|Year : 2017 | Volume
| Issue : 1 | Page : 75-81
Perinatal care practices in home deliveries in rural Bangalore, India: A community-based, cross-sectional survey
N Ramakrishna Reddy1, CT Sreeramareddy2
1 Department of Community Medicine, Bangalore Medical College and Research Institute, Bangalore, India
2 Department of Community Medicine, Sapthagiri Institute of Medical Sciences and Research Institute, Bangalore, India
|Date of Web Publication||12-May-2017|
N Ramakrishna Reddy
Department of Community Medicine, Bangalore Medical College and Research Institute, Bangalore
Background A slowing in the decline in neonatal mortality in India has hindered progress made in reducing overall child mortality. The persisting use of unsafe home deliveries and harmful neonatal care practices may contribute to this stagnation in neonatal mortality rates.
Methods A community-based cross-sectional study of mothers residing in rural Bangalore, India, who had given birth within 42 days of the day of home visit was done during 2013–2014. Trained health workers interviewed women who delivered at home about perinatal care practices. The questionnaire used was adapted from previous studies assessing perinatal care practices according to World Health Organization guidelines. Descriptive analyses of perinatal practices were reported as frequencies. The association of various factors with the outcomes clean cord care, thermal care and early initiation of breastfeeding were assessed using multivariate logistic regression analyses.
Results Of a total of 2230 deliveries, 945 (42.4%) took place in hospitals, while the remainder were at home (57.6%). Among home deliveries, only 30.6% were attended by a skilled worker; a safe-delivery kit was used in 40.6% and 47.1% of attendants had washed their hands before delivery. In most cases (94.6%), the umbilical cord was cut after delivery of the placenta and a non-sterile instrument was used in 26.6% of births. Harmful practices of applications on the cord stump (35.0%), bathing within 6 h (61.6%), pre-lacteal feeding (30.8%) and delayed initiation of breastfeeding (73.3%) were reported. Wrapping was usually delayed, and most (64.7%) neonates were wrapped between 10 min and 60 min after birth. Being Hindu was positively associated with good perinatal care practices, and attending antenatal care at least once was associated with clean cord care and early breastfeeding. Having a trained birth attendant at delivery was associated only with clean cord care. Having a medical doctor/nurse in attendance was associated with only early initiation of breastfeeding. Being a member of a scheduled caste/tribe was positively associated with clean cord care and thermal care.
Conclusion Appropriate and culturally acceptable behaviour-change communication strategies are needed to improve delivery and neonatal care practices in Bangalore.
Keywords: home delivery, India, neonatal mortality, perinatal care
|How to cite this article:|
Reddy N R, Sreeramareddy C T. Perinatal care practices in home deliveries in rural Bangalore, India: A community-based, cross-sectional survey. WHO South-East Asia J Public Health 2017;6:75-81
|How to cite this URL:|
Reddy N R, Sreeramareddy C T. Perinatal care practices in home deliveries in rural Bangalore, India: A community-based, cross-sectional survey. WHO South-East Asia J Public Health [serial online] 2017 [cited 2019 Jun 15];6:75-81. Available from: http://www.who-seajph.org/text.asp?2017/6/1/75/206169
| Background|| |
Annually, 2.6 billion babies born worldwide die during the neonatal period, and nearly 98% of these deaths occur in low-income countries while infants are being cared for by mothers, relatives or traditional birth attendants (TBAs). Important causes of neonatal deaths are infections (tetanus, sepsis/pneumonia and diarrhoea) and complications arising from premature birth, birth injuries and birth asphyxia. Over the last decade, the infant mortality rate has declined steadily, owing to effective child-survival interventions. However, this rate of declining infant mortality has recently stagnated, owing to a very slow decline or static rate of neonatal mortality. This could be attributed to improper delivery and neonatal care practices that follow immediately after birth, particularly in home deliveries.
