Grandmothers' influence on child care

Effects of household composition on infant feeding and mother-infant health in northern Kenya

BACKGROUND

Households with alloparents, individuals other than the mother who care for an infant, can shift members' roles and affect mother-infant health.

AIMS

To investigate how household composition relates to infant feeding and infectious disease risk in mother-infant dyads, the team utilized data from breastfeeding dyads (n 208) surveyed during a prolonged drought and food scarcity in northern Kenya.

METHODS

Households were classified by the presence/absence of potential alloparents, distinguishing non-siblings and siblings of the infant. Regression models for breastfeeding frequency, complementary feeding status, and recent infections (n 83) evaluated these outcomes' associations with household type while accounting for food insecurity, adjusted for infant age, infant sex, and maternal age.

RESULTS

Household type was unassociated with breastfeeding frequency, but the presence of non-sibling alloparents interacted with food insecurity, predicting increasing breastfeeding frequency as food insecurity intensified among dyads living with non-sibling alloparents. Households with non-sibling alloparents were also inversely associated with complementary feeding but had no association with infection. Households with siblings were inversely associated with (protective against) infant and maternal infection.

CONCLUSION

Further research is needed to understand the interactive influence of household social and food ecologies on mother-infant diet and health under diverse cultural rules and norms for alloparenting.

Impact of kinship support on child mortality in the Upper East Region of Ghana: assessing the Grandmother Hypothesis

BACKGROUND

The grandmother is an important kin member whose contribution to childcare and survival has been recognized in the literature, hence the Grandmother Hypothesis. This article examines the effect of the presence of a grandmother on child mortality.

METHODS

Data were obtained from the Navrongo Health and Demographic Surveillance System, located in the Upper East Region of Ghana. Children born between January 1999 and December 2018 were included in the analysis. Person-months lived for each child were generated. The multilevel Poisson regression technique was employed to investigate the effect of a grandmother on child survival.

RESULTS

In all, 57 116 children were included in the analysis, of which 7% died before age 5 y. Person-months were generated for the children, which produced 2.7 million records, with about 487 800 person-years. After controlling for confounders, results showed that children in households with paternal grandmothers are 11% less likely to die compared with those without paternal grandmothers. However, when other confounders were taken into accounts, the beneficial effect of maternal grandmothers disappeared.

CONCLUSIONS

We conclude that the presence of grandmothers improves child survival, thus sustaining the Grandmother Hypothesis. The experiences of these grandmothers should be tapped to improve child survival, particularly in rural areas.

Do non-maternal adult female household members influence child nutrition? Empirical evidence from Ethiopia

Child malnutrition is an enormous public health problem in low- and middle-income countries (LMICs). In this paper, we study the relationship between non-maternal adult female household members (AFHMs) and under-5 child nutritional outcomes using nationally representative Ethiopian Demographic and Health Survey data, 2016. Because most of the primary inputs that go into the production of child health are intensive in maternal time, having additional AFHMs may ease the time constraints of the child's mother. We use anthropometric measures such as height-for-age z-scores (HAZ) and weight-for-age z-scores (WAZ) to measure stunting and underweight, respectively, as objective indicators of child nutritional status. Among our sampled households, we find that 40% of the children are stunted, 18% severely stunted, 27% underweight and 8% severely underweight. Furthermore, about 20% of the sampled children live with at least one extra non-maternal AFHM. The multivariate regression results suggest that an additional AFHM is associated with significantly higher HAZ and WAZ scores and less likelihood of severe stunting compared with children living with fewer AFHMs. Finally, the paper discusses the potential pathways through which non-maternal AFHMs can influence child nutritional status.

