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Thesis on Infant Mortality

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    Chapter 1 INTRODUCTION Children are vital to the nation’s present and its future. Parents, grandparents, aunts, and uncles are usually committed to providing every advantage possible to the children in their families, and to ensuring that they are healthy and have the opportunities that they need to fulfill their potential. Yet communities vary considerably in their commitment to the collective health of children and in the resources that they make available to meet children’s needs.

    This is reflected in the ways in which communities address their collective commitment to children, specifically to their health. In recent years, there has been an increased focus on issues that affect children and on improving their health. Children are generally viewed as healthy when they are assessed by adult standards, and there has been a great deal of progress in reducing childhood death and diseases. Death is a certainty of life. Everyone who born alive has to die sooner or later while the first year of new life is the most important and vulnerable period for child.

    Infant mortality has traditionally been viewed as an indicator of the social and economic well-being of a society. It reflects not only the magnitude of those health problems which are directly responsible for the death of infants, such as diarrheal and respiratory infections and malnutrition, but the net effect of a multitude of other factors, including prenatal and postnatal care of mother and infant, and the environmental 2 conditions to which the infant is exposed.

    The high level of infant mortality is an indication of discouraging socio-economic development and along with the poor government commitment for improving health status of its nation. Millennium Development Goal (MDG) 6 focuses on improving maternal health, with target 5 aiming to reduce the child and infant mortality ratio by two-thirds, between 1990 and 2015. Like many developing countries Pakistan too, is facing with problems of high infant mortality especially, in the rural areas. So this study was focused to explore the determinants f infant mortality in the, “Warayamal”, a village of district Chakwal. Infant mortality refers to deaths of children under the age of one year. It is measured by the infant mortality rate, which is the total number of deaths to children under the age of one year for every 1,000 live births. The infant mortality rate is often broken down into two components relating to timing of death: neonatal and post neonatal. The neonatal mortality rate refers to the number of deaths to babies within 28 days after birth (per 1,000 live births). Sometimes a special type of neonatal mortality is assessed.

    The prenatal mortality rate measures the number of late fetal deaths (at or after 28 weeks gestation) and deaths within the first 7 days after birth per 1,000 live births. The post neonatal mortality rate involves the number of deaths to babies from 28 days to the end of the first year per 1,000 live births. The distinction between neonatal (and prenatal) and post neonatal mortality 3 is important because the risk of death is higher close to the delivery date and the causes of death near the time of birth/delivery are quite different from those later in infancy.

    Therefore, effective interventions to reduce infant mortality need to take into account the distribution of ages at death of infants (Encyclopedia of Death and Dying, 2010). Every day, 1500 women die in pregnancy or due to childbirth related complications worldwide. Two thirds of all maternal deaths in Asia and the Pacific occur in India (540 deaths per 100,000 live births) and Pakistan (500). Every year about 11 million children die, of which 10 million are in the developing world. South Asia is the continent where world’s poorest population is habituating.

    It’s social and economic indicators stand out in terms of the number of persons below the poverty line, some of the lowest literacy and high infant mortality rates. Pakistan has the highest maternal and infant mortality rate in the South Asia-male: 70. 65 deaths per 1,000 live births and female: 63. 91 deaths per 1,000 live births; total: 67. 36 deaths per 1,000 live births; neonatal mortality: 53 (per 1,000 live births) in which 32 percent with low birth weight, institutional delivery is just 34% and only 29 percent are feeded with early initiation f breast feeding and 55 percent feeded on breast milk up to 2 years Pakistan is still in a high infant stage of development as revealed in the census. The infant mortality rate is 106 in rural areas in Punjab and this figure is much high. Also there is a need to explore infant 4 mortality in socio economic perspective of rural areas (UNICEF, 2010). Mortality in female infants was 1. 3 times higher than in male infants. Discrimination, which may lead to increased mortality among female children, has been the subject of many previous studies.

    The World Health Organization has reported that the sex disparities in health and education are higher in South Asia (Khanna et al. 2005). The human society even having acknowledged this universal truth has been continuously trying to postponing death since the dawn of civilization. Developed nations are largely successful in it. But under developed countries have failed in declining mortality especially infant mortality rates. The infant mortality rate in Pakistan is quite high and every 11th child who is born alive dies before reaching of his first birth day (Cleland and Farooqui, 1998).

    The figure is extremely high when compared with infant mortality rates with some developed countries like Zealand and United States where these rates are 6. 7 and 7. 2. In China and Indonesia mortality rates are 31 and 46. In developing countries infant mortality rate 64 in Bangladesh, 111 in Zambia, 98 in Pakistan, 74 in India (Arnold and Cushman, 2005). All the developing countries including, Pakistan are making utmost effort to decline the mortality rate among the mothers and children right from the pre-natal 5 stage to toddler stage.

    The main factors responsible for the increased death rate among the women are the high level of still-birth and physically or mentally handicapped births of the children, lack of health facilities, lacking in utilizing of these facilities, financial incapacities to afford health facilities, repeated pregnancies, and the poor level of nutrition and polluted environment. At the same time, the traditions of our country have hinder our people to be benefited from the modern health care system because in rural areas still the people don’t want to use the facilities available at hospital or medical centers.

    Due to these reasons, the mother-child health is severely affected and the result is in the form of many diseases and disabilities Therefore, rural areas of Pakistan have become challenge to planners, sociologists, administrators and even to politicians to chalk out some programs to overcome the serious health problems particularly the high level of child morbidity and mortality (Akhtar et al. , 2005). UNICEF pointed out that just over one in 10 Pakistani children die before their first birth day. Rates are also highly differentiated according to class, region and the rural urban divide. While in very poor families it is around 230 per 1000.

    Rural areas generally suffer more infant mortality than towns (UNICEF, 1992). The causes of infant and childhood mortality during the first months and years of life may be roughly divided between endogenous and exogenous. The term endogenous refers to deaths caused by factors that are independent of pathological socioeconomic and cultural conditions into which a child is born. The endogenous 6 causes are therefore associated with biological and genetic factors influencing the survival chances after birth. It has to be noted that the endogenous factors are strongly influenced by environmental factors such as poor hygienic conditions.

    It is quite difficult to imagine an exogenous factor which would not operate through endogenous causes of a child’s death. In our opinion, such a solely exogenous cause is preferential infanticide, which is determined culturally, and is not affected by any biological mechanisms. The above-defined terminologies provide a useful frame of reference for the study of mortality determinants over the first five years of human life. It has to be stressed that the biological (endogenous) factors are closely related and influenced by cultural (exogenous) factors.

    The biological factors, such as developmental deficiencies or chromosomal anomalies, are usually assumed to be the main causes of death in the first days of life. However, the environmental (cultural) factors, also contribute to the survival chances by influencing the mother’s health, either directly or through demographic variables. The mother’s poor health status might translate into a premature or hypothrophic2 birth. Therefore, in both of these coincidental chains, the mother is the most important factor through which the external environment influences the fetal development of the child.

    A child’s health status might also be influenced directly by demographic variables like sex, survival status of adjacent siblings, season of birth, survival of parents, or presence of extended family. Especially the sex of the newborn child greatly influenced its fate. Male infants are much more likely to die within the first 24 hours after delivery than female infants. It has to be noted that 7 exogenous factors affect not only the mother’s health, but also the child’s health. Apart from the bio-genetic factors, exogenous factors—such as epidemics, wars, and famines—determined child survival to a large extent (Tymicki, 2009).

    Ensuring the survival and wellbeing of children is a concern of families, communities and nations throughout the world. Since the turn of the 20th century infant and child mortality in more developed countries has steadily declined and, currently, has been reduced to almost minimal levels. In contrast, although infant and child mortality has declined in the past three decades in most less developed countries; the pace of change and the magnitude of improvement vary considerably from one country to another.

    In Pakistan infant mortality is still very high and the neonatal mortality contributes more than half of the Infant Deaths. In 1950s it was around 50 percent of the Infant mortality; in 1990s it was about 60 percent of the infant mortality. We can reduce the infant mortality by identifying the factors (proximate determinants such as, demographic factors, environmental factors, nutritional factors and health seeking behavior) associated with neonatal and post- neonatal mortality. The neonatal mortality in the province of Punjab is slightly increased; however, it is not significant (Mahmood, 2002).