The World Health Organization (WHO) has outlined a set of practices called “essential newborn care”, to prevent neonatal morbidity and mortality. These include hygiene during delivery; keeping the neonate warm; early initiation and exclusive breastfeeding; care of the eyes; care during illness; and immunization and care of low-birth-weight neonates. Family members need to understand these childbirth and essential neonatal care practices, in order to seek appropriate and timely care during birth and the neonatal period.
In India, the infant mortality rate is 40 per 1000 live births and neonatal mortality is about 29 per 1000 live births. The third National Family Health Survey, 2005/2006, reported that, in India, 65.4% of all deliveries and 75.3% of deliveries in rural areas take place in a home setting. Several studies from south-Asian and African countries have reported that high-risk traditional neonatal care practices during home deliveries persist in rural,,,, as well as urban areas.,, Estimation of the proportion of hospital deliveries and skilled birth attendance, and an understanding of traditional community and household neonatal care practices, are necessary for implementation of culturally sensitive and acceptable behaviour-change communication programmes aimed at changing practices. This report quantitatively describes the perinatal care practices in a rural area of India near Bangalore.
| Methods|| |
This study was carried out in the field practice area covering three primary health-care centres (PHCs) affiliated to Bangalore Medical College and Research Institute (BMCRI), Karnataka, India. The three PHCS are located 25 km north west of Bangalore and the field practice area covered by these three PHCs has a total population of 88 000, the majority of whom are farmers, or semiskilled or unskilled labourers.
This was a community-based cross-sectional study of mothers giving birth at home who resided in the field practice area of BMCRI. Prospective recruitment of mothers was carried out by field auxiliary nurse midwives (ANMs) during routine home visiting between 1 January 2013 and 31 December 2014.
All women who resided in the field practice area of BMCRI and had given birth within 42 days of the date of the visit were included.
Ethics and informed consent
Before the start of the interview, all eligible women were given an explanation about the purpose of the interview and invited to participate. They were free to refuse participation or not answer any of the questions. Verbal consent was sought and confidentiality of information was assured. The study received ethical approval from the independent research ethics committee of BMCRI.
Questionnaire and interviewers
The questionnaire and conceptual framework were adapted from those of two studies carried out in Nepal., The questionnaire was developed in English and translated into Kannada. The translated questionnaire was pretested among 20 mothers living outside the study area. The necessary modifications were made to the questionnaire after pretesting. The questionnaire contained sections on sociodemographic profile and the antenatal, intranatal, postnatal and neonatal periods. Six ANMs, two from each of the PHCs, were trained in administering the questionnaire and in interview techniques.
All the women who resided in the field practice area and had given birth within 42 days of the date of their visit were included by the ANMs during routine home visits. The field ANMs identified all the births and collected information about neonatal care practices for home births only. For all deliveries identified by the ANMs, the questionnaire interviews covered the following aspects:
- the place of delivery, principal person who conducted the delivery and the use of a clean home-delivery kit;
- the type of instrument used to cut the umbilical cord and whether the instrument was sterilized;
- the type of material used to tie the umbilical cord and whether it was sterilized;
- whether substances (dressings) were applied to the cut end of the cord;
- the time of wrapping the baby in relation to delivery of the placenta, and the time after birth when the neonate was bathed;
- whether the neonate was given any pre-lacteal food or drink;
- the number of hours after birth that breastfeeding was initiated;
- whether the baby was taken to a health facility for a check-up and whether BCG vaccine was given.
Clean cord care was defined as use of a clean instrument for cutting, a clean cord tie and no substance application to the cord. Thermal care was defined as drying or wrapping the baby before the delivery of the placenta and delaying the first bath for 1 or 2 days. Early initiation of breastfeeding was defined as initiating breastfeeding within 1 h of birth without giving pre-lacteal feeds. Other factors considered in the analysis were age, religion, education, caste, asset score (as a proxy for income), antenatal care, parity and attendance at the birth. The asset score was calculated based on five pairs of household items possessed by the family. Each pair of items, if present, was given a score of one and if absent given a score of zero. The maximum score if all items were present was five and the minimum score if none were present was zero.
