Newborn care: traditional practices in Nepal

Old ways are not always wise ways. Modern expertise can reduce mortality, says Siddhartha Yadav

About 90% of deliveries in Nepal take place at home and only 6% are attended by a skilled health worker.^{w1 w2} This one was no exception. The setting was a shabby hut in a village in the plains, about 10 km away from the nearest town with a hospital. It takes about an hour and half by the fastest means available in the village—the bullock and cart. "This is not the first time we are doing this," says the local "woman expert" in conducting labour. She smiles, "We will deliver the baby in the usual traditional way."

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The word "traditional" reverberated in my mind. I wondered what the implications might be. What if there was some complication during the delivery? And what about the care of the newborn baby? What if emergency care is needed, as in birth asphyxia, where expert help within a matter of minutes can save life?

Nepal is a country with a neonatal mortality of 39 per 1000 live births.^w3 In the past two decades, neonatal mortality in many poor countries has remained fairly constant despite the fall in infant mortality.^{w4 w5} The direct causes of neonatal mortality in poor countries are infections, birth asphyxia, complications of prematurity, and congenital anomalies.^w6 To what extent are these explained by harmful traditional practices?

The World Health Organization's guidelines for essential care of newborn babies mention cleanliness, thermal protection, initiation of breathing, early and exclusive breast feeding, eye care, immunisation, management of illness, and the care of infants with low birth weight.^w7 Some traditional practices of newborn care may not be in accordance with these guidelines. The fact that most births take place at home shows that such traditional methods might be used most of the time.

Practices relating to care of a newborn baby can be classified as^w7:

Good practices worth promoting

Harmful practices that should be discontinued

Harmless practices that may be ignored for the time being

Practices that need further research before a decision can be taken as to their beneficial or harmful effects.

Not all traditional practices are harmful. And in turn, some modern practices, such as bottle feeding and the use of pacifiers or dummies, are considered unsafe. Because each community has its own unique culture and tradition, traditional practices also differ from community to community. However, I discuss below some traditional practices for care of newborn babies that are common to many communities in Nepal. I focus on practices that may contribute to neonatal morbidity and mortality.

Cord care—Most of the time, the cord is cut using a razor blade, which may or may not be clean.^w1 Household sickles, which are not sterilised by heat or other means for this purpose, are also commonly used, however.^w1 In many communities, something may be applied on the stump after the cord is cut, most commonly oil or ghee (clarified butter). These are applied most of the time till the cord falls off. Unclean practices for cutting the cord, and traditional practices of applying ghee, cowdung, and so on can lead to infections in newborn babies, the most severe being neonatal tetanus.^{w8 w9}

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Prelacteal feeding—A small number of newborn babies may be fed with honey, sweets, or ghee before breastfeeding.^w2 It is said that the baby's first taste should be something sweet. Prelacteal feeds have been associated with negative breastfeeding outcomes.^{w10 w11}

Colostrum discarded—Colostrum is regarded as dirty milk in some communities of Nepal and is considered harmful for the baby. Colostrum is rich in immunoglobulins and depriving newborn babies of it could predispose them to infections and undernutrition.^w12 The foremilk may also be discarded in subsequent feeding.

Both animal and human breast milk—In addition to breast milk, babies may be fed with cow's or goat's milk immediately after birth. The popular belief is that these will make the baby more intelligent. Buffalo milk is not preferred because it is thought to make you dull. However, guidelines recommend that babies be exclusively breast fed as many times as demanded for the first six months of their life.^w13

Early bathing—Newborn babies are considered dirty because they come out of their mother's womb. So, almost all the newborn babies are bathed within the first hour of birth.^{w1 w2} This may lead to hypothermia. WHO recommends that bathing should not be carried out before six hours after birth, and preferably on the second or third day of life, as long as the baby is healthy and its temperature normal.^w14

Delayed wrapping—Wrapping babies may be delayed in many cases.^{w1 w2} The usual practice is to wait for the placenta to deliver before cutting the umbilical cord and wrapping the baby.^{w15 w2} WHO recommends that after birth the baby should be immediately dried with a dry towel, including its head, while the cord is still attached.^w14

Wrapping in old clothes—Old worn out clothes rather than new ones are sometimes used to wrap the baby. In some cases the old clothes are not washed and dried properly. This may act as a source of infection. However, further research is needed before classifying this practice as harmful.