    The inverse relationship between socio-economic variables of the parents and infant and child mortality is well established by several studies and it holds true 8 irrespective of the overall level of mortality in the national populations. The influence of parental education on infant and child health and mortality has proved to be universally significant. The father’s education, mother’s education and their work status each have independent effects upon child survival in developing countries. Economic conditions of the household also help in explaining the variation in infant and children mortality.

    The nature of housing, diet, access to and availability of water and sanitary conditions as well as medical attention all depend on the economic conditions of the household. For example, poor families may reside in crowded, unhygienic housing and, thus, suffer from infectious disease associated with inadequate and contaminated water supplies and with poor sanitation. Maternal factors, which are biological attributes of birth, such as the age of mother at the time of childbirth, birth order and birth interval have significant effects on child survival.

    Infant and child mortality are also affected by the sex of the child, and infants born to mothers who have lost a child are at greater risk of dying during infancy. Breastfeeding has numerous bio-demographic, social, and economic effects. It affects the health and nutritional status of, both, the mother and child. The role of breastfeeding is very important in the post-neonatal period. Health seeking behavior includes both, preventive and curative measures.

    Preventive measures include immunization against preventive diseases such as tuberculosis, polio, measles, neonatal tetanus and smallpox, whereas curative measures include the care and types of treatment undertaken for specific conditions, both modern and traditional (Mahmood, 2002). 9 In developing societies, like Pakistan people still seek health care from the traditional health care practitioners. This is a significant factor of poor mother-child health status and high incidence of children mortality and morbidity. Majority of the selected women (47. %) delivered their baby under the supervision of traditional birth attendants. Doctors only supervised 35% births. The dream of high health status for all Pakistani can only be achieved when people have access to modern health care system home. Population Report of the world fertility survey in 1985 reported that in 19 out 29 countries infant mortality rates were higher among children born fourth or later, and in 25 of 29 countries infant mortality rates were higher among children born seventh or later (Akhtar et al,. 2005).

    Infant mortality varies among different groups of population due to different causes like, endogenous and exogenous factors. A low standard of living in rural areas of Pakistan is the norm. Housing is poor with inadequate ventilation and high occupancy, often with cattle or other domestic animals. Transmission of respiratory diseases is common under such conditions. Low standards of health affect a society in many ways. Malnutrition, diarrheal illness, acute respiratory infections, neonatal tetanus and malaria are the common causes of infant mortality. An estimated 200,000 infants die each year due to diarrhea alone.

    The varying characteristics of the Punjab lead to infant mortality to vary due to the regional, biological, demographic and socio-economic factors in locations. Many 10 endogenous factors like sex of child and sex preference child and mother health maternal age at marriage and birth order, birth interval, birth weight, breast feeding, contraceptive use and exogenous factors like region, residence, child’s birth place, mother’s and father’s education, religiosity, land ownership, livestock, assets, income, occupation, housing traits like water and toilet facilities ( UNICEF, 2002).

    Theoretically, Child’s mortality is influenced by its mother’s education, little explicit attention has been paid to the possibility that also the education of other women in the community may be of importance. Three main causal channels are relevant: social learning, social influence, and indirect mechanisms. Social learning means that knowledge and attitudes are transmitted directly from others by communication and observation, whereas social influence refers to a more passive imitation of behavior, driven by a desire to gain other people’s approval or avoid sanctions.

    The indirect mechanism is that others’ ideas, resources, or behavior can influence society and social institutions and thereby individual behavior or events (kravdal, n. d). P ak is ta n i s st il l in a high infant and child mortality state of development as revealed in the 1998 census. The infant mortality rate is 106 in rural Punjab, Pakistan. This figure is much high in rural areas of northern 11 Punjab of Pakistan.

    Population Policy was introduced in 2002 with the goal to achieve population stabilization by the year 2020 through the expeditious completion of the demographic transition that entails declines in fertility and mortality rates and to improve the quality of life. The high rate of infant and child mortality will necessarily undermine efforts being under taken to reaching replacement level of fertility by the year 2020. It has been recognized that improving women’s welfare can be an important measure to reduce child mortality.

    Reduction of child mortality rates is mentioned as one of the key strategy to achieve population stabilization. Thus, there is a need to explore the determinants of infant mortality in socio-economic perspective because knowledge of some of the factors affecting infant mortality is a fundamental requirement for devising appropriate policies and strategies to accelerate decline in infant mortality and population stabilization. Therefore, the fundamental objective of this study was to explore the determinants of infant mortality.

    This research will be helpful for the policy makers, demographers and other researcher for further investigation. Study was focused on following objectives: 12 To explore current patterns of infant mortality in socio-economic and demographic perspective To assess the knowledge and attitudes towards safe motherhood To examine the patterns of births preparedness and new-born care those have a potential threat for infant mortality 13 Chapter 2 REVIEW OF LITERATURE

    Caldwell (1990) investigated that early supplementation had adverse of reducing breast milk intake because the child was not hungry, as well as possibly exposing the child to hygienic practices. To him mothers should use preparing supplements given to infant when breast milk suddenly inadequate. Mahmood (1993) explained that mortality and health status cannot be treated in isolation but it is related very intricately with some of the social economic conditions. Economic aspects of illness may often over shadow the other aspects of social component.

    Poor income may result in lower standard of living which stands for inadequate food, shelter and recreational that adversely affects health of family members. Above all, the cost of the medical care may put a family under a heavy burden of debt, which may further deteriorate their living conditions. 14 Thus it may prove a vicious circle specifically for people with poor resources. The significance of phenomena of infant mortality is hardly irrevocable for its socio- economic and demographic implications.

    As infant mortality, in general is considered to explanative of overall socio-economic development. The factors that play an important role in the child health are education of mother, household income, occupation of father, standard of living etc. , and other demographic factors such as age of mother at birth, birth interval and health care factors like medical facilities and immunization. Zahid (1996) stated that the highest mortality occurred among children born to mothers aged less than 20 years.

    The survival status of the preceding child has a strong association with neonatal, infant and child mortality in Pakistan. The death of a preceding child probably indicates the importance of biological factors, including physiological deficiencies in the mother and environmental problems which could carry over to later births. Neonatal and infant mortality is higher for males than for females, as expected; this relationship is then reversed for child mortality. There are some gender related differences in child rearing practices that favor boys over girls.

    The analysis of birth order pattern has found mortality to be the highest among first order births, and lowest for third order births before increasing again as the birth order increases. The high mortality of first and high order births may be related to the age of the mother at the child’s birth which is termed as high risk births for very young and older mothers. Neonatal, infant and 15 child mortality are highest for children born less than 18 months after the previous birth. The mortality risk then declines as the birth interval increases. Mortality is higher in rural areas than in urban areas as expected.

    This might be due to factors including sanitation, water supply, and unequal distribution of health facilities between rural and urban areas of the country. Differentials in infant and child mortality are that mother’s education, age at birth and birth interval are strongly correlated with lower neonatal and infant mortality. Maternal education can contribute to the reduction in infant and child mortality by promoting preventive measures. The higher the utilization of health services by mothers during pregnancy and after delivery of the child, the lower the infant and child mortality.

    Therefore, it is suggested that for the improvement of the health conditions of children in Pakistan, first, it is necessary that the educational status of the population in general, and of mothers in particular, should be improved, and second, the health services should be accessible and available for the promotion of health care practices. Zerai (1996) examined socio-economic and demographic variables in a multi-level framework to determine conditions influencing infant survival in Zimbabwe. He employed Cox regression analysis to the 1988 Zimbabwe DHS data to study socioeconomic determinants of infant mortality.

    The unique finding was that women’s average educational levels in their community exert a greater 16 influence on infant survival than the mother’s educational level. This result supports assertions that child survival is strongly impacted by mass education. World Bank (1996) investigated that infant mortality rates are much higher in families with non-educated parents which is particularly pronounced for the mother’s education. To him education is strongly correlated with the type of work. Infant mortality is affected by individual, house hold and community characteristics.

