January 2005, Vol. 11, No. 1

Safe Motherhood
Maternal Health Education Needed in Pakistan

The period of time after a woman gives birth, during which her uterus shrinks and other physical changes that occurred during pregnancy are reversed, is a crucial yet under-researched element of maternity. Although the pregnancy has ended, serious diseases or disabilities associated with pregnancy—such as infection or heavy bleeding—are still possible. In fact, some traditional practices may increase the likelihood of these maladies. Similarly, the neonatal period is critical for infants, and some traditional practices may put their health at risk as well. Population Council researchers Fariyal F. Fikree (director, regional health programs, Cairo office) and Jill M. Durocher collaborated with Tazeen Ali of the Aga Khan University and Mohammad H. Rahbar of Michigan State University to study these topics. They explored postpartum and neonatal health, traditional beliefs and practices, and care-seeking behaviors among new mothers in poor areas of Karachi, Pakistan.

The investigators combined qualitative and quantitative research methods. In July and August 2000, they conducted five focus-group discussions of eight to ten participants each and 15 in-depth interviews. Women in the focus-group discussions and those who were interviewed were young and older postpartum mothers, those who had many children and those who had only one, and trained and untrained traditional birth attendants. From August to November 2000, the researchers also conducted a survey among 525 Muslim women who were six to eight weeks postpartum in five impoverished settlements in Karachi, Pakistan.

Postpartum health
The investigators found that maternal care was adequate; more than three-quarters of recent mothers sought antenatal care, and more than half delivered their babies in a hospital or maternity home. Only 16 percent of women who had delivered their babies in a health care facility had been counseled to attend a postpartum clinic, however. Of these, only 26 percent actually attended.

The most clinically significant symptoms during the immediate postpartum period, heavy vaginal bleeding and high fever, are potentially fatal if women do not receive appropriate and timely care. About half of the women in the study reported at least one symptom of illness, with 21 percent experiencing high fever, 14 percent having heavy vaginal bleeding, and nearly 10 percent reporting foul-smelling vaginal discharge (see Table 1). Women did not know the underlying biological cause of their ailments; they frequently attributed them to “weakness.”

Traditional practices
The researchers also discovered that traditional practices that might cause infection or exacerbate bleeding were common during the delivery and recovery. For example, women described traditional birth attendants massaging the vaginal walls with mustard oil during labor to ease delivery. Nearly 18 percent of women said that in order to facilitate uterine shrinkage or to prevent infection, family members or birth attendants had prepared herbal powders or sticks for insertion into the vagina or rectum. Additionally, although many new mothers are concerned by heavy vaginal bleeding, elders and traditional birth attendants often perceive such bleeding as beneficial. They believe that menstrual blood, which they consider impure, is retained during pregnancy and released afterward. Thus, they encourage new mothers to eat foods that are thought to increase postpartum bleeding.

Care-seeking behaviors
Women generally sought care initially from close relatives or traditional healers. However, if they continued to suffer, they eventually approached a Western-trained health care provider. One woman described her experience, “I first went to the dai [traditional birth attendant] for a massage for body pain. Then I went to a holy man for holy medication. Eventually everyone goes to the doctor to be cured.”

Delays in seeking appropriate care may stem from the common belief that certain symptoms are not only normal but desirable. Similarly, “many women believe that heavy vaginal bleeding and foul-smelling vaginal discharge occur from weakness caused by the rigors of labor and delivery and should therefore be endured,” states Fikree. The delay in care-seeking might be compounded, the researchers said, by male-dominated decisionmaking. More than 85 percent of women in the study sample said that they could decide to visit a clinic for a sick child or for themselves. However, study participants’ answers to other key questions indicate that they may not have the freedom necessary to complete this task. Nearly 65 percent said that they needed to get permission to visit a clinic, especially for themselves, and more than 78 percent reported that they needed permission to travel in a bus or rickshaw.

Feeding the newborn
The investigators also asked women about practices used in the care and feeding of their newborns. In Pakistan and other areas of South Asia, routine care of the newborn, including traditional feeding, bathing, and cord care practices, may prove harmful.