Does maternal grandmother's support improve maternal and child nutritional health outcomes? Evidence from Merida, Yucatan, Mexico

In humans, high levels of investment are required to raise offspring, because of the prolonged developmental period and short interbirth intervals. The costs borne by individual mothers may be mitigated by obtaining social support from others. This strategy could be particularly valuable for first-time mothers, who lack first-hand experience and whose offspring have higher mortality risk than later-born siblings. As raising children is potentially stressful, mothers may gain from others sharing their experience, providing knowledge/information and emotional support. Being genetically related to both mother and grandchild, maternal grandmothers may be especially well placed to provide such support, while also gaining fitness benefits. We tested the over-arching hypothesis that first-time mothers and their young children supported by the maternal grandmother would have lower levels of stress and better health outcomes, compared to mother-infant dyads lacking such grandmaternal support. A cohort of 90 mother-infant dyads (52 with grandmaternal support, 38 without) was recruited in Merida, Mexico. We assessed anthropometry and body composition in both mother and child, along with maternally perceived stress and child temperament, and documented maternal social relationships. No differences were found in perceived stress/temperament or anthropometry of either mothers or children, according to the presence/absence of grandmaternal support. However, a composite score of whether grandmothers provided advice on infant feeding was positively associated with child nutritional status. Mothers without grandmaternal support reported seeking more informational and emotional support from other female relatives for childcare, potentially compensating for limited/absent grandmaternal support. Our findings may help develop interventions to improve maternal and child health by targeting the dynamics of maternal social networks. This article is part of the theme issue 'Multidisciplinary perspectives on social support and maternal-child health'.

Maternal Grandmothers' Household Residency, Children's Growth, and Body Composition Are Not Related in Urban Maya Families from Yucatan

This study analyzes the influence of grandmothers' household residency on the presence of low height-for-age and excessive fat (FMI = fat mass [kg]/height [m²]), waist circumference, and sum of triceps and subscapular skinfolds in a sample of 247 6- to 8-year-old urban Maya children from Yucatan, Mexico. Between September 2011 and January 2014, we obtained anthropometric and body composition data from children and mothers, as well as socioeconomic characteristics of participants and households. Grandmothers' place of residence was categorized as either in the same household as their grandchildren (n = 71) or in separate households (n = 176). Multiple logistic regression models were used to analyze the association between grandmothers' residency and outcome variables. Models were adjusted for maternal anthropometric characteristics and the following socioeconomic variables: family size, location, maternal education, monthly family income, and household crowding. Models showed that the presence of grandmothers in their grandchildren's households was not associated with any of the outcome variables. In contrast, larger family size, overcrowding in the household, and lower family income predicted low height-for-age in children. Larger family size decreased the risk for being overweight based on the three parameters of body composition. Overcrowding in the household increased the risk for greater skinfolds thickness, while low family income increased the risk for higher fat mass index. The residency of grandmothers in their adult daughters' households is not significantly associated with the outcome variables in this sample of urban Maya families. Instead, maternal anthropometric characteristics and socioeconomic conditions of the family have a greater influence on the overall growth of children.

Grandmothers - a neglected family resource for saving newborn lives

Across the globe, the well-being of newborns is significantly influenced by the knowledge and practices of family members, yet global health policies and interventions primarily focus on strengthening health services to save newborn lives. Predominant approaches to promote newborn survival in non-western cultures across the Global South are based on a western, nuclear family model and ignore the roles of caregivers within wider family systems, whose attitudes and practices are determined by culturally prescribed strategies. In this paper, I review evidence of a neglected facet of newborn care, the role and influence of senior women or grandmothers.Based on a family systems frame, I reviewed research from numerous settings in Africa, Asia and Latin America that provides insight into family roles related to newborn care, specifically of grandmothers. I identified primarily published studies which provide evidence of grandmothers' role as culturally designated and influential newborn advisors to young mothers and direct caregivers. Research from all three continents reveals that grandmothers play similar core roles in newborn care while their culturally specific practices vary. This review supports two main conclusions. First, future newborn research should be conceptualised within a family systems framework that reflects the structure and dynamics of non-western collectivist cultures. Second, newborn interventions should aim not only to strengthen health services but also influential family caregivers, particularly grandmothers and the indigenous social support networks of which they are a part, in order to improve family-level newborn practices and save newborn lives.

The contribution of grandmother involvement to child growth and development: an observational study in rural Pakistan

INTRODUCTION

Early childhood interventions primarily focus on the mother-child relationship, but grandmothers are often critical in childcare in low-resource settings. Prior research is mixed on how grandmother involvement influences child outcomes and there is a paucity of research on grandmother caregiving in low-income and middle-income countries. We examined the role of grandmother involvement on child growth and development in the first 2 years of life cross sectionally and longitudinally in rural Pakistan.