    Individual characteristics are the characteristics which are related to parents at marriage, at first birth, education, income, occupation, and landownership and livestock assets. Government of Pakistan (1997) recognized infant mortality as one of the main challenges and a key development goal before the human society when the world summit for children in 1990 set forth a package of objectives aimed to reduce infant mortality by one third or 50 and 70 deaths per 1000 births, which is less to be implemented by the year 2000.

    This war reaffirmed at ICDP (International Conference on population and Development) in 1994. The government of Pakistan through Health Department) recently introduced population policy to achieve population stabilization by the year 2020 to aid social and economic development and improve quality of life. The national population 17 policy paid full attention towards awareness and promotion of quality family planning & rural health services to all married couples.

    Oscar (1999) documented in his study of co-variants of infant mortality in the Philippines, Indonesia and Pakistan and found that the risk of dying of children born to older mothers as well as younger mothers would be greater than babies born to mother at prime reproductive ages. In each country babies born to women less than 20 years of age experience much higher mortality than children born to women of prime reproductive age i. e. , 20- 30.

    Manda (1999) used data from the 1992 DHS in Malawi to study the relationship between infant and child mortality and birth interval, maternal age at birth and, birth order, with and without controlling for other relevant explanatory variables. He also investigated the direct and indirect (through its relationship with birth intervals) effects of breastfeeding on childhood mortality. The study employed proportional hazards models. The results show that birth interval and maternal age effects are largely limited to the period of infancy.

    Rashida (2000) pointed out that 70% population of Pakistan lives in rural areas, so majority of the children are born and brought up there. The overall 18 condition of our villages gives their life as start with multiple disadvantages. They suffer from illness caused by malnutrition and unsanitary conditions. Iodine deficiency is quite prevalent in the Northern areas of Pakistan. Poor maternal nutrition status result in the high incidence (about 25%) of low birth weight babies, iron-deficiency anemia and other complications of pregnancy in the women of child bearing age persist.

    Protein-energy-malnutrition is prevalent in the vulnerable population. Voland and Beise (2002) looked at the question whether the existence or non-existence of grandmothers had an impact on the reproductive success of a family. We found that fertility (measured by intervals between births) was not influenced by grandmothers. However, maternal grandmothers tended to reduce infant mortality when the children were between six and twelve months of age. During these six months, the relative risk of dying was approximately 1. times higher if the maternal grandmother was dead at the time of the child’s birth compared to if she was alive. Interestingly, the existence of paternal grandmothers approximately doubled the relative risk of infant mortality during the first month of life. We interpret this as being the result of a tense relationship between mother- and daughter- in-laws. Grandmothers could be both helpful and a hindrance at the same time. Geographic proximity tended to increase the effects found. If this ambivalent impact of grandmothers on familial reproduction could be eneralized beyond the Krummhorn population, the hypothesis that the evolution of the post- generative life span could be explained by grandmotherly kin-effects would have to 19 be stated more precisely: the costs of social stress in the male descendency would have to be subtracted from the benefits of aid and assistance in the female descendency. Freemantle (2003) concluded that Indigenous infants living in a remote location were at a significantly increased risk of death due to infection compared with their peers living in a rural or metropolitan location.

    The risk of death for Indigenous children was more than three times higher than for non- Indigenous children. This risk was significantly increased when most of the perinatal maternal and infant variables were considered. Accident and injury, and infection were the main causes of mortality amongst Indigenous children. For non-Indigenous children the main causes were also accident and injury, followed by infection and cancer. However, the risk of accidental death for Indigenous children was nearly 4? times higher, and death due to infection nearly seven times higher, than for non- Indigenous children.

    The childhood mortality rate in Indigenous children was highest in those born in remote areas, and in rural areas for non-Indigenous children. Ogunjuyigbe (2004) concluded that infant and child mortality remain disturbingly high in developing countries despite the significant decline in most 20 parts of the developed world. The state of the world’s children indicated that about 12. 9 million children die every year in developing world Common causes of child mortality and morbidity include diarrhea, acute respiratory infections, measles, and malaria.

    Many children in Nigeria die mainly from malaria, diarrhea, neonatal tetanus, tuberculosis, whooping cough and bronchopneumonia. Morbidity and mortality of the child as being influenced by underlying factors of both biological and socio-economic, operating through proximate determinants. Dirty feeding bottles and utensils, inadequate disposal of household refuse and poor storage of drinking water to be significantly related to the high incidence of diarrhea. Maternal education to be a significant factor influencing child survival.

    Knowledge of measles and diarrhea is quite pertinent in an understanding of the role of cultural beliefs in health seeking among the Yoruba. In the traditional Yoruba setting, measles attack is usually attributed to a variety of causes which have no link with the concept of virus. Measles attack is traditionally considered as a punishment for breaking family taboos or as an evil deed from witches or enemies. The belief that the measles attack is caused by enemies is common among polygynous family where co-wives are natural suspects.

    While measles is perceived as deadly disease among the Yorubas, diarrhea is perceived merely as a means of getting rid of body impurities or as a sign of ‘teething’, ‘crawling’, or ‘stretching’. Also some mothers believe that diarrhea is caused by consumption of sweet things. Mothers with this view will not likely introduce oral rehydration solution to their children since it contains sugar and salt. 21 Population Council (2005) reported that the infant mortality rate was more than twice high in class five (workers) as in class one (professionals of) in Pakistan.

    There is a large variation in infant mortality rates across the different states. To them this difference is due to unequal distribution of economic growth over India and poorer people benefited most in states with low infant mortality rates in their study the infant mortality in India much faster in rural areas. Kembo and Ginneken (2005) stated that hat children born to young mothers (less than 20 years) and those born to older mothers 40-49 years) should have higher mortality than those born to mothers aged 20-39 years.

    The lower risks of child death among children who are first born and those born to mothers aged 40-49 years found in this paper are deviations from the expected mortality pattern and require further investigation. Birth order and preceding birth intervals, maternal age and type of birth are dominant determinants of infant mortality, but they are less pronounced in child mortality. Both maternal and paternal education affects infant mortality. Provision of piped drinking water and flush toilets to households has a stronger impact on child mortality than infant mortality.

    Endogenous factors are dominant during infancy while during the childhood exogenous factors are dominant age. Thus family and health planning in Zimbabwe should be directed at educating men and women with low educational levels and those in rural areas about the benefits of birth spacing and encouraging them to use birth spacing techniques. This 22 suggests that improving maternal and child health services, screening for high-risk pregnancies and making referral services for high-risk pregnancies more accessible, particularly to the rural women and children, will also contribute to improvement of child survival rates.

    Wichmann (2006) reported that 25% of all preventable diseases are due to a poor physical environment. ‘ Furthermore, over 40% of the global burden of disease attributed to environmental factors falls on children below five years of age, who account for about 10% of the world’s population. The burden of disease is defined as lost healthy life years, which includes those lost to premature death and those lost to illness as weighted by a disability factor (severity). Air pollution is the largest single environment-related cause of ill health among children in most countries.

    WHO estimated that the number of people exposed to unsafe indoor air pollution levels exceed those exposed to unacceptable outdoor air pollution levels in all of the world’s cities collectively. In other countries it is the second, after the scarcity of safe water. Globally, 2. 6% of all ill-health is attributable to indoor smoke from dirty fuels (such as wood, animal dung, crop residues, coal, paraffin), nearly all in poor regions. Wood, animal dung, coal, crop residues and paraffin (hereafter ‘polluting fuels’) are at the bottom of the energy ladder regarding combustion efficiency and cleanliness. 3 Islam et al. (2006) explained that benefits of breastfeeding on the health of an infant as an inexpensive and an appropriate source of nutrition are well accepted. It gives the baby best protection against diarrhoea, infections and food allergies and thus reduces infant mortality. The people who recognize the beneficial effects of breast-feeding are quite fretful about the declining trend in the duration of breastfeeding in many developing countries.

