|Year : 2013 | Volume
| Issue : 1 | Page : 42-48
Effect of community-based behavior change communication on delivery and newborn health care practices in a resettlement colony of Delhi
Mamta Parashar1, SV Singh1, Jugal Kishore1, Ajay Kumar2, Milan Bhardwaj3
1 Department of Community Medicine, Maulana Azad Medical College, New Delhi, India
2 Department of Pediatrics, Maulana Azad Medical College, New Delhi, India
3 Department of Medicine, Lady Hardinge Medical College, New Delhi, India
|Date of Submission||04-Jan-2010|
|Date of Acceptance||18-May-2012|
|Date of Web Publication||31-Jan-2013|
Department of Community Medicine, Maulana Azad Medical College, New Delhi - 110 002
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Neonatal morbidity and mortality in India continue to be high. Among other reasons, newborn care practices are major contributors for such high rates. Objective: To assess the effect of behavior change communication (BCC) package among pregnant women regarding neonatal care. Materials and Methods: Semistructured and pretested schedule was used to interview 200 multigravidas on various aspects of neonatal care. Based on the preliminary data, BCC package was designed and implemented in intervention block in the community. Follow-up was done to find out change in their behavior. Statistical Analysis: Data were analyzed using Epi info and Fischer exact test and chi - square test were applied in the baseline data. A P value of less than 0.05 was considered significant. Effect of the BCC package is given in terms of relative risk. Results: BCC package increased 1.76 times higher number of deliveries conducted by trained dais in intervention group. There was significant improvement in using sterile cord tie (P = 0.01), applied nothing to the cord (P < 0.0001) and giving bath to their baby within 6 h of birth (P = 0.02) in intervention group as compared to nonintervention group. Significant difference was found between the two groups with regard to breastfeeding practices of baby. Harmful practices were reduced in the intervention group. Significant improvement was found in intervention group as compared to nonintervention group with regard to knowledge of danger signals, physiological variants, management of breastfeeding-related problems, and awareness of skin-to-skin technique for the management of hypothermic baby. Conclusion: Inadequate knowledge and adverse practices regarding neonatal care among mothers in study areas were found. BCC package had favorable impact on behavior of mothers for neonatal care in intervention group.
Keywords: Behavior change communication, breastfeeding, community intervention, hypothermia, neonatal health care
|How to cite this article:|
Parashar M, Singh S V, Kishore J, Kumar A, Bhardwaj M. Effect of community-based behavior change communication on delivery and newborn health care practices in a resettlement colony of Delhi. Indian J Community Med 2013;38:42-8
|How to cite this URL:|
Parashar M, Singh S V, Kishore J, Kumar A, Bhardwaj M. Effect of community-based behavior change communication on delivery and newborn health care practices in a resettlement colony of Delhi. Indian J Community Med [serial online] 2013 [cited 2017 Jun 26];38:42-8. Available from: http://www.ijcm.org.in/text.asp?2013/38/1/42/106627
| Introduction|| |
Out of 26 million babies born in India every year, 1.2 million die before completing the first 4 weeks of their life. This mortality contributes to 30% of 3.9 million neonatal deaths worldwide.  So, India is home to the highest number of both births and neonatal deaths in the world. Twenty-eight percent of Indian population lives in urban areas, of which more than one-fifth lives in slums where urban poor have higher neonatal mortality rate (NMR). According to SRS 2009, India is having a birth rate of 22.22 per 1000 population and infant mortality rate of 53 infant deaths per 1000 live births; however, it is around 34-38 per 1000 live births in the urban areas.  There is a variation in urban areas also, where highest rates recorded in slum and resettlement colonies. Therefore, neonatal health among urban poor communities is a national priority. Interventions which include tetanus toxoid vaccination, clean delivery, breastfeeding, care of low-birth-weight babies, and antibiotics for neonatal infection can avert neonatal deaths up to 72%. 