METHODS

We used data from the Bachpan Cohort, a longitudinal birth cohort in rural Pakistan. Maternally reported grandmother involvement in daily instrumental and non-instrumental caregiving was collected at 3 and 12 months. A summed score was created and categorised into non-involved, low and high. Outcomes included 12-month and 24-month child growth, 12-month Bayley Scales of Infant and Toddler Development and 24-month Ages and Stages Questionnaire-Socioemotional. We used multivariable generalised linear models to estimate mean differences (MD) at 12 months (n=727) and 24 months (n=712). Inverse probability weighting was used to account for missingness and sampling.

RESULTS

In our sample, 68% of children lived with a grandmother, and most grandmothers were involved in caregiving. Greater 3-month grandmother involvement was positively associated with 12-month weight z-scores; however, greater involvement was associated with lower 24-month weight z-scores. High 12-month grandmother involvement was associated with improved 12-month cognitive (MD=0.38, 95% CI -0.01 to 0.76), fine motor skills (MD=0.45, 95% CI 0.08 to 0.83) and 24-month socioemotional development (MD=-17.83, 95% CI -31.47 to -4.19). No meaningful associations were found for length z-scores or language development.

CONCLUSION

In rural Pakistan, grandmothers provide caregiving that influences early child development. Our findings highlight the complex relationship between grandmother involvement and child weight, and suggest that grandmothers may positively promote early child cognitive, fine motor and socioemotional development. Understanding how grandmother involvement affects child outcomes in early life is necessary to inform caregiving interventions.

How do grandparents influence child health and development? A systematic review

Grandparents are often a key source of care provision for their grandchildren, yet they are sidelined in caregiving research and policy decisions. We conducted a global, systematic review of the literature to examine the scope and quality of studies to date (PROSPERO database CRD42019133894). We screened 12,699 abstracts across 7 databases, and identified 206 studies that examined how grandparents influence child health and development. Indicators of grandparent involvement were contact, caregiving behaviors, and financial support. Our review focused on two research questions: how do grandparents influence child health and development outcomes, and what range of child outcomes is reported globally? We examined study design, sample characteristics, key findings, and outcomes pertaining to grandchildren's physical health, socio-emotional and behavioral health, and cognitive and educational development.  Our search captured studies featuring grandparent custodial care (n = 35), multigenerational care (n = 154), and both types of care (n = 17). We found substantial heterogeneity in the data provided on co-residence, caregiving roles, resources invested, outcomes, and mechanisms through which "grandparent effects" are manifested. We identified two important issues, related to operationalizing indicators of grandparent involvement and conceptualizing potential mechanisms, leading to gaps in the evidence base. Currently, our understanding of the pathways through which grandparents exert their influence is constrained by limited data on what grandparents actually do and insufficient attention given to interpersonal and structural contexts. We present a conceptual framework to explicitly measure and theorize pathways of care, with a view to inform research design and policy implementation. We underscore the need for more robust data on three indicators of caregiver involvement-contact, behavior, and support-and for careful description of structural and interpersonal contexts in caregiving research.

Fever awareness, management practices and their correlates among parents of under five children in urban India

Background

Awareness regarding fever is reportedly low among Indian urban parents, leading to its over- management among under five children. We attempted to study the awareness and fever management practices of South Indian urban parents. The objectives were to find the awareness of parents regarding childhood fever management, and correlates of practices.

Methods

One hundred parents of under-five children with history of fever in past three months were randomly selected and interviewed using a predesigned tool. Children's weight and height was measured. Awareness scores for causes of fever and fever management were constructed. Logistic regression was done to identify correlates of incorrect practices.

Results

95% parents were aware about correct temperature above which fever became harmful. Awareness score for causes of fever was poor (<1) among 41% parents. Mothers' complications awareness scores were better than fathers (p<0.05). 81% parents used antibiotics; only 18% consulted a doctor before doing so. 17% parents using antibiotics did not complete the prescribed course. The independent correlates of poor fever management practices were working parents (OR: 6.28; 95%CI: 1.7-23.16), lesser number of children (OR: 3.08; 95%CI: 1.01-9.37), poor compliance for antipyretics (OR: 9.20; 95%CI: 1.64-51.52) and giving antipyretics without consulting doctors (OR: 5.43; 95%CI: 1.69-17.47). Poor knowledge of available pediatric antipyretic preparations was negatively correlated (OR: 0.13; 95%CI: 0.02-0.64).