    Shamim and Waseem (2006) noted that bottle use is a public health issue in poor and illiterate mothers of developing countries while, in Pakistan, laws are enacted against its propagation. The attributes associated with increased bottle use were mother’s older age, illiteracy and increased parity. It is used not only to give milk but all other types of fluids e. g. water, tea, juice. , etc. its adverse effects are more profound in the under developed world due to limited economic resources, lack of clean water, unhygienic surroundings and illiteracy amongst mothers.

    The prevalence of unsuitable and/or low-quality bottles and teats further aggravate the situation. The hazards include over dilution of milk with resultant malnutrition. There is increased susceptibly to diarrhea and other gastro-intestine infections, ear infections, allergic tendency and dental caries. In Pakistan, the risk of infant mortality was estimated to be 4. 5 times higher in bottle fed babies as compared to breast-fed. Many studies on infant feeding practices in Pakistan have found the declining trend and decreased duration of exclusive breast-feeding.

    The breast milk substitute should comprise of a precisely reconstituted formula or properly 24 sterilized fresh milk. The other important essentials are availability of fuel, clean water, appropriate equipment and time for preparation, with preferably refrigeration facilities. The left over milk in the bottle should be discarded; however, it is observed that, in poor communities of Pakistan, the left over milk is often given for subsequent feeds due to limited resources, which favors the growth of pathogens.

    Mixed breast and bottle-feeding was found to be the most common practice in infancy. This approximates the bottle-feeding pattern found in urban areas of Bangladesh. Bottle use appeared to get more common as the age of infant increased. Employed women have been found to use bottle more than housewives. Rahman (2007) found that education and media exposure can reduce inequality. A strong association exists between the level of education of women and use of reproductive-maternal health services.

    It improves the status of women, increases age at marriage, reduces unwanted fertility, and improves utilization of health services by contributing towards self-confidence of women, improving their maternal skills, increasing their exposure to information, and thereby altering the way others respond to them. Conversely, media broadcasts have tremendous coverage and influence, particularly among women of reproductive age, instigating significant improvements in health status during pregnancy and also better utilization of health services.

    Thus, women exposed to mass media are better informed about health service facilities compared to non-exposed women. 25 Berg and Reiter (2008) analyzed the effects of early-life conditions (economic, nutritional, meteorological, in terms of disease exposure, and otherwise) on mortality rates later in life. Recently, there has been a growing interest in the importance of conditions early in life on health and mortality outcomes later in life. Knowledge on the magnitude of such long run effects may have policy implications.

    If being born under certain adverse conditions increases the individual mortality rate in the long run (and therefore has a negative effect on longevity) then the value of life is reduced for those affected, and this would increase the benefits of supportive policies for such groups of individuals. The long-run effect of early-life conditions on the mortality rate may be smaller than the instantaneous effect of current conditions, but the former exert their influence over a longer time span, and they are more amenable to preventive intervention between infancy and the manifestation of the effect.

    Jamal and Hussain (2008) explained that neonatal and post-neonatal mortality were found moderately high in Bangladesh, varying significantly by a number of characteristics related to socio-economic, bio-demographic and health care facilities. The results suggest that education of parents had been identified the most important socio-economic characteristics – for which infant mortality were varied significantly. Fathers’ education played dominant role in reducing the risk of post-neonatal mortality and mothers’ education played significant role in reducing 26 he risk of neonatal mortality. Mothers’ occupation was found to have significant influence on post-neonatal mortality only; however, fathers’ occupation has played significant role in reducing the risk of post-neonatal mortality. The neonatal and post-neonatal mortality was found significantly low for the children who born in medium (5-7 members) and large (8 members) sizes family. There were no significant variation in mortality for the socio-economic variables – religion, mother’s exposure to mass media, place of residence and working status of mother.

    Among bio-demographic variables, breast-feeding status was found to have significant influence on neonatal and post-neonatal mortality. Further, mother’s age at the birth of child and type of birth had significant influence on neonatal and post- neonatal mortality. Birth spacing was found significant for neonatal mortality only and the risk of neonatal mortality was very low if the birth spacing was more than 30 months. There was no significant variation in infant mortality according to sex of the child.

    Kapoor (2010) concluded that education of the mother has often been treated as a proxy for socio-economic status. Mothers who are more educated tend to get married upon adulthood, this in turn delays child bearing. She is likely to be more knowledgeable about nutrition, health care and hygiene of the infant (washing and feeding practice, care of the sick child and immunization). It is still quite common in villages to cut the umbilical cord with unsterilized sickles, keep the cooked food uncovered and exposed, leave the child un-immunized or follow orthodox methods 27 o cure common childhood diseases like tetanus and diarrhea. Educated mother is can take advantage of public health services and can earn more. She can change the range of feeding and child care practices without imposing significant extra cost on the household. Work status of the mother can have a two way effect on mortality. The need to work outside the house, may affect child survival rates simply by preventing the mother from caring for the infant. The dual burden of employment and household work can reduce the time available for childcare activities.

    This could lead to substantial effect through a lack of feeding, especially breast feeding early in life. On the other hand, working outside the home leads to higher family income and gives the mother a modern outlook, both of which could increase the probability of survival. Role of women as agricultural laborers also seem to have a significant and negative influence of infant mortality. Due to diversity of cultural norms might influence and govern the attitudes towards female children, female work participation rates and other factors important to infant mortality.

    Chowdhury et al. (2010) concluded that Infant and child mortality reflect a country’s level of socioeconomic development and quality of life. Socio-economic variables (e. g. , place of residence, religion, marital status, education, occupation, family income, household income etc. ) reflect the socio-economic status of a community that have a high influence on morbidity and mortality level. Parent’s occupation determines the economic status, nutrition and housing condition, access 28 to health care and clothing of a family.

    It has been noted that mother’s education and occupation, type of latrine and electricity are the influential factors of neonatal, post neonatal, infant and child mortality. Both male and female education participation needs to increase because it consequently brings an improvement in infant and child mortality situation. Quamrul et al. (2010) stated that the infant and child mortality influenced by a number of socio economic and demographic factors such as sex of the child, mother’s age at birth, birth order, preceding birth interval, length and survival of preceding sibling(s)..

    Sex and birth order of the child, maternal age at birth, birth interval, and survival of earlier sibling(s) has significant effect on infant and child mortality. However, the relative importance of these factors in relation to infant and child mortality risks varies with the level of social and economic well-being of a society. A number of studies conducted in different parts of the world by have revealed the influence of maternal age at delivery on the health and survivorship of children. Since a very young mother usually less than 20 years of aged mother is biologically not fully mature and the chances of pregnancy related omplications are high and she might not be able to provide good care for the infants effectively. Woman with short birth intervals have insufficient time to restore their nutritional reserves, a situation, which is thought to be adversely, affected fetal growth. This situation may have a deficit on the nutrition of the young’s child. Levels of infant and child mortality in many developing countries remain unacceptably high, and 29 they are disproportionably higher among high-risk groups such as newborn and infant of multiple births.

    A mother’s poor health and poor nutritional status may also have postnatal consequences such as impaired lactation and render her unable to give adequate care to her children. Infant mortality is higher for boys than for girls but child mortality is lower for boys. United Nations (2010) reported that There is increasing evidence that The Millennium Development Goal (MDG 4) of reducing children mortality can be achieved, but only if countries in Sub-Saharan Africa, Southern Asia and Oceania target the biggest killers of children.

    In sub-Saharan Africa, diarrhea, malaria and pneumonia cause more than half of under-five deaths. A common feature of countries that have made the most substantial progress, especially in sub-Saharan Africa, has been rapid expansion of basic public health and nutrition interventions, such as immunization, breastfeeding, vitamin A supplementation, and safe drinking water. However, on the whole, coverage of low-cost curative interventions against pneumonia, diarrhea, and malaria, remains low. In Southern Asia, more than half of all childhood deaths occur in the 28 days after birth.