It has been realized that good knowledge and favorable attitudes are not sufficient to have preventive action in the individual and community. There is a need of changing behavior, which is directly related to change in bad practices. So, the communication should be such which can focus on behavior change. It is only possible with research-based, client-centered, benefit-oriented, service-linked, and professionally developed behavior change communication (BCC).  Moreover to achieve Millennium Development Goal 4 of 2/3 rd child mortality reduction by the year 2015, major advances in neonatal survival must be achieved through wide-scale implementation of cost-effective interventions in the community. For shaping the better health of neonate, care starts from the antenatal period of the mother itself along with this; several factors during birth and after birth affect the health of neonate. According to 6 th Joint Review Report  on National Rural Health Mission (NRHM) in addressing child health, management of diarrhea and ARI guidelines have been revised and circulated to all states. Additionally, an Information Education Communication (IEC)/BCC package is being worked out in consultation with IEC Division to promote the use of oral rehydration salt solution (ORS) and zinc in states. It was also found that, though there was some IEC material on Reproductive and Child Health (RCH) issues and Janani Suraksha Yojana (JSY) displayed, these were sporadic and had no thought out strategy behind them to influence clients or service providers. BCC was lacking both in terms of any coordinated effort and content of messages. Most clients were not being counseled to stay back for 48 h at the facility and on postnatal messages such as initiation of breastfeeding, postpartum contraception, and nutrition. However, not much information was available on impact of BCC on neonatal health. Therefore, in the present study BCC package is used in the community to assess its impact on neonatal health care.
| Materials and Methods|| |
Community-based intervention study.
Gokulpuri, a resettlement colony in East Delhi, one of the urban field practice areas of Department of Community Medicine, Maulana Azad Medical College. Population of 20,364 is divided into four blocks which were randomly divided into two each intervention and nonintervention blocks. Geographically, the blocks were distinct but contamination cannot be ruled out.
Study was conducted for a period of 12 months beginning from January 2006 to December 2006.
All antenatal care (ANC) mothers excluding primigravida (because of increased possibility of first delivery at parental home) were included in both the groups during the study period. During the enrolment period, 106 women in intervention group and 108 women in control were included, but 100 women in each group provided complete information. There were various reasons for providing incomplete formation such as left to their native place in other state before delivery, change of residence, or refusal.
The Maulana Azad Medical College Institutional Ethical Committee approved the research protocol as a part of Doctor of Medicine (MD) thesis. All primigravida mothers in intervention block were also informed about the messages of intervention package, though they were excluded from the study. Control subjects were medically advised according to their need and their queries were satisfied. Written consent was obtained from each subject before enrolling them in the study.
Pregnant women with expected date of delivery between 1 st March 2006 and 31 st December 2006 in both intervention and control blocks were chosen for the study. A house-to-house visit was made in all chosen subjects to get the information in both (intervention and nonintervention) blocks. The data were collected using predesigned and pretested semistructured questionnaire. It included information regarding identification, socioeconomic status (using Kuppuswami scale), behavior about full term/preterm delivery, safe and clean delivery, cord care and hygiene, physiological variants, prevention of hypothermia, prevention of neonatal infection, breastfeeding, prelacteal feeds, low birth weight (LBW) newborn care at home, danger signs in neonates and health-seeking behavior of mother in case of sickness of neonates, causes of neonatal morbidity and mortality, and institutional delivery. Primary outcome measures include all the information regarding neonatal care. The study was conducted in three phases in both interventions as well as control block: phase I was for base line collection of data, phase II was intervention phase, and phase III was to follow-up survey after delivery.
Baseline as well as postintervention information was collected for all parameters mentioned above. Based on the base line data BCC package was designed and implemented in the community. Investigator (First author) had provided the package to the intervention block only for the group of 9 month pregnant women after March till 31 st December 2006 in their respective Anganwadis. Birth attendants of block were also called to attend the Intervention. There were 12 Anganwadis in the area. 4 out 5 angawadis in intervention blocks were used for delivering BCC package. In some cases it was delivered to home when pregnant did not attend Anganwadi. A pamphlet was designed having clear and simple messages in local language and was distributed to women. For those who could not read their literate family members were asked to read for them. BCC package was given explaining why such messages were important for them. Such educational activities which is indicated in Reproductive and Child health (RCH) program was absent in the area before commencement of study.
Behavior change communication package
This contains messages with pictures under following headings: safe and clean delivery by trained personnel or safe and clean home delivery, use of disposable delivery kit, cord care , eye care, home-based thermal care and prevention of hypothermia in neonates, i.e., skin to skin contact method (kangaroo mother care), breastfeeding, prevention and management of breastfeeding-related problems, home-based treatments to prevent cracked nipples, measures to prevent infections in LBW babies, danger signals, and physiological variants of neonate.
Tools of behavior change communication
Counseling, posters, pamphlets, demonstration.
Place where behavior change communication package was provided
Anganwadis of intervention blocks.