Massaging—Massaging babies with mustard oil is a well established practice in Nepal.^w16 It is believed that this will promote strength, maintain health, and provide warmth. Massaging can have detrimental effects for preterm babies or for babies whose skin barrier function is otherwise suboptimal. Recently there have been increasing concerns about this traditional practice of massage with mustard oil as it is thought to predispose the newborn baby to hypothermia.^w2

Gifts of money—Relatives who come to visit the baby usually put paper banknotes inside the baby's palms. The risk of infection related to this practice needs to be ascertained.

Most pregnancies in Nepal are unplanned, and preparation for birth is minimal.^w17 The adult literacy rate, the percentage of people aged at least 15 who can read and write, for women in Nepal is 35%.^w18 Poor maternal education has been identified as a risk factor for home delivery.^w19 Women know little about the importance of delivery by a skilled attendant or of guidelines for care of newborn babies. Only 69% of pregnant women go for one antenatal check-up, and only 44% of women going for their first antenatal check-up complete four visits.^w20

Home delivery unattended by a skilled health worker is the single most important factor for use of harmful traditional practices in immediate care of the newborn baby. In rural areas women have a strong cultural preference for home deliveries because institutional deliveries are inaccessible.^w2 Many areas of Nepal are hours away from the nearest healthcare setting. The health system, too, at community level suffers from unfilled posts, absenteeism, shortfalls in equipment and drugs, and limited support for community based staff.^w21

Pregnancy in Nepal is considered a "woman's thing," and it is the mother in law who is usually involved in the care during and after the pregnancy. The status of the mother in law in a Nepali family is usually such that the pregnant woman may have no choice but to follow harmful traditional practices despite being aware of their potential hazards.

Even for deliveries that take place in healthcare settings, people may adopt traditional practices after being discharged. It may be frustrating for health professionals to lose babies saved from birth asphyxia to infections caused by some traditional practices.

The currently prevalent traditional practices of care for newborn babies may contribute to neonatal morbidity and mortality. They become more important when viewed in light of poor antenatal healthcare services. For example, only 45% of pregnant women take two doses of tetanus toxoid vaccines in pregnancy in Nepal,^w18 a fact, that emphasises the importance of clean cord cutting practice, especially in the babies of unvaccinated mothers.

To understand the effect of traditional practices on newborn health, they need to be first identified, and their effect on the health of newborn babies should be evaluated.^w7 Once beneficial and harmful practices are identified, suitable communication strategies should be developed to educate mothers and the community.

Consideration of traditional practices should be a part of the overall strategy for reducing neonatal mortality. In Nepal the main interventions for reducing neonatal mortality are implemented through the Ministry of Health's national safe motherhood programme, which aims to tackle maternal and neonatal mortality in an integrated approach to maximise synergies between the two and to increase cost effectiveness. A national neonatal strategy was developed in 2004 to raise the profile of care of newborn babies.

Although much emphasis has been laid on the provision of skilled birth attendants and improved obstetric services in health facilities as key interventions to reduce neonatal and maternal mortality,^w22 community based approaches may be more cost effective in reducing neonatal mortality.^w23 In rural Nepal local participatory women's groups are reducing neonatal mortality by 30% by an action-learning cycle (doing, observing, thinking, and designing) to identify local perinatal problems, and devising strategies to solve them.^w24 Training of traditional birth attendants has been undertaken in Nepal. Difficulty in supervising their activities, their tendency to revert back to old methods, and their reluctance to refer, however, have prohibited widespread implementation of such training.^w25

As I sit outside, I hear the wail of the baby inside the hut. It seems that all has, so far, gone well for this newborn child. Others may not be so lucky. Everybody around me is excited and anxious while I am lost in my own thoughts about how the cord might be cut or if the baby will be bathed or the colostrum will be fed or not. "There is still a long way to go," I tell a young boy waiting to see the baby. He nods and smiles as if in agreement.

Competing interests: None declared.

References w1-w25 are on studentbmj.com

       

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