    To substantially reduce these deaths, innovative solutions are required, including to provide compensation for women to deliver in designated centers or to increase the use of public–private partnerships to improve provision of skilled delivery services. Undernutrition is an underlying cause of at least a third of all under-five death. Increased nutrition 30 interventions, such as early and exclusive breastfeeding, will reduce not only undernutrition but also the prevalence of pneumonia and diarrhea. Chapter 3

    MATERIALS AND METHODS 3. 1 STUDY AREA District Chakwal is bordered by the districts of Rawalpindi and Attock in the north, district Jhelum in the east, district Khushab in the south and district Mianwali in the west. The total area of district Chakwal is 6609 square kilometers and the total population is 1059451, 87. 7 percent of which lives in rural areas and 12. 3 percent in the urban areas, making it a predominantly rural district pivoted on an agrarian economy with a very small industrial sector (Govt. of Pakistan, 1998). 31

    Study was conducted in Waryamal village–rural area of district Chakwal, situated in the north of city at the distance of 10 KM with a number of 143 households having an estimated population of 1270. 3. 2 SAMPLING A sample of 40 respondents was selected from 143 households by using purposive sampling as it was focused on only those households in which there were cases of infant mortality in last 8-10 years. One respondent was selected from each household and this respondent was selected purposively as every respondent in the household was not eligible for interview so main focus was the parents of infants. . 3 DATA COLLECTION Data was be collected by using interview schedule having both open and close ended questionnaires. Researcher conducted face to face structured interviews based on interview schedule rather than dropping questionnaire. 3. 4 PRE-TESTING Interview schedule was constructed on the basis of information provided by key informants and literature review. Pre-testing was done in order to ensure the validity and 32 accuracy of interviewing schedule and quality of data. During pre-testing some ambiguities were identified so, a few modification and addition were. . 5 DATA ANALYSIS Collected data was analyzed statistically through Statistical Package for Social Sciences (SPSS. 13) and was presented in the tabulated form by statistical techniques of percentage and frequency by using the following formula: P = (F/N) X 100 Chapter 4 RESULTS AND DISCUSSIONS Table 1 shows that a handsome number of girls (27 %) were early marriages and 33% were married within the range of 18-25 years. While 28% were married within the age group of 25-35. There were also few cases (12%) of delayed marriages also within age group of more than 35.

    It is evident from the literature that early marriage practice is a threat to mother-child health. UNICIEF reported that very few girls in early marriages in developing countries have access to contraception; nor would delayed pregnancy necessarily be acceptable to many husbands and in-laws. Indeed, in many societies, childbearing soon after marriage is integral to a woman’s social status. The risks of early 33 pregnancy and childbirth are well documented: increased risk of dying, increased risk of premature labor, complications during delivery, low birth-weight, and a higher chance that the newborn will not survive.

    Pregnancy-related deaths are the leading cause of mortality for 15-19 year-old girls worldwide (UNICIEF, 2001). Table 2 reflects that majority of mothers were illiterate (43%), 32% has passed primary class, 10% were middle passed while just 5% were matriculate. And only 10% were more than matric up to MSc level. It shows that community awareness about mother child health can not be improved easily. 4. 1: Current Pattern of Infant Mortality in Socio-economic and Demographic Perspective Table 1. Age Distribution of mother when she married

    Age Frequency Percentage Less than 18 11 27 18-25 13 33 25-35 11 28 More than 35 5 12 TOTAL 40 100

    Table 2. Distribution of the Educational Background of mothers Education Frequency Percentage Illiterate 17 43 34

    Primary 13 32 Middle 4 10 Matric 2 5 Up to MSc 4 10 Total 40 100 Table 3. Distribution of the educational background of fathers

    Education Frequency Percentage Illiterate 14 36 Primary 9 23 Middle 9 23 Matric 5 10 Up to MSc 3 8 Total 22 100

    Table 4. Distribution of family pattern of respondents Origin Frequency Percentage Joint 22 55 Extended 11 27 Nuclear 7 18 Total 40 100 Table 5. Distribution of numbers of children living with you 35 No. f children Frequency Percentage 1 5 10 2 11 21 3-5 19 59 5+ 5 10 Total 40 100 Table 6. Distribution of parent’s jobs according to their sex

    Parents job Frequency Percentage Only father 28 70 Only mother 3 7 Both 9 23 total 40 100 Table 3 reflects that educational background of the fathers is also not satisfactory that is always a major potential threat for the reproductive health.

    Data from the field shows that majority (36%) of respondents was illiterate, 23% were primary passed and same (23%) were middle class passed. A few (10%) were matriculate while higher level education was too low (8%). In such situation where 36 parental educational is so low obviously it increases the chances of infant mortality due to lack of proper knowledge about reproductive health. Table 4 shows that majority (55%) of respondants were living in joint families and 27% were in extended families while a few (18%) were in nuclear family pattern.

    Table 5 shows that majority (59%) of the families had children in the range of 3-5 and there were families (10%) who had more than 5 children. Only 21% families had 2 children and 10% were with single child but as it was noted from the field they were newly married and still they were interested in few more children. Now it can be evaluated that in poor rural areas where literacy is low, larger size of family can be major threat for infant mortality as you can not afford the proper health facilities for all children. Table 7.

    Distribution of mother’s occupation 37 Mother’s occupation Frequency Percentage Professional 4 10 House wife 28 70 Labor and others 8 20 Total 40 100 Table 8. Distribution of monthly income of household

    Monthly Income (Rs) Frequency Percentage Up to 5000 5 12 5000-10000 20 50 10000-15000 8 20 More than 15000 7 18 Total 40 100

    Table 6 reflects that main earner (70%) of the households are father wile mothers are normally not allowed for jobs as it is cultural norms of the society. as change is coming in rural areas too due to modernization and increasing poverty level. It can be noted that 25% of the families both spouses were earning for their families. There were also female headed households (7%) where mother was sole earner. 38 Table 7 shows that majority (70%) of the mothers was house wife, 20% were involved in labor and just 4% were in professional occupation.

    This table clearly indicates the females have less exposure and authority in society than men that can trigger the infant mortality. It is clear from table 8 that majority (50%) of respondent belong to lower economic class (5000-10000 Rs), 20% were earning 10000-15000 Rs /month and 12% living in hand to mouth as their monthly income was up to 5000 only. While 18% of the respondents were living in relatively good position as their monthly income was more than 15,000 Rs. It can be concluded that overall scenario of their economic conditions is not good at all.

    Due to poverty they can not afford utilization of costly health services so infant mortality rate is high in the area. Table 9. Distribution of the No. of dead infant in last 10 years according to their sex Dead infants Frequency Percentage Males 21 44 Females 26 56 Total 47 100 Table 10.

    Distribution of the ages of infant at death 39 Ages Frequency Percentage Prenatal (1 week) 17 44 1 Month (Neonatal) 11 28 3 Months (Post n a t a l ) 7 18 Infant (1year) 5 10 Total 40 100

    Table 9 shows that majority (56%) of dead infant were females while male infants were also in great in numbers 27%. As it has been discussed in chapter 2 that infant mortality rate is always higher in female infants due to son preference and gender discrimination. Table 10 describes that death rate is very high (44%) among prenatal l (1st week) while it is lower (28%) in natals ( 1st month). Mortality rate among postnatals( up to 3 months) is 18% and 10% in the infants (3-12 months). It is clear from above data that the more lethal time period for an infant is first three months.

    There is need to adopt serious precautionary measures in this time period. 40 Table 11 shows that 90% mothers were exposed to TV, 15 % have also arability of radio and 7% were exposed to newspaper and 11% has also touched with other sources too. In spite of the media exposure, awareness about mother-child health was not satisfactory. Reason for that was that they were not utilizing it for the purpose of information but they were using it for the purpose of entertainment. as it was noted in the field that whenever commercials of family planning ran they change the channels or engaged in other households works.

    So there was need to adopt other measures to educate them about the reproductive health. 4. 2. Assessment of the Knowledge and attitude towards safe motherhood Table 11. Distribution of media habits in mothers Media Habits Percentage TV 90% Radio 15% Newspaper 7% Any other sources 11%

    Table 12. Distribution of perception of mothers about diarrhea for infant 41 Diarrhea is Dangerous Frequency Percentage Yes 12 30 No 16 40 To some extent 12 30 Total 40 100 Table 13.