Data were analyzed using Epi info and Fischer exact test and Chi - square test were applied in the baseline data. A P value of less than 0.05 was considered significant. Effect of the BCC package in intervention group compared to nonintervention group is given in terms of relative risk.
| Results|| |
Both intervention and nonintervention groups were comparable as far as literacy, socioeconomic status, husband's occupation, religion, and their knowledge, beliefs, and intranatal and neonatal health practices at the baseline level is concerned [Table 1].
|Table 1: Baseline characteristics of study subjects in intervention and nonintervention groups|
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Maternal delivery practices
During follow-up survey within 7 days after delivery, the data revealed that more mothers preferred to deliver at institutions in the intervention block (43%) than nonintervention block (31%). However, this difference had not reached to the statistical significant level.
There was improvement in home delivery practices in intervention group but does not reached to significant level. After exposure to BCC package, 56.1% of mothers in intervention and 31.8% of mothers nonintervention group had delivered by trained dais (i.e., 1.76 times higher).
Intrapartum and early neonatal care practices among all women
There were significant improvements in using sterile cord tie (intervention 42.1% versus nonintervention 21% mothers; P = 0.01) and no application on cord (intervention 45.6% versus nonintervention 5.7%; P < 0.0001). All attendants (100%) in both intervention and nonintervention blocks washed hands with soap and water as well as using clean surface for delivery. Clean blade was used by 92.9% in intervention and 86.1% in nonintervention block, respectively. These differences were not statistically significant (data not presented in table).
There were 60 and 72 women in intervention and nonintervention groups who adopted practices to prevent hypothermia. Out of these women, a significant less number in intervention group (63.1%) did not give bath to their babies within 6 h as compare to nonintervention group (84.05%) (RR = 0.61, CI 0.43-0.86, P = 0.009). More number of women wrapped in prewormed towel at birth in intervention group (RR = 1.74, CI 1.29-2.3). 50 (83.3%) of intervention and 59 (82%) in nonintervention block women had their delivery in warm room and 56 (93.3%) in intervention and 65 (90.3%) in nonintervention block women kept their babies with them (RR = 1.1). Vernix caseosa was removed in 4.3% babies in the nonintervention group whereas 3.3% in the intervention group did so. Significant proportion of women in intervention block checked temperature of their babies (Intervention 52% versus nonintervention 8.6% (RR = 2.67, CI 1.92-3.71, P < 0.05) [Table 2].
|Table 2: Practice to prevent hypothermia in home deliveries in intervention and nonintervention groups|
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Neonatal care practices among all women
Significant difference was found among the two groups with regard to practice of colostrum and breastfeeding to their babies within 1 h after birth and induction of burping observed during follow-up. However, no significant difference was found with regard to exclusive breastfeeding on 7 th day of follow-up, but this behavior changed significantly in intervention group after 28 days (P < 0.01). There was no significant difference with regard to practice of keeping the head and feet covered appropriately.
Hazardous neonatal practices
Harmful practices such as prelacteal feed, application of kajal, and jhar phoonk were reduced due to exposure to BCC package in intervention as compared to nonintervention group but none of these practices except giving artificial nipple after 28 days reached to a significantly level [Table 3].
Knowledge about medical conditions and danger signs that required consultation had increased significantly in intervention as compared to nonintervention group during follow-survey on 7 th day after delivery and even maintained after 28 days of delivery. Knowledge regarding physiological conditions except erythema toxicum, meconium discharge, milia had increased significantly in the intervention as compared to nonintervention women during follow-up survey on 7 th day and remains unchanged even after 28 days [Table 4]. Significant improvement in awareness of various techniques such as skin to skin technique and management of hypothermic baby was found in intervention as compared to nonintervention group during the follow-up period on 7 th day as well as after 28 th day [Table 2].
|Table 3: Harmful neonatal practices in study groups (within 7th and after 28th day of delivery - follow-up survey)|
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|Table 4: Correct knowledge about physiological conditions of neonates that do not require medical consultation|
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Beneficial effects of BCC on mothers
BCC package had increased many times the chances of mother to manage their breastfeeding-related problems as compared to the mothers of nonintervention block. Such difference was found to be statistically significant on 7 th day as well as after 28 days in follow-up period. Except in the prevention of infection by avoidance of over handling a significant improvement was found in intervention mothers with regard to their knowledge of care of low birth babies on 7 th day and after 28 days during follow-up period [Table 5].
|Table 5: Breastfeeding-related neonatal care practices among study groups (within 7th and after 28th day of delivery - follow-up survey)|
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| Discussion|| |
BCC package for neonatal care had positive effect on women in intervention group as observed by other researchers, ,,, although improvement in institution deliveries was not significant as compared to nonintervention group. The focus of the package was to improve neonatal care but reasons for poor accessibility and acceptability of institutional delivery was not discussed that could be the cause of insignificant change. The reasons reported by mothers were poor accessibility and high cost of hospital delivery, difficulty in transportation, and unfriendly attitude of doctors toward the patients. However, the present study emphasized that there is a need of improvement of quality of care at institutional level.