Conclusion

Fever awareness was fair among urban parents. Mothers had better awareness than fathers. Increased awareness for correct fever management of under-five children is desirable among urban parents to reduce misuse of antibiotics and antipyretics.

Newborn-Care Practices and Health-Seeking Behavior in Rural Eastern Ethiopia: A Community-Based Study

BACKGROUND

Most of the newborn deaths in developing countries occur at home. Up to two-thirds of these deaths would have been prevented if mothers and newborns had received known and effective interventions. The objective of this study is to determine newborn-care practices and health-seeking behavior in rural Eastern Ethiopia.

METHODS

A community-based cross-sectional study was conducted in Adadle district, Ethiopian Somali Regional State. A multi-stage random sampling technique was applied. Women of reproductive age group (15-49 years) living in Adadle District were eligible to participate in the study. Data were entered, cleaned and analyzed using Statistical Package for Social Sciences version 19 for windows.

RESULTS

A total of 829 women between the ages of 15 and 49 years were involved in the study. Of which, 698 women had a live birth, 23% reported that their babies were placed in skin-to-skin contact with their mothers' belly/chest before the placenta was delivered, 79% of newborns were bathed within 24 h of delivery. From this figure, 71% of the babies were bathed within the first 12 h after delivery and 44% reported their baby was ill during the first week of life.

CONCLUSION

The study had shown suboptimal newborns practice in the study area, which put the newborns into significant health risk. Strong public education and capacity building to frontline health workers can be recommended.

Addressing barriers to exclusive breast-feeding in low- and middle-income countries: a systematic review and programmatic implications

OBJECTIVE

Despite numerous global initiatives on breast-feeding, trend data show exclusive breast-feeding (EBF) rates have stagnated over the last two decades. The purpose of the present systematic review was to determine barriers to exclusive breast-feeding in twenty-five low- and middle-income countries and discuss implications for programmes.

DESIGN

A search of Scopus, MEDLINE, CINAHL and PsychINFO was conducted to retrieve studies from January 2000 to October 2015. Using inclusion criteria, we selected both qualitative and quantitative studies that described barriers to EBF.

SETTING

Low- and middle-income countries.

SUBJECTS

Following application of systematic review criteria, forty-eight articles from fourteen countries were included in the review.

RESULTS

Sixteen barriers to EBF were identified in the review. There is moderate evidence of a negative association between maternal employment and EBF practices. Studies that examined EBF barriers at childbirth and the initial 24 h post-delivery found strong evidence that caesarean section can impede EBF. There is moderate evidence for early initiation of breast-feeding and likelihood of practising EBF. Breast-feeding problems were commonly reported from cross-sectional or observational studies. Counselling on EBF and the presence of family and/or community support have demonstrated improvements in EBF.

CONCLUSIONS

Improving the counselling skills of health workers to address breast-feeding problems and increasing community support for breast-feeding are critical components of infant and young child feeding programming, which will aid in attaining the 2025 World Health Assembly EBF targets. Legislation and regulations on marketing of breast-milk substitutes, paid maternity leave and breast-feeding breaks for working mothers require attention in low- and middle-income countries.

Grandmothers' knowledge positively influences maternal knowledge and infant and young child feeding practices

OBJECTIVE

To examine associations between grandmothers' knowledge and infant and young child feeding (IYCF) practices and to test whether the associations are independent of or operate via maternal knowledge.

DESIGN

Cross-sectional household survey data from households with a child under 5 years (n 4080). We used multivariate regression analyses, adjusted for child, maternal, grandmother and household characteristics, and district-level clustering, to test associations between grandmothers' knowledge and IYCF practices for children aged 6-24 months living with a grandmother. We used causal mediation to formally test the direct effect of grandmothers' knowledge on IYCF practices v. maternal knowledge mediating these associations.

SETTING

Two hundred and forty rural communities, sixteen districts of Nepal.

SUBJECTS

Children aged 6-24 months (n1399), including those living with grandmothers (n 748).

