checked for objectivity.

The Researcher explained the purpose of study and interview, and affirmation of confidentiality and freedom to withdraw from study at any time were explained to participants verbally as well as on a written sheet.

Rigour

In the present study of the qualitative part, four components of trustworthiness, credibility, transferability, dependability and confirmability were applied. These are the main parameters for appraising the rigours of the qualitative study given by Lincoln and Guba.16

Ethical considerations

The institutional ethical committee approved the study, and administrative approval was obtained from the concerned authorities of selected community heads. A written informed consent was obtained from all the participants, and their anonymity was considered while discussing the results.

Data analysis

The quantitative data were entered into the spreadsheet and analyzed by using descriptive statistics (frequency & percentages), and qualitative data were collected through interview in Hindi language and translated into English and back to Hindi; the data which is translated was validated by a language expert by comparing the verbatims in both the languages, before going for thematic analysis. All the codes related to the research question were combined, and sub-themes and themes were extracted with the help of RQDS online software.

Results

Quantitative findings

Demographic data of the informants

Out of 25, 17(68%) of the informants were mothers, and 8 (32%) were mothers-in-law’; and the decision maker was the husband in 16(64%) of the participant’s home (Table 1).

Table 1.Demographic Information about Informants (N=25)
Information about Informant F(%)
Informants Mother 17(68)
Mother in-law 08(32)
Religion Hindu 18(72)
Muslim 07(28)
Occupation Home maker 23(92)
Job 02(08)
Education Illiterate 09(36)
Primary 08(32)
Middle School 06(24)
Graduate 02(08)
Family Type Nuclear 18(72)
Joint 07(28)
Habitat Rural 12(48)
Urban 13(52)
Decision Maker Husband 16(64)
Self 04(16)
Both 02(08)
Father-in-law 03(12)

The majority, 22(88%) of the participants (both mother and infants), were healthy; one mother and two infants died due to different reasons. Nearly half, 12 (48%) of the women were in their thirties, and six (24%) women never had any antenatal visits, whereas 18(72%) took two doses of TT injection, and 07(28%) never took any supplementation dduring pregnancy. (Table 2) Nearly half of 12(48%) of the participants’ families belong to the upper lower class (IV), and only 01(4%) are in the lower class.

Table 2.Demographic and Obstetric Profile of Mothers
Information about Mother Healthy Mother & Child
f (%) (n=22)
Deceased Mother / Infant
f (%) (n=3)
Age (in years) 20-25 7(28) 1(4)
26-30 5(20) -
30-35 10(40) 2(8)
Education Illiterate 6(24) 2(8)
Primary 4(16) 1(4)
Middle 8(32) -
Graduate 4(16) -
Occupation Home maker 19(76) 3(12)
Job 3(12) -
Place of Delivery Hospital 16(64) 1(4)
Home 6(24) 2(8)
Gender of Baby Male 13(52) 1(4)
Female 9(36) 2(8)
Birth Registration Yes 20(80) 2(8)
No 2(8) 1(4)
Mode of Transport Public 17(68) 3(12)
Personal 5(20) -
Distance HCF/km 1-10kms 5(20) -
11-20kms 12(48) 1(4)
21-30kms 5(20) 2(8)
During pregnancy Stayed In-Law’s Home 22(88) 3(12)
No. of Visits No Visits 3(12) 3(12)
Two visits 17(68) -
Four or more 2(08) -
Tetanus Toxoid dose 1dose 5(20) 02(8)
2doses 17(68) 01(4)
Iron & Folic Acid Supplementation Not Taken 6(24) 01(4)
Four months 16(64) 02(8)
Ultrasonography Done 10(40) -
Not Done 15(60) 3(12)
Gravida G1 7(28) 1(4)
G2 -G3 10(40) -
≥G4 5(20) 2(8)
Type of Delivery NVD 16(64) 3(12)
LSCS 6(24) -
Delivered by Local Dai 6(24) 2(8)
Nurse 9(36) -
Obstetrician 7(28) 1(4)
Baby Status At the time of birth Healthy (Alive) 22(88) 2(8)
Died - 1(4)
Details of Maternal & Infant Mortality Maternal - 1(4)
Infant - 2(8)

G-Gravida; NVD-Normal Vaginal Delivery; LSCS- Lower Segment Cesarean Section

Causes of maternal and infant mortality

One mother died during early postpartum. The causes involved in her condition were pre-existing anemia, PIH, pre-eclampsia, and eclampsia, and mother also experienced severe hemorrhage during delivery and post-natal period. Two infants died; one was stillborn, and the other was due to fever, cough, diarrhoea, and vomiting during infancy. In addition, the baby was not fed breast milk.