Significantly more pregnant women of intervention block had delivered by trained dai as compared to nonintervention block (P value < 0.05). The similar effects had been observed by other researchers. , In the present study the cord of newborn was tied using a clip or a rubber band in institutional deliveries, while sterile thread or clip (available in the delivery kit) was used in 42.1% of intervention block deliveries and 21.7% of nonintervention intervention block deliveries. This difference was found to be significant (P < 0.01). As a common perception of people, cord tie with common thread in home delivery is presumed to be safe. Similarly, improvement of delivery practices at home was seen in other studies after intervention. 
Some good delivery practices were already prevalent in the community such as washing of hands by attendants before delivery and usage of clean surface. There was no significant difference between the two groups with regard to the following practices: wiping the baby dry after birth, delivery in a warm room, covering the head and feet of baby, and practice of rooming in. Similar findings were also reported by other researchers. , This could be due to exiting traditional practices in the community which did not change within short period.
Although good practice of washing hands, using clean instrument was prevalent in both the blocks, but even then more cases of local umbilical infection occurred in the nonintervention block. These cases might be due to widely prevalent harmful practice of applying things on the cord like turmeric with oil or ghee, just oil or ghee and talcum powder. These applicants were also used in institutional deliveries but after the child were brought home. Similarly, Bennett et al. (1995)  revealed that topical application of ghee to the umbilical wound poses a significant risk for neonatal tetanus. Therefore, such harmful practices should be discouraged.
Practice of giving first bath within 6 h had significantly decreased in the intervention block, as they were made aware about the consequences of hypothermia. Similar findings were observed in Nepal infant care practices improved after intervention.  Bang et al. (2005)  in a study from rural Maharashtra shown that trained Village Health Guides (VHWs) were able to reduce hypothermia morbidity and mortality in intervention group.
More women in the intervention block initiated breastfeeding within 1 h and duration of feeding was also increased. Similar observations were made by Haider et al. (2000)  in which breastfeeding duration was increased in the intervention group as compared to nonintervention group. Significant difference was found among the two groups with regard to practice of Colostrums feeding to their baby after birth. Knowledge of exclusive breastfeeding was imparted and a significant improvement in behavior of mothers was seen similar to findings in other studies. ,, Education given regarding breastfeeding technique practices, knowledge of prevention, and management of breastfeeding problems were readily accepted by pregnant females as they were receptive to this issue during this period. Significant difference was found between the two groups with regard to these knowledge and practices. Significant difference was found between the two groups with regard to practice of induction of burping within 7 days.
Harmful practices (prelacteal feed, application of kajal, jhar phoonk for neonatal illness, and use of artificial nipple) were reduced due to exposure of BCC package in intervention block. But this effect was significant up to seven only. After 28 days, except the practice of using artificial nipple, the difference was not significant. This could be due to the fact that most of the women influenced in their feeding practices by other traditional factors present in the community. Practice of application of kajal could not be decreased significantly as they had deep rooted beliefs that it would beautify and clear the eyes. Similarly, jhar phoonk for any neonatal illness in both 7 th and 28 th day of birth did not change much that could be due to presence of strong cultural beliefs and influence of mother-in-law and other elderly females of the family. Harmful practice of prelacteal feed was not changed after intervention because of similar reasons. Mass media advertisement of prelacteal feed (janam ghutti, 555) could also be the cause of unchanged practice. Mothers were very eager to learn about the danger signs of common morbidity in neonates in intervention group as compare to nonintervention group. Similar findings were observed in another study,  but not in another study carried out by Bolam et al. (1998)  in Nepal. Similar to findings of Dezoysa et al. (1998)  in urban slums in Delhi, the present study also found out that mother had preferences to local unqualified practitioners regarding neonatal care.
Dragovich et al. (1997)  had concluded from their study that when health workers possess knowledge of how to prevent hypothermia this knowledge may not be translated into practice. Similarly, in the present study knowledge of mothers increased significantly after telling them about care of hypothermia and low birth babies. Knowledge of care of LBW babies may be translated in practice, as observed by Datta et al. (1987)  in Haryana.