RESULTS

We found that the odds of optimal breast-feeding practices were higher (early breast-feeding initiation: 2·2 times, P=0·002; colostrum feeding: 4·2 times, P<0·001) in households where grandmothers had correct knowledge v. those with incorrect knowledge. The same pattern was found for correct timing of introduction of water (2·6), milk (2·4), semi-solids (3·2), solids (2·9), eggs (2·6) and meat (2·5 times; all P<0·001). For the two pathways we were able to test, mothers' correct knowledge mediated these associations between grandmothers' knowledge and IYCF practices: colostrum feeding (b=10·91, P<0·001) and the introduction of complementary foods (b=5·18, P<0·001).

CONCLUSIONS

Grandmothers' correct knowledge translated into mothers' correct knowledge and, therefore, optimal IYCF practices. Given grandmothers' influence in childcare, engagement of grandmothers in health and nutrition interventions could improve mothers' knowledge and facilitate better child feeding.

Do grandparents compete with or support their grandchildren? In Guatemala, paternal grandmothers may compete, and maternal grandmothers may cooperate

Previous research has found that the presence of grandparents, particularly grandmothers, is often positively associated with child survival. Little research has explored the potential mechanisms driving these associations. We use data from rural Guatemala to test whether contact with and direct investment (advice and financial) from grandparents is associated with child health, proxied by height. Our results demonstrate the complexity of family relationships and their influence on child health, suggesting that both cooperative and competitive relationships exist within the family. The clearest evidence we find for grandparental influence is that having a living paternal grandmother tends to be negatively associated with child height. By contrast, contact with maternal kin appears broadly to be beneficial for child height, although these relationships are weaker. These patterns are mirrored in maternal body mass index, suggesting grandparental influence acts partly through maternal health. These findings support the hypotheses that, under conditions of limited resources, family relationships may be competitive within the family lineage which shares the same resource base, but cooperative when there are few costs to cooperation. Finally, financial assistance from maternal grandfathers is positively correlated with infant length but negatively with the height of older children, perhaps because the receipt of financial support is an indication of need. The provision of advice shows no associations with child height.

Maternal Perceptions and Views About Breastfeeding Practices Among Emirati Mothers

BACKGROUND

Understanding women's breastfeeding perceptions and experiences is increasingly recognized as a vital tool to provide effective support that would encourage the extension of the breastfeeding period.

OBJECTIVE

To identify and explore the perceptions and views that influence the feeding and weaning decisions of Emirati mother.

METHODS

A qualitative study using indepth interviews was undertaken with a convenience sample of 45 Emirati mothers who had infants aged between 6 months and 2 years. Participants were interviewed in the health centers in 3 cities in United Arab Emirates. Data were recorded through field notes and analyzed thematically using grounded theory analysis.

RESULTS

The following themes emerged: influences of others on the decisions to breastfeed, sources of information, infants' behavior and participants' views and decisions about when to introduce supplementary feeding, knowledge of and attitudes toward current World Health Organization recommendations, and mothers' perception of the benefits of breastfeeding. Grandmothers in this study played an important role in the breastfeeding practices of Emirati mothers. They supported breastfeeding, however, some encouraged giving the infants prelacteal feeds for a variety of reasons: colic, hunger, promoting growth, and hydration. Fathers, according to the mothers, either supported or ignored breastfeeding practices.

CONCLUSION

Health promotions and health care facilities failed to deliver the message of exclusive breastfeeding. Mothers in our study were resorting to the expertise of the grandmothers and receiving information and advice about child feeding from them. The findings highlight the need for successful intervention programs to be implemented for mothers and grandmothers through health care providers.

Kin and Child Survival in Rural Malawi : Are Matrilineal Kin Always Beneficial in a Matrilineal Society?

This paper investigates the impact of kin on child survival in a matrilineal society in Malawi. Women usually live in close proximity to their matrilineal kin in this agricultural community, allowing opportunities for helping behavior between matrilineal relatives. However, there is little evidence that matrilineal kin are beneficial to children. On the contrary, child mortality rates appear to be higher in the presence of maternal grandmothers and maternal aunts. These effects are modified by the sex of child and resource ownership: female children and children in households where women, rather than men, own land suffer higher mortality rates in the presence of maternal kin. These modifiers suggest the detrimental effects of matrilineal kin may result from competition between such kin for resources. There are some positive effects of kin on child survival: the presence of elder siblings of both sexes is correlated with higher survival rates, and there is some weak evidence that paternal grandmothers may be beneficial to a child's survival chances. There is little evidence that any male kin, whether matrilineal or patrilineal, and including fathers, affect child mortality rates. This study highlights the importance of taking social and ecological context into account when investigating relationships between kin.