Cultural practices during pregnancy

80% of women increased their frequency of eating and, at the same time, restricted various fruits, vegetables and specific foods. Only some of the mothers utilised Healthcare facilities; however, all mothers took tetanus toxoid (TT) injection, and iron. (Table 3)

Table 3.Cultural Practices During Pregnancy
Practices Healthy Mother & Infant
n=22, f (%)
Deceased Mother / Infant
n=03, f (%)
Common Initial Practices
Inform family and relatives 4(16) 2(8)
Performing special pooja 17(68) 1(4)
Celebrate 20(80) 3(12)
Dietary Modification during Pregnancy
Frequency increases 19(76) 1(4)
Green leafy & other vegetables increase 11(44) 1(4)
Fruits 14(56) 3(12)
Pulses & Cereals 17(68) 3(12)
Foods that you restrict:
Yellow color fruits (papaya, mango) 20(80) 3(12)
Hot and spicy food 22(88) 3(12)
Eating less (no full stomach) 21(84) 3(12)
Drinking less fluids 19(76) 1(4)
Activities Performed
Activities of daily living 22(88) 3(12)
Beating paddy 12(48) 2(8)
Bringing wood from jungle 13(52) 1(4)
Bringing water & Grass 15(60) 3(12)
Activities Restricted:
Lifting heavy weights 11(44) 3(12)
Duration of Rest & Sleep in a Day:
6-8 hours 20(80) 3(12)
More than 8 hours 2(8) -
Hygienic practices during pregnancy:
Daily bath 15(60) 1(4)
Cleaning of private parts 15(60) 1(4)
Specific colored clothing (red & Yellow) 13(52) 1(4)
Use of undergarments 6(24) 1(4)
Utilization of health care facilities 16(64)
Yes 19(76) -
If Yes,
Registration 19(76) -
Regular checkups 17(68) -
Necessary investigations 15(60) -
TT injections 22(88) 3(12)
Iron & Folic acid supplementation 16(64) 2(8)
Ultrasonography 10(40) -
Rituals / cultural activities
Godbarai (Baby shower) 14(56) -
Special Pooja 8(32) 3(12)
Preference of Birthing:
Home 6(24) 2(8)
Hospital 16(64) 1(4)

Practices during delivery

Many participants had social restrictions (84%), fed the delivery mother with sugar tea/porridge (88%), and provided psychological reassurance to make the mother stronger to face the delivery process (80%). Only 60% of participants said they wash their hands before and after touching mother and baby.

Cultural practices after delivery

All (100%) of them said they took light food during the post-natal period. Special Laddu prepared with ghee and nuts was taken by 68% of the women. It’s essential to observe that only 60% of participants feed their baby within one hour (Golden Hour) of birth, while 64% had practiced pre-lactational feeds (jaggary water, honey, sugar water). More than 50% of them practiced exclusive breastfeeding till 6 months of age of the baby (Table 4).

Table 4.Cultural Practices after Delivery
Practices Healthy Mother & Infant
n=22, f (%)
Deceased Mother / Infant
n=02, f (%)
Foods & Dietary Practices
Light food 22(88) 3(12)
Porridge 19(76) 1(4)
Vegetables 16(64) 2(8)
Non-vegetarian foods 8(32) 1(4)
Special Laddu prepared with ghee and nuts 16(64) 1(4)
Foods & Dietary Practices omitted
Gas producing foods 22(88) 2(8)
Minimize fluids 19(76) 1(4)
Spices 22(88) 2(8)
Activity & Rest:
Reduced activity 6(24) 1(4)
Increased resting hours 16(64) 1(4)
Bath / Hygiene:
Daily bath of mother 16(64) 1(4)
Hair wash of mother 13(52) 1(4)
Frequent Perineal care 14(56) 1(4)
Use of sanitary pads 13(52) -
Family involvement in the care of mother & Baby
Yes 19(76) 1(4)
Other Practices
Separate room for mother & Baby 9(36) -
Clean & ventilated room 14(56) 1(4)
Cow urine sprinkles in & around house 17(68) 3(12)
Post-natal pooja 22(88) 3(12)
Cord Care:
  • Apply nothing
  • Baby oil
  • Ghee
  • Mothers’ milk
6(24)
9(36)
6(24)
1(4)
-
2(8)
-
-
Practices done with new born baby immediately after birth
Change of clothing 17(68) 1(4)
First Feeding within one hour of delivery 14(56) 1(4)
Pre-lactational feed (jaggary water, honey, sugar water) 14(56) 2(8)
Regular breast feeding 18(72) 2(8)
Rooming-in 15(60) -
Other practices:
      Kajal to the eyes
      Soap is inserted into the anus for easy passing of stool.