    Distribution of number of visits to health service No. of Visits Frequency Percentage Once a week 1 3 After 2 weeks 4 10 Once in month 8 20 Only in serious problem 27 67 Total 40 100

    Table 14. Distribution of Use of boiled water Boiled Water Frequency Percentage Yes 4 10 No 10 25 Not always 26 65 total 22 100 42

    Table 12 provides the perception of the mothers about seriousness of diarrhea. As it has been discussed in chapter 2 that diarrhea is most killer for children in the world but majority (40%) of the mothers were not perceiving it dangerous at all and 30% replied the it is not so much dangerous. Only 309% were awarded of deadly consequences of this disease. In such situation, there is need to address social cultural determinants that are deeply rooted in the perception so that we can combat the infant mortality issue.

    Table 13 evaluates the health seeking behaviors of the mothers. It can be noted the majority (67%) of the mothers were going to health providers only in serious complications while only 20% were going monthly and just 10% were going after 15 days. Only 1 respondent was going to basic health unit weakly due to a relative, working there. It is obvious that such situation can worsen the infant health where people like to visit the facility in critical situations.

    Table 14 reflects that majority (65%) of the respondents were not always using boiled water for their infant, only 10% mother were using boiled water while 25% were totally using unboiled water. This is pure lack of awareness which was causing gastro-intestinal diseases that’s why diarrhea was common in the area. 43 Table 15. Distribution of complications during pregnancy

    Pregnancy Complications Percentage Spotting (slight vaginal bleeding) 79% Blurring of vision 76% Unconsciousness 74% High blood pressure 55% Severe abdominal pain 54% Swelling in face 38% Severe vomiting 32% High fever with 26% Fits or Convulsions 6% Jaundice 8% Table 16. Distribution of vaccination course completed during life of infants

    Vaccination Frequency Percentage Full 8 20 Few time 26 65 No 6 15 Total 40 100 Table 17. Distribution of local perception about prevalence of disease in last 10 years Common Diseases Frequency Diarrhea 73% Malaria 56% Allergy 39% Typhoid 34% Measles 23% Jaundice 17% Total 40 44 Table 18. Distribution of visit to health providers

    Facilities/Service providers Frequency Percentage Community Midwife 3 7 BHU/RHC 15 38 DHQ 11 27 Private hospital 2 5 LHW/LHV 9 22 Total 40 100 Table 15 provides the Pregnancy Complications most common among the mothers that shows that conditions of motherhood. Majority of mothers reported (79%, 76% and 74%) the complications like, spotting (slight vaginal bleeding), blurring of vision and unconsciousness respectively. Complications like, abdominal pain (54%), swelling of face (38%), severe vomiting (32%) and high fever (26%) were so common and were major threat for mother-child health care. While fits (6%) and jaundice (8%) were also reported.

    This is the overall scenario of miserable conditions of a pregnant female that’s why maternal mortality rate is highest in the chakwal district from whole country. Table 16 describes that community people are not interested in long term vaccination programs that is the reason majority (65%) of the families did not complete the vaccine course for infants while 15% has not been vaccinated at all among them few were died in first month. Just 20% of infants were fully vaccinated in last 10 years but still they died. 45 Table 17 reflects that epidemiological scenario of the study areas. Most common diseases were diarrhea (73%), malaria (56%), allergy (39%), typhoid (34%), measles (23%) and jaundice (17%).

    Although there were ecological determinants of diseases were noted in the areas but there were a lot of sociocultural factors that were responsible of diseases that will be discussed at the end of this chapter. Table 19. Distribution of animals in the courtyard Animals in the Courtyard Frequency Percentage Yes 27 68 No 13 32 Total 40 100 4. 2: Patterns of Births Preparedness and New-born Care those have a Potential Threat for Infant Mortality Table 20. Distribution of place of delivery 46

    Place of Delivery Frequency Percentage Midwife 25 64 BHU/RHC 5 12 DHQ 3 7 Private doctor 2 5 LHW/LHV 5 12 Total 40 100 Table 18 describes the health seeking behaviors of the community.

    Most of the mothers (38%) go to BHU, 27% go to DHQ, and 22% go to LHV/LHW, 7% go to midwife for home medicines and 5 % access the private hospitals. But as it has been discussed in the table 13 that majority of the respondents consult the health providers only in critical situations that’s why infant mortality was high in the area. Table 19 depicts a sketch of rural agricultural community who keep animals in their courtyards. it can be noted that majority (68%) of local were keeping their animals in the courtyards where all family is involved in the household activities and children were playing there too. One can easily imagine the hygiene of the household in such environment.

    Only 32% of the respondents have not animals in their courtyards but as noted in fieldwork their hygienic conditions were not satisfactory. That’s why diseases like; malaria and diarrhea were common in the area (table 17). 47 Table 20 reflects that majority (64%) of women were accessing the midwife for delivery in the own or her home, depends upon the situation and domestic norms. A small number (12%, 12%) were going to BHU/RHC and LHV/LHW for the delivery respectively. While 7% were going to DHQ as it was 10km from village and transport is not available always and 5% of the respondents were going to private hospitals. Table 21. Distribution of No. of outcome of pregnancy

    Pregnancy Outcome Frequency Percentage Live birth 22 55 Still birth 8 20 Abortion 10 25 Total 40 100 Table 22. Distribution of mode of delivery 48 Mode of Delivery Frequency Percentage Normal vaginal delivery 25 62 Assisted vaginal delivery 13 32 Caesarean section 2 6

    Total 40 100 Table 23. Distribution of surface for delivery Surface for Delivery Frequency Percentage cloth 15 38 Floor 13 33 Chatai 10 25 Others 2 5 Total 40 100 49 Table 24. Distribution danger signs in postpartum period

    Postpartum Period Frequency Percentage High fever 13 33 Excessive vaginal bleeding 11 27 Unconsciousness 8 20 Fits or Convulsions 2 5 Prolapsed uterus 2 5 Total 40 100 Table 21 shows that majority (55%) of the respondents reported the out outcome of pregnancy was live birth while 20% reported still birth. Abortions (25%) as outcome of pregnancy were also in considerable numbers. Table 22 shows that majority of delivery was normal, 32% of the vaginal deliveries were assisted and 6% were caesarean deliveries. Even in normal 50 deliveries many postpartum complication were noted from field that will be discussed later. Table 23 shows that surface of the delivery was different in different cases and situations.

    Cloth (38%), floor (33) and chatai (25%) were used in most of the cases while 2% of the deliveries used other means for delivery. Unhygienic surface was reported for delivery that spread the infections. Table 24 explains the common danger signs reported in postpartum period in the mothers after delivery. The most common signs were high fever (33%), excessive vaginal bleeding (27), unconsciousness (20%), fits (5%) and prolapsed uterus (5%). It can be concluded that if a mother is in such a critical conditions in poor and rural community where awareness is also low and gender discriminations Table 25. Distribution of danger signs in newborns 51

    Danger Signs In Newborns Percentage Baby is very cold/shivering 42% Blue skin color 37% Difficult breathing 22% Fever/High fever 21% Skin lesion 20% Yellow skin color (Jaundice) 17% Red swollen eyes 10% Fits/Abnormal/Jerky movement 8% Unable to suck/poor sucking 8% Baby won’t cry/weak cry 7% Table 26.

    Distribution of main reason that you choose this care provider for conducting delivery 52 Main Reasons Frequency Percentage Family choice 18 45 Low cost 12 30 Nearby 8 20 More knowledgeable 2 5 Total 40 100 Table 27. Distribution of decision to seek health care

    Decision-making Frequency Percentage Midwife/ Dai 18 45 Husband 13 33 In-laws 5 12 Myself 4 10 Total 40 100 is high what will be consequences for infant? Obviously such situation triggers the infant mortality rate. 53 Table 25 shows that most dangers signs reported newborns who became the victim of death in last 10 years.