Perceptions and experiences of community members on caring for preterm newborns in rural Mangochi, Malawi: a qualitative study

Background

The number of preterm birth is increasing worldwide, especially in low income countries. Malawi has the highest incidence of preterm birth in the world, currently estimated at 18.1 percent. The aim of this study was to explore the perceived causes of preterm birth, care practices for preterm newborn babies and challenges associated with preterm birth among community members in Mangochi District, southern Malawi.

Methods

We conducted 14 focus group discussions with the following groups of participants: mothers (n = 4), fathers (n = 6) and grandmothers (n = 4) for 110 participants. We conducted 20 IDIs with mothers to preterm newborns (n = 10), TBAs (n = 6) and traditional healers (n = 4). A discussion guide was used to facilitate the focus group and in-depth interview sessions. Data collection took place between October 2012 and January 2013. We used content analysis to analyze data.

Results

Participants mentioned a number of perceptions of preterm birth and these included young and old maternal age, heredity, sexual impurity and maternal illness during pregnancy. Provision of warmth was the most commonly reported component of care for preterm newborns. Participants reported several challenges to caring for preterm newborns such as lack of knowledge on how to provide care, poverty, and the high time burden of care leading to neglect of household, farming and business duties. Women had the main responsibility for caring for preterm newborns.

Conclusion

In this community, the reported poor care practices for preterm newborns were associated with poverty and lack of knowledge of how to properly care for these babies at home. Action is needed to address the current care practices for preterm babies among the community members.

Infant and Young Child Feeding Perceptions and Practices among Mothers in a Rural Area of West Bengal, India

Background:

There are many wrong practices and perceptions of Infant and Young Child Feeding (IYCF) prevalent among different socio-demographic groups.

Aim:

To observe IYCF perceptions and practices among mothers in a rural area of West Bengal.

Subjects and Methods:

Clinic-based cross-sectional descriptive study by interviewing mothers of 0-23 month old children. Appropriate response to each selected key question was assigned a score of + 1 for objective assessment. Data analysis was done by standard statistical methods using the statistical software SPSS 13.0 (Kolkata, India) for windows version. Percentages were calculated for descriptive statistics. Chi-square test of significance was employed whenever required.

Results:

65.8% (225/342) mothers did not initiate breast feeding within 1 h of birth, 41.7% (90/216) mothers of children aged 6 months or more did not exclusively breastfeed their babies up to 6 months and 28.1% (96/342) used bottles for baby-feeding. Perception scores among younger than 20-year-old mothers were found to be highest; however, practice score increased significantly with age. Though perception and practice of mothers with some education were significantly better they wane with higher education. Lowest practice score was found in the richest per capita income group.

Conclusion:

Emphasis should be given to IYCF education sessions.

Clean delivery practices in rural northern Ghana: a qualitative study of community and provider knowledge, attitudes, and beliefs

Background

Knowledge, attitudes and practices of community members and healthcare providers in rural northern Ghana regarding clean delivery are not well understood. This study explores hand washing/use of gloves during delivery, delivering on a clean surface, sterile cord cutting, appropriate cord tying, proper cord care following delivery, and infant bathing and cleanliness.

Methods

In-depth interviews and focus group discussions were audiotaped, transcribed, and analyzed using NVivo 9.0.

Results

253 respondents participated, including women with newborn infants, grandmothers, household and compound heads, community leaders, traditional birth attendants, and formally trained health care providers. There is widespread understanding of the need for clean delivery to reduce the risk of infection to both mothers and their babies during and shortly after delivery. Despite this understanding, the use of gloves during delivery and hand washing during and after delivery were mentioned infrequently. The need for a clean delivery surface was raised repeatedly, including explicit discussion of avoiding delivering in the dirt. Many activities to do with cord care involved non-sterile materials and practices: 1) Cord cutting was done with a variety of tools, and the most commonly used were razor blades or scissors; 2) Cord tying utilized a variety of materials, including string, rope, thread, twigs, and clamps; and 3) Cord care often involved applying traditional salves to the cord - including shea butter, ground shea nuts, local herbs, local oil, or “red earth sand.” Keeping babies and their surroundings clean was mentioned repeatedly as an important way to keep babies from falling ill.