19(76)
4(16)

2(8)
2(8)
Practices in child rearing till one year
Exclusive breast feeding till 6 months 15(60) -
Weaning started at 6 months 18(72) -
Administered scheduled Vaccines 14(56) -
Health check-ups 8(32) -

Qualitative findings

Many themes and sub-themes evolved during different phases of pregnancy:

Cultural practices during pregnancy

The themes during pregnancy were food and eating practices, religious practices, physical activity and rest, hygiene and clothing, social celebrations, and attending antenatal care facilities (Table S5 in the online supplementary document). Many participants expressed various problems which they experienced during availing of ANC services (Box 1).

Box 1.Common problem identified for non-utilization of health care services: (n=12)
  • Family did not allow to visit health care centre (n=8)

  • Iron & Folic acid causes constipation and harm to baby(n=6)

  • Thought not sick enough to go to health facility(n=7)

  • Problems with transportation (n=5)

  • More faith in traditional medicine (n=9)

  • Influence of mother-in-law / relative regarding maternal and child care (n=10)

  • Customs & culture does not allow (n=8)

Practices during Delivery

The themes that evolved during delivery practices were related to Place of Delivery, Cleanliness while conducting delivery, Nutritional Supply, and Delivery Process (Table S6 in the online supplementary document*).*

Practices after delivery

The themes that evolved relate to post-natal period: Practices related to Disposal of Waste, Care of Post-natal women, Care of Babies, Breast Feeding (Table S7 in the online supplementary document*).*

Practices in care of baby

Pre-lactational feeds (Honey, sugar water, holy water, etc.) were commonly given to newborn babies. New clothes were not allowed to be put on the baby, as it resulted in harmful effects by evil spirits. Few mothers expressed that they applied home remedies on the babies’ umbilical cord as they dry it faster (Table S8 in the online supplementary document*).*

Discussion

Analysis of the presented study data depicted numerous socio-economic and cultural factors and practices involved in health care during pregnancy, delivery and after care of mother and baby.

In the present study, almost half of the participants belonged to the upper-lower socio-economic class. A significant number of women delivered at home, and many did not register the birth. Similar results were seen in studies.3,10,17–20 Very few utilized antenatal care services; many women did not go for any checkups at all, while most of the women had only two antenatal visits, which does not fulfil the national or international guidelines for the number of antenatal visits. Studies reported that in spite of continuous persistence from the state and central governments of India about Iron and Folic acid supplementation during pregnancy, it should be started once the woman is pregnant and continue the Iron supplementation throughout the pregnancy.3,19,20

Women and families assumed that going to hospital would result in caesarean deliveries, and most of them faced problems for utilization of ANC services, mainly because family did not allow to go health care center, supplements caused constipation, transportation-related issues and had faith in taking traditional medicine.3,10,19–21

Although the government of India recommends 100% institutional deliveries,22 many women in the present study delivered at home with the help of local untrained dai. A systematic review and meta-analysis by Wondemagegn AT et al. found that antenatal care visits were significantly associated with lower neonatal death rates among newborns delivered from mothers who had antenatal care visits.23 In another systematic review and meta-analysis by Tekelab et al. on the impact of antenatal care on neonatal mortality in sub-Saharan Africa revealed that utilization of at least one antenatal care visit by a skilled provider during pregnancy reduces the risk of neonatal mortality by 39%.24