The majority of women—55 percent— fed their children initially with traditional substances such as honey, ghutti (an herbal paste), water, green tea, or other foods (see Table 2). Studies have shown that breast milk is the best first food for babies and that such “prelacteals” may be harmful to infants. Honey, for example, may contain the dormant spores of a bacteria that causes a rare but very serious condition called infant botulism.

The vast majority of mothers, 99 percent, went on to breastfeed their newborns regularly, with 14 percent of mothers introducing breastfeeding within the first half hour and nearly 30 percent within the first hour after birth. Nearly 8 percent of newborns, however, were not breastfed for two or more days after birth. And 71 percent of mothers supplemented their infants’ regular food with the traditional substances listed above.

Mothers had various reasons for these feeding practices. For example, one mother said that she gave her newborn water mixed with sugar and salt so that the baby would urinate frequently. “By urinating, the heat inside the baby’s body is released and then the baby feels hungry. This is necessary for the newborn’s health.” Ghutti and honey are thought to reduce colic and gastrointestinal problems. Another mother explained, “Ghutti helped to clean the stomach, released the pain, and allowed the stool to be passed.” Some consider withholding breast milk for the first few days to be beneficial because of a perceived impurity in the breast milk. “My mother-in-law said that the first milk is dirty because it has been stagnant for nine months. So, I let this milk come out, and I gave my baby buffalo milk with a bit of water mixed in it for three days,” said one mother.

The researchers noted the success of mass media educational campaigns in promoting breastfeeding. A traditional birth attendant told the investigators, “Now they say on television that one should give breast milk to the baby. So, we tell the women that doctors have told us that the child should receive mother’s milk first of all.”

Caring for the newborn
Certain traditional care practices may be harmful for the baby. Nearly 87 percent of mothers said that their infants were washed immediately or within a half hour of delivery, an action that can result in hypothermia, dangerously low body temperature. This was done to remove the vernix—the protective material that covers the skin of a fetus and is considered dirty or harmful. A large majority of women applied various substances to the umbilical stump to promote healing. A substantial minority used antiseptics or antibiotic ointments or powders, which are beneficial. More than half, however, treated the stump with mustard oil, coconut oil, surma (which contains antimony, a metallic element), or other traditional substances. When applied to an unhealed umbilical stump, these materials may lead to sepsis, a potentially deadly infection of the blood. Daily massage with mustard oil is another common newborn-care ritual that may induce sepsis.

On the basis of their findings, the researchers suggest that health care providers view antenatal care visits as opportunities to educate women about the biomedical causes of serious postpartum illnesses, such as heavy bleeding or high fever, and about benign and beneficial feeding and care practices for the newborn. Physicians can also use these visits as opportunities to encourage women to attend routine postpartum checkups.

However, Fikree and her colleagues contend, it is not appropriate or feasible to recommend interventions that depend entirely on the biomedical model. They suggest that their results have illustrated the fundamental role that traditional beliefs and practices play in the health-seeking and care-giving behaviors of new mothers in these areas of Pakistan. “We recommend that care givers help women to differentiate between benign and harmful practices. Total seclusion after childbirth may harm mothers and infants, for example, while rest is beneficial. Harmless traditional practices can be encouraged in counseling sessions and through information dissemination, and risky ones discouraged,” says Fikree. “In this way we can maintain traditions in a healthier way.” Women receive information from family members, elders, and traditional birth attendants, the investigators found, so these groups as well as pregnant women and mothers of newborns should be targeted with educational messages.

Sources
Fikree, Fariyal F., Tazeen S. Ali, Jill M. Durocher, Mohammad Hossein Rahbar. 2005. “Newborn care practices in low socioeconomic settlements of Karachi, Pakistan,” Social Science & Medicine 60(5): 911–921.

Fikree, Fariyal F., Tazeen Ali, Jill M. Durocher, and Mohammad H. Rahbar. 2004. “Health service utilization for perceived postpartum morbidity among poor women living in Karachi,” Social Science & Medicine 59(4): 681–694.  

Outside funding
The John D. and Catherine T. MacArthur Foundation

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See Also

• Reproductive Health/Safe Motherhood/Postpartum Care

• Population Briefs, Articles on Safe Motherhood/Postpartum Care