Conclusions

This study suggests a widespread understanding in rural northern Ghana of the need for clean delivery. Nonetheless, many recommended clean delivery practices are ignored. Overarching themes emerging from this study included the increasing use of facility-based delivery, the disconnect between healthcare providers and the community, and the critical role grandmothers play in ensuring clean delivery practices. Future interventions to address clean delivery and prevention of neonatal infections include educating healthcare providers about harmful traditional practices so they are specifically addressed, strengthening facilities, and incorporating influential community members such as grandmothers to ensure success.

Investigating the spatial variations of high prevalences of severe malnutrition among children in Papua New Guinea: results from geoadditive models

BACKGROUND

Papua New Guinea (PNG) is one of the nutritionally vulnerable countries with a high rate of children death without showing a sign of improvement in last two decades. Current study investigated the prevalences of stunting and wasting among a cohort of children in PNG and described the spatial features of these outcomes at the province and district-levels.

OBJECTIVE

To determine the prevalences of stunting and wasting among a cohort of children in PNG and to describe the spatial features of these outcomes at the province and district-levels. We also described the spatial features of these outcomes at province and district-levels.

METHODS

The health and nutritional status of 683 children aged less than five years was assessed using a cross-sectional multi-stage household survey conducted in the Eastern Highlands and Madang Provinces of PNG during the period of 2003-2004. Growth z-scores such as height-for-age and weight-for-age were generated using World Health Organization classifications.

RESULTS

The prevalences of stunting (height-for-age z-score less than -2.0) were 59% and 49% in the Eastern Highlands and Madang respectively (P = 0.019). The prevalences of wasting (weight-for-height z-score less than -2.0) were 14% and 22% in Eastern Highlands and Madang respectively, (P = 0.039); overall, only 21% of the children had completed all their scheduled vaccines and 95% of the caregivers had less than primary school education. Our statistical maps showed considerable spatial variations (province- and district-levels) with regard to the stunting, wasting and other key factors within a relatively small geographical region.

CONCLUSIONS

Current study determined one of the highest prevalence of stunting among children in PNG. The impact of geographical locations on the risk factors must be recognized as it affects epidemiology and intervention coverage.

Re-examining authoritative knowledge in the design and content of a TBA training in India

Since the 1990s, the TBA training strategy in developing countries has been increasingly seen as ineffective and hence its funding was subsequently reallocated to providing skilled attendants during delivery. The ineffectiveness of training programmes is blamed on TBAs lower literacy, their inability to adapt knowledge from training and certain practices that may cause maternal and infant health problems. However most training impact assessments evaluate post-training TBA practices and do not assess the training strategy. There are serious deficiencies noted in information on TBA training strategy in developing countries. The design and content of the training is vital to the effectiveness of TBA training programmes. We draw on Jordan's concept of 'authoritative knowledge' to assess the extent to which there is a synthesis of both biomedical and locally practiced knowledge in the content and community involvement in the design of TBA a training programme in India.

FINDINGS

The implementation of the TBA training programme at the local level overlooks the significance of and need for a baseline study and needs assessment at the local community level from which to build a training programme that is apposite to the local mother's needs and that fits within their 'comfort zone' during an act that, for most, requires a forum in which issues of modesty can be addressed. There was also little scope for the training to be a two way process of learning between the health professionals and the TBAs with hands-on experience and knowledge. The evidence from this study shows that there is an overall 'authority' of biomedical over traditional knowledge in the planning and implementation process of the TBA training programme. Certain vital information was not covered in the training content including advice to delay bathing babies for at least six hours after birth, to refrain from applying oil on the infant, and to wash hands again before directly handling mother or infant. Information on complication management and hypothermia was not adequately covered in the local TBA training programme.