Mothers who died were anemic during pregnancy, with high blood pressure resulting in pre-eclampsia and eclampsia during delivery. Studies also supported the present results, as maternal deaths happened due to complications during pregnancy and the post-natal period.13,21,25 Factors involved in neonatal death were fever, cough, diarrhoea & vomiting. In addition, mother had breast feeding problems too, where child was fed with a bottle. In contrast, neonatal deaths were reported to be high due to aspiration and mismanaged intra-natal period. It has also been reported that baby nutrition plays a major role in baby survival.2,26–29 Cultural practices during pregnancy that the women practiced were increased frequency of eating and used eating less amount of food, and drinking less fluids, as they believe a full stomach puts weight on the growing foetus inside the womb and more fluids make the baby puffy and oedematous. Studies have shown that maternal nutritional status is one of the most important things during pregnancy, directly influencing pregnancy outcomes. Importantly, diets with a higher intake of fruits, vegetables, legumes, and fish generally have positive pregnancy outcomes.30–32 Eating green leafy vegetables, fruit, pulses, and cereals was also common practice. In addition, majority of women were not eating papaya, mango, and all kinds of spices during pregnancy, as they said it is harmful to the baby. However, consuming unripe or semi-ripe papaya (which contains high levels of latex that causes marked uterine contractions) could be unsafe during pregnancy.33–36

Apart from that, women shared that they usually do activities of daily living, bringing wood from the jungle, bringing water and grass and beating paddy, as they believe these activities ease the delivery process and less complications during delivery; at the same time, lifting heavy weights and climbing heights were avoided. Similarly, studies supported regular exercises decrease the risk of GDM, prevent hypertensive and cardiovascular-related problems, decrease the duration of labor and reduce the risk of cesarean deliveries, help to regulate weight, and positively affect psychological status.27,37–39

Social restriction to enter into the women’s room during home delivery, as they express allowing many people, is bad for the mother and baby and has a chance for evil spirits to enter into the room. As evidence justifies, prevention of infection is the scientific principle behind the above practice.40 They feed women with sugar tea/porridge for emerging the women for delivery, and they also practice giving fenugreek and ghee when delivery starts; they believe that this eases the process of delivery and shortens it, too.36,40 Further, TBAs conducted home deliveries and were very unhygienic in conducting delivery as they did not have the habit of washing hands before conducting delivery, not boiling instruments and cutting the cord with available sharps. Similar practices were reported in two more studies.41,42 Also mentioned re-using the same blade for cord-cutting after washing without sterilization.43

Women were eating light foods for easy digestion, especially laddu, which is made up of ghee and dry fruits and a smaller number of women used to eat non-vegetarian foods during the post-natal period. Dietary restrictions were also very common, which would reduce the nutritional requirements for breast-feeding women in Asia.44 Most women omitted gas-producing foods and spices from food. A similar trend was seen in a study related to omitted foods and dietary practices, as production and foods that are hot are avoided during the post-natal period.45 However, hygienic practices like daily baths, perineal washes and use of sanitary pads were poorly practiced. In concurrence with the above points, a study also presented the role of perineal pads in the prevention of infections.45

The practices involved in care new born were giving honey, jaggary water, or sugar water as pre-lacteal feeds, not feeding the baby with colostrum, applying baby oil on umbilical cord for healing, and kajal into new born eyes; which were perceived to be helpful for the newborn, but, as these practices are more harmful.38 It is believed that colostrum is dirty milk that should not be given to babies. Also, fewer women followed exclusive breast feeding and started weaning at six months. Similar findings have been reported in a study stating that pre-lacteal feeds were given universally, as sugar water was the common solution. Castor oil is given to the baby, believing that it cleans out the baby’ inside by making them pass a stool, then baby is fed with another mother’s milk.43 Only a few had health checkups for newborns and received scheduled immunization, as that causes discomfort to the baby, and the baby becomes ill.

Limitations

The results are drawn based on the information collected from the less participants, drawing conclusions for generalizations would be inappropriate. There was very minimal supportive previously published data from the region. Reaching the houses in hilly regions and convincing others to participate in the study was challenging.

Conclusions

The findings of the present study show that among various cultural beliefs and practices, it is important to identify the appropriate and safe practices during the perinatal period and encourage them to practice; at the same time, it is also crucial to discourage the mothers and families not to practice those which are harmful to both. There are many blind faiths and beliefs which are running through the families as a tradition; there is a need to break the chain and safeguard the mother and baby, ultimately contributing to bringing down maternal and infant mortality.


Funding

None

Disclosure of interest

The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests.

Additional material

Additional information is provided in the online supplementary document.