The data were analysed using SPSS (Statistical Package for Social Sciences) version 18.0. For all births identified over the 2 years studied (n = 2230), frequency distributions were calculated for each of the childbirth practices, such as place of birth and presence of a birth attendant. However, to better understand perinatal care practices during home births, the frequency distributions of safe delivery, hand washing by a birth attendant, instrument used to cut the cord, and dressing applied to the stump of the umbilical cord are presented for home deliveries only (n = 1285). In the sample of births that took place at home, clean cord care, thermal care and early breastfeeding were treated as binary outcome variables. Multivariate logistic regression, with clean cord care, correct thermal care and early breastfeeding as separate outcomes, was performed to determine their associations with risk factors such as religion, education, caste, asset score (as a proxy for income), antenatal care, parity and attendance at the birth. All the independent variables were entered into the regression models simultaneously (enter method). Odds ratios (ORs) and 95% confidence intervals (CIs) were obtained for factors related to care practices. All P values below 0.05 were considered statistically significant.
| Results|| |
During the 2-year study period, a total of 2292 singleton births and 15 twin births were identified; 63 stillbirths, 14 mothers with whom interviews were either incomplete or interview was not possible, and the second baby in the case of twins, were excluded from analyses. A total of 945 deliveries took place in hospitals; the remaining 1285 deliveries were home deliveries and formed the final sample for the analyses. The total sample of 2230 births was analysed for sociodemographic profile (see [Table 1]) and the 1285 births that took place at home were analysed for place of birth and principal birth attendant and safe delivery and neonatal care practices (see [Table 2],[Table 3],[Table 4],[Table 5]).
|Table 2: Place of home delivery and principal birth attendant (n = 1285)|
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|Table 3: Cleanliness and hygiene practices during home deliveries (n = 1285)|
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Sociodemographic profile of all participants
The background sociodemographic profile of all 2230 participants is shown in [Table 1]. The median age of the mothers was 25 years (interquartile range [IQR]: 21–28 years). Most mothers were in the age group 20–29 years (64.2%). However, 192 (8.6%) women did not know their exact age. The religion of the respondents was Hindu for 1822 (81.7%) mothers, followed by Muslim for 314 (14.1%) mothers. A majority (1156, 51.8%) of the mothers belonged to a scheduled caste or tribe or other backward class. A total of 1189 (53.3%) mothers had not attended school beyond primary level, and a majority (1447, 64.9%) of the mothers owned some agricultural land.
Obstetric and antenatal-care histories of all participants
The median age at marriage for all 2230 participants was 18 years (IQR: 18–20 years) and their age at first pregnancy was 19 years (IQR: 18–21 years). The median number of pregnancies was 2 (IQR: 1–4) and 1140 (51.1%) women were pregnant for the first time. The median number of antenatal visits was 4 (IQR: 2–6) and 589 (26.4%) mothers had had no antenatal check-up during their previous pregnancy (data not shown).
Place of delivery and delivery attendant
Only 945 (42.4%) deliveries took place in hospitals - 499 in private, 410 in government, and 36 in charitable hospitals. Most deliveries (1285, 57.6%) took place at home or in other places, such as a field. For the purposes of this study, these are all categorized as home births. The place of delivery and main birth attendant for these home births are shown in [Table 2]. The attendance at birth was classified as (i) skilled (doctors, nurses, ANMs); (ii) semiskilled (village health workers, outreach health workers, who do not receive formal training in delivery and neonatal care); (iii) TBAs (not technically trained in childbirth); and (iv) others (friends family members, neighbours). According to this classification, a skilled birth attendant (medical doctor, nurse, ANM) was present for 30.6% of deliveries.