KEY CONCLUSIONS

The suggested improvements include the need to include a baseline study, appropriate selection criteria, improve information in the training manual to increase clarity of meaning, and to encourage beneficial traditional practices through training.

Breast feeding practices and newborn care in rural areas: a descriptive cross-sectional study

Context:

Breastfeeding practices play an important role in reducing child mortality and morbidity. This study was aimed to describe the breastfeeding practices prevalent in rural areas.

Objectives:

The primary objective of this study was to describe the breastfeeding and newborn care practices in rural areas and the secondary objective was to describe the factors affecting the initiation and duration of breastfeeding.

Settings and Design:

The study was conducted in primary health care center (PHC) that is attached to a medical college in Kengeri, rural Bangalore, Karnataka.

Materials and Methods:

Mothers with children who were 9 months old who came to the PHC for measles vaccination were included in the study and data was collected using the pre-tested questionnaire on breastfeeding and newborn practices.

Results:

Our study shows 97% of the mothers initiated breastfeeding, 19% used pre lacteal feeds, 90% had hospital deliveries and 10% had home deliveries, and 50% used a house knife to cut the umbilical cord among home deliveries.

Conclusions:

This study emphasizes the need for breastfeeding intervention programs especially for the mother during antenatal and postnatal check-ups and practices like discarding the colostrum and early/late weaning are still widely prevalent and need to be addressed.

Birthing Practices of Traditional Birth Attendants in South Asia in the Context of Training Programmes

Traditional Birth Attendants (TBA) training has been an important component of public health policy interventions to improve maternal and child health in developing countries since the 1970s. More recently, since the 1990s, the TBA training strategy has been increasingly seen as irrelevant, ineffective or, on the whole, a failure due to evidence that the maternal mortality rate (MMR) in developing countries had not reduced. Although, worldwide data show that, by choice or out of necessity, 47 percent of births in the developing world are assisted by TBAs and/or family members, funding for TBA training has been reduced and moved to providing skilled birth attendants for all births. Any shift in policy needs to be supported by appropriate evidence on TBA roles in providing maternal and infant health care service and effectiveness of the training programmes.

This article reviews literature on the characteristics and role of TBAs in South Asia with an emphasis on India. The aim was to assess the contribution of TBAs in providing maternal and infant health care service at different stages of pregnancy and after-delivery and birthing practices adopted in home births. The review of role revealed that apart from TBAs, there are various other people in the community also involved in making decisions about the welfare and health of the birthing mother and new born baby. However, TBAs have changing, localised but nonetheless significant roles in delivery, postnatal and infant care in India. Certain traditional birthing practices such as bathing babies immediately after birth, not weighing babies after birth and not feeding with colostrum are adopted in home births as well as health institutions in India. There is therefore a thin precarious balance between the application of biomedical and traditional knowledge. Customary rituals and perceptions essentially affect practices in home and institutional births and hence training of TBAs need to be implemented in conjunction with community awareness programmes.

A influência da rede social da nutriz no aleitamento materno: o papel estratégico dos familiares e dos profissionais de saúde

Objetivou-se levantar e categorizar trabalhos científicos sobre a influência da rede social da lactante no contexto da amamentação. Para isto, realizou-se uma revisão bibliográfica nas principais bases de dados em saúde (MEDLINE, LILACS, SciELO), utilizando como palavras chaves os descritores: aleitamento materno, desmame e família (e suas versões em inglês e espanhol). Foram consultados também livros, teses, dissertações, publicações em órgãos internacionais e nacionais (OMS, UNICEF, Ministério da Saúde). Pode-se observar que os atores que compõem a rede social da nutriz são capazes de exercer interferência na decisão de amamentar, através de diferentes âmbitos, tais como o incentivo/apoio à iniciativa; o repasse de conhecimentos e valores culturais; a tradição familiar e o cultivo do desinteresse/desestímulo e da pressão exercida sobre a lactante em relação à forma de alimentar a criança. Destarte, pode-se inferir sobre a necessidade de implementação de novas práticas de saúde no que tange à forma de cuidado a este grupo populacional. Vale ressaltar a importância de que os profissionais se capacitem para uma escuta sensível sobre o significado da lactação desde o olhar da nutriz. Por fim, destaca-se o papel importante da rede social da lactante, principalmente a família, para o sucesso da amamentação.