Neonatal deaths contribute maximum to infant mortality rate and simple intervention in the form of BCC can avert such mortality. BCC can be applied through health workers in the community to improve neonatal care that can decrease the morbidity and mortality among infants. Limitations of the study include inability of assessment of cost effectiveness of such package and its effect on neonatal mortality as an outcome. We could not also involved elderly females, mother-in-law, dais, and other reproductive age group nonpregnant women and health workers during demonstration and counseling sessions, which might have improved the practices further in intervention group. Geographically, the blocks were distinct but contamination cannot be ruled out; however, the effect was stilled beneficial in intervention group.
It is concluded that mothers in the study area had inadequate knowledge and carrying out some harmful practices. Various myths were prevalent that could be the reasons for such harmful practices and delay in health care seeking behavior for neonatal care. Behavioral change communication package designed according to the felt need of the community has favorable impact on the knowledge and safe practices of mothers for neonatal care. This study advocates larger community based behavior change interventional research to save neonates, so that it can help in the formulation of national neonatal care strategy.
| References|| |
|1.||Government of India, Ministry of Health and Family Welfare, Child Health Division, New Delhi, 2000. |
|2.||Registrar General of India. Sample Registration Survey 2009. Government of India 2010. |
|3.||WHO. World Health Report 2006. Report of Director General, Geneva: WHO; 2006. |
|4.||Kishore J. National Health Program of India: National Policies and Legislations related to Health. New Delhi: Century Publications; 2010. p. 178-9. |
|5.||Government of India. NRHM 6 th joint Review Mission Report. Department of family welfare. Ministry of Health and family Welfare, Government of India 2009. |
|6.||Bang AT, Bang RA, Reddy HM, Deshmukh MD, Baitule SB. Reduced incidence of neonatal morbidities: Effect of home-based neonatal care in Rural Gadchiroli, India. J Perinataol 2005;25:S51-61. |
|7.||Haider R, Ashworth A, Kabir I, Huttly S. Effect of community-based peer counselors on exclusive breastfeeding practices in Dhaka, Bangladesh: A randomized controlled trial. Lancet 2000;356:1643-7. |
|8.||Lutter C, Perez-Escamilla R, Segall A, Sanghvi T, Teruya K, Wickham C. The effectiveness of a hospital based program to promote exclusive breastfeeding among low income women in Brazil. Am J Public Health 1997;87:659-63. |
|9.||Morrow A, Guerrero M, Shults J, Calva JJ, Lutter C, Bravo J, et al. Efficacy of home-based peer counselling to promote exclusive breastfeeding: A randomised controlled trial. Lancet 1999;353:1226-31. |
|10.||O'Rourke K. The effect of hospital staff training on management of obstetrical patients referred by traditional birth attendants. Int J Gynaecol Obstet 1995;(48 suppl):S95-102. |
|11.||Datta N, Kumar V, Kumar L, Singh S. Application of case management to the control of acute respiratory infections in low- birth-weight infants; a feasibility study. Bull World Health Org 1987;65:77-82. |
|12.||Osrin D, Mesko N, Shrestha BP, Shrestha D, Tamang S, Thapa S, et al. Implementing a community-based participatory intervention to improve essential newborn care in rural Nepal. Trans R Soc Trop Med Hyg 2003;97:18-21. |
|13.||Bennett J, Azhar N, Rahim F, Kamil S, Traverso H, Killgore G, et al. Further observations on ghee as a risk factor for neonatal tetanus. Int J Epidemiol 1995;24:643-7. |
|14.||Bolam A, Manandhar D, Shrestha P, Ellis M, Costello A. The effects of postnatal health education for mothers on infant care and family planning practices in Nepal: A randomized controlled trial. Br Med J 1998;316:805-11. |
|15.||Bartlett AV, Paz de Bocaletti ME, Bocaletti MA. Neonatal and early postneonatal morbidity and mortality in a rural Guatemalan community: The importance of infectious diseases and their management. Pediatr Infect Dis J 1991;10:752-7. |
|16.||De Zoysa I, Bhandari N, Akhtari N, Bhan MK. Careseeking for illness in young infants in an urban slum in India. Social Sci Med 1998;47:2101-11. |
|17.||Dragovich D, Tamburlini G, Alisjahbana A, Kambarami R, Karagulova J, Lincetto O, et al. Thermal control of the newborn: Knowledge and practice of health professional in seven countries. Acta Paediatr 1997;86:645-50. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]