Childbirth and neonatal care practices in home deliveries
Cleanliness and hygiene practices are shown in [Table 3]. Safe-delivery kits, which contain a clean razor blade, a surface for cutting the cord, soap to wash hands, a plastic sheet and a clean cord tie, were used in only 522 (40.6%) of the home deliveries. The safe-delivery kit was mainly obtained from accredited social health activist workers (ASHAs), TBAs or ANMs. The birth attendant had washed his/her hands before attending the delivery in only 605 (47.1%) of the deliveries. Most attendants (73.4%) used a new blade, while others used potentially harmful instruments, such as an old blade (16.3%), scissors (1.5%) or a kitchen knife (0.4%), to cut the cord. Only 191 (14.9%) mothers responded that the instrument used to cut the cord was sterilized by boiling in water (data not shown). After the cord was cut, 835 (65.0%) mothers did not apply anything to the stump of the cord. Oil (22.7%), turmeric (9.4%) and harmful substances such as animal dung, ash/soot, vermilion, etc. (7.4%) were also applied to a small number of cord stumps.
The practices related to the maintenance of warmth to prevent neonatal hypothermia are shown in [Table 4]. Most (86.1%) neonates were wiped within 1 h but wrapping immediately after birth was done for only 9.6%. The cloths used to wrap babies after birth were mostly new or washed (75.1%) (see [Table 3]). Wrapping was usually delayed, and most (64.7%) neonates were wrapped between 10 min and 60 min after birth. A total of 61.6% of the neonates received a bath within 6 h after birth. The majority of neonates (83.0%) were placed on their mother’s skin within 4 h after birth.
The neonatal feeding practices are shown in [Table 5]. A total of 69.2% were breastfed. Initiation of breastfeeding within 1 h after birth was noted in 26.7% of neonates. However, within 24 h, 79.8% of the mothers had initiated breastfeeding. The common pre-lacteal feeds given were animal’s milk (12.8%) and honey (8.5%). Other pre-lacteal feeds given were rice water (3.3%), sugar water (3.5%) and formula feeds (1.5%). Almost one third (30.8%) of the mothers had given something other than breast milk after birth.
Multivariate analysis of factors determining neonatal care practices
The results of the multivariate logistic regression of neonatal care practices during home delivery, namely clean cord care, thermal care and early initiation of breastfeeding, are shown in [Table 6]. Compared with other religions, being Hindu was positively associated with clean cord care (adjusted OR: 1.96, 95% CI: 1.56–2.32), correct thermal care (adjusted OR: 2.26, 95% CI: 1.80–2.83) and early initiation of breastfeeding (adjusted OR: 1.46, 95%CI: 1.22–1.76). Similarly, having made at least one antenatal care visit was positively associated with clean cord care (adjusted OR: 1.87, 95% CI: 1.61–2.18) and early initiation of breastfeeding (OR: 1.29, 95% CI: 1.10–1.52) but not with correct thermal care. Delivery attended by a TBA/ASHA was positively associated with clean cord care (adjusted OR: 1.72, 95% CI: 1.46–2.03) but not with correct thermal care or early initiation of breastfeeding. Deliveries attended by a medical doctor/nurse were positively associated with early initiation of breastfeeding (adjusted OR: 1.61, 95% CI: 1.20–2.18) but not with correct clean cord or thermal care. On the other hand, not belonging to a scheduled caste or tribe was negatively associated with clean cord care (adjusted OR: 0.75, 95% CI: 0.60–0.94) and thermal care (adjusted OR: 0.50, 95% CI: 0.39–0.64), whereas home deliveries attended by a medical doctor/nurse were negatively associated with correct thermal care (OR: 0.55, 95% CI: 0.40–0.76). For early initiation of breastfeeding, belonging to the Hindu religion (adjusted OR: 1.46, 95% CI: 1.22–1.76), having made at least one visit for antenatal care (adjusted OR: 1.29, 95% CI: 1.10–1.52) and delivery attended by a medical doctor or a nurse (adjusted OR: 1.61, 95% CI: 1.20–2.18) were the significant determinants.
|Table 6: Factors associated with three neonatal care practices in home deliveries (n = 1285)|
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| Discussion|| |
This study describes the perinatal care practices during home deliveries in a rural community in Bangalore, India. A significant proportion of the deliveries took place at home, where the presence of a skilled attendant at birth was not common, and hygiene practices during delivery were unsatisfactory. Wrapping the neonate after birth was generally delayed and neonatal bathing was an almost universal practice. Initiation of breastfeeding was also usually delayed for more than an hour and pre-lacteal feeding was very common.