    These danger signs include; shivering (42%), blue skin (37%), respiratory problem (22%), high fever (21%), skin leision (20%), yellow skin/jaundice (17%), red eyes (10%), poor suck (8%) fits and abnormality (8%), no or poor cry (7%). Table 26 indicates the reasons to choose health provider. It can noted that majority (45%) of the women relied on their family and 30% of the respondents preferred low cast, 20 % preferred short distance of facility and just 5 % considered knowledge of care provider for the conducting delivery. Table 27 the autonomy of women to seek health facility. It can be noted only 10 % decided at their own, Majority (45%) of the mothers are guided by midwife, 33% followed their husbands in such situations while other (12%) relied on their in-laws. Table 28. Distribution of time period of breastfeeding for infants 54

    Breastfeeding Frequency Percentage No 5 12 Up to 3 months 2 5 3-6 months 4 10 Up to 1 year 12 30 1-2 year 17 43 Total 40 100 Table 29.

    Distribution of first time start of breast-feeding Started Breast-feeding Frequency Percentage Within 1 hour 1 3 1-3 1 3 3-6 5 14 6-12 12 34 More than 12 16 46 Total 35 100 Table 30.

    Distribution of time period of infant when he was kept naked after birth Naked after birth ( minutes) Frequency Percentage Up to 10 7 18 10-20 12 30 20-45 21 42 Total 40 100 55 Table 31. Distribution of type of cloth was used to wrap infant after birth

    Type of Cloth Frequency Percentage Towel/blanket 6 15 Old cloth 24 60 New cloth 10 25 Total 40 100 Table 28 reflects the decreasing trends of breast feeding even in rural community. It can be noted that only 43% of infants were feeded from 1-2 years, 30% were brest feeded from6-12 months and 10% of the mothers breast feeded their infants from 3-6 months. While 5% of these just breast feeded their infant up to 3 months and 12% of these did not involve in breast feeding due to insufficiency of milk or poor sucking.

    Table 29 shows the first time initiation of breast-feeding. It shows majority (46%, 34%, 14%) of the mothers started breast-feeding very late. i. e. , more than 12 hours, 6-12 hours and 3-6 hours respectively. Only 3% started breast-feeding within 1 hour while 3% also started 1-3 hours later. Such delays become very lethal 56 for infants where they are not vaccinated completely and living in poor and unhygienic conditions as it has been discussed in chapter 2. Table 30 provides the information about the time period in that baby has been kept naked. Majority (42%) of the infants were kept naked 20-45 minutes and 30% were kept naked 10-20 minutes while 18% were covered within 10 minutes.

    It can be also noted from table 24 this long duration for the baby leads to shivering (42%) of the infants. Table 32. Distribution of the weight of infant at birth Weight Frequency Percentage Normal 15 38 Less 19 47 More 6 15 Total 40 100 Table 33. Distribution of the size of infant at birth 57

    Size Frequency Percentage Normal 17 43 Shorter 17 42 Taller 6 15 Total 40 100 Table 31 indicates the distribution of types of the cloth that was used to wrap the infant after birth. Majority (60%) of infants was wrapped in old cloths and 25% were covered by new cloths. While blanket and towel were used for 15% of the infant.

    All the health personals question the hygiene of the old cloths that is always polluted with germs and can spread infections and it is also discussed in table 24, there were a lot of cases of skin problems in infants. Table 32 shows that majority (47%) of infants were perceived week due to under-weight, 38% were considered as normal while 15% were over-weighted. It was noted from field observation that malnutrion was common in the mothers and children. Black spot under eyes were clearly visible in mothers. 58 Table 33 shows that majority (42%) of infants were perceived shorter, 43% were considered as normal while 15% were taller. Table 34 depicts that majority of the families used ghutti as first food for infants, only 5% of the mothers provided colostrum.

    While animal milk (23%) and formula milk (5%) were also used as first food for infant. Table 34. Distribution of first food of newborn First Food of Newborn Frequency Percentage Ghutti 31 77 Colostrum 2 5 Animal milk 9 23 Formula milk 2 5 Total 40 100 Table 35.

    Distribution for rejection of the of colostrum Rejection of Colostrum Frequency Percentage Elders didn’t allow 23 57 It is dirty 9 23 Harmful to child 6 15 Child didn’t suck 4 10 Total 40 100 59 Table 36. Distribution for first medical examination after birth st Medical Examined Frequency Percentage Same day 3 8 1 weak 6 15 1 month 11 27 Only in seriousness 20 50 Total 40 100 Table 37. Distribution of advices for new-born after examination Advices Frequency

    Percentage Keep the baby warm 13 32 Breastfeeding 11 27 Immunization 9 23 Colostrum 5 13 Danger signs 2 5 Total 40 100 Table 35 reflects the reason to reject colostrum.

    Majority (57%) of respondents did not use it because elders were not in favor of it, 23 % of the mothers thought it dirty and 15% rejected due to its harmful impacts for infant. While 10% of the mothers complained that at time their infant could not able to suck it. 60 Table 36 reflects that only 8% of infants were provided by medical care on first day, 15% were provided with medical care in first week and 27 % were taken for medical examination within first month. Majority of infants were taken to health providers in only critical situations. Table 37 describes the responses of health service providers advices for the infant after medical examination.

    Majority of the infants were advised to keep them warm, 27% were asked for breast-feeding and 23 % were referred for immunization. While 13% of the infants were advised for colostrum. Danger signs (5%) were also present in the few infants also. Table 38 describes the major causes of infant death in last 10 years as told by victim families. Among these killers, diarrhea (35%) and pneumonia (30%) were most common. While respiratory infections (10%), typhoid (2%) and other (5%) also reported. There are also families who believe on superstitious believes like, evil eyes (18%) for cause of death for their infants. Table 38. Distribution of perceived cause of death 61

    Cause of Death Frequency Percentage Diarrhea 14 35 Pneumonia 12 30 Evil eyes 7 18 Respiratory infection 4 10 Typhoid 1 2 Others 2 5 Total 40 100 Table 39. Distribution of perception about less breast-feeding during her disease

    Less Breast-feeding during Disease Frequency Percentage Yes 26 65 No 6 15 Don’t Know 8 20 Total 40 100 Table 40. Distribution of type of feeding Type of Feeding Frequency Percentage Bottle feeding 5 12 Breast feeding 11 27 Both 24 61 Total 40 100 Table 41. Distribution of Sources of drinking water 62

    Sources of Water Frequency Percentage Open Wells 27 68 Hand pump 4 10 Electric motor 9 22 Total 40 100 Table 39 shows that majority (65) of the mothers were in the favor of less breast-feeding during her disease as it could further weakened him only 15% denied this assumption. While 20% of the mothers replied that they don’t know.

    This lack of medical knowledge about health and crude cultural practices fuel up infant mortality rate. Table 40 provides the information about type feeding given to the infants. Infants were feeded by breast (27%) and bottle (12%) too. Majority (61%) of the mother were feeding their infants by both means. as we have discussed in chapter 2 imbalance mixture of formula milk can also leads to infant mortality through diarrhea. 63 Table 41 discusses the sources of water for households. It is noted from field that that most of the village water is saline and women go to fetch the water from open wells (68%) with sweat water, at far off place that is in unhygienic condition and potential threat for gastro-intestinal diseases.

    Use of domestic electric motors (22%) and hand pump (10%) also present there. But as it has been noted by researcher personal and domestic hygiene was not satisfactory at all. Table 42. Distribution of preceding birth interval Preceding Birth Interval Frequency Percentage 24+ months 11 27 1st birth 11 27 Less than 24 months 18 46 Total 40 100 Table 43. Distribution of types of latrine

    Types of latrine Frequency Percentage Unhygienic toilet 22 77 Hygienic toilet 9 23 Open areas 9 23 Total 40 100 64 Table 42 shows that majority (46%) of the parents do not care for 2 years break in pregnancy while 70% of the families has 3-5 children as it has been discussed in table 5. 0nly 27% 0f parents has birth interval more than 2 years while 27% of mothers have experienced first time of birth we can not predict their fertility behavior to reduce the family size. Short birth interval and large family size both can be a threat to mother-child health. Table 43 describes the sketch of unhygienic environment.