Place of delivery and birth attendance
The proportion of home deliveries in this study (57.6%) was close to the national average of 65.4%, but lower than that for Nepal and Bangladesh., Though the health facility is in close proximity to Bangalore city, it is surprising that almost two thirds of births were home deliveries. However, it can be argued that home deliveries are prevalent in urban areas as well.,, The cost of care in private hospitals, poor-quality services or waiting periods in government hospitals may be the cause for persistence of home deliveries in this rural area. Skilled attendance for home deliveries has been prioritized, yet it was common for TBAs and unskilled persons to conduct deliveries. However, a meta-analysis has reported that training TBAs may bring about improvements in performance and perinatal mortality. Government outreach workers like ANMs and ASHAs trained in delivery care were present in a very small proportion of births, which is of concern for the functioning of primary health-care services in this area.
Hygiene during delivery
WHO recommends “five cleans” to maintain hygiene during delivery. These are: clean surface, clean hands of attendant, clean cord, clean cord tie without dressing and clean and dry wrapping of the baby. To maintain these “cleans”, kits for safe home delivery are manufactured and distributed free of charge, but, discouragingly, in 60% of the deliveries no kit was used and only half of the birth attendants had washed their hands. These practices are reportedly better in Nepal., Encouragingly, in nearly 70% of the home deliveries, a new blade was used to cut the umbilical cord and no dressing was applied to the stump of the cord. Practices like application of harmful substances (dressing) to the stump of the umbilical cord have been well described in earlier studies and were also prevalent in this study area.,,, It is well known that application of substances like ghee (clarified butter) to the umbilical cord is a risk factor for neonatal tetanus. The present study found that, in addition to being Hindu and being from a scheduled caste or tribe, use of antenatal care services and delivery attendance by a TBA/ASHA were positively associated with clean cord care. A study from Uttar Pradesh has reported that home visits and antenatal counselling improved delivery care practices. The present results suggest that women who had at least one antenatal visit may have received counselling about the “cleans” during delivery and therefore practised clean cord care.
WHO has emphasized that thermal control of the neonate is an essential part of neonatal care, and bathing the neonate either immediately or within half an hour negatively affects thermal control. In the present study, bathing of the neonate seems to be a universal practice, since more than 90% of the neonates were bathed after birth, as in south Asian countries.,,, Religious or cultural beliefs may be responsible for such practices because it is thought that vernix is “dirty looking” and bathing is “ritual cleansing”. Neonates should be dried and wrapped immediately after birth. Wrapping was usually delayed, since just under 10% of neonates were wrapped immediately, which was similar to previous studies.,,, Being a Hindu was positively associated with thermal care, while not belonging to scheduled caste or tribe, and delivery attended by a medical doctor or nurse, were negatively associated with thermal care. This latter finding is consistent with other studies from India, which have suggested that health-care providers may not recognize the need for thermal care to prevent neonatal hypothermia.
The delayed initiation of feeding and pre-lacteal feeding is contrary to the findings from a rural population in Uttar Pradesh, where pre-lacteal feeding was a universal practice and breastfeeding was delayed for several days. Breastfeeding initiation rates (26.7% within an hour after birth) were very low compared to those reported in studies from Nepal, Pakistan and Bangladesh.,,, Traditional practices of giving non-breast-milk food, usually only once immediately after birth, are thought to be unnecessary and potentially harmful. In a study from rural Uttar Pradesh, early initiation of breastfeeding was positively associated with being Hindu, attendance for at least one antenatal visit and the presence of a skilled birth attendant.
Though from a small area of rural India, the results from this study are important for safe-motherhood programmes, to either ensure the presence of skilled personnel during delivery or provide accessible and acceptable services, as at least one antenatal visit and skilled birth attendance were associated with clean cord care and early initiation of breastfeeding. It is important to continue the provision of community outreach services, satellite birthing facilities, and training of TBAs and ASHAs, to improve neonatal care., Culturally appropriate and sensitive strategies to change behaviour and practices are necessary to avoid the high-risk neonatal care practices that are prevalent in this rural population.
This study had some limitations. Therefore, interpretation of the results needs caution. Nearly half the mothers were educated up to primary level only (4 years of schooling), which may have resulted in inaccurate reporting about delivery and neonatal care practices. An attempt was made to minimize recall bias by interviewing mothers within 42 days after birth but there could also have been some reporting bias from the mothers. Some questions about some reported risky neonatal care practices like oil massage, discarding colostrum, etc. were not asked. Many such practices are a result of traditional customs/beliefs and there was no opportunity to qualitatively explore such traditions during this study. Finally, the study was limited to a small area; hence, extrapolation of the results to the other populations of India is limited.
Harmful delivery and neonatal care practices are prevalent in this rural population and there is a need for interventions to encourage community members, family members, TBAs and ASHAs to change practices. Skilled birth attendance or utilization of health facilities for childbirth, as well as neonatal care practices, should be improved in this community. Improving maternity care facilities, the quality of maternity care and community health education would help to improve uptake of facility deliveries.
Acknowledgements: We thank the auxiliary nurse midwives for identifying the births and interviewing the mothers at home. We also thank the interns posted at primary health centres, and staff, for their cooperation and help with conducting this study.
Source of support: Nil.
Conflict of interest: None declared.
Authorship: Both the authors contributed equally towards conceptualization of the study, acquisition of data and analyses, interpretation of results and writing and reviewing the manuscript for publication.
| References|| |
Liu L, Oza S, Hogan D, Perin J, Rudan I, Lawn JE et al. Global, regional, and national causes of child mortality in 2000–13, with projections to inform post-2015 priorities: an updated systematic analysis. Lancet. 2014; 385(9966):430–40. doi:10.1016/S0140–6736(14)61698–6.
Wang H, Liddell CA, Coates MM, Mooney MD, Levitz CE, Schumacher AE et al. Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384(9947):957–79. doi:10.1016/S0140–6736(14)60497–9.
Liu L, Johnson HL, Cousens S, Perin J, Scott S, Lawn JE et al. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet. 2012;379(9832):2151–61. doi:10.1016/S0140–6736(12)60560–1.
Geldsetzer P, Williams TC, Kirolos A, Mitchell S, Ratcliffe LA, Kohli-Lynch MK et al. The recognition of and care seeking behaviour for childhood illness in developing countries: a systematic review. PLoS One. 2014;9(4):e93427. doi:10.1371/journal.pone.0093427.
Baqui AH, Williams EK, Darmstadt GL, Kumar V, Kiran TU, Panwar D et al. Newborn care in rural Uttar Pradesh. Indian J Pediatr. 2007;74(3):241–7. doi:10.1007/s12098-007-0038-6.
Barnett S, Azad K, Barua S, Mridha M, Abrar M, Rego A et al. Maternal and newborn-care practices during pregnancy, childbirth, and the postnatal period: a comparison in three rural districts in Bangladesh. J Health Popul Nutr. 2006;24(4):394.
Osrin D, Tumbahangphe KM, Shrestha D, Mesko N, Shrestha BP, Manandhar MK et al. Cross sectional, community based study of care of newborn infants in Nepal. BMJ. 2002;325(7372):1063. doi:10.1136/bmj.325.7372.1063.
Darmstadt GL, Hussein MH, Winch PJ, Haws RA, Lamia M, El-Said MA et al. Neonatal home care practices in rural Egypt during the first week of life. Trop Med Int Health. 2007;12(6):783–97. doi:10.1111/j.1365–3156.2007.01849.x.