    It was noted in field too that children were playing courtyard with animals and hiding in unhygienic latrine (23%) and only 23% toilets were hygienic. While 23% of the families were using open areas for this purpose. Table 44 explains the local perception about causes of diarrhea. Cause of diarrhea was perceived by evil eye (27%), indigestible food by mother (27%), unsuitable mother milk (18%), measles and hot food (13). It was shocking that neither a single mother pointed out polluted water/ stuff or unhygienic conditions can be responsible for diarrhea. 65 Table 45 presents the incidence and prevalence of diarrhea in the study area. Majority of the mothers reported this incidence from last 4-12 months, while 32% Table 44. Distribution of Cause of diarrhea

    Cause of diarrhea Frequency Percentage Measles 6 15 Mother milk unsuitable 7 18 Hot food 5 13 Indigestible food by mother 11 27 Evil eye 11 27 Total 40 100 Table 45. Distribution of mothers about incidence of diarrhea Incidence of Diarrhea Frequency Percentage Past 2 weeks 6 16 Past 3 months 13 32 4-12 months 21 52 Total 40 100 of mothers reported this in last 3 months. While 16% of the mothers experienced this disease in last 2 weeks.

    So it can be conclude that diarrhea is so common in the area and there is totally lack of awareness as it has been discussed in the table 43. 66 4. 1. CONCLUSIONS On the basis of findings, conclusions are depicted as follows:- 67 It can be stated that different demographic and socio-economic factors are primarily responsible for health and rearing of children. The determinants of infant mortality are family size, family structure, gender discriminations, income of household, education and knowledge of parents, mother health, availability and quality of health services, access to these facilities, environmental factors such as hygiene etc. Most of the families of this poor agricultural community are living in joint and extended families and family size is also larger.

    So due to poverty it is very difficult to provide better health facilities to the infants because consultancy fee of good doctors, medical tests and costly medicine are unaffordable a poor family so they prefer home remedies and cheap and near facilities that can not improve health standard of infants. In large families it is also impossible for an individual level care of infants that overall becomes a major threat for infant life. Literacy rate of parents, especially of mother is very low that is a big hazard for mother –child health. We can not reduce infant mortality without educating the mothers who has a key role in child rearing. UNICEF pointed out that just over one in 10 Pakistani children die before their first birth day. Rates are also highly differentiated according to class, region and the rural urban divide. While in very poor families it is around 230 per 1000. 68

    Rural areas generally suffer more infant mortality than towns (UNICEF, 1992). World Bank reported that infant mortality rates are much higher in families with non-educated parents which is particularly pronounced for the mother’s education. To him education is strongly correlated with the type of work. Infant mortality is affected by individual, house hold and community characteristics. Individual characteristics are the characteristics which are related to parents at marriage, at first birth, education, income, occupation, and landownership and livestock assets (World Bank, 1996). In developing societies, like Pakistan, people still seek health care from the traditional health care practitioners.

    This is a significant factor of poor mother-child health status and high incidence of children mortality and morbidity. Majority of the selected women (47. 5%) delivered their baby under the supervision of traditional birth attendants. Doctors only supervised 35% births. The dream of high health status for all Pakistani can only be achieved when people have access to modern health care system home. Population Report of the world fertility survey in 1985 reported that in 19 out 29 countries infant mortality rates were higher among children born fourth or later, and in 25 of 29 countries infant mortality rates were higher among children born seventh or later (Akhtar et al,. 2005).

    Other factors such as birth intervals are very short in community while girls are facing the problems of early marriages too due to increasing crimes and poverty too. Females are not autonomous so their authorities don’t prefer the family 69 planning techniques although few mothers were engaged in job but yet there is another issue of social acceptance and she faced the discriminations by family too that in turns threatens the infant health because she feels difficulty to manage time for children with job.. Mahmood (1993) explained that mortality and health status cannot be treated in isolation but it is related very intricately with some of the social economic conditions. Economic aspects of illness may often over shadow the other aspects of social component.

    Poor income may result in lower standard of living which stands for inadequate food, shelter and recreational that adversely affects health of family members. Above all, the cost of the medical care may put a family under a heavy burden of debt, which may further deteriorate their living conditions. Thus it may prove a vicious circle specifically for people with poor resources. The significance of phenomena of infant mortality is hardly irrevocable for its socio- economic and demographic implications. As infant mortality, in general is considered to explanative of overall socio-economic development. The factors that play an important role in the child health are education of mother, household income, occupation of father, standard of living etc. and other demographic factors such as age of mother at birth, birth interval and health care factors like medical facilities and immunization. 70 Breast feeding has so vital role in infant health but as it has been seen in community this trend is declining and was replaced by bottle feeding which has own hazard in poor and illiterate community. There was also norm that of ghutti as first food for infant that delays the breast feeding up to many hours. It was also noted that there were cultural barriers of rejecting colostrum and less breast feeding during diseases like diarrhea. So it downs the immunity level of children with an additional threat of malnutrition.

    Moreover most of the infant were not completely vaccinated too. Gender discriminations (son preference, ignorance of females especially in case of multiple birth and unwanted babies) are needed to be addressed as it was noted that due to this factor infant mortality rate was higher in girls. Shamim and Waseem (2006) noted that bottle use is a public health issue in poor and illiterate mothers of developing countries while, in Pakistan, laws are enacted against its propagation. The attributes associated with increased bottle use were mother’s older age, illiteracy and increased parity. It is used not only to give milk but all other types of fluids e. . water, tea, juice. , etc. its adverse effects are more profound in the under developed world due to limited economic resources, lack of clean water, unhygienic surroundings and illiteracy amongst mothers. The prevalence of unsuitable and/or low-quality bottles and teats further aggravate the situation. The hazards include over dilution of milk with resultant malnutrition. 71 There is increased susceptibly to diarrhea and other gastro-intestine infections, ear infections, allergic tendency and dental caries. In Pakistan, the risk of infant mortality was estimated to be 4. 5 times higher in bottle fed babies as compared to breast-fed.

    Many studies on infant feeding practices in Pakistan have found the declining trend and decreased duration of exclusive breast-feeding. The breast milk substitute should comprise of a precisely reconstituted formula or properly sterilized fresh milk. The other important essentials are availability of fuel, clean water, appropriate equipment and time for preparation, with preferably refrigeration facilities. The left over milk in the bottle should be discarded; however, it is observed that, in poor communities of Pakistan, the left over milk is often given for subsequent feeds due to limited resources, which favors the growth of pathogens.

    Mixed breast and bottle-feeding was found to be the most common practice in infancy. This approximates the bottle-feeding pattern found in urban areas of Bangladesh. Bottle use appeared to get more common as the age of infant increased. Employed women have been found to use bottle more than housewives. Mahmood (2002) concluded that infant and child mortality are also affected by the sex of the child, and infants born to mothers who have lost a child are at greater risk of dying during infancy. Breastfeeding has numerous bio- demographic, social, and economic effects. It affects the health and nutritional status of, both, the mother and child.

    The role of breastfeeding is very important in the post-neonatal period. Health seeking behavior includes both, preventive and 72 curative measures. Preventive measures include immunization against preventive diseases such as tuberculosis, polio, measles, neonatal tetanus and smallpox, whereas curative measures include the care and types of treatment undertaken for specific conditions, both modern and traditional. Common diseases in the areas were diarrhea, tetanus, respiratory infections, measles, pneumonia, malaria and malnutrition but the most severe threats were diarrhea and pneumonia. Illiteracy, poverty and unhygienic domestic environment were major causes of diarrhea.

    Toilets were uncleaned, hands and dress were dirty, animals were kept in courtyards, pots were kept uncovered, inaccessibility of clean water and uses of unboiled water, these all were so common. While crude cultural etiologies of diarrhea like hot food, evil eye, mother milk as impropriate and perceiving it as not threating were also shocking and needed to address. The other killer was pneumonia. Babies after birth were kept naked for a long time for cultural norms and lacks of awareness while infant was already was not vaccinated and breast feeded too so it leads to pneumonia. WHO (2009) stated that, the most common causes of child mortality are pneumonia, diarrhoea, malnutrition, malaria, and measles. All of these diseases are linked to the socio-economic conditions of the children. “If you want to control 73

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