Syed U, Asiruddin S, Helal MS, Mannan II, Murray J. Immediate and early postnatal care for mothers and newborns in rural Bangladesh. J Health Popul Nutr. 2006;24(4):508–18.
Fikree FF, Ali TS, Durocher JM, Rahbar MH. Newborn care practices in low socioeconomic settlements of Karachi, Pakistan. Soc Sci Med. 2005;60(5):911–21. doi:10.1016/j.socscimed.2004.06.034.
Rahi M, Taneja DK, Misra A, Mathur NB, Badhan S. Newborn care practices in an urban slum of Delhi. Indian J Med Sci. 2006;60(12):506–13. doi:10.4103/0019–5359.28980.
Sreeramareddy CT, Joshi HS, Sreekumaran BV, Giri S, Chuni N. Home delivery and newborn care practices among urban women in western Nepal: a questionnaire survey. BMC Pregnancy Childbirth. 2006;6:27. doi:10.1186/1471–2393-6–27.
Bhutta ZA, Darmstadt GL, Hasan BS, Haws RA. Community-based interventions for improving perinatal and neonatal health outcomes in developing countries: a review of the evidence. Pediatrics. 2005;115(2 Suppl.):519–617. doi:10.1542/peds.2004–1441.
Statistical package for the social sciences (SPSS). Statistical software: version 18.0. Chicago, IL: SPSS, Inc.; 2008.
Bohren MA, Hunter EC, Munthe-Kaas HM, Souza JP, Vogel JP, Gülmezoglu AM. Facilitators and barriers to facility-based delivery in low- and middle-income countries: a qualitative evidence synthesis. Reprod Health. 2014;11(1):71. doi:10.1186/1742–4755-11–71.
Das A, Rao D, Hagopian A. India’s Janani Suraksha Yojana: further review needed. Lancet. 2011;377(9762):295–6. doi:10.1016/S0140–6736(11)60085–8.
Sibley LM, Sipe TA, Brown CM, Diallo MM, McNatt K, Habarta N. Traditional birth attendant training for improving health behaviours and pregnancy outcomes. Cochrane Database Syst Rev. 2007;(3):CD005460. doi:10.1002/14651858.CD005460.pub3.
Scott K, Shanker S. Tying their hands? Institutional obstacles to the success of the ASHA community health worker programme in rural north India. AIDS Care. 2010;22(S2):1606–12. doi:10.1080/09540121. 2010.507751.
Kesterton AJ, Cleland J, Sloggett A, Ronsmans C. Institutional delivery in rural India: the relative importance of accessibility and economic status. BMC Pregnancy Childbirth. 2010;10(1):30. doi:10.1186/1471–2393-10–30.
Bennett J, Ma C, Traverso H, Agha SB, Boring J. Neonatal tetanus associated with topical umbilical ghee: covert role of cow dung. Int J Epidemiol. 1999;28(6):1172–5.
Iyengar SD, Bhakoo ON. Prevention of neonatal hypothermia in Himalayan villages. Role of the domiciliary caretaker. Trop Geogr Med. 1991;43(3):293–6.
Kumar V, Shearer JC, Kumar A, Darmstadt GL. Neonatal hypothermia in low resource settings: a review. J Perinatol. 2009;29(6):401–12. doi:10.1038/jp.2008.233.
Chandrashekhar TS, Joshi HS, Binu V, Shankar PR, Rana MS, Ramachandran U. Breast-feeding initiation and determinants ofexclusive breast-feeding - a questionnaire survey in an urban population of western Nepal. Public Health Nutr. 2007;10(2):192–7. doi:10.1017/S1368980007248475.
Holman DJ, Grimes MA. Colostrum feeding behaviour and initiation of breast-feeding in rural Bangladesh. J Biosoc Sci. 2001;33(01):139–54.doi:10.1017/S0021932001001390.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]